塚本 知子

Purpose: Fundoscopic exams are conducted during outpatient consultations to assess intracranial disease and complications from chronic diseases. Low level of confidence in these skills which physicians have is one of the causes that implementation frequency is low. Research has not yet identified specific measures through which the healthcare system may increase the implementation of fundoscopic exams nor a qualitative process that enables physicians to gain confidence in their fundoscopic exam skills. We introduced a checklist and conducted a mixed-methods study. Methods: This study is a before-and-after study, within an embedded-experimental mixed-methods design. We sampled 15 physicians in the department of general medicine at a university hospital assigned to initial consultation. We introduced a checklist to verify whether the fundoscopic exam was implemented. Measures are implementation ratio of the fundoscopic exam to the total number of indication cases, and Visual Analog Scale (VAS) values for the confidence in procedure are measured before and after the intervention. We obtained qualitative data from interviews and used the Modified Grounded Theory Approach. Results: We observed significant increases in the implementation ratio (19.2% (29/151 cases) vs 64.8% (105/162 cases), p<0.001) and in the VAS value for the confidence (1.89 mm vs 4.68 mm (p<0.001)). Analysis of the interviews revealed the following. To increase the implementation, it is necessary to reduce the <Lack of confidence> and <Forgetting>, which is prevented by the checklist. The <Lack of successful experiences in detecting abnormalities> leads to a <Lack of confidence>. Repeated executions result in <Successful experiences and confidence building>. Conclusion: The intervention increased the implementation ratio, thereby increasing successful experiences and confidence among physicians. The growth of confidence boosted motivations to implement fundoscopic exams.

A 16-year-old boy who was a non-smoker presented with a prolonged severe dry cough and malaise of 3 months in duration. Despite an increase in the patient's inflammatory marker levels, no respiratory lesions were radiologically or serologically detected. We suspected that the cough reflex pathway had been stimulated by large vessel vasculitis (LVV, a non-respiratory inflammatory condition) and diagnosed the patient with Takayasu arteritis. While inflammation of either the ascending pharyngeal or pulmonary artery have been reported to cause cough in patients with LVV, the present case shows that intense inflammation of the aortic arch and the starting portion of its main branches may stimulate a vagus nerve branch as a novel mechanism causing cough.

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.

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.

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 < 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.

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: Carnett'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'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'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's test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p<0.001, respectively). The positive likelihood ratio of Carnett'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'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.

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.

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.