Incomplete Examination Research Articles

Improvements in VA health services for women veterans.

Since the early 1980s, health care for women veterans in the Department of Veterans Affairs (VA) has improved considerably, although problems still remain. The lack of privacy for women at many VA facilities and the provision of incomplete physical examinations for women continue to be problematic issues. A 1992 congressional appropriation of $7.5 million has substantially increased the awareness of women veterans health care in the VA. This appropriation, from Public Law 102-585, Veterans Health Care Act of 1992, Title I-Women Veterans Health Programs, has allowed VA to expand services for women veterans. Using these funds, VA has established eight comprehensive women veterans health centers, 23 full-time women veterans coordinators, and four regional stress disorder teams. This paper describes these and other important new initiatives and discusses how they will serve as the foundation on which VA expands care for women within the context of a changing health care system.

The treatment of war injuries of the brachial plexus

To our knowledge there is little information available on the treatment of war injuries of the brachial plexus (BP)? -3 Most publications present a small number of patients with short or incomplete follow-up examinations. The reported results of treatment of brachial plexus injuries in World War II era were discouraging to the point that Brooks 4 believed that these treatments are rarely profitable or justifiable. Nulsen and Slade 3 also reported overall discouraging results from the study of 117 cases treated at different World War II treatment centers, and recommended early exploration only for cases of injuries to the upper elements, they also believed that treatment of the lower elements did not yield satisfactory results. With the progress in the operative techniques and the emergence of microsurgery, improved results have been subsequently reported? -8 During the revolution in Iran and the following IraqIran war (1979-1987), 2629 patients with peripheral nerve injuries were treated by the author. The purpose of this article is to report the experiences gained in treating 369 patients with brachial plexus injuries, and more specifically the results of 246 of these cases with followup evaluations of 5 or more years after surgery.

Evaluation of Torrey and Yolken's Feline Viral Zoonosis Theory of Schizophrenia

A formal method of evaluation is applied to a theory presented by Drs. Torrey and Yolken, which asserts that cases of viral schizophrenia are due to a zoonosis from house cats. A formal method of theory evaluation is described, and the Torrey and Yolken theory is subjected to analysis by the method. The theory is found to be weak in several areas stemming from inadequate description of both the relevant clinical population and the viral pathogenesis, as well as an incomplete examination of available data bearing on a hypothesized association between schizophrenia and cat ownership. At this point, further work is indicated at the level of theory development before proceeding with research or clinical activity.

Renal Doppler, Renal Artery Stenosis, and Renovascular Hypertension

There are two methods of duplex evaluation for renal artery stenosis (RAS): (a) direct interrogation of the main renal artery and (b) indirect duplex evaluation of the distal renal arterial tree (distal main renal artery, segmental or interlobar branches of the renal artery). Direct and indirect methods have comparable sensitivity (low 90% range) and specificity (mid-90% range) for detection of ≥ 60% RAS. Direct interrogation requires that the entire length of both renal arteries be evaluated and is plagued by a relatively high technical failure or incomplete examination rate, long examination times, and difficulties in measuring accurate velocities due to suboptimal angles of incidence. Indirect evaluation, on the other hand, is technically successful in the vast majority of cases and less time consuming than direct interrogation. We recommend the indirect method for initial evaluation, but direct interrogation whenever the indirect evaluation is equivocal or abnormal. Although less demanding than direct methods, indirect duplex methods still require a thorough understanding of Doppler principles and meticulous technique. Direct interrogation criteria for ≥ 60% RAS are (a) renal artcry-to-aortic ratio (RAR) of ≥ 3.5 or (b) peak systolic velocity (PSV) ≥ 180 cm/s in association with poststenotic turbulence. Indirect parameters to diagnose ≥ 60% diameter RAS include acceleration time (AT) <.07 s, acceleration index (Al)<2.78 kHz/s2/MHz, acceleration (ACC)<3 m/s2, absence of the normal early systolic peak (ESP), difference in resistivity index between the ipsilateral and contralateral kidney (RID) <—5, and marked asymmetry in the shape of waveforms between the right and left kidneys or between upper-h mid-, and lower portions of one kidney. We found pattern recognition for loss of ESP the most expedient and sensitive parameter for 60% diameter RAS (91% sensitivity. 96% specificity). Limitations of indirect Doppler methods include insensitivity for 50% diameter RAS, inability to distinguish severe stenosis from occlusion, and insensitivity for stenosis in an accessory or segmental renal artery. In addition, bilateral indirect Doppler abnormalities may be due to occlusive disease proximal to the renal arteries (i.e., aortic coarctation) rather than bilateral RAS. Duplex sonography is useful to assess the effectiveness of revascularization procedures, [percutaneous transluminal angioplasty (PTA). stent placement, surgical graft placement]. After successful revascularization, indirect Doppler parameters return to normal immediately. Their failure to return to normal indicates a poor technical result and also predicts a poor blood pressure response to treatment. Patients with indirect Doppler abnormalities have higher systolic and diastolic blood pressures than subgroups of hypertensive patients who have a ≥ 10% of RAS based on clinical selection criteria.

A survey of lower limb amputation in diabetic patients.

A retrospective survey of non-traumatic and non-neoplastic lower limb amputations in Newcastle upon Tyne during 1989-91 was performed. Hospital data were cross-checked with the local limb fitting centre to ensure 100% ascertainment. The diabetic patients were found to be 39% of amputees and 42% of operations (all levels). Incidence of diabetes amputation was 5.7 per 100,000 population per year. Fifteen percent of the diabetic patients had diabetes first diagnosed when they were admitted for amputation. For the known diabetes patients, 46% were under diabetes care by general practitioners only. Forty-seven percent of the patients who were under the care of a hospital service for diabetes had incomplete foot examination and assessment. Mortality rate within 30 days after diabetic amputation was 10% and median life expectancy following amputation was 22 months. It seems likely that assessment and management of the diabetic foot remains suboptimal in Newcastle, and that protocols and audit of care could lead to improvements without additional resources.

Radiologic Evaluation of the Horse Relevant to Purchase

Adequate radiographic evaluation of the horse relevant to purchase examination requires the successful integration of technique, interpretation, and reporting. A thorough knowledge of lameness and disease can be masked by incorrect interpretation resulting from poor-quality films or an incomplete examination. Thus, care must be taken to produce an adequate number of high-quality films on which to base a report, which allows you to describe changes that are present. This information, coupled with your physical examination, other laboratory data, and the knowledge of the expressed use of the horse will allow you to advise prospective owners on the decision that they will ultimately make.

Haemostatic responses and vasopressin release during colonoscopy in man.

1. During major abdominal surgery there are increases in Factor VIII and plasminogen activator activity, associated with elevated plasma concentrations of vasopressin, of a magnitude shown to affect haemostasis. 2. To investigate the mechanisms involved in the haemostatic response to surgery, 12 patients undergoing fibre-optic colonoscopy were studied, of which six had a complete and six had an incomplete examination. 3. Venous blood samples were taken before, during and after the procedure for assay of plasma vasopressin, adrenaline and noradrenaline concentrations, Factor VIII coagulant activity, von Willebrand factor antigen level, euglobulin clot lysis time, tissue-type plasminogen activator activity and tissue-type plasminogen activator inhibition. 4. In the six patients who underwent a complete procedure the median plasma vasopressin concentration rose from 0.6 pg/ml to 153 pg/ml during colonoscopy. Factor VII coagulant activity rose from 0.9 to 2.4 i.u./ml and von Willebrand factor antigen level rose from 139 to 224%. Plasminogen activator activity increased from 20 to 144 units and tissue-type plasminogen activator activity rose from 107 to 1338 m-i.u./ml, whereas tissue-type plasminogen activator inhibition fell from 4.8 to 1.0 i.u./ml. 5. In the six patients in whom a limited procedure was performed, there were no changes in haemostatic function or in plasma vasopressin concentration. Plasma concentrations of adrenaline and noradrenaline did not change in either group. 6. The results indicate that vasopressin regulates the intrinsic coagulation pathway and fibrinolytic system in the absence of adrenaline release.

無症候性顕微鏡的血尿症例に対する膀胱鏡検査の意義

As a prospective study on asymptomatic microhematuria, complete urological examinations including cystoscopy, IVP, ultrasound and urinary cytology were performed on 422 patients over 40 years old between January 1987 and December 1988 (group A). The results of group A was compared with that of retrospective study on 266 patients, who had incomplete urological examination between January 1984 and December 1985 (group B). Cystoscopy was performed on 321 patients (87.2%) in group A and on 108 patients (40.6%) in group B. Bladder tumor was found in 10 cases (2.4%) in group A, including 7 cases of male patients (5.7%), but in only 1 case (0.4%) in group B. Since the negative rate of abnormal urinary cytology was 50% and that of abnormal IVP was 90% in 10 cases of bladder tumor in group A, cystoscopy was considered to be an essential examination for the screening of patients with asymptomatic microhematuria over 40 years old patients.

Anal canal stenosis and pseudo‐obstruction

Mechanical large bowel obstruction and pseudo-obstruction can be difficult to differentiate because clinical symptoms and signs are often misleading. Although plain abdominal radiographs showing diffuse gaseous distension, no shut-off point and gas in the rectum are very suggestive of pseudo-obstruction, incomplete clinical examination with over-reliance on the abdominal radiographs may lead to large bowel mechanical obstruction being misdiagnosed as pseudo-obstruction. We report a rare case of large bowel obstruction occurring secondary to anal canal stenosis.

Medical Clearance: Fact or Fiction in the Hospital Emergency Room

Prior medical clearance is an important variable in the psychiatric assessment of the emergency room patient. An analysis of documentation of prior physical examinations on a consecutive series of 137 patients seen in a general hospital emergency room and referred for psychiatric consultation revealed wide variance in physical examinations. The authors discuss the implications of incomplete physical examinations for psychiatry and offer proposals for standardization of this important aspect of patient evaluation.

Cystic Tumors of the Pancreas

Within a 12-year period we treated 67 patients (49 women, 18 men; mean age, 61 years) with cystic neoplasms of the pancreas, including 18 serous cystic adenomas, 15 benign mucinous cystic neoplasms, 27 mucinous cystadenocarcinomas, 3 papillary cystic tumors, 2 cystic islet cell tumors, and 2 cases of mucinous ductal ectasia. Mean tumor size was 6 cm (2 to 16 cm). In 39% the patients had no symptoms, and in 37% the lesions had been misdiagnosed as a pseudocyst. Computed tomography was useful for detection, for distinguishing the microcystic subgroup of serous cystadenoma, and for showing rim calcification (all 7 cases were malignant) but was not reliable for distinguishing neoplasm from pseudocyst, serous from mucinous tumors, or benign from malignant. Arteriography showed hypervascularity in 4 of 10 serous adenomas, 3 of 11 mucinous carcinomas, and 1 of 1 papillary cystic tumors. Endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia. Stenosis or obstruction of the pancreatic duct indicated cancer. The tumor was resected by distal pancreatectomy in 25 patients, by proximal resection in 29, and by total pancreatectomy in one, with no operative deaths. Forty-four per cent of the tumors were malignant. In 10 cases the tumor was unresectable because of local extension or distant metastases, and those patients died at a mean of 4 months. Seventy-five per cent of those resected for cure are alive without evident recurrence. Because the epithelial lining of the tumor was partially (5% to 98%) absent in 40% to 72% of cases of the major tumor types, and the mucinous component comprised only about 65% of mucinous cystadenoma lining, misdiagnoses on frozen and even permanent sections were made. Mitoses and histologic solid growth correlated with malignancy. Neuroendocrine elements were seen in 87% of benign and 47% of malignant mucinous tumors. It is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous. Incomplete examination of the cyst wall can be misleading, however. It is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected, with the possible exception of asymptomatic confirmed serous cystadenomas.

The accuracy of bedside neurological diagnoses

The accuracy of bedside diagnoses was prospectively studied in 100 consecutive patients admitted to the neurology service at New England Medical Center, Boston. Each patient was evaluated independently by a junior resident, a senior resident, and a staff neurologist, who were required to make an anatomical and etiological diagnosis based solely on the history and physical examination. Fourteen patients were excluded because their diagnoses were known before admission. Of the remaining 86 patients, it was possible to confirm anatomical and etiological diagnoses in 40 by matching the clinical syndromes with highly specific laboratory findings. In the other 46 patients, the diagnoses could not be confirmed because the laboratory studies (including magnetic resonance imaging) were negative or nondiagnostic. In the 40 patients with laboratory confirmed final diagnoses, the clinical diagnoses of the junior residents, senior residents, and staff neurologists were correct in 26 (65%), 30 (75%), and 31 (77%), respectively. There was a trend for error rates to be higher among junior residents than staff (p = 0.06). The errors by the junior residents, [senior residents], (staff) were attributed to incomplete history and examination in 4 [1] (0), inadequate fund of knowledge in 4 [3] (3), and poor diagnostic reasoning in 6 [6] (6). These results indicate that technology is not a panacea for our diagnostic difficulties and that there is room for improvement in our clinical skills, especially diagnostic reasoning.

The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica.

The quality of care of random samples of about 40 infants admitted with acute gastroenteritis to each of five hospitals in Jamaica was assessed. Low levels of adherence to consensus care criteria appeared to be correlated with high levels of hospital-specific severity standardized mortality ratios X100 (SSMRs); poor adherence, SSMR 127-230; intermediate adherence, SSMR 95; good adherence, SSMR 14. The main deficiencies in care at certain hospitals were: non-weighing of infants, incomplete physical examination, inadequate estimation of fluid requirements, and irregular recording of fluid intake. To improve the effective care of infants with gastroenteritis, a quality assurance program is required.

Recognition of coarctation of the aorta. A continuing challenge for the primary care physician.

Coarctation of the aorta (CoA) in its classic form presents with characteristic and distinctive physical findings. However, in our survey less than one third of 106 consecutive patients in whom CoA was ultimately diagnosed had the correct diagnosis made by the referring physician. Our survey suggests that in asymptomatic infants and children, an incomplete physical examination explains the diagnostic failure. However, in infants presenting with heart failure, the diagnostic signs of CoA may be obscured and more difficult to recognize even when specifically sought. This survey reaffirms the need for specific physical examination techniques in all infants and children to facilitate early recognition of CoA; these include the palpation of pulses and proper measurement of blood pressure.

Demyelination and neurological signs in experimental allergic encephalomyelitis

Because of the reported absence of demyelination in some animals with neurological signs of experimental allergic encephalomyelitis (EAE), it has been suggested that these signs are not due to demyelination. The present study demonstrates that there is ample demyelination in the central nervous system (CNS) and peripheral nervous system (PNS) to account for the neurological signs in rats with myelin basic protein (MBP)-induced acute EAE as well as in rats and rabbits with whole-spinal-cord-induced acute EAE. The main reasons for failure to detect demyelination in animals with neurological signs of EAE appear to be inadequate histological techniques and incomplete examination of the nervous system, particularly the PNS and the lumbar, sacral and coccygeal segments of the spinal cord.

A user-oriented validation method for clinical data.

The patient data in hospitals is prone to many errors during computerization because of the large human element involved during the processes concerned. A user-oriented validation method, which has been found to be practical and acceptable, is suggested. A non-statistical approach is adopted in this regard. The qualitative requirements of all users for validation have been taken as the guidelines to achieve maximum user acceptability. A user-oriented data code sheet, whose format changes for different disease groups, has been devised to prevent most of the typographical errors. These code sheets have also been found to be of considerable help to doctors in keeping a check on any missed or incomplete investigations, examinations and history recording. The validation program detects all errors of a typographical nature and all commonly possible logical errors. In addition, the program outputs data values, whose accuracy is doubtful, in the form of warning messages like WARNED DATA and ERRONEOUS DATA. The data fields which do not contain any data are also output to help the clinicians to take note of investigations and clinical tests not done or whose results are awaited. The logical errors, if any, also help them in detecting and identifying atypical cases in any given disease group at the earliest possible stage of a patient's hospitalization. In this paper, the need for a user-oriented and non-statistical approach to the validation of clinical data has been discussed in detail and its advantages enumerated.

Laparoscopy in the staging and planning of therapy for pancreatic cancer

Although staging of pancreatic cancer is critical to the planning of therapy, many patients come to laparotomy with liver or peritoneal metastases not suspected or detected during conventional preoperative testing. We performed laparoscopic examinations as part of the staging evaluation of 40 patients with proved pancreatic cancer who were candidates for curative resection or intraoperative radiotherapy. In each patient, laparoscopy was the last test before laparotomy and was carried out only if all other test results were negative for metastases. In 14 of 40 patients, single, small (1 to 2 mm) metastatic nodules were detected and verified by biopsy in the liver (6 patients), on the parietal peritoneum (7 patients), and in the omentum (1 patient). It is likely that several of these lesions would have been overlooked at routine exploration. Because of the positive findings, therapy was altered in all 14 patients. None received intraoperative radiotherapy, nine who did not have jaundice were discharged without operation, three had biliary or gastric bypass only, and two were treated by percutaneous biliary stenting. Of the 26 patients who had negative findings on laparoscopic examination, the absence of gross metastasis was confirmed at laparotomy in 23. Three false-negative findings were caused by incomplete examination of the liver in two patients and a central liver lesion in one patient. Therefore, 43 percent of all patients (17 of 40) had demonstrable but unsuspected nonlocal metastases, and laparoscopic examination detected 82 percent (14 of 17) of these. The overall accuracy of laparoscopy was 93 percent and that of examination with negative findings, 88 percent. In eliminating useless laparotomy and redirecting treatment plans, laparoscopy contributes significantly both to the proper management of patients with pancreatic cancer and to increased efficiency of resource utilization.

The use of colonoscopy in the study of synchronous colorectal neoplasms

Over a 5-year period, 185 patients with primary colorectal carcinoma were studied by colonoscopy for synchronous neoplasms. Twenty-eight patients had incomplete examinations due to obstructing tumors, and 157 had total colonoscopy. Sixty patients (35.9%) had synchronous neoplasms, of which 43 (25.7%) were adenomatous polyps, 5 (3%) were villous polyps, and 12 (7.2%) were carcinomas. The planned surgical procedure was altered on 7 of 12 synchronous cancers (58.3%), 10 of 38 adenomatous polyps, and 17 of 157 (10.8%) patients who underwent total colonoscopy. Preoperative colonoscopy is deemed essential for the optimal management of the patient with colorectal carcinoma.

Clinical Experience with the Fieldmaster Perimeter

Perimetry performed on a Fieldmaster Model 200 on a consecutive series of 167 patients in a clinical practice setting demonstrated that Fieldmaster testing elicited 95% of defects found on Goldmann kinetic perimetry with very few false-positive or false-negative results; relatively unskilled personnel were able to conduct Fieldmaster testing well; and as our personnel and patients became familiar with the test, the rate of incomplete examinations declined to less than 2%.

How to Reduce Medicolegal Involvement in Cases of Trauma

The lessons learned from 52 medicolegal cases related to trauma are discussed. The role of informed consent is usually indirect. Surprise complications result in anger, and anger may provoke a suit. The emergency situation may be responsible for an incomplete examination, absence of a plan of management, or need to work with inexperienced personnel. An emergency does not preclude the need for prolonged followup in some situations. The availability of numerous devices has complicated the medicolegal problems. Recent relevant court decisions are discussed.