A 70-year-old male visits his primary care physician because of progressive weight loss. He has a 20-year history of smoking 2 packs of cigarettes a day and was diagnosed with diabetes mellitus 6 years ago. After physical examination, the physician tells the patient he suspects adenocarcinoma at the head of the pancreas. Which of the following physical examination findings would support the diagnosis?

Lymphadenopathy of the umbilicus

A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

Second opinion from a neurologist

Withdraw ventilation support and mark time of death

Repeat examination in several hours

A 27-year-old soldier is brought to the emergency department of a military hospital 20 minutes after being involved in a motor vehicle accident during a training exercise. He was an unrestrained passenger. On arrival, he has shortness of breath and chest pain. He appears pale and anxious. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. He is alert and oriented to person, place, and time. Examination shows pale conjunctivae and mucous membranes. There is bruising on the chest, extremities, and abdomen. The lungs are clear to auscultation. He has normal heart sounds and flat neck veins. The abdomen is flat, soft, and mildly tender. The remainder of the physical examination shows no abnormalities. High-flow oxygen is applied, and intravenous fluid resuscitation is begun. A chest x-ray is obtained. Which of the following is the most appropriate next step in management?

CT scan of the chest with contrast

Intubation with positive pressure ventilation

A 60-year-old-man presents to his physician with worsening myalgias and new symptoms of early fatigue, muscle weakness, and drooping eyelids. His wife presents with him and states that he never used to have such symptoms. His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type II, and pilocytic astrocytoma as a teenager. He denies smoking, drinks a 6-pack of beer per day, and endorses a past history of cocaine use but currently denies any illicit drug use. His vital signs include temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 87/min, and respiratory rate 15/min. Physical examination shows minimal bibasilar rales, but otherwise clear lungs on auscultation, grade 2/6 holosystolic murmur, 3/5 strength in all extremities, and benign abdominal findings. The Tensilon test result is positive. Which of the following options explains why a chest CT should be ordered for this patient?

Evaluation for mediastinal botulinum abscess

Evaluation of congenital vascular anomaly

Exclusion of underlying lung cancer

Assessment for motor neuron disease

A 28-year-old woman comes to the emergency department for a rash that began 3 days ago. She has low-grade fever and muscle aches. She has no history of serious illness and takes no medications. She has had 5 male sexual partners over the past year and uses condoms inconsistently. Her temperature is 38.1°C (100.6° F), pulse is 85/min, and blood pressure is 126/89 mm Hg. Examination shows a diffuse maculopapular rash that includes the palms and soles. The remainder of the examination shows no abnormalities. A venereal disease research laboratory (VDRL) test is positive. Which of the following is the next appropriate step in management?

Fluorescent treponemal antibody absorption test

Physical exam-directed testing for USMLE Step 2 CK: High-Yield CCS Cases Lessons

Core Principles - Examine, Then Order!

Principle: Physical exam findings guide test selection by modifying pre-test probability.
Goal: Avoid the inefficient "shotgun approach" of ordering numerous non-specific tests.
- This ↑ diagnostic yield, ↓ costs, and minimizes patient harm.

⭐ A test is most useful when the pre-test probability is intermediate (~30-70%). Strong clinical findings can move the probability to be very high or very low, often reducing the need for further testing.

Cardiovascular System - Heartfelt Investigations

Murmur: Echocardiogram (first-line).
Pericardial Rub: ECG (widespread ST elevation), then Echocardiogram.
S3 Gallop / Dyspnea: Pro-BNP, Echocardiogram, Chest X-ray (cardiomegaly).
Unequal Pulses / BP / Tearing Chest Pain: CT Angiogram (rule out aortic dissection).
Radio-femoral Delay: Doppler, CT/MR Angiogram (coarctation).

Echocardiogram of mitral valve prolapse with measurements

⭐ Beck's Triad for Cardiac Tamponade: Hypotension, Distended Neck Veins (JVD), and Muffled Heart Sounds. A clinical diagnosis prompting urgent pericardiocentesis.

Respiratory System - Breathing Easy with Tests

Link physical findings directly to your initial test choice. This targeted approach saves time and resources, focusing on the most probable diagnosis.

Dullness to percussion: Indicates fluid or consolidation.
- Initial Test: Chest X-ray (CXR) to identify pleural effusion or lobar pneumonia.
Hyper-resonant note: Suggests trapped air.
- Initial Test: CXR to look for pneumothorax.
Crackles (Rales): Implies fluid in alveoli.
- Initial Test: CXR. Consider Brain Natriuretic Peptide (BNP) if suspecting a cardiac origin.
Wheeze: Airway narrowing.
- Initial Test: Spirometry / Pulmonary Function Test (PFT).
Stridor: Upper airway obstruction.
- Initial Test: Laryngoscopy or X-ray of the neck (lateral view).

⭐ On auscultation, egophony ("E" to "A" change) has a high specificity for consolidation.

Abdominal & GI Exam - Gut Feelings to Certainty

Translating physical signs into diagnostic action is key. Specific abdominal maneuvers point towards high-probability diagnoses, guiding the most appropriate initial imaging or lab tests.

Sign	Suspected Diagnosis	Best Initial Test
Murphy's Sign	Acute Cholecystitis	USG Abdomen
McBurney's, Rovsing's, Psoas, Obturator	Acute Appendicitis	USG Abdomen / CT
Cullen's, Grey Turner's	Hemorrhagic Pancreatitis & Retroperitoneal Bleed	CT Abdomen, Amylase/Lipase
Caput Medusae	Portal Hypertension	LFTs, USG Doppler

Neurological Exam - Nerve-Wracking Decisions

Your physical exam is pivotal. Neurological red flags mandate immediate imaging to exclude life-threatening conditions like mass effect or ↑ICP before proceeding to procedures like a lumbar puncture. This sequence prevents iatrogenic herniation.

⭐ In suspected meningitis with signs of ↑ICP (papilledema, focal deficits), always get a CT head before LP to prevent brainstem herniation.

High-Yield Points - ⚡ Biggest Takeaways

Physical examination is a diagnostic filter, not just a ritual; use it to guide your investigations.

Order tests to confirm or refute diagnoses suggested by specific physical signs.

A new cardiac murmur directly indicates the need for an ECG and 2D Echocardiogram.

Abdominal signs like guarding or tenderness should prompt targeted imaging like ultrasound or CT.

Focal neurological deficits are a clear indication for immediate neuroimaging (CT/MRI).

This sign-to-test strategy is crucial for efficient diagnosis in CCS cases.

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