Importance Of Clinical Examination Research Articles

Diaphragmatic Hernia (Bochdalek Hernia) in an Adult: a Case Report

Bochdalek hernia (BH) is the most common type of congenital diaphragmatic hernia and constitutes 85% of cases. In adults BH is extremely rare. Most of them are asymptomatic. We present a case of BH in an adult patient to point out the importance of clinical examination and computed tomography (CT) scan in reaching the exact diagnosis. A 17-year-old male was presented to the surgery department with a 3-days history of recurrent abdominal pain, vomiting and unable to lie flat. The BH was confirmed on computed tomography (CT) imaging and the patient underwent emergency laparotomy and per-operatively we found part of stomach, greater omentum, splenic flexure of colon along with spleen herniated into the left hemithorax through a defect of approximately 8x6cm in the left postero-lateral aspect of the diaphragm. Reduction of hernia contents and surgical repair of the defect was done with non-absorbable suture. His post-operative period was uneventful. Although rare, this disorder should be recognized and treated appropriately to avoid complications. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 64-67

A case Report of Simultaneous Subacute Thyroiditis and COVID-19 Infection. A Rare Presentation or Mere Coincidence?

Subacute thyroiditis is an uncommon thyroid disease which usually occurs after a viral infection. During COVID-19 pandemics, several subacute thyroiditis cases were identified during or after COVID-19. Due to their similar manifestations and high prevalence of COVID-19, subacute thyroiditis might be neglected if the clinicians do not keep it in mind. In this care report, we present a missing patient with SARS-COV-2 infection and subacute thyroiditis which was not suspected until the latent phase of the disease. The patient report can be a re-emphasis on the importance of clinical examination and especially paying attention to palpation of the thyroid gland.

X-ray and anatomical features of the lower jaw alveolar cortical layer in children

Introductionthe world studies showed the interest in measurement of the buccal or anterior cortical plate thickness. Data indicate a significant superiority of the spongy substance over the compact one in the distal part of the jaw, which makes it possible to think about a higher effectiveness of transcortical injections. The empirical “rule of 10″ provides for the choice of a method of anesthesia in children for primary teeth but demonstrates difficulties with high-quality anesthesia accompanied for permanent teeth. Therefore, the importance of clinical examination and anatomical investigation of the jaw cortical plate in children for competent planning of transcortical interventions has been determined. AimTo study the features of the clinical and X-ray anatomy of the cortical layer in distal alveolar part of the mandible in children. Material and methodsThe assessment of the X-ray anatomical characteristics of the mandible was carried out according to 150 anonymized cone-beam computed tomograms of patients aged 6–12 years, performed for the treatment of major diseases. Qualitative assessment and examination of the cortical plate of the distal alveolar part of the mandible were carried out on the skeletonized certified preparations of aged 6–12 in the amount of 50. ResultsThe age characteristics of the cortical plate in the area of the chewing group of teeth in the mandible were determined according to macro anatomical studies, which confirms with the X-ray results. Therefore, the obtained images serve as actual confirmation of X-ray studies, which are ranked by age. The thickness of the cortical plate in the second primary molar of the mandible in subgroups 6, 7 and 8 years has a proportional increase from the cervical region to the apical projection. The average thickness of the cortical plate is 1.57 mm at 6 years, 1.52 mm at 7 years, 1.6 mm at 8 years and 1.84 at 9 years. The cortical plate thickness in the first primary molar of the mandible in subgroups 6 and 7 years has a proportional decrease from the cervical region to the apical projection as well as an inverse proportion to age. The average thickness of the cortical plate is 1.33 mm. In the first molar of the mandible at the age limit of 6–12 years the attention is drawn to the linear increase in tissue volume from the cervical region to the apical projection up to 8 years. At 6–8 years the average thickness of the cortical plate in this age group is 1.74 ± 0.2 mm, at 9 years - 2.03 mm, at 10 - average value in the cervical region it is 1.53 ± 0.23 mm, in the root middle it is 2.19 ± 0.13 mm and in the apical projection it is 1.98 ± 0.16 mm, at 11–2.22 mm and at 12–2.35 mm. For the second primary molar the average thickness of the buccal cortical plate of the second primary molar is 1.4 mm in cervical part, 1.68 mm in the root middle and 1.81 mm in the apical projection. Finally, thickness of the buccal cortical plate in the cervical region of the first permanent molar is 2 mm in groups. ConclusionThe study makes it possible to determinate with noninvasive way the age limit for the least pronounced zone of the buccal cortical plate.

Ovarian Tumours: Discordance between Clinical and Radiological Findings: A Case Series.

The five major types of ovarian tumors in females of different age groups are discussed here with respect to discordance between ultrasonography, clinical features and histopathology findings. The importance of clinical examination cannot be denied in such cases as total dependence on investigation modalities may lead to wrong diagnosis and treatment. Five such cases admitted in the year 2017-2018 at Era's Lucknow medical college and hospital were selected for this series. All the cases had varied presentation, and diagnosis in each case was difficult as the nature of the masses differed markedly from the radiological findings. Even in expert hands, a radiological conclusion must go hand in hand with a proper clinical correlation.

The importance of clinical examination in the diagnosis of laterocervical lymphadenopathy – case presentation

Cervical lymph nodes represent a common site of meta­s­ta­­ses for malignancies of the head and neck and, in the absence of a known primary site, the treatment options can be challenging. In patients with a nodular formation with laterocervical localization, the differential diagnosis should always consider the potential metastasis of squamous cell carcinoma of the ENT sphere. This paper emphasizes the importance of a complete physical and imaging exa­mi­na­tion, as well as histopathological diagnosis, which led to a diag­nosis of squamous cell carcinoma originating in the larynx, in an otherwise nonspecific clinical setting.

The Importance of Clinical Examination under General Anesthesia: Improving Parametrial Assessment in Cervical Cancer Patients.

Simple SummaryIn most cases, the treatment strategy (radiation or surgery) in cervical cancer patients depends on whether the parametrium shows tumor involvement. Traditionally, clinical pelvic examination under general anesthesia (EUA) has been used to determine whether tumor spread into the parametrium is present. During the recent decade, however, magnetic resonance imaging (MRI) has been increasingly used to determine whether parametrial tumor extension is present, and several studies have indicated that MRI might be superior to EUA. In this study, we demonstrate that EUA still plays an important role in pre-therapeutic evaluation of cervical cancer patients, and that display of MR images in the operating room (augmented EUA) achieves superior results in predicting parametrial tumor spread when comparted to MRI alone, especially in larger tumors. Best predictive results were observed in cases when radiologists and gynecological oncologists agreed on parametrial status, highlighting the importance of interdisciplinary patient assessment.Background: Parametrial tumor involvement is an important prognostic factor in cervical cancer and is used to guide management. Here, we investigate the diagnostic value of clinical examination under general anesthesia (EUA) and magnetic resonance imaging (MRI) in determining parametrial tumor spread. Methods: Post-operative pathological findings of 400 patients with primary cervical cancer were compared to the respective MRI data and the results from EUA. The gynecological oncologist had access to the MR images during clinical assessment (augmented EUA, aEUA). Results: Pathologically proven parametrial tumor invasion was present in 165 (41%) patients. aEUA exhibited a higher accuracy than MRI alone (83% vs. 76%; McNemar’s odds ratio [OR] = 2.0, 95%CI 1.25–3.27, p = 0.003). Although accuracy was not affected by tumor size in aEUA, MRI was associated with a lower accuracy in tumors ≥2.5 cm (OR for a correct diagnosis compared to smaller tumors 0.22, p < 0.001). There was also a decrease in specificity when evaluating parametrial invasion by MRI in tumors ≥2.5 cm in diameter (p < 0.0001) compared to smaller tumors (< 2.5 cm). Body mass index had no influence on performance of either method. Conclusions: aEUA has the potential to increase the diagnostic accuracy of MRI in determining parametrial tumor involvement in cervical cancer patients.

Rotator Cuff Tears: An Everlasting Enigma

Rotator Cuff (RC) tear is a common cause of disability and pain for which middle aged and elderly individuals seek orthopaedic consultation. A unique feature of RC tear treatment is that it encompasses an entire spectrum, which ranges from humble conservative methods to complicated tendon transfers. There is a now a fair amount of agreement about which treatment modality must be offered to whom, based on tear type, tendon retraction, tissue quality and patient profile. What must be borne in mind however, is that no bridges be burnt when choosing a treatment method. This would keep the door open for a salvage or revision procedure to help the patient. This issue of the Asian Journal of Arthroscopy is a symposium dedicated to management strategies for Rotator cuff tears. The importance of clinical examination in a patient with shoulder pain and weakness cannot be overemphasized. It is the cornerstone of formulating an individualized treatment plan. Vivek Pandey has discussed the methodology for all the relevant tests to accurately diagnose a rotator cuff tear, along with their pearls and pitfalls. One of the most important reasons why arthroscopic shoulder surgery in general and rotator cuff surgery is particular has evolved, is the remarkable progress in imaging, especially Magnetic Resonance scans. Anupama Patil has written a detailed descriptive review in this subject. An understanding of the nuances of imaging will help the clinician to clinically co-relate her findings. A sound clinician is one has a grasp of theoretical concepts developed and validated over the years. The ability to a classify rotator cuff tear based on imaging findings and co-relating clinically in the foundation on which every treatment decision is made. Ram Chidambaram has written an exhaustive review detailing all classification systems for rotator cuff tear. Jaap Willems has presented an algorithm for such decision making based primarily on age and tear morphology. The non-operativ

Perioperative Malignant Infarct in a Patient undergoing Mandibular Reconstruction with Free Fibular Flap Surgery for Oral Cancer: A Case Report

Oral cancer is among the top three cancers in India. Surgery is the recommended treatment option for early-stage and locally advanced resectable cases. The incidence of perioperative stroke in patients undergoing neck dissection for head and neck cancer is only 0.2%. In the following article, we report the first case of perioperative malignant infarct in a patient undergoing mandibular reconstruction with free fibula flap surgery for oral cancer. An eighty-year-old male diagnosed with locally advanced carcinoma of the oral cavity underwent mandibular reconstruction with free fibula flap surgery. In the perioperative period, he developed malignant infarction involving the right middle and posterior cerebral artery in the immediate postoperative period, however, it was diagnosed after 36 hours of surgery. He was managed conservatively and discharged with a favorable outcome. This case highlights the importance of clinical examination in such a case, along with the difficulties faced in examining the patient in the perioperative period.

Analysis of risk factors, clinical features and visual outcome in cases of non-arteritic anterior ischemic optic neuropathy (NA-AION) at a tertiary eye care centre in India

We did an analysis of risk factors, clinical features and visual outcome in cases of non-arteritic anterior ischemic optic neuropathy (NA-AION) at a tertiary eye care centre in India. This is a prospective, observational, clinical study. A total of 60 eyes of 60 consecutive adult patients with disc oedema, due to non-arteritic AION, presenting in the Neuro-ophthalmology clinic of a tertiary care eye hospital, were enrolled over a period of 18 months (in specified period) according to the inclusion criteria. The study, including patient recruitment and data collection, was approved by the Institutional Review Board. All patients provided written informed consent after they received information about the disease and its relevant investigations along with the risks associated. Sample collection was done by application of inclusion and exclusion criteria on the patients presenting to the clinic. The study was carried out for a period of 6 months for each subject. The major outcomes of the study were: Metabolic Syndromes are the most significantly associated risk factors for the occurrence of NA AION. Clinical investigations mainly show the characteristic findings as mentioned in literature, with very little variation. However the importance of clinical examination, mainly pupillary reaction and fundus evaluation by slit lamp biomicroscopy, cannot be overlooked. Visual acuity is highly variable at presentation with cases even presenting with normal or near normal visual acuity. Visual outcome showed significantly improvement within 6 months of presentation. Non arteritic anterior ischemic optic neuropathy (NAION) was the most common form of ischemic optic neuropathy in our study. It is an idiopathic, ischemic insult of the optic nerve head characterized by acute, monocular, painless visual loss with optic disc swelling. The systemic risk factor which we found to be most strongly associated with was diabetes mellitus followed by systemic hypertension. Also an

The Importance of Clinical Examination in a Patient with Dysphagia: a Case Report

The aim of this paper is to emphasize the importance of careful history taking in patients with dysphagia. Dysphagia is defined as the difficulty in forming or moving the foods and liquids safely from the mouth to the stomach. Traditionally, swallowing can be divided into four stages: oral preparatory stage, oral stage, pharyngeal stage, and esophageal stage. However, it has to be emphasized that the division of swallowing into different stages is artificial and the act of swallowing should be considered as a whole process. Therefore, a careful history taking will yield the likely underlying pathophysiologic process and anatomic site of the problem in most patients. Although patients explain their disease-related symptoms undoubtedly, it is necessary for the clinicians to be aware of some other suspicious pathologies. Herein, we present the case of a patient with Schatzki ring (SR) who had a feeling “something stuck in the throat” during ingestion of solid foods.

The Importance of Clinical Examination in a Case of İmperforate Hymen Case Mimicking Ovarian Torsion

The Importance of Clinical Examination in a Case of İmperforate Hymen Case Mimicking Ovarian Torsion

Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned

COVID-19 is an ongoing global pandemic caused by a betacoronavirus named SARS-CoV-2. Within few months after the first index case is identified in Wuhan city of China, it attained a global pandemic status due to its unique epidemiology and pathophysiology. It typically presents with signs and symptoms of viral pneumonia. Patients with cardiac disease are at increased risk of COVID disease and create a diagnostic dilemma in differentiating from respiratory illnesses for the cardiologists. Furthermore, ST-segment changes in electrocardiogram and troponin elevation which form a key diagnostic point in the diagnosis of acute coronary syndromes are frequently seen in COVID-19 patients. This is a matter of utmost concern as the diagnostic dilemma caused may lead to many patients who may not have epicardial coronary artery disease that may be taken up for invasive angiography. Moreover, the prejudice caused by the COVID-19 is leading to fewer admissions for acute coronary syndromes and fewer primary percutaneous transluminal coronary angioplasty leading to inappropriate management of deserving patients with genuine acute coronary syndromes. These patients form a very important chunk of population as on the one hand, they are more likely to spread the infection if they are improperly triaged, and on the other hand, they are less likely to receive proper guideline-directed treatment of cardiovascular syndromes increasing the mortality from primary cardiac pathology. The following case highlights the above-mentioned issues faced in triaging and treating a patient who presented a diagnostic dilemma. Our patient a 53-year-old lady who is a known case of chronic coronary syndrome with effort-induced angina on exertion for the last 4 months on medical management presented to the emergency department, after being rejected admission by three hospitals, with features of chest pain at rest 5 days prior to admission associated with dyspnea and nonproductive cough along with elevated troponin and ST elevation. She was initially diagnosed as acute coronary syndrome with acute heart failure and was taken up to the cardiology ward where a proper clinical examination suggesting right middle lobe localized crackles and chest X-ray findings prompted the suspicion of COVID-19, testing for which by a viral RNA-based test came as positive. This case illustrated the unique challenge posed by the COVID-19 for the cardiologist and the importance of clinical examination and a high index of suspicion needed along with prompt isolation of any suspected case. She was shifted to the COVID ward from where she was discharged after 5 weeks.

Iliopsoas Abscess in a 24-Months-Old Child: Management in Absence of an Identifiable Organism

Iliopsoas abscess presents with vague and variable symptoms and is less commonly encountered in a clinical setting. The most common causative agent is staphylococcus aureus. In our case, a 2-year-old boy presented with high-grade fever, difficulty in walking, and pain in the right leg near the hip joint. Psoas sign was positive but his blood cultures were negative and CT scan showed a necrotic mass with peripheral enhancement measuring 7.0x4.2x2.6 cm in all three dimensions in right Psoas muscle. Biopsy of the abscess was denied and the patient was managed conservatively with intravenous ceftriaxone and metronidazole. This case highlights the importance of clinical examination and then co-relating it radiologically and focuses on the importance of broad-spectrum antibiotics when necessary investigation (biopsy in our case) is denied.

Acute aortic dissection presenting as st segment elevation myocardial infarction- importance of clinical examination revisited

Acute aortic dissection presenting as st segment elevation myocardial infarction- importance of clinical examination revisited

Gaucher’s Disease - A Rare Cause of Massive Splenomegaly

Gaucher’s disease (GD) is a lysosomal storage disorder due to glucocerebrosidase deficiency; it’s one of the rare genetic diseases for which therapy is now available. Lysosomal storage of the substrate in cells of the reticuloendothelial system leads to multisystem manifestations, including involvement of the liver, spleen, bone marrow, lungs, and nervous system. Three different subtypes have been identified: Type 1, non-neuropathic form, adult onset; type 2, acute neuropathic form, infantile onset; type 3, neuropathic form, juvenile onset. The diagnosis is confirmed by presence of less than 15% activity of the enzyme Glucocerebrosidase in peripheral leucocyte with presence of Gaucher cells in macrophase monocyte system, is the pathological hallmark. Enzyme replacement therapy (ERT) is now available. We are reporting a case here which presented with cytopenia and massive splenomegaly. This case has been presented to focus on the importance of clinical examinations, differentiating from other diseases of similar manifestations, enzyme activity and bone marrow study for early diagnosis.&#x0D; J MEDICINE JUL 2019; 20 (2) : 98-101

The Importance of Clinical Examination in Traumatic Brachial Plexus Injuries

The Importance of Clinical Examination in Traumatic Brachial Plexus Injuries

Uterine Perforation on Invasive Hydatidiform Mole during EMACO Treatment

Objective: Improving skill and knowledge to recognize and manage&#x0D; a rare case of uterine perforation on invasive hydatidiform mole.&#x0D; Method: Case report.&#x0D; Result: A 42 years old Indonesian woman, Parity 2 Abortus 2 with&#x0D; history of 2 c-sections and 2 curettage, came with chief complaint of&#x0D; recurrent vaginal bleeding since 4 months before admission. Patient&#x0D; had a history of previous curettage with indication of hydatidiform&#x0D; mole and recurrent bleeding with no histopathology results. On examination we found a vesicular mass with infiltration, destroying&#x0D; the right-front uterine corpus, size 8x6 cm with an internal echo&#x0D; mass. Chest x-ray showed multiple nodules in the lung. The patient,&#x0D; considered as low risk Gestational Trophoblastic Neoplasia patient&#x0D; with FIGO Score of 6, underwent chemotherapy with 2 series of&#x0D; methotrexate . Due to the non-declining level of -hCG, the regimen&#x0D; was added with EMACO. In the process of chemotherapy, the pa-tient’s-hCG declined but then she complained of major abdominal pain. Exploratory laparotomy was performed and we found a mass sized 5x5x5 cm on the right side of the uterus at the broad ligament with a rupture at the posterior part of the mass sized 0.5x0.5 cm. Upon incision of the uterus, we found a mass from the right side protruding to the isthmus of the uterus. Histopathology showed necrosis, blood and chorionic villi in myometrium corresponding to invasive mole. Patient was then given another 5 series of EMACO and her condition was unremarkable during the remaining course of treatment.&#x0D; Conclusion: Invasive mole treatment is determined based on the&#x0D; risk factors. Uterine perforation still occurred in this case regardless&#x0D; of the decreasing hCG level during EMACO treatment. It emphasizes&#x0D; the importance of clinical examination as chemotherapy responsiveness.&#x0D; Long-term treatment can have a good prognosis but good&#x0D; collaboration between the gynecologist and the patient is essential.&#x0D; [Indones J Obstet Gynecol 2014; 3: 162-165]&#x0D; Keywords: EMACO, invasive mole, perforation

Arteriovenous Fistula: A Rare Complication of Peripheral Venous Cannulation and an Example of the Importance of Clinical Examination

Arteriovenous fistula is a rare complication of peripheral venous cannulation. We report a case of a 79-year-old male who presented with a subcutaneous swelling on the anterio-lateral aspect of his right forearm. The ‘lump’ developed at the same site as the insertion of a previous peripheral venous cannula. Careful clinical examination and later radiological confirmation diagnosed an arteriovenous fistula. The patient was referred to a vascular surgeon for advice regarding further management. This case demonstrates the importance of clinical examination for the accurate diagnosis of ‘Lumps and Bumps’ prior to surgical treatment.

5 Management of head/face trauma in football: a case report

About 11–40% of all sports injuries involve the face. In football, head/face injuries represent only 8 to 18% of all injuries. In Qatar national football championship, it was estimated during the last 3 seasons to 2%. Because of the growing interest in concussion, the majority of sport physicians know how to deal with such conditions, but other serious injuries such as face fractures can be underestimated. Sport physicians should be familiar with the anatomy of the facial region, the most common types of facial injuries and their initial management. A 33 year old football player, with unremarkable medical history, had a face trauma during a match in April 27 2014 (min 56). The first evaluation on field found a player suffering from headache, dizziness with balance disorder and pain on the right side of the face. There was no bleeding, no vomiting and no neck pain with normal vision and normal breathing. The Glasgow coma scale was 14/15. SCAT3 was performed and the decision was to substitute him and to transfer him to Hospital. The examination on the bench found normal vital signs and painful palpation of the upper right side of the face. There was no neurological deficit, no blurred vision and no cervical spine tenderness. The inspection and palpation of the nasal septum was normal. In hospital, skull X-rays (fontal and lateral view) were performed and gave normal findings. Then, he received an injection of Diclofenac (75 mg) which resulted in an improvement of his symptomatology. However, the reassessment noted a flattening of right cheek with numbness and a mild restriction in mouth opening. A CT scan showed a fracture of the anterior and lateral walls of the right maxillary sinus with hemosinus. He had surgery on April 28 2014 with good evolution and return to full training on July 15 2014. This case illustrates the importance of clinical examination. Moreover, if there is a history of sufficient force to result in suspected fracture then CT scan is usually the first investigation requested. If only X-rays are available, standard views for face imaging are Occipito-Mental (OM) and Occipito-Mental at 30 degrees angulation (OM30). In this context, the team physician should be familiar with immediate management of face/head trauma and if he is not comfortable with the acute management of the injury, should insist on more urgent care (or a second opinion) on behalf of his patient. Recognition of such conditions is critical for appropriate management and to preserve the health and career of the football player.

Reduction in the use of diagnostic tests in infants with risk factors for early-onset neonatal sepsis does not delay antibiotic treatment.

Despite a low positive predictive value, diagnostic tests such as complete blood count (CBC) and C-reactive protein (CRP) are commonly used to evaluate whether infants with risk factors for early-onset neonatal sepsis (EOS) should be treated with antibiotics. We investigated the impact of implementing a protocol aiming at reducing the number of diagnostic tests in infants with risk factors for EOS in order to compare the diagnostic performance of repeated clinical examination with CBC and CRP measurement. The primary outcome was the time between birth and the first dose of antibiotics in infants treated for suspected EOS. Among the 11,503 infants born at ≥35 weeks during the study period, 222 were treated with antibiotics for suspected EOS. The proportion of infants receiving antibiotics for suspected EOS was 2.1% and 1.7% before and after the change of protocol (p = 0.09). Reduction of diagnostic tests was associated with earlier antibiotic treatment in infants treated for suspected EOS (hazard ratio 1.58; 95% confidence interval [CI] 1.20-2.07; p <0.001), and in infants with neonatal infection (hazard ratio 2.20; 95% CI 1.19-4.06; p = 0.01). There was no difference in the duration of hospital stay nor in the proportion of infants requiring respiratory or cardiovascular support before and after the change of protocol. Reduction of diagnostic tests such as CBC and CRP does not delay initiation of antibiotic treatment in infants with suspected EOS. The importance of clinical examination in infants with risk factors for EOS should be emphasised.