Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades.

OBJECTIVES: To investigate the hypothesis that junior doctors' examination skills are deteriorating by assessing the medical admission note examination record. DESIGN: Retrospective study of the admission record. SETTING: Tertiary care hospital. METHODS: The admission records of 266 patients admitted to Wellington hospital between 1975 and 2011 were analysed, according to the total number of physical examination observations (PEOtot), examination of the relevant system pertaining to the presenting complaint (RelSystem) and the number of body systems examined (Nsystems). Subgroup analysis proceeded according to admission year, level of experience of the admitting doctor (registrar, house surgeon (HS) and trainee intern (TI)) and medical versus surgical admission notes. Further analysis investigated the trend over time in documentation with respect to cardiac murmurs, palpable liver, palpable spleen, carotid bruit, heart rate, funduscopy and apex beat location and character. RESULTS: PEOtot declined by 34% from 1975 to 2011. Surgical admission notes had 21% fewer observations than medical notes. RelSystem occurred in 94% of admissions, with no decline over time. Medical notes documented this more frequently than surgical notes (98% and 86%, respectively). There were no differences between registrars and HS, except for the 2010s subgroup (97% and 65%, respectively). Nsystems declined over the study period. Medical admission notes documented more body systems than surgical notes. There were no differences between registrars, HSs and TIs. Fewer examinations were performed for palpable liver, palpable spleen, cardiac murmur and apex beat location and character over the study period. There was no temporal change in the positive findings of these observations or heart rate rounding. CONCLUSIONS: There has been a decline in the admission record at Wellington hospital between 1975 and 2011, implying a deterioration in local doctors' physical examination skills. Measures to counter this trend are discussed.

LTB4 is a signal-relay molecule during neutrophil chemotaxis.

Neutrophil recruitment to inflammation sites purportedly depends on sequential waves of chemoattractants. Current models propose that leukotriene B(4) (LTB(4)), a secondary chemoattractant secreted by neutrophils in response to primary chemoattractants such as formyl peptides, is important in initiating the inflammation process. In this study we demonstrate that LTB(4) plays a central role in neutrophil activation and migration to formyl peptides. We show that LTB(4) production dramatically amplifies formyl peptide-mediated neutrophil polarization and chemotaxis by regulating specific signaling pathways acting upstream of actin polymerization and MyoII phosphorylation. Importantly, by analyzing the migration of neutrophils isolated from wild-type mice and mice lacking the formyl peptide receptor 1, we demonstrate that LTB(4) acts as a signal to relay information from cell to cell over long distances. Together, our findings imply that LTB(4) is a signal-relay molecule that exquisitely regulates neutrophil chemotaxis to formyl peptides, which are produced at the core of inflammation sites.