Clinical Examination Assessment Research Articles

Reliability of Clinical Examination and Ultrasonography for the Assessment of Axillary Lymph Node Status in Breast Cancer Patients in Bangladesh

Background: In the treatment arena of oncology, there has been growing interests in developing the clinical prediction tools to estimate the risk and severity of patients with breast cancer having axillary nodal metastases. Clinical examination and ultrasonography (USG) for the assessment of axillary lymph node status in breast cancer patients is a traditional diagnostic method in detecting breast cancer and its status. But we have very limited research-based data regarding the effectiveness of clinical examination and USG for the assessment of axillary lymph node status in breast cancer patients. Aim of the study: The aim of this study was to assess the reliability of clinical examination and ultrasonography for the assessment of axillary lymph node status in breast cancer patients. Methods: This was a prospective observational study conducted in the Department Surgery & Oncology, Dhaka Medical College Hospital, BSMMU & NICRH Dhaka, Bangladesh during the period from January 2014 to December 2015. In total 100 patients of several age groups with breast cancer patients attended, diagnosed and treated in the mentioned hospital were selected as the study population. Proper clinical examination and ultrasonography for the assessment of axillary lymph node status were done for every participant. All data were processed, analyzed by MS Office and SPSS program as per need. Results: According to the validity test, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood ratio (LR) of the clinical examination in assessment of auxiliary lymph node status in breast cancer patients were 53.7%, 85.0%, 93.5%, 31.5%, 60.0% and 3.58% respectively. As per the validity test, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood ratio (LR) of the USG in assessment of auxiliary lymph node status in breast cancer patients were 73.8%, 85.0%, 95.2%, 44.7%, 76.0% and 4.91 respectively.

Clinically significant discrepancy between clinical and pathologic stage of early-operable cervical cancer.

5526 Background: The cornerstone of the management of cervical cancer (CC) traditionally relies on clinical examination assessment (CE) of tumor size (TS) and local extension of disease. Previous reports demonstrate poor accuracy of CE, with the most common discrepancy being failure to identify parametrial involvement (PI). The goal of this study is to determine the accuracy of CE in comparison to final pathology (FP) in early operable CC. Methods: This is a multi-center retrospective review of patients with early CC (FIGO stage IB1, IIA1). Data on age, race, histology, stage, CE findings, FP report and receipt of adjuvant radiation therapy (RT) were collected. CE findings included TS, PI and vaginal involvement (VI). CE of TS, PI, and VI were compared to FP. Subanalysis was also conducted based on TS ( < or ≥ 2cm) and location of tumor (exophytic vs endophytic). Analysis was performed using paired-T and Cohen’s Kappa tests. Results: Final analysis included 135 patients. Mean age was 52.6 years. The majority of patients had squamous cell carcinoma (72.6%). Overall, there was a significant difference between CE of TS compared to FP; mean error of 1.22 cm (p < 0.0001). In those with tumors ≥ 2cm the mean error was 1.28 cm (p < 0.0001). No significant discrepancy was observed in tumors < 2 cm (mean error: 1.10cm; p = 0.5). CE of TS of endophytic tumors was poor (mean error 1.68cm; p = 0.004) compared to exophytic tumors (mean error: 1.12 cm; p = 0.693). There was no significant difference in the identification of VI between CE and FP (3.7% vs 8.89%; p = 0.067). No patients with PI on CE were included in this analysis. However, 14.07% of patients were found to have PI on FP (p < 0.0001). There was no difference in the accuracy CE of TS between non-obese ( < 30 kg/m2) and obese patients (≥30 kg/m2), mean error 1.13 and 1.3, respectively (p = 0.061). As a results of FP, 55 patients (40.7%) received adjuvant RT and 38 patients (28.14%) were upstaged from IB1 to IB2. Of these 38 patients, 36 (94.7%) went on to receive adjuvant RT. Conclusions: CE of TS and PI is inaccurate, especially in tumors ≥ 2cm and endophytic tumors. This suggests imaging should be strongly encouraged, particularly in the setting of the updated FIGO 2018 staging system and recent debate over surgical approach.

Estimation of Mean Left Atrial Pressure in Patients with Acute Coronary Syndromes: A Doppler Echocardiographic and Cardiac Catheterization Study

Doppler echocardiography, including the ratio of transmitral E to tissue Doppler e' velocities (E/e'), is widely used to estimate mean left atrial pressure (mLAP). This method, however, has not been validated in patients with acute coronary syndromes. Fifty-seven patients with acute coronary syndromes who underwent left heart catheterization and transthoracic echocardiography within 8hours of each other were retrospectively analyzed. Forty-two of the patients (74%) were men, with a mean age of 65±11years. Patients with known cardiomyopathy, atrial fibrillation, or left-sided valvular disease were excluded. Doppler mLAP was estimated using Nagueh's formula (1.24×[E/e']+1.9). Invasive mLAP was estimated using the formula of Yamamoto etal. (1.20×mean left ventricular diastolic pressure - 0.82), wherein we averaged left ventricular diastolic pressure starting from the isovolumic relaxation phase to the post-A inflection point. Subanalyses were performed in groups with reduced or normal left ventricular ejection fraction (EF). There was stronger agreement between the two techniques to estimate mLAP in the reduced EF group (r=0.73, r2=0.53, P<.001) compared with the normal EF group (r=0.33, r2=0.11, P=.08). The κ statistic for agreement was 0.34 for the overall study cohort, suggesting fair agreement according to partition values of mean mLAP: <8, 8 to 15, and >15mm Hg. Left atrial volume index did not correlate with invasively estimated mLAP in this cohort. In patients with acute coronary syndromes, Doppler- and catheter-derived estimates of mLAP correlate well in patients with reduced EFs. In the acute setting, echocardiographic evaluation is a reliable adjunct to clinical examination in assessment of heart failure in this subgroup of patients.

Utility of clinical examination and CT scan in assessment of penetrating neck trauma.

Managing penetrating injuries adequately and effectively depends a great deal on proper assessment of the injury. This study carried out was done at The Aga Khan University Hospital to assess the role of clinical examination and CT scan imaging in evaluation of penetrating neck injuries. A total of 68 students were included, with ages ranging from 3 to 74 years. The involved zones and the injured structures were noted. Results showed a high sensitivity of clinical examination in assessing vascular (81%) and airway trauma (77%), with a low sensitivity for esophageal trauma (34%). For CT scan the sensitivity was 90% for vascular trauma, 83% for airway trauma and 53% for esophageal injuries. Clinical findings and CT scan imaging are important assessment tools for evaluation of penetrating neck traumas, with a high sensitivity for vascular and airway injuries.

Development of an Objective Structured Clinical Examination For Assessment of Clinical Skills in an Emergency Medicine Clerkship

Assessment of medical students in their emergency medicine (EM) clerkship is often based on clinical shift evaluations and written examinations. Clinical evaluations offer some insight into students’ ability to apply knowledge to clinical problems, but are notoriously unreliable, with score variance that may be driven as much by error as by actual student performance.1–6 Clinical evaluations are also limited by the unpredictability of pathology in emergency department (ED) patients, and by patient safety considerations that prevent students from independently managing patients, especially those with high-acuity conditions. Additionally, there is evidence that the basic skills of history and physical exam are rarely observed by faculty members, and the feedback they receive on these domains is limited.7–9 These factors hinder EM educators in their effort to objectively assess students’ progress relative to clerkship objectives, particularly those that pertain to emergent care. The objective structured clinical exam (OSCE) is one potential solution to these problems. Described in 1975 by Harden et al, an OSCE is designed to assess the clinical competence of medical trainees through direct observation of skill performance in a variety of stations.10 OSCEs have been widely adopted in medical education and in other health professions.11–13 These exams are viewed as a valuable form of clinical assessment due to their demonstrated reliability and inherent flexibility for assessing a wide variety of knowledge application and skills.11 In EM, OSCEs have been used mainly in postgraduate medical education to assess resident communication skills and clinical performance.14,15 One OSCE for interns was shown to accurately predict future clinical performance scores.12 A recently published evaluation of an EM OSCE for medical students demonstrated validity evidence supporting this method of assessment.16 These studies suggest that OSCEs can be used effectively in EM education, and yield valid assessment data.

The role of limb perfusion studies in the paediatric ischaemic limb.

To study the use of limb perfusion scans in children with limb-threatening ischaemia and determine whether such scans are helpful in making clinical decisions. This retrospective study compared the clinical, scan and surgical findings in children who had limb perfusion scans for critical limb ischaemia at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, from July 2001 to December 2010. Records were reviewed and the data analysed for aetiology, clinical findings, limb perfusion results, operative findings and outcome. There were complete clinical and scan records for 20/22 patients, aged 1 month to 12 years. The causes of limb ischaemia were meningococcal septicaemia (n = 9), septic shock (n = 6), hypovolaemic shock due to gastroenteritis (n = 4), and electrical burns (n = 1). The clinical, scan and surgical findings correlated in 40/48 imaged limbs. In one leg the findings did not correlate, but the perfusion scan results predicted the outcome. In the remaining seven cases the exact correlation was uncertain owing to technical difficulties or absent operative notes. This study describes a method for performing limb perfusion studies in children. Limb perfusion studies correlated well with surgical findings. These studies were useful in treatment decisions, parent and patient counselling and surgical planning. They supplemented clinical examination in assessment of the children.

Application of objective structured clinical examination in assessment of interns of traditional Chinese medicine in anesthesiology department

Objective To investigate the application efficacy objective structured clinical exam- ination （ OSCE ） in assessment of interns of traditional Chinese medicine in anesthesiology department. Methods Totally 62 interns were examed by OSCE formulated by anesthesiology department before de- partmental rotation. Contents of the exam included preoperative evaluation, endotracheal intubation tech- nique, deep venipuncture, lumbar puncture, case analysis, medical documents writing, etc. Assessment was made by exam results and questionnaire survey. Quantitative data were analyzed by ANOVA and results of questionnaire were analyzed by calculating percentage of each option and describing directly. Results Test results showed that the score of medical document writing was the highest （ 18.25 ＋ 1.53 ） , while that of case analysis was the lowest （ 13.49 ＋ 1.46 ） and there was no significant difference in scores of three clinical skills. Questionnaire survey showed the OSCE method is superior to traditional method since it is more scientific, objective and fair. Conclusions OSCE method can scientifically as- sess the clinical practice effect of interns of traditional Chinese medicine in anesthesiology department. Meanwhile, it can find the shortcomings in the teaching, which is helpful in promoting the assessment and improvement of clinical teaching. Key words: Objective structured clinical examination ; Anesthesiology ; Rotation examina- tion ; Speciality of traditional Chinese medicine

Sonographic examination of the abnormal scrotum

Sonography of scrotal masses is now being evaluated as an adjunct to clinical examination in assessment of scrotal masses. The accuracy of ultrasound in discrimination of solid and cystic masses cannot be disputed. This paper will report on the reasons for referral, the sonographic diagnosis and effect on clinical management of 20 patients. Lesions examined include hydrocele, haematocele, epididymal lesions, abscess and solid testicular masses. A brief review of current literature will also be considered. An analysis will be made of diagnostic accuracy including ability to anatomically locate abnormalities.