ABSTRACT
Introducción. El informe médico es un documento legal, escrito y emitido por el médico, en el que se expone la historia clínica y los métodos diagnósticos y terapéuticos aplicados al paciente. Objetivo. Evaluar el grado de conocimiento de los pacientes respecto al informe médico y la utilidad otorgada a éste. Pacientes y métodos. Se incluyeron pacientes consecutivos atendidos en primera visita en cuatro consultas de neurología general. Se evaluaron mediante un estudio descriptivo: los datos demográficos (edad, sexo y nivel de estudios), el grado de conocimiento sobre el médico remisor (nombre, especialidad y motivo de derivación), la historia médica (antecedentes personales, tratamiento, dosis, razones para su empleo o motivos para no aportarlo) y el informe médico (solicitud, razones para no aportarlo y utilidad otorgada). Se compararon estos resultados entre diferentes áreas sanitarias y según el nivel cultural. Resultados. Se incluyeron 378 pacientes (edad media: 49,1 ± 20,6 años; 62,2% mujeres; 40,2% con estudios primarios; 23,3% con estudios secundarios). El 41,5% desconoce el nombre del médico remisor; el 5,5%, su especialidad, y el 2,6%, el motivo de derivación. El 3,7% desconoce sus antecedentes personales, el 20,4% no aporta tratamiento (el 49,3% ignoraba que hiciera falta), el 4,8% desconoce la indicación y el 27,6% no sabe la dosis. El 14,3% no aporta informe médico y el 18,0% solicita uno (el 61,7% por trámites burocráticos y el 28,0% por información). Sólo el 18,0% sabe que en el informe médico está la información del paciente. Conclusión. El paciente desconoce la utilidad e importancia del informe médico, pese a ser un documento legal en el que queda recogida la información referente a su enfermedad (AU)
Introduction. The medical report is a legal, written document issued by the physician, exposing the clinical history and the diagnostic and therapeutic protocols applied to the patient. Aim. To evaluate the patient knowledge about the medical report and its usefulness. Patients and methods. We included consecutive first-visit patients attended in four general neurology offices. The descriptive analysis included: demographic data (age, sex, level of studies), degree of knowledge on the referring doctor (name, specialty, reason for referral), medical history (medical antecedents, treatment, dosage, reasons for its intake, reasons for not providing it) and the medical report (applications, reasons for not providing it and awarded usefulness). These data were compared between different sanitary areas and cultural levels. Results. We included 378 patients (average age: 49.1 ± 20.6 years-old; 62.2% women; 40.2% with primary studies; 23.3% with secondary studies). 41.5% did not know the name of the referring doctor, 5.5% his specialty and 2.6% the reason for referral. 3.7% did not know their medical antecedents, 20.4% did not provide the treatment (49.3% did not know it was necessary), 4.8% did not know why they took it and 27.6% the dosage. 14.3% did not provide the medical report and 18.0% applied it (61.7% for bureaucratic reasons and 28.0% for information). Only 18.0% knew that the medical report included the medical information of the patient. Conclusion. The patient does not know the usefulness and importance of the medical report, despite being a legal document exposing the medical information of the patient disease (AU)
Subject(s)
Humans , Comprehension , Medical Records , Hospital Information Systems , Health Knowledge, Attitudes, Practice , Patient Access to Records , 24419ABSTRACT
Introducción. La enfermedad de Creutzfeldt-Jakob es una encefalopatía espongiforme transmisible, en la que típicamente se produce el acúmulo de una isoforma alterada de la proteína priónica en el cerebro. La forma esporádica se caracteriza por presentar una demencia rápidamente progresiva, con síntomas y signos de afectación piramidal, extrapiramidal, cerebelosa, cortical y presencia de mioclonías. El diagnóstico se basa en los hallazgos clínicos en combinación con los resultados típicos del electroencefalograma, estudio de líquido cefalorraquídeo o la neuroimagen. Casos clínicos. Presentamos dos casos detectados entre los años 2008 y 2010 en el Hospital del Henares, en Coslada. Caso 1: mujer con pérdida de fuerza progresiva en las extremidades, cambio en su comportamiento con labilidad emotiva y tendencia al aislamiento. Valorada inicialmente como una paciente psiquiátrica, en los meses posteriores presentó una situación de inmovilidad absoluta con tendencia al mutismo. El fallecimiento se produjo a los seis meses del inicio de los síntomas. Caso 2: varón con cuadro progresivo de alteración de la visión en forma de hemianopsia homónima derecha, dificultad para la emisión del lenguaje, mareo e inestabilidad. Progresivamente manifestó un síndrome cerebeloso con mioclonías generalizadas hasta su fallecimiento, 10 semanas después del inicio de los síntomas. En ambos casos el electroencefalograma mostró un patrón típico y la proteína 14-3-3 fue positiva en el estudio de líquido cefalorraquídeo. Conclusión. Nos ha llamado la atención una incidencia tan elevada en tan corto período y en un área sanitaria de apenas 170.000 habitantes (AU)
Introduction. Creutzfeldt-Jakob disease is a transmissible spongiform encephalopathy, in which there is typically an accumulation of an altered isoform of the prion protein in the brain. The sporadic form is characterised by presenting a rapidly progressive dementia, with signs and symptoms of pyramidal, extrapyramidal, cerebellar and cortical involvement, as well as the presence of myoclonias. Diagnosis is based on the clinical findings in combination with the typical results of an electroencephalogram, cerebrospinal fluid study or neuroimaging. Case reports. We report two cases detected between the years 2008 and 2010 in the Hospital del Henares, in Coslada, Madrid. Case 1: a female with progressive loss of strength in her limbs, change in her behaviour with mood swings and a tendency towards seeking to isolate herself. Although initially considered a psychiatric patient, in the months that followed she became absolutely immobile with a tendency towards mutism. Death occurred six months after the onset of symptoms. Case 2: a male with a progressive picture of altered vision in the form of right homonymous hemianopia, difficulty in verbally expressing language, dizziness and instability. The patient gradually developed a cerebellar syndrome with generalised myoclonias until his death, 10 weeks after the onset of symptoms. In both cases, the electroencephalogram showed a typical pattern and 14-3-3 protein was positive in the cerebrospinal fluid study. Conclusions. Such a high incidence over such a short period of time and in a health district of barely 170,000 inhabitants seems rather surprising (AU)
Subject(s)
Humans , Male , Female , Creutzfeldt-Jakob Syndrome/diagnosis , Electroencephalography , Prion Diseases/diagnosis , 14-3-3 Proteins/cerebrospinal fluidABSTRACT
INTRODUCTION: Creutzfeldt-Jakob disease is a transmissible spongiform encephalopathy, in which there is typically an accumulation of an altered isoform of the prion protein in the brain. The sporadic form is characterised by presenting a rapidly progressive dementia, with signs and symptoms of pyramidal, extrapyramidal, cerebellar and cortical involvement, as well as the presence of myoclonias. Diagnosis is based on the clinical findings in combination with the typical results of an electroencephalogram, cerebrospinal fluid study or neuroimaging. CASE REPORTS: We report two cases detected between the years 2008 and 2010 in the Hospital del Henares, in Coslada, Madrid. Case 1: a female with progressive loss of strength in her limbs, change in her behaviour with mood swings and a tendency towards seeking to isolate herself. Although initially considered a psychiatric patient, in the months that followed she became absolutely immobile with a tendency towards mutism. Death occurred six months after the onset of symptoms. Case 2: a male with a progressive picture of altered vision in the form of right homonymous hemianopia, difficulty in verbally expressing language, dizziness and instability. The patient gradually developed a cerebellar syndrome with generalised myoclonias until his death, 10 weeks after the onset of symptoms. In both cases, the electroencephalogram showed a typical pattern and 14-3-3 protein was positive in the cerebrospinal fluid study. CONCLUSIONS: Such a high incidence over such a short period of time and in a health district of barely 170,000 inhabitants seems rather surprising.