生坂 政臣

BACKGROUND: This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. METHODS: The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. RESULTS: For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). CONCLUSION: Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

OBJECTIVE: This study was performed to investigate the factors influencing the correlation between physician satisfaction and patient satisfaction in an outpatient setting. METHODS: New patients attending the General Medicine Outpatient Clinic of Chiba University Hospital and their physicians were enrolled. After the initial consultation, both the patients and the physicians completed an anonymous questionnaire. RESULTS: There were 875 patients (381 men and 494 women; mean age: 54 years) and 10 physicians (4 men and 6 women; mean experience: 6 years). The satisfaction of the patients and the physicians was not correlated (r=0.14, p<0.001). A logistic regression analysis revealed that the factors associated with greater physician satisfaction were "guidance/advice from senior colleagues" [odds ratio (OR)=2.03; 95% confidence interval (CI)=1.76-2.34] and "confidence in the diagnosis" (OR=1.52; 95%CI=1.37-1.69), while "a difficult patient" (OR=0.73; 95%CI=0.68-0.78) was associated with reduced satisfaction. The factors associated with greater patient satisfaction were "the doctor listened carefully" (OR=1.98; 95%CI=1.62-2.42) and "my diagnosis is correct" (OR=1.57; 95%CI=1.41-1.74). One item in the questionnaire for the physicians, "I diagnosed psychogenic illness" (OR=0.87; 95%CI=0.81-0.94), was associated with lower patient satisfaction. CONCLUSION: The satisfaction of the patients and the physicians was not correlated. If only the factors promoting the satisfaction of one party are targeted, the satisfaction of the other party will not increase. The satisfaction of the physicians may be increased by receiving advice from mentors and an improved diagnostic ability, while the patients wants a physician who listens carefully and makes the correct diagnosis.

A 34-year-old Japanese woman presented with a 2-year history of generalised bone pain, muscle weakness and gait disturbance. The patient had been following a restricted diet (without fish or dairy products) and avoiding ultraviolet exposure for 8 years to manage her worsening atopic dermatitis. Physical examination revealed generalised bone tenderness and bilateral symmetric proximal muscle weakness. Vitamin D-deficient osteomalacia was diagnosed based on the laboratory examination findings, which indicated high serum alkaline phosphatase, high intact parathyroid hormone, and low 25-hydroxyvitamin D levels. Her symptoms improved after oral active vitamin D and calcium administration. To the best our knowledge, this case is the first report of vitamin D-deficient osteomalacia in an adult patient due to excessive dietary restriction for managing atopic dermatitis. We emphasise the importance of increasing awareness of vitamin D deficiency as a risk factor for the development of osteomalacia, and caution against excessive avoidance of sun exposure and dietary restriction.

A 50-year-old Japanese man was referred to our department with pain in his limb joints persisting for 3 months. Although his joints showed no redness, swelling or tenderness, he had a limited range of motion of his hip and shoulder joints, suggesting a diagnosis of polymyalgia rheumatica (PMR). However, his relatively young age and subacute course along with the absence of morning stiffness made the diagnosis uncertain. We performed positron emission tomography/CT, which revealed 18F-fluorodeoxyglucose uptake in bilateral upper and lower joints, consistent with PMR. There was also uptake by a sacral tumour, suggesting a diagnosis of paraneoplastic syndrome. Immunoglobulin A-κ type M protein was detected in serum and bone marrow aspiration/biopsy identified diffuse proliferation of atypical plasma cells, confirming a diagnosis of multiple myeloma. The patient received chemotherapy, which alleviated his limb pain, and achieved stringent complete remission after autologous peripheral blood stem cell transplantation.

Purpose We hypothesized that even with appropriate clinical information, abnormal CT findings can still be missed if correct diagnostic predictions are not made. Materials and methods Of 388 total students (97 5th-year medical students x 4), students who detected abnormalities without clinical information were eliminated. The remaining students (hereafter, subjects) obtained clinical information, made diagnostic predictions, and reevaluated images. The proportion of failures in detecting abnormalities was compared between the correct prediction group and the incorrect prediction group. In the correct prediction group, the relationship between failures of detection and the ranking of the correct diagnosis was also examined. Results A total of 341 subjects were assessed. The proportion of subjects who failed to detect abnormalities in the correct prediction group (47.7 %, 93/195) was significantly lower (P &lt; 0.001) than in the incorrect prediction group (85.6 %, 125/146). In the correct prediction group, the proportion of subjects who failed to detect abnormalities was significantly lower (P = 0.004) when the correct diagnosis was ranked first (38.5 %, 42/109) compared with lower rankings (59.3 %, 51/86). Conclusion Making appropriate diagnostic predictions and estimating the possibility of them based on clinical information is important to avoid missing abnormal CT findings.

A 57-year-old woman presented with a fever and left-sided hip and back pain. The hip pain was explained by L3 radiculopathy because the pain was distributed on the L3 dermatome accompanied by allodynia. On the other hand, the back pain was located on the left side 1 cm from the spinal process of the L3-4 vertebrae. Enhanced computed tomography of the abdomen revealed an abscess in the left paravertebral muscle, and pyomyositis was diagnosed. Following percutaneous drainage via ultrasound, both the hip and back pain immediately improved. Paraspinal pyomyositis as well as lesions inside the spinal canal should therefore be considered in the differential diagnosis of patients presenting with fever, back pain, and radiculopathy.<br>

A 51-year-old woman presented with a 3-month history of left-sided chest pain. The pain was colicky, without associated tenderness, and involved the T5-8 thoracic dermatomes. We suspected referred pain from peptic ulcer, and upper gastrointestinal endoscopy revealed multiple ulcers in the middle-third of the gastric lesser curvature. As the patient was on non-steroidal anti-inflammatory drug (NSAID) treatment for tension headaches, NSAID-induced peptic ulcer was diagnosed. Proton-pump inhibitor (PPI) treatment resulted in prompt pain relief. There are few reports of chest pain as the sole presenting symptom of peptic ulcer. Nevertheless, although rare, peptic ulcer should also be considered in the differential diagnosis of chest pain.

PURPOSE: To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. PARTICIPANTS AND METHODS: Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A "correct" diagnosis was one where the predicted disease matched the final diagnosis code. RESULTS: A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, -3.6) (χ (2)=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. CONCLUSION: Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors' competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further consultation hours.

Pain is physiologically classified as nociceptive pain, neuropathic pain, and psychogenic pain. Nociceptive pain is further divided into visceral pain, somatic pain, and referred pain. Visceral pain is dull, and it is difficult to locate the origin of such pain. Somatic pain is sharp, severe, and well localized. On receiving visceral input for pain, it affects somatic nerve inputting to the same spinal segments, then referred pain is felt in the skin and muscles supplied by it. Referred pain is felt in an area that is located at a distance from its cause. History taking is the most important factor for determining the cause of pain. Generally, all the necessary information regarding pain can be acquired if pain-related history is obtained using the "OPQRST" mnemonic, that is, onset, provocation/palliative factor, quality, region/radiation/related symptoms, severity, and time characteristics.

Background: Taking a good history is important for the diagnosis of abdominal pain. We investigated questionnaire items that were significantly correlated with causes of abdominal pain requiring hospitalization. We also studied the combination of responses that could exclude severe disease.<br>Method: Between February 2006 and December 2007, 296 of 317 patients with abdominal pain who attended our Outpatient Department completed a questionnaire for their abdominal pain. They included 32 patients requiring hospitalization (severe group) and 264 other patients (mild group). The percentage of positive responses to each questionnaire item was compared between the two groups, and those showing a significant difference were employed for logistic regression analysis.<br>Results: The following 4 responses were selected: "It is less than 7 days since the onset of pain" (odds ratio [OR], 2.8; 95% confidence interval [95% CI], 1.2-6.4); "The pain is exacerbated by walking" (OR, 2.8; 95% CI, 1.3-6.2); "The pain is accompanied by weight loss" (OR, 3.8; 95% CI, 1.5-9.8); and "The pain wakes me at night" (OR, 2.3; 95% CI, 1.1-5.2). If a patient had none of these responses, the predictive value was 0.03 for severe disease.<br>Conclusions: Our findings suggested that pain reported within 7 days, exacerbation by walking, nocturnal awakening, and associated weight loss are features of abdominal pain that predict severe disease. Conversely, severe disease can be almost completely excluded in patients negative for all 4 features.

Rationale, aims and objectives To investigate the subsequent behaviour of doctor-shopping patients (defined as those attending multiple hospitals for the same complaint) who consulted our department and factors related to cessation of doctor shopping. Methods Patients who presented without referral to the Department of General Medicine at Chiba University Hospital in Japan (our department) completed a questionnaire at their first visit. A follow-up questionnaire was also sent to them in order to assess doctor shopping after 3 months. Then items in the questionnaires were investigated for significant differences between patients who continued or stopped doctor shopping. Logistic regression analysis was performed with items showing a significant difference between patients who stopped doctor shopping and those who continued it, in order to identify independent determinants of the cessation of shopping. Results A total of 978 patients who presented spontaneously to our department consented to this study, and 929 patients (95.0%) completed questionnaires correctly. Among them, 203 patients (21.9%) were identified as doctor shoppers. The follow-up survey was completed correctly by 138 patients (68.0%). Among them, 25 patients (18.1%) were found to have continued doctor shopping, which was a significantly lower rate than before (P &lt 0.001). Logistic regression analysis selected the following factors as independent determinants of the cessation of doctor shopping: 'confirmation of the diagnosis' (odds ratio: 8.12, 95% confidence interval: 1.46-45.26), and 'satisfaction with consultation' (odds ratio: 2.07, 95% confidence interval: 1.42-3.01). Conclusion Doctor shopping decreased significantly after patients consulted our department, with 'confirmation of the diagnosis' and 'satisfaction with consultation' being identified as contributing factors. © 2010 Blackwell Publishing Ltd.

We report a 54-year-old man with osteomalacia due to a bladder reconstruction performed 35 years previously. He had had slowly progressive chest and back pain for 18 months. Osteomalacia due to metabolic acidosis was suspected based on hyperalkalinephosphatasemia and a high serum chloride level, and the diagnosis was confirmed by bone scintigraphy. His symptoms and blood electrolyte levels were improved by oral medication, including sodium hydrogen carbonate. Measurement of the serum chloride level is simple and useful for evaluating acidosis, for which a regular blood test is essential in patients who have undergone bladder reconstruction.

Objective : The outpatient diagnostic processes of novice and trained residents were compared, as to the working diagnosis time and the correct tentative diagnosis rate after history taking to the final diagnosis.<br>Methods : Three physicians who had received outpatient training in our department for ≥2 years were defined as "trained residents", and another three physicians participated in this study from their first day of training at the outpatient clinic were defined as "novice residents". The study was done at Chiba University Hospital in Japan. The working diagnosis time was defined as the time for the physicians to make a tentative diagnosis for each patient based on history taking, and was calculated from the starting and ending times entered into a computer. By comparing the working diagnoses and the final diagnoses, the correct diagnosis rate was determined for each physician.<br>Results : The correct diagnosis rates for trained residents were 87%, 87%, and 85%, respectively. These rates were significantly higher than those of novice residents, which were 73%, 69%, and 55%, respectively (all P<0.001). The working diagnosis times of trained residents were significantly shorter than those of novice residents (all P<0.001). The trained residents still made mostly correct diagnoses after a long time, while the novice residents made more wrong diagnoses as time passed.<br>Conclusion : The working diagnosis time was shorter and the correct diagnosis rate was higher in the trained resident group than the novice resident group. Trained residents were able to eventually make a correct diagnosis, even when they failed to make the correct diagnosis initially. On the other hand, the correct tentative diagnosis rate was generally lower for novice residents, and the rate was markedly lower when patients had diseases that could not be diagnosed at an early stage.

OBJECTIVE: Patient medical history is important for making a diagnosis of causes of dizziness, but there have been no studies on the diagnostic value of individual items in the history. This study was performed to identify and validate useful questions for suspecting a diagnosis of benign paroxysmal positional vertigo (BPPV). METHODS: Construction and validation of a disease prediction model was performed at the outpatient clinic in the Department of General Medicine of Chiba University Hospital. Patients with dizziness were enrolled (145 patients for construction of the disease prediction model and 61 patients for its validation). This study targeted BPPV of the posterior semicircular canals only with a positive Dix-Hallpike test (DHT + BPPV) to avoid diagnostic ambiguity. Binomial logistic regression analysis was performed to identify the items that were useful for diagnosis or exclusion of DHT + BPPV. RESULTS: Twelve patients from the derivation set and six patients from the validation set had DHT + BPPV. Binomial logistic regression analysis selected a "duration of dizziness ≤15 seconds" and "onset when turning over in bed" as independent predictors of DHT + BPPV with an odds ratio (95% confidence interval) of 4.36 (1.18-16.19) and 10.17 (2.49-41.63), respectively. Affirmative answers to both questions yielded a likelihood ratio of 6.81 (5.11-9.10) for diagnosis of DHT + BPPV, while negative answers to both had a likelihood ratio of 0.19 (0.08-0.47). CONCLUSION: A "duration of dizziness ≤15 seconds" and "onset when turning over in bed" were the two most important questions among various historical features of BPPV.

Objective Carnett&apos;s test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles. It is useful for differentiating abdominal wall pain from intra-abdominal pain. However, no study has reported its association with psychogenic abdominal pain. We evaluated its diagnostic usefulness in psychogenic abdominal pain. Methods Two physicians performed Carnett&apos;s test on each patient, but only one received the medical history. The other physician only conducted the test. Based on the final diagnosis, patients were categorized into 3 groups: psychogenic pain, abdominal wall pain, or intra-abdominal pain. Each group was analyzed in association with the results of Carnett&apos;s test conducted by the blinded physician. Patients A total of 130 outpatients with the chief complaint of abdominal pain who had abdominal tenderness. Results There were 22 patients with psychogenic abdominal pain, 19 with abdominal wall pain and 62 with intra-abdominal pain. In patients with psychogenic pain or abdominal wall pain, Carnett&apos;s test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p &lt; 0.001, respectively). The positive likelihood ratio of Carnett&apos;s test for psychogenic abdominal pain was 2.91 (95% confidence interval [CI], 2.71-3.13), while the negative likelihood ratio was 0.19 (95% CI, 0.11-0.34). The corresponding values for abdominal wall pain were 2.62 (95% CI, 2.45-2.81) and 0.23 (95% CI, 0.13-0.41), respectively. Conclusion Carnett&apos;s test may be useful for ruling in and ruling out psychogenic abdominal pain in addition to distinguishing between abdominal wall pain and intra-abdominal pain.

We report a 38-year-old mestizo man with the sudden onset of left upper abdominal pain while climbing Mt. Fuji, which is the highest mountain in Japan. Enhanced computed tomography showed splenic infarction. Although his peripheral blood smear was normal, a hemoglobin S level of 40% established the diagnosis of sickle cell trait (SCT). This trait is common worldwide, but is not well recognized by doctors in Japan because no Japanese patients with SCT have been reported. However, in Japan it is important to consider SCT when assessing foreign patients with splenic infarction.

Familial Mediterranean fever (FMF) had been considered a rare disease in Japan, but since the identification of the causative gene (MEFV) for pyrin/marenostrin in 1997, the occurrence of FMF has been successively reported. We reviewed the clinical features of 7 patients diagnosed with FMF by gene analysis. Methods During April 2003 and March 2005, we investigated the clinical symptoms, treatment and MEFV types of 7 FMF patients who consulted the General Outpatient Clinic of Chiba University Hospital. Results Six patients were in their 20-30s, and one was 54 years of age. There were 4 males and 3 females including a mother and child, and an adult male and his female cousin. Three were solitary incidences. In addition to intermittent fever, 4 patients had chest pain, 1 had abdominal pain, and 1 had chest or abdominal pain. The frequency of attacks was once per 3 months to 1 year in the early stage of the disease, but it slowly increased with disease progression. Leukocytosis and C-reactive protein (CRP) elevation were noted during attacks in all patients. On investigation of MEFV, heterozygosity for the compound pyrin L110P-E148 Q/M694I, E148Q/M694I, L110P/E148Q and heterozygosity for pyrin variant M694I alone were detected. Daily administration of colchicine at 0.5 mg prevented attacks in 6 patients, however 1 patient required 1.0 mg for adequate prevention. Conclusions Although the incidence is rare, internists should be aware of the characteristic symptoms of FMF: periodic fever and serositis symptoms, and its presence in Japan despite the disease name.

We studied the molecular basis of protein C deficiency in 28 Japanese families including 4 asymptomatic families. Two showed a decreased level of function with a normal antigen concentration consistent with type II protein C deficiency and the remaining 26 showed type I deficiency with decreases in both function and antigen level. All the exons and intron/exon junctions of the protein C gene were studied using a strategy combining polymerase chain reaction (PCR) amplification and rapid nonradioactive single-strand conformational polymorphism (SSCP) analysis. The PCR-amplified fragments with aberrant migration on SSCP analysis were sequenced. We identified 11 missense mutations, 1 nonsense mutation, 2 neutral polymorphisms, 1 frameshift deletion, 1 inframe deletion, and 1 splice site mutation. We also identified two different rare mutations in the 5'-untranslated region in the protein C gene that may be responsible for the phenotype. Of these molecular defects, ten were novel. From the results of genetic analysis of 47 Japanese families with protein C deficiency reported in this and previous studies, Phe139Val and Met364Ile substitutions and a G8857 deletion were only found in Japanese subjects and seem to be a founder effect. In contrast, Arg169Trp and Val297Met substitutions, both occurring at CG dinucleotides, were commonly observed in not only Japanese but also Western populations, indicating that these are hot spots for mutation in the protein C gene. These molecular defects were found in 22 families in total, accounting for 47% of Japanese families with protein C deficiency. The structural models of the second EGF and protease domains of activated wild-type and mutant human protein C suggest a possible substrate binding exosite on two loops one from amino acid position 349 to 357 and the other from position 385 to 388, both of which are close to each other in the three-dimensional model.