Levine’s Sign


Other Known AliasesPalm Sign, Cossio’s Sign, Cossio-Levine’s Sign

DefinitionClenched fist held over the sternum while a patient is describing their chest pain and classically is the right hand, as cardiac pain can refer to the left arm.

Image result for levine sign

Clinical SignificanceThere is very little significance to this sign and has been studied to only have a 14% sensitivity for cardiac chest pain, but is a classic physical exam finding and frequent pimp fodder.

History – Named after Samuel Albert Levine (1891-1966), who was an American cardiologist and attending physician at The Brigham Hospital in Boston, MA, and assistant professor of medicine at Harvard University.  He graduated Harvard at the age of 20 and was the first physician to diagnose President Franklin Roosevelt with poliomyelitis.  He was a pioneer in coronary thrombosis research and was the second physician to ever diagnose the condition, which he described it in his classic book Clinical Heart Disease in 1936. 

Samuel-Albert-Levine-1964.jpgImage result for samuel a levine

Image result for levine clinical heart disease

He is also the namesake of The Levine Scale, a 1 to 6 grading system to characterize the intensity  of heart murmurs, and Lown-Ganong-Levine syndrome, which is a pre-excitation syndrome causing a shortened PR interval with normal QRS complexes in tachycardia.

Image result for levine scale

The Levine Scale

Image result for lown ganong levine syndrome

Lown-Ganong-Levine Syndrome



  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Edmondstone WM. Cardiac chest pain: does body language help the diagnosis? BMJ. 1995;311(7021):1660-1. [pubmed]
  6. Levine HJ.  Profiles in Cardiology: Samuel A. Levine (1891-1966).  Clin Cardiol.  1992;15:473-476
  7. Bedford DE. Samuel Albert Levine (1891-1966). British heart journal. 1966; 28(6):853-4. [pubmed]
  8. Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. The American journal of cardiology. 2008; 102(8):1107-10. [pubmed]
  9. Lown B, Ganong WF, Levine SA. The syndrome of short P-R interval, normal QRS complex and paroxysmal rapid heart action. Circulation. 1952; 5(5):693-706. [pubmed]

PAINE #PANCE Pearl – Dermatology



What are the 5 things to assess in a suspicious lesion/mole to evaluate for melanoma?




The ABCDEs of melanoma will help you identify suspicious lesions that will need dermatologic follow-up



  • Draw a line through the lesion and the two halves do not look similar, it is concerning

Border Irregularity

  • If the borders of the lesion are not uniform and smooth, it is concerning


  • Different colors within the same lesion are concerning


  • ≥ 6 mm is concerning


  • Any lesion that changes in size, shape, color is concerning


The is also another set of criteria that was developed in the UK by the United Kingdom National Institute for Clinical Excellence (NICE) and by the Scottish Intercollegiate Guidelines Network called the Glasgow Seven-point Checklist.  These guidelines incorporate 3 major and 4 minor criteria and any major or 3 minor criteria is an indication for referral.


  • Change in size or new lesion
  • Change in shape
  • Change in color


  • Diameter ≥ 7mm
  • Inflammation
  • Crusting or bleeding
  • Sensory change

Once a patient has been referred to a dermatologist, they use a similar seven point system on dermoscopy to diagnose melanoma.

Major (2 points each)

  • Atypical pigment network
  • Blue-whitish veil
  • Atypical vascular pattern

Minor (1 point each)

  • Irregular streaks
  • Irregular pigmentation
  • Irregular dots/globules
  • Regression structures


A melonoma score of ≥ 3 is required for diagnosis



  1. National Collaborating Centre for Cancer (UK). Melanoma: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2015
  2. Scottish Intercollegiate Guidelines Network. Cutaneous Melanoma. A national clinical guideline. January 2017.
  3. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E, Delfino M. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Archives of dermatology. 1998; 134(12):1563-70. [pubmed]
  4. http://www.dermoscopy.org/consensus/2d.asp


Wood’s Lamp


Other Known Aliases – Ultraviolet (UV)-A lamp, blacklight

Definition – Handheld UV light that emits UV-A (long-wave) light with a violet filter, which blocks most of the visible light, and only allows the UV-A through

Image result for wood's lamp


Clinical Significance – There are many medical applications for using UV light for quick, bedside diagnosis.  One of these is for fungal infections of the skin, most commonly Tinea infections.  Tinea infections will fluoresce under UV-A light.

Image result for wood's lamp tinea

Tinea versicolor

Image result for wood's lamp tinea capitis

Tinea capitis


History – Named after Robert W. Wood (1868-1955), who was an American physicist, inventor, and a pioneer in infrared and ultraviolet photography.  In 1903, he developed a filter that would block visible light, but be transparent to both infrared and ultraviolet light.  He won several awards and honors in the field of optics (he even has a crater on the moon named after him) and is the namesake of the R.W. Wood Prize of the Optical Society of America, which recognizes outstanding discovery, achievement, or invention.

Robert Williams Wood.png


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Ponka D, Baddar F. Wood lamp examination. Canadian family physician Medecin de famille canadien. 2012; 58(9):976. [pubmed]
  6. Ducharme EE, Silverberg NB. Selected applications of technology in the pediatric dermatology office. Seminars in cutaneous medicine and surgery. 2008; 27(1):94-100. [pubmed]

#37 – Conjunctivitis





The conjunctiva is a mucous membrane that that lines the surface of the eyelids (palpebral) and globe up to the limbus (bulbar).


The conjunctiva itself is made up of non-keratinized squamous epithelium with goblet cells and substantia propria, which is highly vascularized.

The important thing to remember is that the conjunctiva is transparent, unless inflamed (which is termed “injected”).

Bacterial Conjunctivitis


  • Bacterial conjunctivitis is more common in children than adults (though viral is most common overall).
  • Transmission is spread from direct contact with infected drainage or contaminated objects
  • Pathogens
    • S. aureus, S. pneumoniae, H. influenza, M. catarrhalis
  • Signs and Symptoms
    • Redness and drainage in one eye
    • Matted shut in the morning
    • Drainage
      • Continues throughout the day
      • Thick and purulent
  • Special Concerns
    • Neisseria gonorrhoeae
      • Concurrent STI symptoms
      • Rapid onset of symptoms (< 12 hours)
      • More pain and tenderness with marked chemosis and lymphadenopathy
      • Admission with emergency ophthalmology evaluation
        • Keratitis and perforation may occur

Viral Conjunctivitis


  • Most common cause of acute conjunctivitis
  • Highly contagious and is spread through direct contact with drainage or contaminated objects
  • Pathogens
    • Adenovirus is the most common
  • Viral prodrome
    • Fever, adenopathy, pharyngitis, URI, conjunctivitis
  • Drainage
    • Watery, mucoserous drainage
    • Matted/thick in the morning with scant, watery drainage throughout the day
  • Corneal injection with burning/gritty sensation
  • Starts unilateral and spreads to contralateral eye within 48 hours of symptoms onset
  • Follicular pattern on palpebral conjunctiva
  • Self-limiting process
    • Worsens for 3-5 days with gradual resolution over the next 7-10 days

Allergic Conjunctivitis


  • Caused by airborne allergens that initiate an IgE-mediated local response with mast cell degranulation and release of histamine
  • Drainage
    • Watery and stringy
  • Signs and Symptoms
    • Bilateral eye involvement
    • Periorbital edema
    • Allergic symptoms
      • Sneezing, coughing, rash, sore throat
    • Profuse itching
    • Marked chemosis and injection
      • Bullous chemosis may occur in severe causes or as a result of itching

Non-Infectious/Non-Allergic Conjunctivitis


  • Causes
    • Mechanical or chemical insult
      • Patients with chronic dry eyes
      • Patients s/p irrigation from chemical splash
      • Transient foreign body
  • Self-limiting and spontaneously improve within 24 hours

Distinguishing Between The Types


Special Considerations for Contact Lens Wearers


These patients are at an increased risk for Pseudomonas infections and should be advised to refrain from wearing their contacts and to have a formal evaluation by an ophthalmologist to rule-out serious infection.  Any antibacterial treatment in these patients should also cover for Pseudomonas.



With the exception of gonococcal conjunctivitis, all types are self-limiting and will improve on their own.  Having said that, bacterial conjunctivitis will improve faster with topical antibiotics.



  • Erythromycin 5mg/gram ointment – 1cm ribbon 4x/day for 5-7 days
  • Trimethoprim-polymyxin B 0.1%-10,000 units/mL – 1-2 drops 4x/day for 5-7 days
  • Ciprofloxacin 0.3% – 1-2 drops 4x/day for 5-7 days


Viral and Allergic

  • Antihistamine/decongestant drops
    • Pheniramine/naphazoline – 1-2 drops 4x/day
    • Olopatadine 0.2% – 1 drop daily
    • Azelastine 0.05% – 1 drop 2x/day



  • Eye lubricants

Return to Work/School Issues


The safest recommendation is to be out until there is no longer any discharge, but this is not practical since it could last for up to 2 weeks.



  • I tell patients that you treat it like the common cold and practice good hand hygiene to limit the spread of any infectious drainage


  • Most schools require 24 hours of therapy before children are allowed to return to school

Cottage Physician



  1. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical therapeutics. 1995;17(5):800-10; discussion 779. [pubmed]
  2. Ullman S, Roussel TJ, Culbertson WW. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. 1987; 94(5):525-31. [pubmed]
  3. Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American journal of ophthalmology. 1986; 102(5):575-83. [pubmed]
  4. Azar MJ, Dhaliwal DK, Bower KS, Kowalski RP, Gordon YJ. Possible consequences of shaking hands with your patients with epidemic keratoconjunctivitis. American journal of ophthalmology. 1996; 121(6):711-2. [pubmed]
  5. Roba LA, Kowalski RP, Gordon AT, Romanowski EG, Gordon YJ. Adenoviral ocular isolates demonstrate serotype-dependent differences in in vitro infectivity titers and clinical course. Cornea. 1995; 14(4):388-93. [pubmed]
  6. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. The Cochrane database of systematic reviews. 2012; [pubmed]
  7. Rose PW, Harnden A, Brueggemann AB. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet (London, England). ; 366(9479):37-43. [pubmed]


Ishihara Test


Other Known AliasesPseudo-isochromatic plates

DefinitionTest for detecting color blindness using different color dots to outline numbers

Ishihara 9.png

Clinical SignificanceAllows for quick assessment of color blindness using different styles plates (a full test is 38 plates) and even differentiate between different types of color blindness.  Research has proven that a score of 12 out of 14 red/green plates indicates normal color vision with a sensitivity of 97% and a specificity of 100%.

History – Named after Shinobu Ishihara (1879-1963), who developed these while working as a military surgeon for the Japanese army during World War I as a better way of assessing color blindness in troops.  He first published these findings in 1917 in Japan and it was first translated and reviewed in the American Journal of Ophthalmology in June 1918 extolling its usefulness.



  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Ishihara S.  Tests for Color Blindness.  AJO. 1918;1(6):457 [article]
  6. Ishihara S.  Tests for Color Blindness.  1972 [book]
  7. http://www.eyemagazine.com/feature/article/ishihara