Contributions of the history,physical examination,and laboratory investigation in making medical diagnoses.

We report an attempt to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. In this prospective study of 80 medical outpatients with new or previously undiagnosed conditions, internists were asked to list their differential diagnoses and to estimate their confidence in each diagnostic possibility after the history, after the physical examination, and after the laboratory investigation. In 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists'' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians'' confidence in their diagnoses.     

Do emergency tests help in the management of acute medical admissions?

A two year combined retrospective and prospective study of 555 acute medical admissions to a district general hospital was carried out to assess the value of emergency biochemical, haematological, radiological, and electrocardiographic tests in diagnosis and treatment. For the study the tests were considered helpful only if they disclosed an abnormality and resulted in a definite diagnosis or change of treatment which would not have been possible from the history and examination alone. A total of 2372 emergency tests were carried out in the 555 patients who presented with 579 acute medical problems. Only 403 (17%) of the test results were abnormal and, of these, only one third helped in treatment and less than one third helped in diagnosis. The most useful diagnostic tests were serum amylase activity in abdominal pain, the electrocardiogram in chest pain, the chest radiograph in respiratory problems, and cerebrospinal fluid analysis in suspected meningitis or subarachnoid haemorrhage. The most useful tests in treatment were blood sugar value in diabetes, PCO2 in obstructive airways disease, and haemoglobin concentration in gastrointestinal haemorrhage. Of the tests requested by far the most often--blood urea and serum electrolyte concentrations--only 7% gave abnormal results and were rarely of any help in either diagnosis or treatment. Analysis of the reasons for the uncritical use of emergency tests by house officers suggested that better undergraduate training, regular audit by senior members of medical units, abolition of routine investigational procedures, and more selective laboratory reports would help to build up the house officer''s confidence in his own skills of history taking and physical examination without recourse to indiscriminate use of laboratory and other investigations.     

DYSFUNCTIONAL UTERINE BLEEDING—The Relationship of Microscopic Observations to Treatment

Dysfunctional bleeding is not an entity, it is a symptom. With proper history, physical examination and laboratory aids a definitive diagnosis can be made. With this diagnosis rational and direct treatment may be instituted. Both diagnosis and treatment are outlined and discussed. When hormonal treatment is indicated, the type, amount and timing must be fitted to the patient''s needs.     

Effect of Supervised Students' Involvement on Diagnostic Accuracy in Hospitalized Medical Patients �� A Prospective Controlled Study

Background

During internships most medical students engage in history taking and physical examination during evaluation of hospitalized patients. However, the students'' ability for pattern recognition is not as developed as in medical experts and complete history taking is often not repeated by an expert, so important clues may be missed. On the other hand, students'' history taking is usually more extensive than experts'' history taking and medical students discuss their findings with a Supervisor. Thus the effect of student involvement on diagnostic accuracy is unclear. We therefore compared the diagnostic accuracy for patients in the medical emergency department with and without student involvement in the evaluation process.

Methodology/Principal Findings

Patients in the medical emergency department were assigned to evaluation by either a supervised medical student or an emergency department physician. We only included patients who were admitted to our hospital and subsequently cared for by another medical team on the ward. We compared the working diagnosis from the emergency department with the discharge diagnosis. A total of 310 patients included in the study were cared for by 41 medical students and 21 emergency department physicians. The working diagnosis was changed in 22% of the patients evaluated by physicians evaluation and in 10% of the patients evaluated by supervised medical students (p = .006). There was no difference in the expenditures for diagnostic procedures, length of stay in the emergency department or patient comorbidity complexity level.

Conclusion/Significance

Involvement of closely supervised medical students in the evaluation process of hospitalized medical patients leads to an improved diagnostic accuracy compared to evaluation by an emergency department physician alone.     

Differential diagnosis in patients with disorders of the patellofemoral joint.

Anterior knee complaints are difficult diagnostic problems. It cannot be overstated that the most important information available is to be found in the patient''s history. Onset, quality, and quantity of symptoms must be assessed. This information is then synthesized to determine the specific functional disabilities resulting from the patient''s anterior knee disorder. Once a history is obtained, a consistent, methodical physical examination can be performed to narrow the differential diagnosis. Radiographic evaluation is used to further hone the differential or to confirm the most likely diagnosis. Ultimately, a specific working diagnosis is selected and treatment is tailored to changing the underlying structural or biomechanical abnormalities that led to the patient''s complaints.     

Making a nutritional assessment.

The assessment of nutritional deficiencies depends on both clinical and laboratory diagnosis. The standard physical examination should be supplemented by nutritional anthropometry, consisting of accurate growth and skinfold measurements. A careful dietary history, preferably taken by a dietitian, is necessary to construct a record of past nutrient intake. Since biochemical abnormalities often appear before clinical signs of nutritional deficiency a battery of biochemical tests is sometimes needed. In unusual cases newer techniques of assessing body composition or immunologic or physiologic function may be required. In all cases the patient''s physical state, nutritional intake and biochemical status must be related to age and sex standards.     

Application of NHG guidelines in patients referred for stable chest pain syndromes

Purpose. Guidelines of the Dutch Association of General Practitioners (NHG) dictate the evaluation, treatment, and referral process of patients with stable chest pain syndromes (CPS). Adherence to this guideline was assessed in a consecutive group of patients referred to our hospital. Methods. We retrospectively studied the records of 296 subjects referred to our outpatient department in 2007 for evaluation of stable CPS. Referral letters were checked for completeness (past and present history, mentioning of risk factors for cardiovascular disease, physical examination, listing of medication) and used to judge adherence to the guideline. In a subset of patients, additional information regarding the referral process was gathered by telephone interview. Results. The referral letter was complete in only 67 patients (23%); items most often not reported were physical examination (63%) and cardiovascular risk factors (62%). Judging from the referral letter, 23 patients (8%) were evaluated in accordance with the NHG guideline prior to their referral. In patients in whom the final diagnosis of angina pectoris was made by the cardiologist, this was 20%. Seventy-nine patients were contacted by telephone after their work-up by the cardiologist; 36 of them (44%) reported being referred at their first visit to their primary physician, while 14 (18%) were referred at their own request. Conclusion: Prior to referral, only a minority of patients with stable CPS were evaluated and treated in accordance with NHG guidelines. Furthermore, their referral letter was often incomplete. (Neth Heart J 2010;18:178-82.)     

Assessment of clinical competence using objective structured examination.

To avoid many of the disadvantages of the traditional clinical examination we have introduced the structured clinical examination. In this students rotate round a series of stations in the hospital ward. At one station they are asked to carry out a procedure, such as take a history, undertake one aspect of physical examination, or interpret laboratory investigations in the light of a patient''s problem, and at the next station they have to answer questions on the findings at the previous station and their interpretation. As they cannot go back to check on omissions multiple-choice questions have a minimal cueing effect. The students may be observed and scored at some stations by examiners using a check list. In the structured clinical examination the variables and complexity of the examination are more easily controlled, its aims can be more clearly defined, and more of the student''s knowledge can be tested. The examination is more objective and a marking strategy can be decided in advance. The examination results in improved feed-back to students and staff.     

Guidelines to birth control counselling of the physically handicapped.

Birth control counselling of well motivated physically handicapped men and women is discussed in a series of suggested steps: (1) preappointment arrangements are made to ensure physical access to the office, and the partner or a helper may be invited to the visit; (2) the patient is encouraged to name the desired birth control method; (3) the patient''s fertility is established from the history and the results of physical examination and laboratory tests; (4) methods of birth control are matched to the patient''s physical and mental capabilities; (5) potential side effects of the proposed methods are considered in the light of the handicap; (6) a method is finally recommended that may be a trade-off, with ease of use balanced against efficacy, and living with side effects balanced against the risks of pregnancy; and (7) rechecks are necessary to ensure that the patient is using the method with skill and satisfaction.     

心内膜下心肌梗死的常见误诊病例浅析

目的:探讨心内膜下心肌梗死的常见误诊原因及对策。方法:回顾性分析9例心内膜下心肌梗死患者的病历资料,包括病史、系统体格检查,ECG、心肌酶谱、胸片、超声心动图检查等。结果:9例心内膜下心肌梗死患者均有临床症状、ECG及心肌酶学指标的动态变化,诊断明确,以冠状动脉病变为其主要病因,在此基础上由其他因素诱导发病。结论:临床医师对心内膜下心肌梗死认识不足、对ECG和心肌酶谱的特异性动态改变未充分认识,是导致误诊的主要原因,建议详细询问病史、系统体格检查及辅助检查,综合判断明确诊断。     

Raised intraocular pressure: an alternative method of referral.

To assess delay in referring patients with suspected glaucoma two methods were studied in a randomised trial: direct referral from optician to ophthalmologist and referral through the patient''s general practitioner. Direct referral was reliable for all 49 patients involved, whereas, of the 44 patients referred through their general practitioner, seven waited over three weeks for referral.     

The diagnostic process: a comparison of scanning techniques.

In choosing between various scanning techniques the factors to be considered include availability, cost, the type of equipment, the expertise of the medical and technical staff, and the inherent capabilities of the system. Although it is difficult to state dogmatically which scanning technique is best for each patient and condition, one or other technique is clearly preferable in some areas of medicine. Ultrasound, for example, should be used in obstetrics, while computerized tomography has revolutionised neuroradiological diagnosis. Nevertheless, there is still no substitute for good history taking and a thorough physical examination. The most important factor determining the choice of technique is the system''s ability to answer the specific question required for the management of the patient.     

Identifying and managing adverse environmental health effects: 1. Taking an exposure history

PUBLIC CONCERN AND AWARENESS ARE GROWING about adverse health effects of exposure to environmental contaminants. Frequently patients present to their physicians with questions or concerns about exposures to such substances as lead, air pollutants and pesticides. Most primary care physicians lack training in and knowledge of the clinical recognition, management and avoidance of such exposures. We have found that it can be helpful to use the CH²OPD² mnemonic (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs) as a tool to identify a patient''s history of exposures to potentially toxic environmental contaminants. In this article we discuss why it is important to take a patient''s environmental exposure history, when and how to take the history, and how to interpret the findings. Possible routes of exposure and common sources of potentially toxic biological, physical and chemical substances are identified. A case of sick-building syndrome is used to illustrate the use of the mnemonic.CaseA 40-year-old married bookkeeper presents with a 3-year history of headaches. She describes having “tight,” bitemporal headaches almost daily that resolve after taking three 325-mg tablets of ASA. She also complains of a “spacey” feeling, difficulty concentrating and remembering, fatigue, a stuffy nose and a full feeling in her ears. Her symptoms improve on weekends and over the holidays and seem to be worse in the winter. Over the past 2 years she has noticed that she gets a stuffy nose and headaches when exposed to perfumes, tobacco smoke and automobile exhaust. Her past medical history is remarkable only for infantile eczema. Her family history is unremarkable other than her mother having hypothyroidism. She is taking no medications other than ASA, does not smoke, reports having no allergies and says she is happily married with no major family, financial or social concerns. She enjoys her work and coworkers. On physical examination she has puffy, dark circles under her eyes, there is loss of light reflex on her left ear drum, and her nasal mucosa appears edematous and erythematous. There are multiple excoriated, erythematous papules 5 mm in diameter on her face, anterior chest and anterior lower legs.Questions surrounding this case: What is sick-building syndrome and how do patients commonly present? What causes or contributes to sick-building syndrome? What are the risk factors? How should cases be managed?     

Value of Routine Multiple Blood Tests in Patients Attending the General Practitioner

The paper describes the investigation of 296 patients selected at random from those attending the general practitioners'' surgery and studied by means of multiple biochemical and haematological tests. The tests that would not normally have been requested led to a new diagnosis of clinical significance in 16·9% of patients, in most instances requiring an alteration of the patient''s therapy. The effect of the profile tests on patient follow-up, referral of patients to hospital, and the need for subsequent investigations was studied by comparing the patients profiled with a control group of patients not having a blood profile. The place of such an investigation in general practice is considered.     

Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice.

OBJECTIVE--To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice. DESIGN--Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients'' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not. SETTING--Inner city health district. PATIENTS--133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up. MAIN OUTCOME MEASURES--Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment. RESULTS--Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients'' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists. CONCLUSIONS--Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients'' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.     

Recording the consultation: model for assessment.

A model has been devised that provides at a glance, a summary of the relative importance of the physical, psychological, and social aspects of a patient''s problem as assessed at the consultation. Its presence in the notes, alongside a medical diagnosis, allows treatment to be planned along recognised lines, while still keeping other aspects of the problem in perspective. It is suggested that this may lead to more appropriate management.     

The confederation worm token.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient''s personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient''s personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.     

甲状腺相关性眼病的研究及治疗进展

甲状腺相关性眼病(TAO)是具有一系列体征和症状的多因素自身免疫性疾病。糖胺聚糖(GAG)的过量沉积、炎性浸润以及细胞因子的过度产生是甲状腺相关性眼病的主要特征。甲状腺相关性眼病的临床表现多种多样,可以从轻度的眼睑肿胀、上睑退缩、结膜充血、眼球突出乃至重度的威胁视力的暴露性角膜溃疡和压迫性视神经病变。通常,根据病史和查体是可以直接诊断甲状腺相关性眼病。实验室检查和影像学检查对于诊断甲状腺相关性眼病也具有一定的作用。目前可以根据"NO SPECS"法、临床活动评分(CAS)和VISA分类这三种方法对TAO病情情况进行分类。甲状腺相关性眼部的治疗包括保守治疗、药物治疗、眼眶放射治疗和手术治疗等,需根据患者的病情来决定其治疗方案。本文的目的是帮助眼科医生了解甲状腺相关性眼病的分期(轻度,中度至重度和视力威胁)的重要性和相关的可用治疗方式。     

Alzheimer's disease: current knowledge,management and research

Alzheimer''s disease is a common neurological condition, appearing as early as age 40 but increasing dramatically in incidence over age 85. Different genetic factors are at play, modified by events over a lifetime. Clinical diagnosis is possible through careful history taking with a reliable informant and a minimum number of laboratory tests. A relatively predictable natural history can be observed, with progression through stages of cognitive loss, functional impairment and behavioural disinhibition or apathy. New medications such as donepezil offer hope for improving or stabilizing symptoms. Such treatment can be administered by primary care physicians with experience in the diagnosis and management of Alzheimer''s disease. Disease stabilization, or even prevention, may be possible in the future.     

De Lange Syndrome: Report of 20 Cases

Typus Degenerativus Amstelodamensis or Amsterdam dwarfism, a syndrome of unknown etiology characterized by mental retardation, a distinctive face, characteristic hands and feet, defective growth and other minor malformations, was first described by Cornelia de Lange in 1933. Approximately 69 cases, including nine autopsies, have been reported in the literature. In this paper we present a further 20, with illustrations of the syndrome from infancy to puberty (including de Lange''s original three cases). The historical, physical, laboratory and radiographic findings of de Lange''s three patients and our 20 are tabulated. Autopsy findings in one of our patients are reported and the literature is briefly reviewed.Although some observers have recently reported chromosome abnormalities in de Lange''s syndrome, we feel that the diagnosis is made from the history and physical examination and that there are no definitive laboratory aids which can confirm the diagnosis. Chromosome studies in all 20 of our patients were normal and the genetic implications are discussed.