BP control. Improvement in a university medical clinic by use of a physician's associate.

Many hypertensive patients, especially those in outpatient clinics at large teaching hospitals, do not achieve BP control. We incorporated a physician's associate into an existing house staff medical clinic and evaluated whether this improved BP control. In patients with moderate or severe hypertension, BP control was achieved in 56% of patients observed by both the physician's associate and the house staff and in 32% of patients observed solely by house staff. Possible contributing factors were more frequent follow-up, simplification of drug regimens, reduced waiting time, more time spent with the patients, and overall greater satisfaction with the physician's associate. We conclude that the addition of a physician's associate to an outpatient clinic is an effective method for enhancing BP control. This can be achieved without establishing a separate hypertension clinic or depriving house staff of experience in the management of hypertension.

Spurious hypertension in the obese patient. Effect of sphygmomanometer cuff size on prevalence of hypertension.

We used standard, large adult, and thigh-size cuffs in random order to take BPs in 470 patients. The prevalences of definite high BP [( HBP]), greater than or equal to 160/95 mm Hg) and borderline HBP [( BHBP ], greater than or equal to 140/90 less than 160/95 mm Hg) were the same with all three cuffs in patients with an arm circumference less than 35 cm, a body mass index less than 34, and a weight of less than 95 kg. The large adult and thigh cuffs did not underestimate the prevalence of HBP in these nonobese patients. The prevalences of HBP and BHBP were twofold greater with the standard cuff than with the large adult or thigh cuffs in obese patients (arm circumference greater than or equal to 35 cm or body mass index greater than or equal to 34 or weight greater than or equal to 95 kg). Routine use of the large adult cuff will provide accurate BP measurement and avoid unneeded evaluation and treatment.

Interrogation and interview: strategies for obtaining clinical data.

During assessment of 55 outpatients, we recorded the numbers and kind of health problems noted during an open-ended interview and during an ;interrogation' based on a structured questionnaire. The combined strategies (interviews and questionnaires) identified a total of 269 problems which were clinically important (i.e. needed medical attention). One hundred and ninety-eight of these problems (74 per cent) were identified by the open-ended interview. Thirtyeight (14 per cent) were identified only by the interview, 71 (26 per cent) only by the questionnaire. We observed that few of the problems detected only by questionnaire were acted upon and that they were therefore only marginally important; most of the problems noted only during interview did lead to further medical action and so were unequivocally of clinical importance. Our data suggest that an open-ended interview, undertaken with the intention of identifying all the patient's health problems, detects those problems well. The routine addition of a lengthy interrogation adds little and is therefore unnecessary.

Computed tomography brain scanning in alcohol withdrawal seizures. Value of the neurologic examination.

We evaluated the usefulness of computed tomography (CT) brain scanning in alcoholic patients with withdrawal seizures (n = 151) and other neurologic problems (n = 87) and compared the findings of a detailed neurologic examination to the results of CT scanning. In patients with seizures, nearly 50% of CT scans were normal, 34% showed generalized cerebral atrophy, and only 15% showed focal structural lesions. When focal neurologic deficits were present, 30% of CT scans showed focal structural lesions compared to 6% when such deficits were absent (p less than 0.0002). The frequency of potentially reversible lesions was 18% in patients with and 1% in patients without focal neurologic deficits (p less than 0.0002). Of patients treated surgically, 9% had focal neurologic deficits and 1% did not (p less than 0.03). Results were similar in alcoholic patients with other neurologic problems. Careful use of the neurologic examination adequately determines which patients need prompt CT scanning. In the absence of either focal deficits on neurologic examination or signs of acute head trauma, CT brain scanning does not improve the evaluation of patients with alcohol withdrawal seizures.