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.     

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.     

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.     

Value of emergency toxicological investigations in differential diagnosis of coma.

Out of 208 cases of coma of unknown aetiology referred to the poisons unit of this hospital during 1978 for emergency toxicological investigations, 108 were found to be due to self-poisoning medical conditions, mainly neurological, accounted for coma in 90 patients; the cause was not ascertained in the remaining 10 cases. More than one preparation had been ingested by 58 (54%) of the poisoned patients, although barbiturates were the drugs most commonly encountered in the severe cases. Toxicological investigations should be considered in the differential diagnosis of coma when history, physical examination, and emergency biochemical measurements yield little diagnostic information.     

Evaluation of Early Diagnostic Services for the Elderly

Medical examination was offered to a group of “high risk” old people who were not necessarily patients or known to their family doctors, but with the agreement of these family doctors. Two clinics set up for this purpose have been running for several years, and the results of examination and follow-up of 300 consecutive patients are reported.Major conditions were found in two-thirds of patients producing functional impairment in most of these.Recommendations as to therapy and management were carried out in 161 of 194 patients but not in the remainder.Clear evidence of improvement was found in half of the patients who carried out recommendations, and this improvement was attributable to earlier diagnosis than would have been achieved without these clinics in 42% of cases.Including all patients examined, the proportion helped by early diagnosis at 18 to 30 months'' follow-up was 23%.It is concluded that the offer of a routine examination to high risk groups is of benefit to old people and a form of medical practice which should be widely adopted.     

Development of renal scars in children: missed opportunities in management. South Bedfordshire Practitioners' Group.

OBJECTIVE--To assess the antecedent medical care of children with renal scars. DESIGN--Retrospective study of both general practice and hospital records. SETTING--12 Group practices in south Bedfordshire and the radiology and paediatric outpatient departments of a district general hospital. SUBJECTS--23 Children with renal scars (six boys, 17 girls) from the 12 group practices, identified from outpatient, radiology, and general practice records. MAIN OUTCOME MEASURES--Number of children in whom a diagnosis of urinary tract infection had been made without prior examination of a mid-stream specimen of urine; number of children who had had a confirmed urinary tract infection that had not been investigated further; number who had experienced delays in investigation or referral; and number who had received inadequate follow up. RESULTS--In all, 11 of the children had received suboptimal medical care, but the management of the other 12 could not have been better. The most common error was failure to investigate possible urinary tract infections, but follow up of confirmed infections was also inadequate. These problems occurred in hospital as well as in general practice. CONCLUSION--Opportunities for intervention had been missed in nearly half of this sample of children with renal scars.     

The ultimate audit.

The necropsy diagnoses in 78 stillborn and young infants have been compared with the clinical diagnoses in an attempt to justify post-morten examination in this age group. Clinical diagnosis was confirmed in over 88% of cases but unexpected changes in diagnosis were made in six cases, which indicates that selection is of no value.     

Prostatism: how useful is routine imaging of the urinary tract?

The clinical effects of routinely imaging the renal tract (by intravenous urography and ultrasonography) were evaluated prospectively in 128 consecutive patients with prostatism. Patients with haematuria, previous renal disease, or infection were excluded. Urologists completed a standard questionnaire in the patient''s notes stating the diagnosis and the intended management. The patient then had intravenous urography and abdominal ultrasonography, urine was analysed, and plasma urea and serum creatinine concentrations and acid phosphatase activity were determined. From six months to a year later the eventual management was compared with the intended management to see the effect of these routine investigations on the outcome. For four out of 28 patients whose management was intended to be conservative the decision was changed; for only three of them was this because of the results of urography, ultrasonography, and biochemical determinations. For 31 patients the management was to be decided by cystoscopic findings, and for none of these was the final decision altered by the results from the investigations after the initial consultation. Similarly for five patients who were assessed urodynamically the final management was not changed by the results of these investigations. The planned management was changed in three of the remaining 64 patients but not because of the results of the initial investigations.Thus no indication was found for either routine urography or ultrasonography, but the total abandonment of imaging of the renal tract would be unwise. Patients scheduled for conservative management (about a quarter of the patients in this study) should have ultrasonography to detect unsuspected hydronephrosis, but in all other patients urography or ultrasonography, or both, is an unhelpful ritual. Moreover, urography is becoming more expensive, and has a recognised (albeit small) mortality.     

Clinical versus laboratory detection of alcohol abuse: the alcohol clinical index.

To determine reliable indicators of alcohol abuse a comprehensive set of clinical and laboratory information was acquired from three groups of subjects with a wide range of drinking histories: 131 outpatients with alcohol problems, 131 social drinkers, and 52 patients from family practice. Findings from clinical examination provided greater diagnostic accuracy than laboratory tests for detecting alcohol abuse. Logistic regression analysis produced an overall accuracy of 85-91% for clinical signs, 84-88% for items from the medical history, and 71-83% for laboratory tests in differentiating the three groups. Further analyses showed 17 clinical signs and 13 medical history items that formed a highly diagnostic instrument (alcohol clinical index) that could be used in clinical practice. A probability of alcohol abuse exceeding 0.90 was found if four or more clinical signs or four or more medical history items from the index were present. Despite recent emphasis on the laboratory diagnosis of alcohol abuse simple clinical measures seem to provide better diagnostic accuracy.     

不明原因发热的临床综合诊断

不明原因发热是临床常见疑难疾病,其定义随着疾病种类的不断变化及诊断流程的进步而逐步完善。不明原因发热(feverof unknown origin,FUO)病因包括感染性疾病、风湿免疫性疾病及肿瘤性疾病三大类,三大病因各自具有不同临床特征。详细病史采集、全面体格检查及常规实验室检查对诊断FUO至关重要,必要时应及时进行相关影像学及病理学检查,疾病的最终诊断应综合分析病史及实验室检查。     

Psychologically mediated abdominal pain in surgical and medical outpatients clinics.

Ninety-six patients complaining of recurrent or persistent abdominal pain were referred consecutively to a surgical clinic and a medical clinic, respectively. They were examined psychiatrically after their initial physical investigation. The psychiatric examination included rating scales for depression and anxiety, a personality inventory, life-events schedule, scale of verbal expressivity, and family and personal patterns of pain and invalidism. Only 15 patients (15-6%) had organic disorders that could be responsible for their symptoms. In the remainder, psychiatric factors were considered primarily responsible for their abdominal pain: 31 were depressed; 21 had chronic tension; in 17 hysterical mechanisms were prominent; and 12 were found to be unrecognised alcoholics. Follow-up at three and six months and recognition by 80% of the psychogenic group that a psychological explanation was plausible, confirmed the diagnoses, and over half responded favourably to psychiatric management. Features distinguishing the organic and psychogenic groups were delineated. Psychiatric assessment has a place among the investigations of non-acute abdominal pain; certainly it should not be condisered simply as "a last resort."     

Accuracy in clinically evaluating pigmented lesions.

OBJECTIVE--To determine the ability of three doctors experienced in managing melanocytic lesions to diagnose correctly melanoma, dysplastic naevi, and various benign pigmented lesions. DESIGN--Independent clinical evaluation and histopathological assessment. SETTING--Pigmented lesion clinic, which patients attend without an appointment for early diagnosis of melanoma. PATIENTS--86 Patients with lesions that were judged to be benign by at least one of the three doctors. INTERVENTIONS--The lesions were excised under local anaesthesia and sent for histopathological examination in coded bottles without clinical details. MAIN OUTCOME MEASURE--Comparison of clinical with histopathological diagnosis for each lesion. RESULTS--A total of 120 lesions were evaluated by at least two of the three doctors. The histopathological diagnoses were made by the same pathologist. The overall sensitivity (diagnostic accuracy) for the three doctors for all types of lesion was 50%. Of the 39 dysplastic naevi, only 19 were identified correctly by all observers, and a further 24 banal lesions were wrongly diagnosed as dysplastic by at least one doctor. Particular difficulty was experienced with small (less than 5 mm), flat lesions, which can be banal or potentially malignant. CONCLUSIONS--Critical diagnosis and management decisions concerning pigmented lesions should always be based on a combination of clinical and histopathological assessments and the history of the patient.     

Fine needle aspiration biopsy of vertebral lesions

OBJECTIVE: To evaluate the accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of vertebral lesions. STUDY DESIGN: Eighty-nine FNAB cases of vertebral lesions from January 1996 to December 2001 were retrieved from the Allegheny General Hospital laboratory information system. The cases were reviewed and correlated with clinical findings, including previous clinical history, primary site of malignancy and final pathologic diagnosis. RESULTS: ENAB diagnoses were malignant in 43 cases, benign in 35, suspicious in 1, unsatisfactory in 7 and false negative in 3. Previous clinical history included malignancy (37 patients), osteomyelitis and systemic disease (11), and nonspecific or no history (41). In 34 cases (38.2%) both aspirates and core biopsies were available, and the diagnoses correlated in 29/34 cases (85%). Surgical or core biopsies in the unsatisfactory/suspicious group showed malignancy in 4 cases (50%). The sensitivity of FNAB of vertebral lesions was 96%, specificity 100%, positive predictive value 100% and negative predictive value 92%, with no false positive cases. CONCLUSION: FNAB of vertebral lesions is an effective, sensitive and specific procedure in the diagnostic workup of a patient with or without a prior history of malignancy. Surgical pathology examination, including core biopsies of unsatisfactory or suspicious lesions, can further improve the diagnostic yield.     

Assessment of fine needle aspiration as a screening test for occult prostatic carcinoma

As part of an ongoing study of objective parameters of prognostic value in prostatic carcinoma, a routine procedure was developed to aspirate all prostates prior to surgery. These targets were different from those of other workers in the field of prostatic fine needle aspiration (FNA), who generally advocate that FNA be confined to suspicious nodules. The aspirations were performed by a large group of practicing urologists who had no special training in prostatic FNA except for guidelines provided by their peers and information available in the literature. This approach permitted an assessment of the performance of FNA as a screening test rather than as a diagnostic procedure. During the period from January 1983 to February 1987, 1,683 patients had prostatic FNAs performed (plus subsequent histologic study). The following diagnoses were rendered: "inadequate/scanty specimen" in 625 cases (37%), "negative/atypical" in 844 cases (50%) and "suspicious/positive" in 214 cases (13%). Histologic examination showed stage A1 prostatic adenocarcinoma in 18 patients. The cytologic diagnoses on these 18 patients were inadequate/scanty in 3 (17%), negative/atypical in 13 (72%) and suspicious/positive in 2 (11%). Of the 214 patients with a positive/suspicious diagnosis by FNA, the diagnosis of prostatic carcinoma was confirmed by tissue evidence in 200; the other 14 patients had either no evidence of prostatic carcinoma on surgical biopsy (needle biopsy/transurethral resection/suprapubic prostatectomy) or had no surgical biopsy. Eight of the 14 patients developed clinical evidence of carcinoma, 1 died of urinary bladder carcinoma and 1 was lost to follow-up. In the remaining four patients, there is still no evidence of prostatic carcinoma after about one-and-one-half years of follow-up. These results indicate that (1) specialized training is required in order to obtain adequate smears by prostatic FNA; (2) prostatic FNA is not a good screening technique for detecting stage A1 prostatic carcinoma; and (3) a positive diagnosis by prostatic FNA, even when not confirmed by tissue biopsy, is still an indication of disease.     

Fine needle aspiration cytology of head and neck masses. Seven years' experience in a secondary care hospital

OBJECTIVE: To study the value of fine needle aspiration (FNA) in the diagnosis of head and neck masses in a secondary care hospital. STUDY DESIGN: FNA from 225 patients with head and neck masses were reviewed. The results were analyzed, according to anatomic location, into 3 groups: inflammatory, congenital and neoplastic. FNA diagnoses were retrospectively correlated with available histologic findings or with the outcome of treatment. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value in the diagnosis were computed. The numbers of lymph node biopsies performed before and after introduction of the procedure were compared. RESULTS: The most common diagnoses were reactive/nonspecific lymphadenitis and tuberculous (TB) lymphadenitis (33% and 21%, respectively). Sensitivity and negative predictive value for TB were 97% and 93%, respectively. The next most common masses were malignant neoplasms, cysts, benign neoplasms and sialadenitis, in 13%, 11%, 9% and 5%, respectively. Carcinomas metastatic to the lymph node were the most common type of cancer, followed by lymphoma and salivary gland carcinoma. The primary site of metastatic carcinomas were nasopharynx (44%) and thyroid (22%). The sensitivity and negative predictive values for the diagnosis of cancer were 95% and 96%, respectively, but reached 100% when lymphoma was excluded. The introduction of FNA reduced the number of lymph node biopsies performed in this hospital by 90%. CONCLUSION: FNA of head and neck masses proved to be a very useful diagnostic tool in separating inflammatory lesions (no surgical excision required) from cystic and neoplastic lesions. It enhanced surgical planning for malignant diseases, allowing rapid referral of lymphomas and cancer cases to tertiary care centers for management. FNA is simple, cost effective and suitable for developing countries and small, secondary care hospitals with limited resources. Skilled personnel and routine audits are the keys to success.     

Fine needle aspiration cytology of the breast. A review of 321 cases with statistical evaluation

To assess the accuracy of fine needle aspirations of the breast performed at our institution, all patients undergoing this procedure between the years 1973 and 1982 were evaluated. Correlation was made between the cytologic and histologic diagnoses whenever possible. Correlations were made with mammography results or clinical impressions when biopsies were not obtained. Our results for sensitivity, specificity, predictive value of a positive diagnosis and predictive value of a negative diagnosis were 65.0%, 100%, 100% and 89.6%, respectively. The data indicate that when adequate, well-prepared samples are submitted to the laboratory, accurate cytologic diagnoses can be made. The high specificity and predictive value of a positive result allow for the early diagnosis, treatment and management of breast cancer.     

Fetal gender determination by first-trimester ultrasound in dairy cows under routine herd management in Northwest Spain

Ultrasonography (US) provides detailed visualization of the fetus in early pregnancy in cows, thus allowing for fetal sex determination. The objective of this prospective observational study was to determine the feasibility and accuracy of a single US examination to diagnose fetal sex in dairy cattle under routine reproductive management conditions. For this purpose, 953 Holstein cows at 7-16 weeks of gestation were examined. Gender assignment was performed in 822 cows, while the genitalia could not be clearly visualized in 131 (13.7%) of the fetuses. After calving, it was verified that 99.3% of the diagnoses were accurate. Fetal sex was correctly determined by US in 99.5% of male fetuses and 98.8% of female fetuses. Fetal sex determination was less accurate when conducted before d 55 of gestation. Likewise, it was verified that fetal sex, cow age and ultrasonographic diagnosis section did not have a significant influence (P>0.05) on diagnostic accuracy. With respect to the plane used for diagnosis, the sagittal view was poorly used for early pregnancy diagnosis, whereas the longitudinal and cross-sectional planes were used most frequently. These results demonstrate that US can be routinely applied under farm conditions to accurately determine the fetal sex in cattle between days 51 and 111 of gestation without apparent influence of cow age, US scanning plane or fetal sex. Conversely, days of gestation affected the accuracy and feasibility of US gender determination, showing poorer results when the diagnosis was made before day 55 of gestation.     

高分辨率CT与常规CT检查对肺小结节及早期肺癌诊断价值的对比研究

目的:对比高分辨率电子计算机断层扫描(CT)与常规CT检查对肺小结节及早期肺癌的诊断价值。方法:将2018年6月2020年1月我院收治的肺小结节及早期肺癌患者94例纳入研究。以随机数字表法将其分为观察组及对照组,每组各47例,对照组实施常规CT检查,观察组则实施高分辨率CT检查。比较两组CT肿瘤征象情况(主要包括毛刺征、分叶征、棘突征、钙化征、空泡征、支气管征、胸膜凹陷征、血管集束征),CT扫描图像质量,诊断肺小结节及早期肺癌的效能。结果:观察组各项CT肿瘤征象人数占比均高于对照组(P<0.05)。观察组CT扫描图像质量优良率为97.87%(46/47),高于对照组的72.34%(34/47)(P<0.05)。高分辨率CT诊断早期肺癌的灵敏度及准确度、特异度分别为96.67%(29/30)、95.74%(45/47)、94.12%(16/17),高于常规CT检查的74.19%(23/31)、74.47%(35/47)、75.00%(12/16)。结论:高分辨率CT检查对肺小结节及早期肺癌诊断价值显著高于常规CT检查,可作为临床肺小结节及早期肺癌诊断的有效影像学手段,值得临床应用。     

The Prevalence of Chronic Respiratory Disease in the Male Physicians of London,Ontario

a survey of respiratory disease among male physicians of London, Ontario, resulted in a 96.3% response.The age-standardized rates of chronic bronchitis were not very different from others reported in the recent medical literature, taking into account smoking habits, but the overall prevalence of bronchial asthma was high (7.4%), with a low prevalence in the category “obstructive lung disease”. The possibility of overlap or interchange in these diagnoses is raised, although the diagnosis of bronchial asthma in this particular group is believed to be well established in every case.A history of seasonal hay fever was given by 19.4%.One of 88 (1%) non-smokers had bronchitis, whereas six of them (7%) had asthma.Rhonchi heard in the chest, on a single examination, appeared to be most closely related to current smoking habits, ventilatory function tests and also to a clinical diagnosis of chronic bronchitis or obstructive lung disease, but not to bronchial asthma.