Basis Of Clinical Examination Research Articles

Basic Clinical Examination of the Shoulder

Successful treatment of shoulder disease requires an accurate diagnosis. In addition to differentiated history taking, clinical examination is the most important component in the diagnosis of shoulder diseases. The present video explains the common provocation tests and functional tests that are used in the basic clinical examination of the shoulder. In addition to general inspection and palpation, the focus is on different diagnostic tests and clinical signs that improve diagnostic accuracy. The present basic clinical examination methods allow a structured approach to clinical issues and can be a good basis, if supplemented by further specific and individual tests.

Association of changes in vaginal microbiome with oligoclonal T-cell expansion and early response to chemoradiation for cervical cancer.

8 Background: The composition of the vaginal microbiome has been shown to affect clearance of HPV virus and transformation to invasive cancer. Clinical studies correlating the vaginal microbiome with immune activation and response to cancer treatment are lacking. We profiled intratumoral T-cell clonality during radiation therapy and correlated it with the diversity of the vaginal flora. Methods: Thirty patients with newly diagnosed locally advanced cervical cancer were enrolled on a prospective study to characterize changes in the cervical microbiome during chemoradiation. Cervical samples were obtained before radiation therapy and during the 1st, 3rd, and 5th week of radiation therapy. The vaginal microbiome was characterized using 16 sRNA gene sequencing to produce operational taxonomic units (OTU’s) representing individual bacterial species. Disease response was categorized as early response (ER), late response (LR), or nonresponse (NR) on the basis of clinical examination at brachytherapy and 3-month PET/CT. Twenty patients had T-cell receptor β sequencing of DNA performed using the ImmunoSEQ platform. The maximum productive frequency of the top three clones (MP3) was used to assess T-cell clonality. Results: Early response was associated with clonal T-cell expansion with an increase of MP3 of 11.1% during treatment as compared to a decline of 6.1% in patients with LR/NR (p = 0.05). Early response was also associated with lower quantity of observed OTU’s of vaginal microbiota (25.0 [SD 12.68]) vs patients with LR/NR (41.15 [SD = 23.3]) (p = 0·03). Increased MP3 was associated with increased abundance of Corynebacteriales (R = 0.90; p < .0001) , Actinomycetales (R = 0.83; p < .0001) and Bifidobacteriales (R = 0.82; p < .0001) . Decreased MP3 was associated with increased abundance of lactobacillus (R = -0.61; p < .0001). Conclusions: Increased diversity of the vaginal microbiome is negatively associated with outcome, supporting previous clinical studies in non-cancer settings. Specific vaginal bacterial species are associated with increased or decreased T-cell clonality at completion of radiation.

MANAGEMENT OF PATIENTS WITH ACUTE LUMBARY PAIN: RECOMMENDATIONS OF EXPERTS AND ACTUAL PRACTICE

The article outlines the current recommendations of experts on the examination and treatment of patients with acute non-specific lumbar pain. It presents a case study of a patient with acute non-specific lumbar pain, which gave rise to the discussion of experts’ recommendations and actual practice. It is noted that the non-specific lumbar pain diagnosis is established on the basis of clinical examination, and in most cases no instrumental examinations, such as magnetic resonance imaging, are required. Information on the high likelihood of rapid recovery, the desirability of maintaining an active lifestyle, social and household activities is of primary importance for the management of a patient with acute lumbar pain. Non-steroidal anti-inflammatory drugs are effective in the alleviation of pain.

Single center experience with laparoscopic adrenalectomy on a large clinical series

BackgroundLaparoscopic adrenalectomy is considered the gold standard technique for the treatment of benign small and medium size adrenal masses (<6 cm), due to low morbidity rate, short hospitalization and patient rapid recovery. The aim of our study is to analyse the feasibility and efficiency of this surgical approach in a broad spectrum of adrenal gland pathologies.MethodsPre-operative, intra-operative and post-operative data from 126 patients undergone laparoscopic adrenalectomy between January 2003 and December 2015 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in case of pheochromocytoma while spironolactone and potassium were employed to treat Conn’s disease. Laparoscopic adrenalectomies were all performed by the same surgeon (CG). First 30 procedures were considered as learning curve adrenalectomies.ResultsOne hundred twenty-six patients were included in the study. Functioning tumors were diagnosed in 84 patients, 27 patients were affected by pheochromocytomas, 29 by Conn’s disease, 28 by Cushing disease. Surgery mean operative time was 137.33 min (range 100–180) during the learning curve adrenalectomies and 96.5 min (range 75–110) in subsequent procedures. Mean blood loss was respectively 160.2 ml (range 60–280) and 90.5 ml (range 50–200) in the first 30 procedures and the subsequent ones. Only one conversion to open surgery occurred. No post-operative major complications were observed, while minor complications occurred in 8 patients (0,79%). In 83 out of 84 functioning neoplasms, laparoscopic adrenalectomy was effective in normalization of endocrine profile.ConclusionsLaparoscopic adrenalectomy is a safe and feasible procedure, even for functioning masses and pheochromocytomas. A multidisciplinary team including endocrinologists, endocrine surgeons and anaesthesiologists, is recommended in the management of adrenal pathology, and adrenal surgery should be performed in referral high volume centers. A thirty-procedures learning curve is recommended to improve surgical outcomes.

Accuracy and reliability of Babinski sign versus finger and foot tapping in the diagnosis of corticospinal tract lesions.

The Babinski sign is one of the most important clinical signs for detecting corticospinal tract (CST) lesions. However, due to variations in testing and interpretation, it has been associated with low interobserver agreement rates. In this study, the diagnostic value of finger and foot tapping in detecting CST lesions was compared to that of the Babinski sign. Three groups of participants were recruited: Group 1 - individuals having CST lesions diagnosed on the basis of clinical examination as well as neuroimaging; group 2 - individuals having a non-CST neurological illness; group 3 - normal individuals who were relatives of the patients recruited. The sensitivity and specificity of finger tapping, foot tapping, and Babinski sign were calculated. 375 patients, 125 in each group, were included. The overall sensitivity for Babinski sign was 49.6% and specificity was 85.8%. The overall sensitivity for finger and foot tapping was 79.5% and specificity was 88.4%. The interobserver agreement between the medical students and the neurologist was greater for finger and foot tapping (Kappa = 0.83) when compared to Babinski sign (Kappa = 0.45). Finger and foot tapping is a valid and reliable test in the clinical diagnosis of corticospinal lesions. The reliability and validity of Babinski sign is variable and thus its ability to diagnose the manifestations of corticospinal lesions is less when compared to the finger and foot tapping test.

Executive function and its clinical correlates among migraineurs

Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients.

Maladie de Bowen du pied droit

We here report the case of a16-year old patient, with no particular past medical history, presenting, with skin swelling at the level of the forefoot evolving for 02 years, at the Department of Dermatology. Clinical examination showed hard budding cutaneous mass painless on palpation covering the 2nd, the 3rd and the 4th, right toes, measuring 4 cm in large diameter. The remainder of the clinical examination was normal, without adenopathies. Skin biopsy was performed at the level of the tumor and histological examination showed carcinoma in situ. Surgical treatment was recommended. Bowen's disease is a relatively rare squamous intraepithelial carcinoma in situ. It mainly affects adults at any age, with predominance in women. The diagnosis is suspected on the basis of clinical examination, but it is confirmed by the anatomo-pathological examination.

Comparison of ratio loaded and unloaded foot area of flat foot and healthy foot in younger adults

This study is aimed to investigate loaded and unloaded foot area ratio (RFA, ratio of foot area) as special tests for the basis of clinical examination of flat foot and healthy foot. Type of foot is determined by Cavanagh’s arch indexes (AI) which is the ratio between mid foot area to entire footprint area excluding the toes. Type of foot is called high arch when AI&lt;0.21, normal/healthy foot when 0.26&gt;AI≥0.21 and flat foot when AI&gt;0.26. The entire loaded foot and footprint area for evaluating AI derived from a digital footprint is modified from document scanner, while the entire unloaded foot area derived from a 3D scanner. One hundred and two healthy students (87 males and 15 females, average aged 20 years and average BMI 22.51 kg/m2) is asked voluntarily for doing footprint and scan. From 102 subjects found 63 participants identified as flat foot and 31 subjects are healthy feet. This study proves that the higher the value of AI the higher the value of RFA and foot type can be predicted by the value of RFA. For type of foot is high arch RFA&lt;0.49, for healthy foot 0.55&gt;RFA≥0.49 and for flat foot RFA&gt;0.55.

Outcomes in Neovascular Age-Related Macular Degeneration when Neovascular Lesion Activity Is Uncertain: Observational Study

To determine the characteristics and outcomes of eyes with neovascular age-related macular degeneration (nAMD) in which choroidal neovascular (CNV) lesion activity was graded as uncertain. Prospective, database, observational study. Treatment-naïve patients with nAMD tracked by the Fight Retinal Blindness! (FRB!) registry initiating treatment between January 1, 2008, and January 1, 2014, with 2 years of follow up. Lesion activity was determined by the clinical judgment of the providing physician on the basis of clinical examination with ancillary testing. Eye-based analysis investigated clinical characteristics and outcomes by proportion of visits with uncertain CNV lesion activity. Encounter-based analysis investigated CNV lesion grading over time with corresponding treatment and follow up. Change in mean visual acuity (number of letters read on a logarithm of the minimum angle of resolution chart) at 2 years. Secondary outcomes included the number of visits and injections. We identified 1631 eyes of 1419 patients with 27 974 visits to 46 retinal specialists. The CNV lesion activity was uncertain at 4601 encounters (16.4%) and experienced by the majority of eyes (52%) and providers (72%). Uncertainty of CNV lesion activity did not significantly decline with increasing number of visits in individual patients (P= 0.97) but did decline from 32% in 2010 to 4% in 2015 (P < 0.001). Eyes having no visits with uncertain CNV lesion grading gained more letters (mean, 7.0) than eyes with moderate or high levels of uncertainty (mean, 3.98 and 3.37; P= 0.03 and 0.02, respectively). The mean probability of receiving an injection was higher in visits with active (0.89) compared with inactive (0.68, P < 0.001) and uncertain (0.69, P < 0.001) CNV lesion activity. Subsequent follow-up length was also decreased in visits with active (mean ± standard deviation [SD],-0.9±39 days) compared with inactive and uncertain CNV lesion activity (mean ± SD, 1.9±39 days, P<0.001, and 2.4±39 days, P < 0.001, respectively). Rates of uncertainty regarding CNV lesion activity were high, and eyes with higher rates of uncertain CNV activity had worse outcomes. Further studies are warranted to establish whether eyes should be treated more aggressively when the activity status of the CNV lesion is uncertain.

Randomized Crossover Trial of Blood Volume Monitoring-Guided Ultrafiltration Biofeedback to Reduce Intradialytic Hypotensive Episodes with Hemodialysis.

Intradialytic hypotension (IDH) is associated with morbidity. The effect of blood volume-guided ultrafiltration biofeedback, which automatically adjusts fluid removal rate on the basis of blood volume parameters, on the reduction of IDH was tested in a randomized crossover trial. We performed a 22-week, single blind, randomized crossover trial in patients receiving maintenance hemodialysis who had >30% of sessions complicated by symptomatic IDH in five centers in Calgary, Alberta, Canada. Participants underwent a 4-week run-in period to standardize dialysis prescription and dry weight on the basis of clinical examination. Those meeting inclusion criteria were randomized to best clinical practice hemodialysis (control) or best clinical practice plus blood volume-guided ultrafiltration biofeedback (intervention) for 8 weeks, followed by a 2-week washout and subsequent crossover for a second 8-week phase. The primary outcome was rate of symptomatic IDH. Thirty-five participants entered, 32 were randomized, and 26 completed the study. The rate of symptomatic IDH with biofeedback was 0.10/h (95% confidence interval, 0.06 to 0.14) and 0.07/h (95% confidence interval, 0.05 to 0.10) during control (P=0.29). There were no differences in the rate or proportion of sessions with asymptomatic IDH or symptoms alone. Results remained consistent when adjusted for randomization order and study week. There were no differences between intervention and control in the last study week in interdialytic weight gain (difference [SD], -0.02 [0.8] kg), brain natriuretic peptide (1460 [19,052] ng/L), cardiac troponins (3 [86] ng/L), extracellular water-to-intracellular water ratio (0.05 [0.33]), ultrafiltration rate (1.1 [7.0] ml/kg per hour), and dialysis recovery time (0.43 [19.25] hours). The use of blood volume monitoring-guided ultrafiltration biofeedback in patients prone to IDH did not reduce the rate of symptomatic IDH events.

Serum Immunogllobulin G Levels in Graves’ disease Patients at Various Stages of Antithyroid Therapy

Thirty six patients with Graves’ disease (GD), diagnosed on the basis of clinical examination and appropriate laboratory tests were classified into three groups (A-C): Group A: twelve newly diagnosed Graves’ disease patients; Group B: twelve hyperthyroid Graves’ disease patients on Antithyroid drug therapy and Group C: twelve Graves’ disease patients who had been rendered cuthyroid with Antithyroid drug (ATD) therapy, Serum lgG was determined by radial immunodiffusion method using commercially available kits (The Binding Site UK). The mean lgG in newly diagnosed patients with GD (Group A) was 18.78±1.81. It was 22.75 ± 1.89 in hyperthyroid GD patients on drug therapy (Group B), 14.3±0.8 in GD patients who were rendered euthyroid with drug therapy (Group C) and 11.85±0.72 in normal controls. The lgG level of group A patients were not significantly different from those of Group B. However, the levels of lgG and lgA were significantly low in group C Graves’ disease patients as compared to group A patients. A significant reduction in lgG LEVEL IN Graves’ disease patients who were rendered cuthyroid after Antithyroid drug therapy as compared to newly diagnosed Graves’ disease patients indicate the immunosuppressive effect of Antithyroid drug therapy.

THE MENTAL HEALTH AND AGGRESSIVE BEHAVIOR OF WOMEN SERVING A SENTENCE IN CORRECTIONAL FACILITY

The evaluation of status of mental health in women with hetero-aggressive, auto-aggressive behavior and without aggression was implemented on the basis of clinical examination of 1054 women serving a sentence in correctional facility. The results of study demonstrated that in women with aggressive behavior mental disorders of pre-clinical and clinical level occur reliably more often. In women with hetero-aggressive behavior organic and personality disorders prevail and in women with auto-aggressive behavior - neurosis-like and depressive disorders. The availability of mental manifestations effect aggressive behavior of women and its forms.

Preoperative Planning for ACL Revision Surgery.

The number of patients undergoing revision surgery following failure of anterior cruciate ligament (ACL) reconstruction has increased over the recent past, following the overall increased number of primary ACL reconstruction performed. Failure of primary ACL reconstruction can be attributed to technical errors, biological failures, or new traumatic injuries. Technical errors include femoral and/or tibial tunnels malposition, untreated associated ligaments insufficiencies, uncorrected lower limb malalignment, and graft fixation failures. Candidates for revision surgery should be carefully selected, and the success of ACL revision requires precise preoperative planning to obtain successful results. Preoperative planning begins with the analysis of the mechanisms of ACL reconstruction failure, and information regarding previous surgery, such as the type of graft implanted, and the position of existing hardware. Appropriate imaging is necessary to evaluate the position of the femoral and tibial tunnels, and abnormal tunnel widening. On the basis of clinical examination and imaging, surgeon can perform an ACL revision procedure in 1 or 2 stages.

Overall health status in patients with mild to moderate carpal tunnel syndrome: A case-control study

Study DesignA case-control study. IntroductionThere are no reports in the literature that evaluate the overall health status (OHS) of patients with mild to moderate forms of carpal tunnel syndrome (CTS) using 36-Item Short Form Health Survey (SF-36). Purpose of the StudyTo assess OHS in patients with mild to moderate CTS, in comparison with healthy subjects. MethodsThe study involved 273 healthy people and 140 people diagnosed with CTS. The CTS diagnosis was made on the basis of clinical examinations and nerve conduction studies. OHS was assessed using the SF-36. ResultsIn the assessment of physical components of OHS, in the CTS group (compared with healthy subjects), the results show significantly lower values in physical functioning, role limitations because of physical health problems, bodily pain, and general health perceptions by 7.44, 23.2, 18.9, and 4.1, respectively. Mental components were lower (in CTS group) only in relation to vitality and social functioning by 4.1 and 5.5, respectively. In the assessment of physical component summary (PCS) and mental component summary (MCS), the results show significantly lower values of PCS (by 13 in CTS group) and no significant differences in the assessment of MCS between patients with CTS and healthy subjects. DiscussionThe perception of the OHS in CTS patients is diminished. Hence, when evaluating the effects of the therapy, not only disease-specific scales should be used, but also the OHS. This will allow an assessment of the impact of CTS on OHS and the impact of applied therapy, not only in terms of a reduction in the main symptoms of the condition. ConclusionsMild and moderate forms of CTS significantly affected the PCS of the OHS and all its subcomponents (physical functioning, role limitations because of physical health problems, bodily pain, and general health perceptions) but did not affect the MCS of OHS evaluated as a whole. There were significant differences in the mental component in the evaluation of vitality and social functioning. Level of Evidence3.

The Selective Conservative Management of Small Traumatic Pneumothorax Following Stab Injuries of the Chest in Emergency Department Patients

Background: Chest trauma is a catastrophic event that affects large number of population and leads to morbidity, disability and mortality. The definition of an occult pneumothorax is uncontested. It is a pneumothorax that was not suspected on the basis of clinical examination or plain radiography, but was ultimately detected with CT and usually treated conservatively. We evaluated the success of selective conservative management of small pneumothorax following stab chest injuries, in Emergency Department patients. Methods: This prospective study was conducted on 30 adult patients admitted to the emergency department with small traumatic pneumothorax following stab injury. All enrolled patients (n = 30) were assessed for the following, demographic data, laboratory investigations, chest x-ray and CT scan. The outcomes measured were discharge safely after successful conservative management, Initial conservative then invasive measurement. Results: There was a statistically significant difference between conservative and non-conservative types of management in the incidence of complications after 1 week follow up (p = 0.001). Conclusion: The majority of asymptomatic small pneumothorax patients following a stab injury can be managed conservatively. Haphazard chest tube insertion and aging may lead to complications in such patients.

Glucose intolerance and insulin resistance in non-alcoholic fatty liver disease: A Hospital-based Cross-sectional Study from Southern Karnataka, India

Context: Non-alcoholic fatty liver disease (NAFLD) is associated with hepatic insulin resistance (IR) and glucose intolerance. Indian data in this area are sparse, and hence, we undertook this study to find the relationship between NAFLD and diabetes. Objective: The objective of this study is to find the relationship between NAFLD and various levels of glucose intolerance and IR. Settings and Design: A cross-sectional study on 150 patients aged 18 or above and diagnosed to have NAFLD by ultrasonography from October 2013 to June 2015 who were admitted or outpatients in the Department of General Medicine, Kasturba Medical College, Manipal. Methodology: NAFLD was graded as mild, moderate or severe by a single radiologist using high-resolution B-mode ultrasonography system. Basic anthropometric, clinical examination and relevant biochemical investigations were done for all patients. Glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and post-load plasma glucose (PG) were measured in all subjects, fasting insulin levels were measured in all subjects by chemiluminescence method to determine IR and it was calculated using homeostasis model assessment model. Statistical Analysis Used: Data were analysed using SPSS software version 15 and P

Relationship between aetiology and left ventricular systolic dysfunction in hypertrophic cardiomyopathy

BackgroundSevere left ventricular (LV) systolic dysfunction is an uncommon complication of hypertrophic cardiomyopathy (HCM) that is associated with poor prognosis. Small observational series suggest that patients with rare causes of...

The Impact of Integrating Oral Health Education into a Medical Curriculum

Objective: The purpose of this study was to evaluate our pilot program incorporating oral health education into the medical curriculum by evaluating students' perspectives on the oral health curriculum. Subjects and Methods: Two hundred second-year students were asked to fill in a presession survey online regarding their familiarity with basic oral health concepts and their comfort level with performing oral examinations, and a postsession survey on paper that repeated the presession questions and added questions on the effectiveness of the session. Results: Of the 200 students, 164 (82%) participated in the surveys. The pre- and postsurvey results showed that the session helped students become more comfortable with performing oral examinations and recognizing risks for periodontal disease, with an increase from 40 (27%) to 119 (82%) and 51 (35%) to 124 (86%), respectively. Conclusion: In this study, the oral health education session contributed to an increase in student awareness and understanding of oral health. Considering the reported effectiveness of the interactive session on student comfort with performing a basic clinical examination, this model shows promise for further use in other institutions.

Systolic time intervals combined with Valsalva maneuver for the diagnosis of left ventricular dysfunction in COPD exacerbations.

BackgroundThe goal of this study was to determine the value of systolic time intervals and their change during Valsalva maneuver (VM) in the diagnosis of left ventricular dysfunction (LVD) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).MethodsWe included 166 patients admitted to the emergency department for AECOPD. Measurement of systolic time intervals included electromechanical activation time (EMAT), left ventricular ejection time (LVET), and EMAT/LVET ratio. These were performed at baseline and during the first strain phase of the VM using a computerized phonoelectrocardiographic method. The diagnosis of LVD was determined on the basis of clinical examination, echocardiography, and brain natriuretic peptide. The values of systolic time intervals were compared between patients with and without LVD; their diagnostic performance was assessed using the area under receiver operating characteristic (ROC) curve.ResultsPatients with LVD (n=95) had a significantly higher EMAT and lower LVET and EMAT/LVET ratio compared to patients without LVD (n=71); the area under ROC curve was 0.79, 0.88, and 0.90, respectively, for EMAT, LVET, and EMAT/LVET ratio. All baseline systolic time intervals changed significantly during VM in patients without LVD but they did not change in patients with LVD. The area under ROC curve increased to 0.84 and 0.93, respectively, for EMAT and EMAT/LVET ratio but did not change for LVET.ConclusionSimple and noninvasive measurements of systolic time intervals combined with VM could be helpful to detect or rule out LVD in patients admitted to the emergency room for COPD excacerbation. The EMAT/LVET ratio seems to have the best diagnostic value.

Acute Appendicitis: A Comparative Study of Clinical, Radiological And Operative Findings

Vermiform appendix, a narrow worm shaped tube, which springs from the posteromedial wall of caecum, although being vestigial, is a favourite site of various disease processes. . Acute appendicitis is the most common cause of an abdomen ''in young adults and thus appendicectomy is the most frequently performed urgent abdominal operation. 1 Various diagnostic modalities are used to diagnose it accurately. The present study is attempted to evaluate the efficiency of clinical examination, radiological investigations, intraoperative and histopathological examination in diagnosis of acute appendicitis. Methods: Fifty consecutive patients suspected of acute appendicitis were admitted, clinically examined, investigatedradiologically, operated and excised samples were examined histopathologically. Results: The results of the study showed that in almost all cases (98%) diagnosis is accurately made only on the basis of clinical examination, while in a significant number of cases (18%), radiological investigations, used for diagnosis, failed to diagnose the positive cases. Conclusion: Acute appendicitis is more a clinical diagnosis rather than radiological and it is better to use radiological investigations only to confirm the diagnosis of acute appendicitis rather to diagnose it primarily because it is clear from the present study that a significant number of positive cases had been missed radiologically.