Piriform Syndrome

Among a variety of deep muscle trigger points, the piriform muscle trigger point is selected for individual scrutiny. This seems fully justified by the great potential for confusing this entity with discogenic disease and consequently having unnecessary surgical procedures carried out.The diagnosis can be made from findings on simple physical diagnostic tests and an appropriate history. Low back and hip pain with pain radiating down the back of the leg should suggest piriform syndrome as part of the differential diagnosis. This is especially true if a female patient has complaint of dyspareunia.Pain and weakness on resisted abduction-external rotation of the thigh is a sign of piriform syndrome. This is confirmed by tenderness and reproduction of the patient''s complaints by digital pressure over the belly of the piriform muscle, completing the diagnostic criteria.Local injection of the muscle belly is curative. There are no laboratory or x-ray findings leading to a diagnosis.     

Relative contributions of history-taking,physical examination,and laboratory investigation to diagnosis and management of medical outpatients.

To evaluate the relative importance of the medical history, the physical examination, and laboratory investigations in the diagnosis and management of medical outpatients some physicians recorded their diagnosis and a prediction of the method of managementafter reading the patient''s referral letter, again after taking the history, and againafter performing the physical examination. These diagnoses and predictions were compared with the diagnosis and method of management which had been adopted two months after the patient''s initial attendance. A diagnosis that agreed with the one finally accepted was made after reading the referral letter and taking the history in 66 out of 80 new patients; the physical examination was useful in only seven patients, and the laboratory investigations in a further seven. In only one of six patients in whom the physician was unable to make any diagnosis after taking the history and examining the patient did laboratory investigations lead to a positive diagnosis.     

Difficulties in diagnosing chronic constrictive pericarditis

This presentation calls attention to the many problems involved in the positive, aetiological and differential diagnosis of chronic constrictive pericarditis. We mention the difficulties in aetiological diagnosis in the absence of an episode of acute pericarditis in the past medical history and the clinical findings similar to vascular decompensated cirrhosis or idiopathic restrictive cardiomyopathy. ECG and two-dimensional echocardiography do not have an important role in diagnosis, and in the absence of computed tomography and magnetic resonance imaging, chest radiography, especially a lateral view, could establish the diagnosis. A delay in diagnosis creates difficulties in the surgical treatment, but this treatment improves the patient''s condition in the long term more than the short term.     

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.     

Impact of bile acids on the growth of human cholangiocarcinoma via FXR

Mast cell activation disease comprises disorders characterized by accumulation of genetically altered mast cells and/or abnormal release of these cells' mediators, affecting functions in potentially every organ system, often without causing abnormalities in routine laboratory or radiologic testing. In most cases of mast cell activation disease, diagnosis is possible by relatively non-invasive investigation. Effective therapy often consists simply of antihistamines and mast cell membrane-stabilising compounds supplemented with medications targeted at specific symptoms and complications. Mast cell activation disease is now appreciated to likely be considerably prevalent and thus should be considered routinely in the differential diagnosis of patients with chronic multisystem polymorbidity or patients in whom a definitively diagnosed major illness does not well account for the entirety of the patient's presentation.     

HYPERPARATHYROIDISM

Because of the variable and vague clinical symptoms of the disease, diagnosis of hyperparathyroidism may be missed or delayed.Presenting symptoms and findings may be localized to the urological system or to the skeletal framework, with indications of abnormal blood calcium levels.In any case in which the patient''s only complaints are malaise, lassitude, or progressive weakness, and in which routine laboratory findings are inconclusive, the blood calcium level should be determined.While not in itself diagnostic, a high level of calcium in the blood will lead to further investigation such as skeletal x-ray studies and blood phosphorus and serum alkaline phosphatase determinations.Vigilance postoperatively to forestall tetany is of great importance.     

Immunodiagnosis of Snake Bite

Management of a patient with snake bite is influenced by the nature of the offending snake. Species diagnosis based on the patient''s history and physical signs is often unreliable and the possibility of making a species diagnosis by immunological means has therefore been investigated. Wound aspirates, blister fluids, sera, and urine samples from patients with snake bite were examined for the presence of species-specific venoms using immunodiffusion. A positive species diagnosis was made in 40 out of 101 patients. Immunodiagnosis was especially successful in patients bitten by the puff adder, Bitis arietans, and the African spitting cobra, Naja nigricollis. A higher success rate could probably be achieved using more specific antisera and more sensitive assay techniques.     

What do patients with medically unexplained physical symptoms (MUPS) think? A qualitative study

Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient.Objectives This study aimed to explore patients'' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful.Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis.Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients'' problems. The clinician''s flexibility should allow adaptation to the patient''s phases of acceptance of the significance of their physical, emotional and social problems.Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.     

Legal obligation of physicians to disclose information to patients.

Obtaining a patient''s consent is a routine daily process for physicians, although many are unaware of the scope of this legal obligation. In 1980 the Supreme Court of Canada changed the law relating to informed consent; promotion of patient autonomy shifted the focus from a standard of professional disclosure to one of a "reasonable patient." Physicians have a legal obligation to disclose to patients specific information, the scope of which is determined by a court on the basis of a reasonable patient''s expectation and the circumstances of the case. This gives rise to many controversies in the practice of clinical medicine. It is difficult for physicians to know which treatment risks require disclosure, since this is decided by a court in a retrospective analysis of the evidence. Will the court recognize exceptions to the duty of disclosing information? If several health care professionals are involved in a patient''s care who has the duty to disclose information? Can this duty be delegated? This paper provides physicians with guidelines that are consistent with the promotion of patient autonomy and comply with the doctrine of informed consent. In addition, it suggests ways of improving awareness of the doctrine and procedures to ease its application.     

Laxative-induced Diarrhoea: A Continuing Clinical Problem

Seven women spent an average of 127 days in hospital and were extensively investigated, including a laparotomy, before their complaints of abdominal pain, diarrhoea, and weight loss were shown to be due to excessive taking of laxatives. All denied taking laxatives and in none were the characteristic features of the effects of cathartics on the colon seen on sigmoidoscopy or radiological examination.Hypokalaemia and other electrolyte abnormalities were common and were thought to be due to a combination of severe diarrhoea and vomiting. The rectal mucosa was seen to be abnormal on biopsy only in the three patients who had taken senna preparations. The diagnosis was not easy and was finally established either by analysis of the urine and stools or by searching the patient''s ward locker.     

AIDS and medical confidentiality.

In summary, I have argued that the arguments offered or hinted at in favour of doctors'' breaking medical confidentiality by passing on information about their patients'' HIV state to others, including other doctors, when this is against the patient''s considered wishes are generally unconvincing. Although in highly exceptional cases there may be justifications for overriding confidentiality, the requirement of medical confidentiality is a very strong, though not absolute, obligation. Patients, their contacts, doctors and their staff, and the common good are most likely to be best served if that tradition continues to be honoured.     

APOPLEXY IN YOUNG ADULTS—DIAGNOSTIC AND THERAPEUTIC OBSERVATIONS

Apoplexy in young adults is due to rupture of an artery or to obstruction, as by clot, by embolus, or by transitory vasospasm. In differential diagnosis, tumor and demyelinizing disease must be considered.Spinal fluid study helps to differentiate between hemorrhagic stroke and stroke due to vascular block. In hemorrhagic stroke, search for the site of bleeding is imperative and angiography, the preferred method of study, should be carried out as soon as the patient''s general condition permits.In vascular occlusive stroke, measures to maintain the blood pressure and to dilate collateral channels are often helpful. Stellate block is most valuable in the acute phase immediately following embolism or thrombosis. In a small percentage of chronic cases, stellate block may be followed by significant recovery of function. Benefit may also be derived at times from systemic vasodilators such as niacin and intravenously administered histamine.     

Detection of Alzheimer's disease and dementia in the preclinical phase: population based cohort study

ObjectivesTo evaluate a simple three step procedure to identify people in the general population who are in the preclinical phase of Alzheimer''s disease and dementia.DesignThree year population based cohort study.SettingKungsholmen cohort, Stockholm, Sweden.Participants1435 people aged 75-95 years without dementia.AssessmentsSingle question asking about memory complaints, assessment by mini-mental state examination, and neuropsychological testing.ResultsNone of the three instruments was sufficiently predictive of Alzheimer''s disease and dementia when administered separately. After participants had been screened for memory complaints and global cognitive impairment, specific tests of word recall and verbal fluency had positive predictive values for dementia of 85-100% (95% confidence intervals range from 62% to 100%). However, only 18% of future dementia cases were identified in the preclinical phase by this three step procedure. Memory complaints were the most sensitive indicator of Alzheimer''s disease and dementia in the whole population, but only half the future dementia cases reported memory problems three years before diagnosis.ConclusionThis three step procedure, which simulates what might occur in clinical practice, has a high positive predictive value for dementia, although only a small number of future cases can be identified.

What is already known on this topic

Alzheimer''s disease is characterised by a preclinical phase, during which cognitive deficits are seen before diagnosisElderly people with subjective memory complaints and objective global cognitive impairment have a high risk of developing Alzheimer''s disease and dementia

What this study adds

This three step procedure (self report of memory complaints, test of global cognitive functioning, and then domain specific cognitive tests) has a positive predictivity of 85-100% for Alzheimer''s disease and dementia at three yearsHowever, only 18% of people in the preclinical phase can be identified using this procedureAbout half of the people in the preclinical phase of Alzheimer''s disease and dementia do not report problems with their memory three years before diagnosis     

Bioethics for clinicians: 2. Disclosure.

In the context of patient consent, "disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The clinician''s goal is to disclose information that a reasonable person in the patient''s position would need in order to make an informed decision. Therefore, clinicians may need to consider how the proposed treatment (and other options) might affect the patient''s employment, finances, family life and other personal concerns. Clinicians may also need to be sensitive to cultural and religious beliefs that can affect disclosure.     

Radiologic assessment in the pediatric intensive care unit.

The severely ill infant or child who requires admission to a pediatric intensive care unit (PICU) often presents with a complex set of problems necessitating multiple and frequent management decisions. Diagnostic imaging plays an important role, not only in the initial assessment of the patient''s condition and establishing a diagnosis, but also in monitoring the patient''s progress and the effects of interventional therapeutic measures. Bedside studies obtained using portable equipment are often limited but can provide much useful information when a careful and detailed approach is utilized in producing the radiograph and interpreting the examination. This article reviews some of the basic principles of radiographic interpretation and details some of the diagnostic points which, when promptly recognized, can lead to a better understanding of the patient''s condition and thus to improved patient care and management. While chest radiography is stressed, studies of other regions including the upper airway, abdomen, skull, and extremities are discussed. A brief consideration of the expanding role of new modality imaging (i.e., ultrasound, CT) is also included. Multiple illustrative examples of common and uncommon problems are shown.     

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.     

The Double Helix: Applying an Ethic of Care to the Duty to Warn Genetic Relatives of Genetic Information

Genetic testing reveals information about a patient's health status and predictions about the patient's future wellness, while also potentially disclosing health information relevant to other family members. With the increasing availability and affordability of genetic testing and the integration of genetics into mainstream medicine, the importance of clarifying the scope of confidentiality and the rules regarding disclosure of genetic findings to genetic relatives is prime. The United Nations International Declaration on Human Genetic Data urges an appreciation for principles of equality, justice, solidarity and responsibility in the context of genetic testing, including a commitment to honoring the privacy and security of the person tested. Considering this global mandate and recent professional statements in the context of a legal amendment to patient privacy policies in Australia, a fresh scrutiny of the legal history of a physician's duty to warn is warranted. This article inquiries whether there may be anything ethically or socially amiss with a potential future recommendation for health professionals or patients to universally disclose particular cancer predisposition genetic diagnosis to genetic family members. While much of the discussion remains applicable to all genetic diagnosis, the article focuses on the practice of disclosure within the context of BRCA1/2 diagnosis. An ‘ethic of care’ interpretation of legal tradition and current practice will serve to reconcile law and medical policy on the issue of physician disclosure of genetic results to family members without patient consent.     

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.     

Réflexions sur la place des médecins spécialistes en médecine nucléaire dans le dispositif d’annonce en cancérologie

Nuclear medicine physicians are very involved in French's oncology announcement procedure. However, their role needs to be analysed and evaluated. Before diagnosis’ announcement, information provided by nuclear medicine physicians are never neutral for patients. Information must not increase patient's anxiety or false patient's sense of reassurance. In this context, it seems necessary to engage in ethical reflexions about nuclear medicine physicians communication challenges.     

The irritable bowel syndrome.

The irritable bowel syndrome (IBS) is an extremely common disorder. It is believed to occur usually after emotional stress and perhaps because of behavioural and dietary factors. There is definite evidence of disturbed gastrointestinal function associated with IBS; however, a diagnostic marker remains elusive. The current trend is to diagnose IBS on the basis of the patient''s history and the findings at physical examination and after minimal investigation. The physician-patient relationship remains the most important factor in the management of IBS. Long-term benefit may be achieved with the use of dietary fibre supplements or stool-bulking agents. The evaluation of currently available drugs is difficult because of the placebo effect. Drug therapy should be aimed at specific symptoms and used mainly during the initial phase of treatment.