Sound Clinical Judgment Research Articles

Report of the Joint Committee for Stroke Facilities

The use of special procedures and equipment has become an integral, progressively complex, and increasingly expensive part of diagnosis and management in cerebrovascular disease. However, tests have enhanced rather than replaced the role of precise neurological examination and sound clinical judgment in caring for the stroke patient. The physician is obligated to understand the nature, limitations, complications, costs, indications, contraindications, and values of the many available diagnostic modalities and to avoid their indiscriminate use; most, and in some cases all, of this information should be known as well by hospital administrators, nurses, allied health professionals, and even the patient and his family. This Section discusses the present status of radiological and other diagnostic studies in disorders of the cerebral circulation. Rapid changes are occurring in this field with the almost daily appearance of new procedures, modifications, and applications, thus increasing the responsibility of all concerned to keep current with these new developments.

The physiology of pregnancy: clinical pathologic correlations. 2.

Pregnancy is a physiologic stress test during which subtle impairment of any organ system is manifested. The hepatic and gastrointestinal systems are the least affected by pregnancy, whereas the endocrine system probably undergoes the greatest stress and presents some of the most confusing test results. Only by being aware of the physiologic changes that accompany pregnancy can the physician make sound clinical judgments regarding both mother and fetus.

Hypersensitivity.

In his preface, Sherman states that this book is primarily concerned with the practical management of hay fever, asthma, and other common allergies. In this respect the author has presented an extremely lucid discussion, relating sound clinical principles and judgment to the practical therapy of atopic problems. Allergic reactions are thoroughly discussed from the standpoint of etiology, diagnosis, therapy, and prevention. The relatively infrequent role of allergy in the causation of certain syndromes as migraine headaches and gastrointestinal disorders is also placed in proper perspective. For the physician, unfamiliar with such techniques, guidelines for proper skin testing and hyposensitization therapy are clearly explained. Certain statements and omissions deserve comment. Recommendations for limitation of intradermal tests to 18 at one sitting and yearly retesting are not universally accepted. The frequent inadequacy of whole-body stinging-insect extracts as test materials in hypersensitive individuals is not sufficiently stressed. The efficacy of bacteral vaccines is

Hypertensive Vascular Disease: Diagnosis and Treatment.

The purpose of this volume is to serve as a practical guide to the investigation and management of the hypertensive patient. This goal has been achieved admirably. The well-informed physician confronted with the hypertensive patient knows that the management of hypertension is a far more complicated problem now than it was two decades ago. We now have at our disposal a number of antihypertensive drugs of varying degrees of potency, each with its own constellation of adverse effects. In addition, we are constantly reminded that we must not overlook potentially curable forms of hypertension. To facilitate their recognition we have new (sometimes risky and costly) methods of investigation. "In the evaluation of the patient with elevated blood pressure there is still room for the use of good clinical judgment without recourse to elaborate laboratory investigation," say the authors. Ample evidence of sound clinical judgment is displayed throughout the text, and

Differential Diagnosis of Hypercalcemia

ALTHOUGH hypercalcemia may occur in a wide variety of diseases, differential diagnosis in any given patient, although sometimes difficult, is usually limited to but a few possibilities. Foremost among these is hyperparathyroidism, the most easily curable of the entities listed in Table 1. Until an assay technic for parathyroid hormone becomes readily available and practical for clinical use indirect approaches to diagnosis must be utilized. This review will be concerned with an evaluation of these approaches, but it is quite clear that there can be no substitute for sound clinical judgment, It should be noted incidentally that, although this review is . . .

Prognostic index for vaginal delivery in breech presentation at term

We have shown by the use of a breech scoring index that potentially difficult breech deliveries may be recognized early in labor, indeed on admission, provided there has been some prior active labor. It would appear that all cases of overt fetopelvic disproportion and, more importantly, most cases of subclinical disproportion will be manifested by a low score (0–3).A breech score of 4 may be indicative of a problem. Further evaluation by radiologic means should be used.There should be no difficulty with breech delivery when the score is high. In fact, where abnormal labor exists, oxytocic stimulation may be used to advantage.The breech score represents an index of sound clinical judgment. It has not been devised to replace an obstetrician's acumen, but only to portray visually the factors involved in his decision to allow a patient with a breech presentation to continue in labor or be delivered by cesarean section.

Clinical problems of cardioversion

Capacitor-discharge countershock offers the physician an effective and even dramatic tool in the treatment of many cardiac arrhythmias. It is not intended to be a substitute for sound clinical judgment or to be a “magic button” with which a cure may be effected. Some of the immediate problems associated with the clinical use of this form of treatment for certain cardiac arrhythmias have been discussed, in order to emphasize its practical advantages as well as its limitations. We have not discussed the problem associated with the use of long-term drug prophylaxis in maintaining normal rhythm once it is established. The push-button technique of reversion should not be withheld as a fearful, ultimate weapon in the war on cardiac arrhythmias, used only when all else has failed, but as a safe, effective instrument with which the physician may restore peace to the heart.

Local Anesthetics: Current Concepts

The science and art of local anesthesia has advanced tremendously during recent years. We now have at our disposal a wide range of local anesthetic solutions all of which are effective and, under normal circumstances, well, tolerated. A small selection of various solutions will equip the dentist to meet almost any situation as far as pain control is concerned. But let us consider each situation beforehand and know exactly what we are injecting and attempt to justify the use of one solution in preference to another in that given situation. Disposable needles offer us much, and aspiration should be automatic at each injection. These advantages, when used with sound clinical judgment, should give us reason for continued pride in dental local anesthesia.

Value of angiography in head trauma.

HomeRadiologyVol. 78, No. 6 PreviousNext ArticlesValue of Angiography in Head TraumaEugene V. Leslie, Bernard H. Smith, John G. ZollEugene V. Leslie, Bernard H. Smith, John G. ZollEugene V. LeslieBernard H. SmithJohn G. ZollPublished Online:Jun 1 1962https://doi.org/10.1148/78.6.930MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractCerebral angiography is a reasonably safe procedure which affords a precise diagnosis in a multiplicity of post-traumatic entities. While its application in any given case rests upon sound clinical judgment, increased use of this method is urged. Voris (1) in 1955 stated that it was often difficult to diagnose sub- and extradural hematomata. He further indicated that the presence of an intracerebral hematoma after trauma was not easily recognized, but that, if a burr hole exploration were unrevealing, the brain should be cautiously explored with cannula. It is fair to say that in most instances these hematomata are readily identified and localized angiographically. Carton (2), making a plea for increased use of this modality in 1959, stressed his dissatisfaction with trephination as the approach to intracranial bleeding in acute trauma. Fasiani (3) and Campbell and Campbell (4) have also emphasized the simplicity, safety, and precision of angiography in the diagnosis and localization of a wide variety of lesions in cases of head injury. Hancock's series (5) indicates that the hazard of the missed lesion, especially the intracerebral hematoma, exceeds the slight risk of angiography.Table I lists the mass lesions and other abnormalities occurring after head trauma in which arteriography is enlightening. As will be seen, one can generally distinguish angiographically the extradural from the subdural hematoma. These extracerebral hematomata can further be differentiated from the intracerebral mass lesions, namely the more severe cerebral contusions and the intracerebral hematomata. Traumatic subarachnoid hemorrhage, probably the most common cause of blood in the cerebrospinal fluid may, for example, be associated with an intracranial hematoma. In point of fact, more than one of these post-traumatic entities may often be present (6), and angiography will frequently help one to appreciate their coexistence. Post-traumatic internal carotid thrombosis is an important although uncommon entity (7). Dural sinus thrombosis following trauma is similarly important but relatively infrequent (8). Both traumatic caroticocavernous fistula and caroticojugular fistula may be the result of penetrating wounds. The former, however, is more frequently associated with basal skull fracture.Angiographic differentiation of the extracerebral hematomata is usually feasible. All have the common feature of an avascular area between the inner table of the skull and the brain.EXTRADURAL HEMATOMAExtradural hematoma is, in most instances, associated with linear fracture of the parietal or temporal bone with resultant severance of the middle meningeal artery or one of its branches. The clinical picture is usually such that immediate surgical intervention is undertaken. Occasionally, however, and, especially when the bleeding is largely venous, the clinical picture will not at once lead to the appropriate diagnosis and angiography will reveal the true situation. Figure 1 is an angiogram obtained less than twenty-four hours after trauma, although, at the time, no history of injury was available. Classically we see displacement of the anterior cerebral artery to the opposite side, medial displacement of the middle cerebral artery, and a lentiform avascular area lying extracerebrally over the convexity of the brain. This appearance, in itself, when encountered within several days of the injury, is typical of an extradural hematoma which, in dissecting the dura off the inner table, opens up a space that is thus convex inward and outward.Article HistoryPublished in print: June 1962 FiguresReferencesRelatedDetailsCited ByVoprosy neirokhirurgii imeni N.N. Burdenko, Vol. 83, No. 4Child's Nervous System, Vol. 34, No. 3Journal of Neurosurgery, Vol. 100, No. 2Neurologia medico-chirurgica, Vol. 41, No. 1Journal of Neurosurgery, Vol. 76, No. 1British Journal of Neurosurgery, Vol. 3, No. 5Journal of Neurosurgery, Vol. 66, No. 5Acta Neurochirurgica, Vol. 60, No. 1-2Surgical Neurology, Vol. 17, No. 3Acta Neurochirurgica, Vol. 55, No. 3-4Journal of Neurosurgery, Vol. 52, No. 1Neuroradiology, Vol. 17, No. 5Angiology, Vol. 27, No. 9The British Journal of Radiology, Vol. 46, No. 542Clinical Radiology, Vol. 22, No. 3Postgraduate Medicine, Vol. 42, No. 2The British Journal of Radiology, Vol. 39, No. 461Journal of Neurosurgery, Vol. 25, No. 4Radiologic Clinics of North America, Vol. 4, No. 1The British Journal of Radiology, Vol. 38, No. 455Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 78, No. 6 Metrics Altmetric Score PDF download

Conservation of the dental pulp—Cavity preparation

The thoughts in this article may be summarized by stating that patients with dental caries are afflicted by a serious ailment. Their teeth are diseased and have carious lesions within them. When a carious lesion is excised, living tissues are cut. Excision of viable dentin is excision of extended living pulp. In order to treat patients with diseased teeth successfully, sound clinical judgment is required in addition to surgical skill. Sound clinical judgment dictates a sensible combination of old and new therapeutic practices for the patient's benefit. The dentist wants each patient to have the best treatment he can provide. The patient receives such treatment when the operation is carefully planned and executed within the broad framework of basic biomechanical principles from which all successful therapy derives. An operation so planned and conducted conserves the dental pulp, promotes patient welfare, and enhances the dentist's professional reputation.

Effective use of diagnostic data

Diagnostic information is invaluable when it is correctly interpreted and effectively used in the treatment plan. A thorough diagnostic service is essential for optimum results. Some patients may present almost insurmountable obstacles by way of extremely unfavorable ridge support, ill health, and/or poor mental attitude. Under these circumstances, satisfaction may be difficult. A thorough knowledge of the subject, an adequate degree of skill and experience, sound clinical judgment, and a maximum effort constitute the dentist's supreme and ultimate resources in coping with and conquering the problems involved in serving the edentulous patient.

Physical treatment of the painful arm and shoulder.

Treatment of a painful shoulder should be preceded by careful diagnostic study. It is convenient to divide the pathological conditions that can cause pain in the shoulder into those that do and those that do not cause limitation of shoulder motion. Wherever feasible, physical therapy is directed toward the cause of the pain. For maximal effectiveness from physical therapy, the treatments should be administered by a fully qualified physical therapist. The physician who prescribes such treatment must exert sound clinical judgment in selecting the specific procedures to be utilized and the frequency and duration of the treatment so that the desired results can be achieved without exceeding the physical tolerance of the patient.

Master two-step test in coronary artery disease.

The Master two-step test is a standardized exercise that permits the making of an electrocardiogram immediately after the activity terminates. The main criterion of the result is the behavior of the S-T segment of the tracing; depression of more than 0.5 mm. in any lead is considered a positive result. The test was applied to 186 patients known to have either angina pectoris or a healed myocardial infarction. By the criterion of ischemic S-T segment depression alone the test was positive in 61.3%; when Master's other criteria were also imposed, the test was positive in 81.7%. The test was applied further to 108 normal persons. By the criterion of ischemic S-T segment depression alone the test was negative in all; when Master's other criteria were also imposed, the test was positive in 19.4%. While a negative result does not exclude coronary insufficiency, a positive one strengthens the diagnosis of suspected coronary disease. Although the only conclusive evidence of coronary insufficiency is believed to be ischemic S-T segment depression, fewer cases escaped detection when all of Master's criteria were utilized. When sound clinical judgment is employed in conjunction with the test, overdiagnosis is infrequent.

Bacteriology in Endodontic Treatment

The successful retention of the treated pulpless tooth as a healthy functioning member of the dental arch is an outstanding achievement. The application of bacteriologie methods to endodontic practice complements sound clinical techniques and judgment. It serves as a continuous control and a measure of aseptic technique, efficacy of drug treatment and surgical débridement. It restores confidence in the practitioner by providing objective evidence to substantiate his skill and competence.

The chemotherapy of bacterial infections refractory to the common antibiotics

Since the introduction and widespread use of antibiotics, organisms such as B. proteus, Ps. aeruginosa, coli-aerogenes, Staph. aureus and the enterococcus have emerged as common etiologic agents of refractory infections. With proper precautions and careful observation, more toxic antibiotics such as polymyxin, neomycin and bacitracin may be successfully employed in the treatment of these infections. In addition, erythromycin, carbomycin and furadantin are more recent chemotherapeutic agents which are of some assistance in combating organisms resistant to the older antibiotics. Of course, it must be stressed that the successful treatment of a refractory bacterial infection depends on the early and proper evaluation of the diagnosis and the host factors involved, as well as consideration of the chemotherapeutic and bacterial agents. The answer to eradication of these infections will most frequently be found in sound clinical judgment, application of longestablished principles of general medical and surgical therapy, and in carefully standardized and controlled laboratory sensitivity determinations.

Uterine inertia.

During the past two decades, marked changes have occurred not only in the teaching but also in the practical application of obstetrics. The "watchful waiting" of some of the best teachers and clinicians has been replaced by sound knowledge and thoughtful application of facts learned, instead of the noninterference advocated formerly. The "newer obstetrics" inquires into the factors that cause uterine inertia, with sound clinical judgment used in determining when passive expectancy should be replaced with active help for the patient. Many teachers are now beginning to teach what they practice rather than to practice radicalism and to teach conservatism. This approach has resulted from the realization that so-called normal labor can result in great harm to both mother and child. A prolongation of either the first or second stage of labor due to inertia may lead to fetal damage if the condition is not corrected by a sane approach

An evaluation of the biopsy as a diagnostic aid

It has not been the purpose of this discussion to deal intimately with the histologic nature of the cases reported; rather, an attempt has been made to show the necessity for histologic examination, in order to catalogue tumors and diseases properly. Perhaps the impression of overemphasis on the biopsy is obtained from such a discussion. If so, it should be again emphasized that the biopsy cannot replace sound clinical judgment or any of the many other diagnostic aids. It can and does, however, often contribute much concrete information as to the exact character of the tumor or disease in question. This information, however, must be properly correlated by the clinician in order to evaluate truly the process in question. The many erroneous beliefs concerning the dangers of biopsy, particularly in suspected malignant lesions, must be approached critically. Being essentially a simple process, one can estimate these dangers in comparison to an inadequate clinical interpretation. This, then, is a plea for the more universal employment of the biopsy as a diagnostic procedure, not only by the exodontist and oral surgeon, but by the general dentist, as well. It is important that whoever sees lesions of the mouth should fully understand their potentialities, in order to increase his ability to provide an adequate service for the patient.

Indications for Surgical Treatment of Goiter

THYROID surgery has in the past ten years been a subject of marked interest; as a consequence of which the widening of the field of operability, the resulting lowered mortality rate and improvement in results have made it, we believe, a field of surgery almost unrivaled in point of its ability to remove crippling, disabling and in many instances ultimately fatal burdens, and return patients so completely to health and activity. Before proceeding directly to the subject of the indications for the surgical treatment of goiter, we wish to stress a point which is of the very greatest importance in dealing with goiter. That is, that the basis of all sound thyroid treatment is diagnosis, and that is based upon sound clinical judgment, an attainment which is acquired only by an extensive experience with thyroid states. There is no clinical situation, in our opinion, where it is so readily possible to go astray as in determining the presence or absence of thyroid toxicity. It may be so simple to demonstrate that ...