The clinical evaluation for diagnosing obstructive airways disease in high-risk patients.

OBJECTIVE: We measured the ability of the medical history, physical examination, and peak flowmeter in diagnosing any degree of obstructive airways disease (OAD). DESIGN: Prospective comparison of historical and physical findings with independently measured spirometry. SETTING: University outpatient clinic. PATIENTS: Ninety-two adult consecutive outpatient volunteers with a self-reported history of smoking, asthma, chronic bronchitis, or emphysema. MEASUREMENTS: All subjects completed a pulmonary history questionnaire and received peak flow (PF) and spirometric testing. The subjects were independently examined for 12 pulmonary physical signs by four internists blinded to all other results. Multivariable analysis was used to create a diagnostic model to predict OAD as diagnosed by spirometry (FEV1 < 80 percent of predicted not secondary to restrictive disease, or FEV1/FVC less than 0.7). RESULTS: The best model diagnosed OAD when any of three variables were present--a history of smoking more than 30 pack-years, diminished breath sounds, or peak flow less than 350 L/min. This model had a sensitivity of 98 percent and specificity of 46 percent. In addition, the model detected all subjects with probable restrictive lung disease. Thirty-one percent of subjects had none of these variables and were at very low (3 percent) risk of OAD. Fifty percent of subjects with one or more abnormal variables had OAD. CONCLUSIONS: The history, physical examination, and peak flowmeter can be used to screen high-risk patients for OAD. Using this diagnostic model, 31 percent of subjects could be classified at very low risk of OAD while half of those referred for spirometry would have abnormal results.

Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?

BACKGROUND: The value of the history and physical examination in diagnosing chronic obstructive pulmonary disease (COPD) is uncertain. This study was undertaken to determine the best clinical predictors of COPD and to define the incremental changes in the ability to diagnose COPD that occur when the physical examination findings and then the peak flowmeter results are added to the pulmonary history. SUBJECTS AND METHODS: Ninety-two outpatients with a self-reported history of cigarette smoking or COPD completed a pulmonary history questionnaire and received peak flow and spirometric testing. The subjects were independently examined for 12 physical signs by 4 internists blinded to all other results. Multivariate analyses identified independent predictors of clinically significant, moderate COPD, defined as a forced expiratory volume in 1 second (FEV1) less than 60% of the predicted value or a FEV1/FVC (forced vital capacity) less than 60%. RESULTS: Fifteen subjects (16%) had moderate COPD. Two historical variables from the questionnaire--previous diagnosis of COPD and smoking (70 or more pack-years)--significantly entered a logistic regression model that diagnosed COPD with a sensitivity of 40% and a specificity of 100%. Only the physical sign of diminished breath sounds significantly added to the historical model to yield a mean sensitivity of 67% and a mean specificity of 98%. The peak flow result (best cutoff value was less than 200 L/min) significantly added to the models of only one of the four physicians for a mean final sensitivity of 77% and a specificity of 95%. Subjects with none of the three historical and physical variables had a 3% prevalence of COPD; this prevalence was unchanged by adding the peak flow results. CONCLUSIONS: Diminished breath sounds were the best predictor of moderate COPD. A sequential increase in sensitivity and a minimal decrease in specificity occurred when the quality of breath sounds was added first to the medical history, followed by the peak flow result. The chance of COPD was very unlikely with a normal history and physical examination.

Screening CMHC outpatients for physical illness.

To assess the prevalence of physical disorders among outpatients treated in Colorado's public mental health system, a total of 175 patients from two community mental health centers received a comprehensive medical screening that included a standard physical examination and laboratory analyses. Of these patients, 46 percent had physical conditions or laboratory test results warranting further medical evaluation. A previously undiagnosed physical health problem was identified in 20 percent of the screened patients, and about 16 percent had conditions that could cause or exacerbate their mental disorder. The authors conclude that public mental health systems should ensure routine assessment of the physical health of psychiatric outpatients and suggest guidelines for developing medical screening procedures in public settings.

Changing patterns of disease on an inpatient medical service: 1961-1962 to 1981-1982.

To assess changes in disease on an internal medicine teaching service, the records of 292 patients admitted to University Hospital, Denver, Colorado, in the academic years 1961-1962 or 1981-1982 were reviewed. It was hypothesized that patients admitted more recently would be older, more chronically and catastrophically ill, and more likely to have multiple illnesses than patients of an earlier era. Over time, length of stay and mortality rates decreased and acuteness of illness increased, whereas age, chronicity, and co-morbidity remained constant. Changes in the prevalence of some common diseases reflected evolving medical and social influences on hospital use. Modern medical residents are exposed to more patients for a shorter time. They see more acute illness but less of the ongoing process of diagnosis and treatment. Awareness of such changes can help educators design residency programs that better prepare internists for practice.

A complication of cleansing enema: retained protective shield of the enema tip.

A retained enema tube sheath was encountered in 4 outpatients who underwent preparation for barium enema. This object can be detected on a plain abdominal roentgenogram, but is more readily apparent as an intraluminal foreign body during barium enema examination. We suggest that a prominent warning to remove the sheath before taking a cleansing enema be attached to the enema tip.

A randomized trial comparing cimetidine to nasogastric suction in acute pancreatitis.

Clinical and experimental evidence has suggested that the use of cimetidine might be harmful to patients with acute pancreatitis. We conducted a randomized study comparing cimetidine to nasogastric (NG) suction in 95 patients with 103 episodes of mild to moderately severe, acute or relapsing pancreatitis (86.4% alcohol related). The groups were comparable on entry to the study, and daily evaluation of several clinical and laboratory criteria revealed no consistent differences between the two groups. When these same criteria were evaluated for time of return to normal, if abnormal on entry to the study, no differences were found. The cimetidine group had a significantly shorter stay in the hospital than did the NG group (6.8 +/- 2.7 vs 8.5 +/- 4.8 days). Neither the incidence of relapse or complication nor the duration and extent of hyperamylasemia were significantly different between patients treated with cimetidine or NG suction. We conclude that cimetidine is safe to use in patients with mild to moderately severe alcohol-related pancreatitis, but it offers minimal advantage over NG suction.

Treating duodenal ulcer: antacids or cimetidine?

Patients with symptomatic duodenal ulcer can be effectively treated with antacids or cimetidine. Many patients with a first episode or an occasional flare-up of ulcer disease should be treated with antacids. Cimetidine should be added if the response is unsatisfactory. Cimetidine should be used initially in patients with severe ulcer diathesis and in those with conditions such as diarrheal disease or chronic renal failure that predispose to troublesome side effects from antacids. For most patients, chronic cimetidine therapy after healing of the ulcer is not warranted. Exceptions are those with severe and complicated disease.

Evaluation of postoperative changes in mental status.

When confronted with a patient with an alteration in mental status following surgery, the physician must consider both organic and psychosocial causes and their synergistic interactions. A careful medical assessment will rule out metabolic disorders, sepsis, cardiopulmonary complications, and adverse drug effects. A mental status examination and psychiatric history from the patient and family will identify psychosocial determinants. Simultaneous treatment of the organic and psychosocial components is essential if the physician hopes to provide the best patient care and maximize the likelihood of recovery.

Perioperative care of patients with cardiac disease.

Patients with cardiovascular disease commonly present with problems requiring surgical treatment. They are more vulnerable than patients without cardiovascular disease to the cardiovascular stresses associated with general anesthesia and surgery--hypotension, hypoxemia, sepsis, and thromboembolism. Their risk of morbidity and mortality is higher. Certain clinical factors have a profound impact on the patient's likelihood of serious cardiac complications or death: Overt heart failure, recent myocardial infarction, and cardiac arrhythmias are the most worrisome. A careful clinical evaluation and formal assessment of the patient's risk dictate better perioperative monitoring and treatment. Early hospital admission provides time for control of other health problems. Prophylaxis with heparin and antimicrobial agents minimizes problems of thromboembolism and sepsis, respectively. Overaggressive treatment of hypertension is avoided, and withdrawal of propranolol or clonidine is carefully supervised. The use of digoxin is restricted to patients with atrial tachyarrhythmias or heart failure. Hemodynamic monitoring via a Swan-Ganz catheter or temporary transvenous pacing may be necessary for selected high-risk patients. Such careful evaluation, monitoring, and treatment are the clinician's methods for improving the chance for patients with heart disease to benefit from surgery.

Hepatitis B. Cytologic localization of virus antigens and the role of the immune response.

Antigens of the hepatitis B virus have been localized within liver tissue by various immunologic, histochemical, and electron microscopic methods. The abundance and distribution of these virus antigens are in part determined by the host immune response. This interaction of immune mechanisms with the hepatitis B virus may be related to the pathogenesis and natural history of human hepatitis B virus infection.