High-Yield Physical Exam Signs
A Step 2 CK rapid-recognition lesson on classic eponymous physical exam signs, mapping each buzzword to its diagnosis and next-best-step, with emphasis on high-yield confusable pairs (pulsus paradoxus vs Kussmaul, Osler vs Janeway, cholecystitis vs cholangitis) and same-name traps.
Eponymous physical exam signs are Step 2 CK favorites because a single phrase can lock a vignette to one diagnosis and drive the next-best-step. You rarely elicit the sign yourself — you read it in the stem ("inspiratory arrest on RUQ palpation," "muffled heart sounds with distended neck veins") and must instantly convert buzzword → diagnosis → confirmatory test → action.
High-yield territory clusters into three habits: memorize the classic triads and eponyms, master the confusable pairs (pulsus paradoxus vs Kussmaul; Osler vs Janeway; cholecystitis vs cholangitis), and watch the same-name trap where one eponym means two unrelated things (Trousseau). The boards reward the student who names the sign and commits to the correct order of workup — imaging before intervention, blood cultures before antibiotics when the patient is stable (but never delay antibiotics in the unstable/septic patient), and treatment before imaging when they are crashing.
Sign → diagnosis, rapid-fire:
- Murphy sign — inspiratory arrest during RUQ palpation → acute cholecystitis
- Courvoisier sign — palpable, nontender gallbladder + painless jaundice → malignant biliary obstruction (pancreatic head cancer), not stones
- Charcot triad — RUQ pain + fever + jaundice → ascending cholangitis; add hypotension + confusion = Reynolds pentad
- Beck triad — hypotension + JVD + muffled heart sounds → cardiac tamponade
- Cullen (periumbilical) / Grey Turner (flank) ecchymosis → retroperitoneal / hemorrhagic pancreatitis (also ruptured ectopic, AAA)
- Rovsing / psoas / obturator signs → appendicitis (retrocecal = psoas; pelvic = obturator)
- Chvostek / Trousseau → hypocalcemia
- Kernig / Brudzinski → meningeal irritation
- Virchow node (left supraclavicular) / Sister Mary Joseph nodule (periumbilical) → metastatic GI malignancy
Vignette: A 34-year-old woman with SLE has 2 days of worsening dyspnea. BP 86/58, HR 122, JVP elevated, heart sounds muffled. Systolic pressure falls 18 mmHg on inspiration. ECG shows low-voltage QRS with beat-to-beat variation in amplitude.
Diagnosis: Cardiac tamponade — Beck triad + pulsus paradoxus (>10 mmHg inspiratory SBP drop) + low voltage / electrical alternans.
Next best step: Bedside echocardiography to confirm (early-diastolic RV free-wall collapse, late-diastolic/systolic RA collapse, and a dilated non-collapsing plethoric IVC). Definitive treatment is pericardiocentesis — done emergently, without waiting for echo, if the patient is in shock.
Don't: aggressively diurese or give vasodilators — tamponade is preload-dependent. Key contrast: tamponade shows pulsus paradoxus but usually no Kussmaul sign (that points instead to constriction or RV infarct).
| Feature | Cardiac tamponade | Constrictive pericarditis | RV infarction |
|---|---|---|---|
| Pulsus paradoxus | Present (hallmark) | Usually absent | Absent |
| Kussmaul (JVP ↑ on inspiration) | Usually absent | Present | Present |
| JVP waveform | Blunted y descent | Prominent x & y (M/W) | Markedly elevated |
| Extra finding | — | Pericardial knock | Inferior STEMI, ST↑ V4R |
| Best test | Echo (RV collapse) | CT/echo/MRI: thick/calcified pericardium | Right-sided ECG |
| First move | Echo → pericardiocentesis | Diuretics → pericardiectomy | IV fluids, avoid nitrates/diuretics |
Vignette A: 45-year-old obese woman, RUQ pain after fatty meals, fever 38.3°C, inspiratory arrest on RUQ palpation (Murphy sign), no jaundice. → Acute cholecystitis. Next: RUQ ultrasound (wall >3 mm, pericholecystic fluid, sonographic Murphy); if equivocal, HIDA scan (non-visualized gallbladder = positive). Treat: IV antibiotics + early laparoscopic cholecystectomy.
Vignette B: 70-year-old with RUQ pain, fever, and jaundice (Charcot triad), now hypotensive and confused (Reynolds pentad). → Ascending cholangitis. Next: IV fluids + broad-spectrum antibiotics + urgent biliary decompression by ERCP — decompress, don't just observe.
Trap — Vignette C: Painless jaundice + palpable nontender gallbladder (Courvoisier) → malignant obstruction (pancreatic head), not gallstones. Next: CT abdomen + CA 19-9.
Infective endocarditis peripheral signs — "FROM JANE":
- Fever
- Roth spots (retinal hemorrhages with pale centers)
- Osler nodes (painful, finger/toe pads — immune-complex mediated)
- Murmur (new regurgitant)
- Janeway lesions (painless, palms/soles — septic emboli)
- Anemia
- Nail-bed splinter hemorrhages
- Emboli (septic)
Never confuse them: Osler = Ouch (painful, immune-mediated) vs Janeway = painless (embolic).
Next step in suspected IE: 3 sets of blood cultures from separate sites + transthoracic echo (escalate to TEE if TTE non-diagnostic with high suspicion, or prosthetic valve/device), then apply the modified Duke criteria.
Endocrine, neuro & vascular signs — with the traps:
- Chvostek (facial-nerve tap → cheek twitch) and Trousseau (BP cuff inflation → carpopedal spasm) = hypocalcemia; Trousseau is more specific (Chvostek has a high false-positive rate). Check ionized calcium and magnesium (low Mg impairs PTH release).
- TRAP: Trousseau sign of malignancy is unrelated — migratory superficial thrombophlebitis, classically pancreatic adenocarcinoma.
- Kernig (knee won't extend with hip flexed) / Brudzinski (neck flexion → hip/knee flexion) = meningeal irritation → lumbar puncture. Give empiric antibiotics ± dexamethasone first; CT head before LP only if focal deficit, papilledema, new seizure, altered mentation, or immunocompromise.
- Pulsus parvus et tardus (weak, delayed carotid upstroke) = severe aortic stenosis; water-hammer / Corrigan pulse with wide pulse pressure = aortic regurgitation.
Practice Clinical Diagnosis now
Board-style questions, spaced-repetition flashcards, and a Socratic AI tutor — free to start.