Combination Of Clinical Examination Research Articles

Diagnostic of intracapsular derangement of TMJ: comparison of clinical examination and condylography with MRI

The purpose of this study was to compare the accuracy of two diagnostic modalities: clinical examination and condylography with magnetic resonance imaging (MRI), in diagnosing intracapsular derangement of temporomandibular joint (TMJ). A total of 38 symptomatic (mean age of 26 years) and 20 asymptomatic (mean age of 21 years) subjects underwent thorough evaluation by the three diagnostic modalities. Findings were interpreted by three experienced investigators using diagnostic categories, then the agreement between the diagnostic modalities was studied. Clinical examination and condylography both alone and in combination, was not reliable for structural diagnostic. However with regard of the condyle-disk disunion without reposition, the two diagnostic modalities demonstrated a better agreement with MRI and the combination of the two diagnostic modalities increased significantly the percentage of agreement with MRI (89% to 96% of agreement). With regard of disunion without reposition, the combination of clinical examination with condylography is a valid diagnostic modality. The low reliability of clinical examination and condylography with regard of both normality and disunion with reposition could probably be explained by the young age of the symptomatic population.

Anti-VEGF Agents in the Treatment of Neovascular Age-related Macular Degeneration: Applying Clinical Trial Results to the Treatment of Everyday Patients

The vision gains reported with monthly intravitreal ranibizumab in the MARINA and ANCHOR trials led to an immediate paradigm shift in the treatment of neovascular AMD with retina physicians universally switching to the pan-VEGF blocking agents ranibizumab and bevacizumab, and patients expecting visual improvement. As these agents are primarily used on a pro re nata (PRN) dosing schedule (because neither patients nor physicians want monthly injections), the factors involved in making the treatment and retreatment decisions are very important in any attempt to maximize vision gain. Analysis of literature, ongoing clinical trials, and the clinical assessments that can aid clinicians in treatment and retreatment decisions. Literature review and perspective. If a monthly injection protocol is not used, clinicians should use both functional and anatomic criteria to attempt to guide treatment and retreatment decisions. Qualitative optical coherence tomography (OCT) appears to be the most sensitive and practical assessment tool to determine anatomic response to treatment but should be used in conjunction with clinical examination. If monthly intravitreal injections are not performed, a combination of clinical examination (looking for new hemorrhage) and qualitative OCT (to assess response to treatment and early signs of recurrent leakage) can be used to guide anti-vascular endothelial growth factor (anti-VEGF), treatments with the goal of maintaining a "normal" retinal anatomy in an attempt to maximize the benefit (visual acuity gains) to risk (number of injections required) ratio.

MRI for the demonstration of subclinical muscle involvement in muscular dystrophy

To compare magnetic resonance imaging (MRI) with clinical examination for the detection of muscle abnormality in patients with muscular dystrophy. Muscle power in 20 patients with a variety of forms of muscular dystrophy was examined clinically using the Medical Research Council (MRC) grading scale, and patients were subsequently imaged with MRI. MRI and clinical examination for the detection of muscle normality and abnormality were compared using a McNemar chi-squared test to examine differences between the two methods. MRI demonstrated radiological evidence of muscle abnormality more often than clinical examination; 50% of movements assessed as normal on clinical examination were associated with muscle abnormalities on MRI, including a significant proportion where there was severe radiological abnormality, indicating that focally advanced disease may be undetectable clinically. The combination of clinical examination and MRI could improve the accuracy of phenotypic characterization of patients with muscular dystrophy, and this in turn could allow a more focussed molecular analysis through muscle biopsy or genetic investigation. This may also be very helpful in the assessment of the degree of muscle compromise not only in the early phases of the disease but especially during follow-up and can be used in therapeutic trials.

Evaluation of Neurologic Deficit Without Apparent Cause: The Importance of a Multidisciplinary Approach

Background/Objective: A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes.Methods: A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology.Results: Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering.Conclusions: The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.

CONGENITAL X-LINKED RETINOSCHISIS CLASSIFICATION SYSTEM

To establish a classification system for congenital X-linked retinoschisis (CXLRS) using clinical examination and optical coherence tomography (OCT). Thirty-eight eyes of 19 patients who carried a clinical diagnosis of CXLRS were examined with OCT and clinical examination. Eyes were classified into one of four types based on a combination of clinical examination and OCT. All patients had bilateral OCT scanning performed at an average age of 8.64 years (range 2.24-17.4 years). Review of OCT scans revealed that 37 of 38 eyes had foveal schisis (97%) while 31 of 38 (82%) eyes had macular schisis deeper than the nerve fiber layer in areas of ophthalmoscopically normal macular retina. The authors termed this flat schisis phenomenon lamellar schisis. Thirty of 38 (79%) had peripheral bullous schisis cavities present. OCT examinations of patients with CXLRS reveal lamellar schisis in areas of ophthalmoscopically normal macular retina in 82% of eyes with the clinical diagnosis of CXLRS. Using both clinical examination and OCT, the authors were able to identify foveal, lamellar, and peripheral schisis, lamellar schisis only identifiable by OCT. These findings allow the authors to propose a classification system. The authors hope this classification system will allow a better understanding of the natural history of CXLRS disease and allow testing of therapeutic options.

Recurrent varicose veins: assessment of the saphenofemoral junction.

Thirty-six consecutive unselected patients, who had apparently previously undergone saphenofemoral ligation for primary uncomplicated long saphenous varicosities and who had then re-presented with recurrent thigh varices emanating from the groin, underwent preoperative clinical assessment, hand-held Doppler and duplex ultrasonographic examination and varicography to establish the presence or absence of saphenofemoral incompetence as the cause of recurrence. All patients underwent reexploration of the saphenofemoral junction (SFJ) via a lateral approach. Twenty-six patients had an intact SFJ (type I recurrence) and ten had varices arising from either a thigh perforator, or from abdominal or perineal veins (type II recurrence). Clinical examination alone was poor at distinguishing type I from type II recurrence. Doppler ultrasonography was sensitive (88 per cent) but non-specific (40 per cent). In contrast, duplex scanning was insensitive (42 per cent) but extremely specific (100 per cent) and accurate, with a positive predictive value of 100 per cent. Varicography also had a specificity and positive predictive value of 100 per cent, a sensitivity of 73 per cent and in addition provided a precise anatomical 'road-map'. A combination of clinical examination and hand-held Doppler ultrasonography seems to be the most appropriate first-line method of preoperative assessment in these patients. Duplex ultrasonography, if available, will provide additional useful information about both the SFJ and the presence of thigh perforators. Contrast examination may be reserved for patients who have equivocal results on non-invasive investigations, who have had more than one previous groin operation or who have, in addition, deep venous disease.

Fine needle aspiration cytology, in relationships to clinical examination and mammography in the diagnosis of a solid breast mass.

The accuracy of clinical examination, mammography and fine needle aspiration cytology in identifying malignancy has been assessed in 1655 breast masses from two time periods. Clinical examination and mammography remained consistent at identifying malignancy but 9 per cent of all breast carcinomas were considered benign by both techniques (sensitivity 91 per cent). Fine needle aspiration cytology, when performed by multiple aspirators in the first study period, had a sensitivity of only 66 per cent for malignancy. During the second period of study, when all aspirates were performed by a single aspirator, sensitivity rose to 99 per cent. The two patients with false negative cytology in this latter period had both clinical and mammographic evidence of malignancy. No patient with malignant cytology was subsequently shown to have benign disease. It is concluded that a combination of clinical examination and mammography, with fine needle aspiration cytology performed by committed individuals with aptitude for the technique and interpreted by experienced pathologists, can identify all patients with breast cancer before surgery.

Papillary thyroid microcarcinoma: A surgical perspective

Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid cancer measuring less than 10mm in its greatest diameter. It is the most common form of thyroid cancer, detected in up to 36% in autopsy studies. The wide availability and use of neck ultrasonography in the evaluation of carotid arteries and of the thyroid resulted in an increased detection of PTMC. PTMC is often multifocal. The diagnosis is usually based on a combination of clinical examination, laboratory investigations, and specialized radiological techniques (mainly neck ultrasonography combined with fine-needle aspiration cytology). A common scenario is the diagnosis of PTMC as an incidental finding following thyroidectomy for a presumably benign thyroid disease. Despite some controversy, most authors agree that PTMC should be treated by total or near-total thyroidectomy, provided it can be performed safely. Because of its many and major advantages, in our clinical practice, total or near-total thyroidectomy is the procedure of choice for the management of PTMC. Given the high incidence of PTMC as an incidental finding and the frequent multi-focality, we also favor total or near-total thyroidectomy for the surgical management of nodular thyroid disease (multinodular goiter or dominant presumably benign thyroid nodule/s). Despite some controversy, we perform central neck lymph node dissection electively, in the presence of cervical lymphadenopathy. Radioiodine ablation therapy may be used as an adjuvant therapy. Prognostic factors (such as tumor multicentricity, positive lymph nodes, capsular or vascular invasion) or scoring systems (such as the AMES) can be used to select patients for radioiodine adjuvant therapy. Suppression therapy is needed after surgical management. Despite the potential for neck lymph node and even distant metastases, the biological behavior of PTMC is in general benign and the prognosis is very good.

A Decade of Live California Sea Lion (<I>Zalophus californianus</I>) Strandings Along the Central California Coast: Causes and Trends, 1991-2000

Stranded marine mammals offer a unique sample of relatively inaccessible wild animals that are more likely to represent the diseased segment of the population and are easy to examine thoroughly. Examination of these animals, therefore, offers a method to detect novel diseases in free-living aquatic mammals. Diseases in marine mammals may reflect environmental changes such as ocean pollution, prey shifts, and global warming. To detect spatial and temporal trends in prevalence of such diseases, we reviewed records for 3,707 California sea lions (Zalophus californianus) that stranded live between 1991 and 2000 along the central California coast. Reasons for stranding were determined from a combination of clinical examinations, hematology and serum biochemistry, radiography, gross necropsy, histopathology, microbiology, and biotoxin assays. Over the ten years, 74% of sea lions stranded in Santa Cruz, Monterey and San Luis Obispo Counties, and 83% of these were admitted between May and October each year. Malnutrition was the most common reason for stranding (32%), followed by leptospirosis (27%), trauma (18%), domoic acid intoxication (9%), and cancer (3%). Strandings caused by malnutrition were greatest during the El Nino events of 1992, 1993, and 1998, while strandings caused by leptospirosis accounted for over 60% of strandings in 1991, 1995, and 1999. Although domoic acid was first reported in California sea lions in 1998, there was a small stranding event in 1992 that, based on clinical examinations and histopathology, was probably also caused by domoic acid. The observed prevalence of cancer among stranded animals remained constant over the past ten years at 3%.

Multiloculated prostate abscess: Treatment with transrectal ultrasound guided transrectal needle aspiration and lavage with the saline and antibiotic

Prostatic abscess is a rare but nevertheless serious disease. It should be diagnosed at an early stage by the combination of clinical examination and transrectal ultrasound, and drained. We treated a 79-year-old case with multiple prostate abscesses (PAs) by using lavage of the saline and antibiotic (cefoxitin) after transrectal ultrasound-guided transrectal puncture and aspiration. We are presenting the transrectal ultrasound images of pre- and postmedication, where we achieved complete success and no relapse was seen in follow-up of 1 year.

Fibroadenoma of the breast.

Fibroadenoma of the breast is a common cause of a benign breast lump in premenopausal women. The consensus view is that women with fibroadenomas are not at significant increased risk of developing breast cancer. Diagnosis is based on the combination of clinical examination, imaging and non-surgical tissue biopsy (the triple test). A clinical diagnosis of fibroadenoma alone is unreliable and does not exclude malignancy even in younger women. The choice of imaging is mammography, combined with ultrasound in older women, and ultrasound alone in younger women. Tissue biopsy, by either fine-needle aspiration or core biopsy, is the most accurate means of establishing the diagnosis. Traditionally, symptomatic fibroadenomas were treated by surgical excision, and this option should always be offered. There is increasing evidence that a conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistent with a fibroadenoma. Patients who choose conservative management need to be informed of the limitation of the tests, and must be assessed promptly if there is symptomatic or clinical change.

Anterior Spinal Artery Syndrome in an Adolescent With Protein S Deficiency

The diagnosis of anterior spinal artery syndrome can be made with high accuracy by thorough clinical examination in combination with typical magnetic resonance imaging findings. Sudden onset of tetra- or paraparesis and dissociated sensory loss with bladder dysfunction are the leading clinical signs. We discuss clinical and radiologic findings in an adolescent presenting with anterior spinal artery syndrome. The laboratory results showed a hereditary protein S deficiency.

Ischemic heart disease in black South African stroke patients.

Stroke patients in western countries frequently have coronary artery disease (CAD). In black Africans, CAD has been reported as being rare in both stroke patients and the general population. In this study, an attempt has been made to determine the prevalence of CAD in a black South African stroke population. The prevalence of CAD was determined by indicators identified through a series of 5 observational studies in black patients diagnosed with stroke. CAD indicators included (1) bedside diagnosis in 741 patients; (2) resting ECG in 555 consecutively admitted patients; (3) a combination of clinical examination, cardiac ultrasound, radionuclide scintigraphy, and multigated blood pool studies in 102 consecutively admitted patients; (4) thallium scintigraphy in 60 patients; and (5) necropsy in 23 patients. On bedside questioning, only 0.7% complained of previous angina. There was no history given of myocardial infarction (MI), but documentation of this was found in the clinical notes of 0.7% of the patients. In the resting ECG study, evidence of myocardial ischemia was present in 14.6% and MI in 2.1%. In the combined study, cardiac ischemia was documented on ECG in 12.7% of patients and evidence of previous MI in 5.8%. Cardiac scintigraphic studies revealed changes of myocardial ischemia in 31.7% and MI in 13.3% of the 60 patients studied. Four (17.4%) of 23 patients in the necropsy study had histological evidence of previous MI, and 50% of all patients had evidence of >50% atherosclerotic stenosis in 1, 2, or 3 coronary arteries. The prevalence of CAD in black African stroke patients is significantly higher than has been documented in the general nonstroke black population as well as in stroke patients. Black stroke patients may have a risk for CAD similar to that of their white counterparts.

Aetiology and diagnosis of persistent nasal disease in the dog: a retrospective study of 42 cases.

Forty-two dogs with a history of persistent nasal disease were evaluated by a combination of clinical examination, thoracic and nasal radiography, retroflexed endoscopy and biopsy, and anterograde rhinoscopy and blind nasal biopsy. A definitive diagnosis was made in 91 per cent of cases. Neoplasia was the most common diagnosis (33 per cent of cases), followed by inflammatory rhinitis (24 per cent). Other diagnoses included periodontal disease (10 per cent), aspergillosis (7 per cent) and foreign bodies (7 per cent). Adenocarcinoma was the most common tumour diagnosed. The clinical findings were found to be too variable to be used as specific diagnostic criteria. Anterograde rhinoscopy and retroflexed endoscopy had higher specificity and sensitivity than radiology for the diagnosis of neoplasia, inflammatory rhinitis, aspergillosis and foreign bodies. With a systematic approach to the investigation of persistent nasal disease, a definitive diagnosis can be successfully obtained in the vast majority of cases.

Functional outcome following spinal cord injury: Significance of motor-evoked potentials and ASIA scores

Objective: Prediction of outcome of ambulatory capacity and hand function in tetraplegic patients with spinal cord injury (SCI) using neurologic examination, according to the protocol of the American Spinal Injury Association (ASIA) and motor-evoked potentials (MEP). Design: Correlation study on a prospective cohort. Setting: SCI center, university hospital. Patients: Thirty-six patients with acute and 34 with chronic SCI. Outcome Measures: (1) ASIA motor and sensory scores, (2) MEP recordings of upper and lower limb muscles, and (3) outcome of ambulatory capacity and hand function. Results: In acute and chronic SCI, both the initial ASIA scores and the MEP recordings were significantly related ( p < .0001) to the outcome of ambulatory capacity and hand function. In tetraplegic patients, the MEP of the abductor digiti minimi muscle (Spearman correlation coefficient, .75; p < .0001) and the ASIA motor score for the upper limbs (Spearman correlation coefficient, .83; p < .0001) were most related to the outcome of hand function. Ambulatory capacity could be predicted by the ASIA motor score of the lower limbs (Spearman correlation coefficient, .78; p < .0001) and by MEP recordings of the leg muscles (Spearman correlation coefficient, .77; p < .0001). In patients with acute SCI, for the period 6 months posttrauma, the ASIA motor score increased significantly (ANOVA, p < .05), whereas the ASIA sensory scores and MEP recordings were unchanged (ANOVA, p > 0.1). Conclusion: Both ASIA scores and MEP recordings are similarly related to the outcome of ambulatory capacity and hand function in patients with SCI. MEP recordings are of additional value to the clinical examination in uncooperative or incomprehensive patients. The combination of clinical examination and MEP recordings allows differentiation between the recovery of motor function (hand function, ambulatory capacity) and that of impulse transmission of descending motor tracts.

A comparison of segmental and marginal bony resection for oral squamous cell carcinoma involving the mandible

Purpose: This study reviews the accuracy of preoperative diagnosis of mandibular invasion by oral squamous cell carcinoma and assesses the role of marginal resection of the mandible in its treatment. Patients and Methods: A retrospective study of a 5-year cohort of 46 patients who underwent mandibular resection for previously untreated oral squamous cell carcinoma was done. Data evaluated included age; sex; site and stage of cancer; preoperative clinical, panoramic, and computed tomography (CT) evaluations; and histologic findings on the resection specimen. The type of mandibular resection (segmental vs marginal) and treatment outcome also were compared. Results: Clinical examination, panoramic radiographs, and CT scans were 78.5% to 82.6% accurate in diagnosing mandibular invasion by squamous carcinoma. Clinical examination and panoramic radiographs are more sensitive than CT scans (86.6% vs 53%), but CT scans were more specific (92.5% vs 80%). The mandible was involved in 65% of patients with segmental resection and 7.6% of patients who had a marginal resection. Nineteen percent of the patients in the marginal resection group died of their oral cancer, two of five patients with local recurrence. Ten percent of patients in the segmental resectiongroup died of oral cancer; no local recurrences were seen. Conclusion: There is no completely accurate method of diagnosing bony invasion of the mandible by oral squamous cell carcinoma. A combination of clinical examination, plain radiographs, and computed tomography (CT) scans may improve the diagnosis. Marginal resection is best reserved for cancers close to the bone with no invasion, minimal cortical invasion, or with early “arrosive” invasion. It is best in the symphysis region. Careful case selection will allow a favorable oncologic outcome with preservation of the mandibular contour.

Early prognosis in coma after cardiac arrest: a prospective clinical, electrophysiological, and biochemical study of 60 patients.

The univariate study of clinical, electrophysiological, or biochemical variables has been shown to predict the outcome in postanoxic coma in about 50% of patients for each type of variable. Previous studies did not, however, consider the prognostic accuracy of a multivariate approach. Sixty patients in coma for more than six hours after cardiac arrest were prospectively examined by means of repeated clinical examinations (including Glasgow coma score (GCS)), EEG, and medianus nerve somatosensory evoked potentials (SEPs). In 16 patients, the early concentrations of serum neuron specific enolase and ionised calcium were also measured. Within the first year after cardiac arrest, 20% of patients made a good neurological recovery; 80% remained in a vegetative state or died. Clinical examination correctly predicted outcome in 58% of patients, SEP in 59%, and EEG in 41%. The combination of clinical examination, SEP, and EEG raised the percentage of correct predictions to 82%, without false pessimistic predictions. Concentrations of serum neuron specific enolase and ionised calcium were of no additional prognostic help. Multivariate regression analysis identified the association of GCS < 8 at 48 hours with abnormal or absent early cortical SEPs as highly predictive of a bad outcome (risk = 97%, 95% confidence interval = 86-99%). The combination of GCS at 48 hours, SEP, and if these are non-conclusive, EEG, permits a more reliable prediction of outcome in postanoxic coma than clinical examination alone.

Assessment of the acceptability of conservative management of fibroadenoma of the breast

A prospective study was performed in 202 patients with 219 fibroadenomas, diagnosed by a combination of clinical examination, ultrasonography and fine-needle aspiration cytology. Patients were given the choice of excision or conservative management with regular monitoring by ultrasonography. Sixteen patients with 18 fibroadenomas opted for excision and all 18 lesions were histologically confirmed as fibroadenomas. A further 152 patients with 163 fibroadenomas were observed for a minimum period of 2 years; 13 fibroadenomas increased significantly in size (all 13 were excised and confirmed histologically as fibroadenomas), 19 decreased significantly in size, 42 resolved and the remaining 89 showed no change in size. Conservative management of fibroadenomas in patients under the age of 40 is safe and acceptable to the majority of women.

Value of Magnetic Resonance Imaging in Patients With Penile Induration (Peyronie's Disease)

Magnetic resonance imaging (MRI) is a noninvasive procedure that enables exact imaging of penile anatomy. A total of 34 patients with clinical Peyronie's disease underwent palpation, ultrasound and MRI after intracavernous injection of 10 microgram prostaglandin E1. MRI images were obtained before and after intravenous application of gadolinium-diethylenetriaminepentaacetic acid. In 34 patients 45 plaques were palpable. Ultrasound revealed evidence of lesions in 66.6 percent of the cases. On MRI 36 of 45 palpable plaques (80 percent) were detected. Not palpable or sonographically revealed indurations could be shown in 4 cases. After intravenous application of gadolinium-diethylenetriaminepentaacetic acid 4 plaques demonstrated contrast enhancement, thus indicating local inflammatory activity. The combination of clinical examination and sonography remains the method of choice for diagnosis and observation of patients with Peyronie's disease. MRI enables exact imaging of penile structures but it does not provide a significant advantage over standard investigative procedures.

ABC of Rheumatology: RAYNAUD'S PHENOMENON, SCLERODERMA, AND OVERLAP SYNDROMES

Several rheumatological conditions are linked to impaired peripheral circulation. These abnormalities may take various forms, including chilblains, acrocyanosis, and Raynaud's phenomenon. This last condition, described by the French clinician Maurice Raynaud in 1862, occurs in up to 5% of an otherwise healthy population, but may be a link between certain autoimmune rheumatic diseases. Raynaud's disease refers to the development of trophic changes as a result of microcirculatory damage and prolonged local ischaemia. Fortunately, gangrene is relatively rare, and, because patients are often young, recovery may be remarkable. #### Disturbances of peripheral circulatory system Chilblains—Painful, burning or itching erythematous lesions of hands or feet (rarely ulceration) precipitated by damp and cold (especially if inadequate clothing worn) Acrocyanosis—Persistent cold, blue, and rather sweaty appearance, usually of hands Raynaud's phenomenon—Episodic, clearly demarcated two or three phase colour change—white (ischaemia), then often blue (stasis), then red (reactive hyperaemia)–of fingers and sometimes toes (rarely nose, tongue, or ears) in response to cold or, less often, emotion Well defined blanching of skin characteristic of Raynaud's phenomenon. Over 90% of patients with Raynaud's phenomenon are female and, at the time of presentation, are often aged under 25. Up to 5% of patients presenting with the condition eventually develop an autoimmune rheumatic disease. The presence of abnormal nail fold capillaries (detected by capillaroscopy) and antinuclear antibodies are of particular value in predicting this development. View this table: Prevalence of Raynaud's phenomenon in autoimmune rheumatic diseases Primary and secondary Raynaud's phenomenon are distinguished by a combination of clinical examination and laboratory investigations. Physical examination should include assessment of peripheral pulses, measurement of blood pressure in both arms, and examination of the neck for the tenderness often associated with a cervical rib. A negative test for antinuclear antibody in an otherwise healthy patient is reassuring but does not completely exclude subsequent development of an autoimmune rheumatic disease. Different types …