Isolated partial anomalous venous connection: a congenital defect with late and serious complications.

The cases of 3 patients with partial anomalous pulmonary venous return with intact atrial septum are reported. The 2 adult patients had evidence of severe pulmonary artery hypertension with markedly increased pulmonary vascular resistance indicating advanced pulmonary vascular obstructive disease. This confirms earlier limited observations and emphasizes the potential for this congenital lesion to develop late, serious complications. In view of this potential, surgical repair of the anomaly should be considered whenever it is found. Descriptions of a successful operative approach are included.

Internal medicine residents' perceptions of the balance between service and education in their night-call activities.

PURPOSE: To quantify the workload of residents on night call and to determine the residents' perceptions of the balance between service and education in their night-call activities. METHOD: Twenty-two internal medicine residents--nine first-year residents and 13 senior residents (i.e., in their second, third, or fourth year)--kept logs of their night-call activities for two periods of 16 days each in 1991-92, at a 772-bed teaching hospital affiliated with Wright State University School of Medicine. The residents used the following five-point scale to rate each activity: 1, strictly service; 3, even balance; 5, strictly education. They also recorded the total times spent on various activities. Data were analyzed by using the independent and paired t-tests. RESULTS: Ninety-eight percent of the logs were returned. The first-year and senior residents did not differ significantly in times spent on logged events. Both the first-year and the senior residents perceived many night-call activities to be weighted toward education, especially those involving evaluation of acutely ill patients being considered for hospital admission (overall mean rating of 3.3). There was no striking difference between the first-year and senior residents' perceptions of the balance between service and education in their activities. CONCLUSION: The residents' perceptions of the relationship between service and education indicate that there was an even balance between the two. The educational aspects of night-call duties can and should remain an integral part of residents' training.

Immunologic myopathy. Linear IgG deposition and fulminant terminal episode.

The histopathologic characteristics of a patient with progressive myopathy, renal failure, hemoptysis, and a fulminant terminal event demonstrated a diffuse vasculitis, type 2 fiber atrophy of muscle, and linear IgG staining of the basement membranes of skeletal muscle fibers and of glomerular capillary basement membranes. Interpretation of electron micrographs confirmed that there was thickening of muscle basement membranes. The data suggest the presence of an antibody to a basement membrane antigen shared by muscle and kidney.

Symptomatic abdominal bronchogenic cyst mimicking acute ischemic heart disease.

A 57-year-old female patient presented with a symptomatic abdominal bronchogenic cyst that was associated with ECG changes. The patient's clinical presentation with chest pain, ST and T wave changes, and rate-related bundle branch block initially suggested a myocardial infarction. The ECG reverted to normal after the cyst was removed. The physiologic origins of these observations are unknown.

A resident's internal medicine practice.

The decision-making experience of residents in a primary care internal medicine training practice was examined. The patient population provided residents appropriate training opportunities but the experience of many residents making decisions about prevalent primary care problems was often inadequate. The residents' evaluation of their educational experience with patients suggests that several elements of patient care affect their ability to learn. These include the occurrence of diseases in their patients, opportunities to treat and follow patients, the chance to use diagnostic procedures, and the option of reviewing their care with supervisors and consultants or through reading. The results of this study and the current understanding of the development of clinical judgment are discussed as arguments for evaluating internal medicine training programs in part by examining the content of residents' decision-making opportunities in their ambulatory patient practices.

Physical diagnosis courses--a question of emphasis.

The ability of 12 students to examine hospitalized patients at the end of a course in physical diagnosis was measured through the use of video tapes of patient examinations and audit of written summaries. The results indicate the course in physical diagnosis underemphasized the most important aspect of the patient examination, the patient interview. The errors most often committed by students performing physical examinations and taking histories from patients suggest that increased observation of students by preceptors would be profitable in improving the course. Course evaluation through video taping of actual student examinations proved highly instructive and useful in developing a more effective program.

Anorexia nervosa in adulthood.

Family physicians and other primary care physicians can work with psychotherapists to provide effective treatment for adult women with anorexia nervosa. The major contributions of family physicians include evaluation and treatment of medical complications and supportive reinforcement of long-term psychotherapy. Family physicians can reassure patients that permanent physical disability can be avoided with successful treatment.

Abdominal computed tomography scan in acute lupus abdominal serositis.

This report demonstrates the value of abdominal computed tomography in the evaluation and management of a patient with abdominal complaints due to systemic lupus erythematosus.

A sophomore physical diagnosis course in an outpatient setting.

A program designed to teach sophomore medical students physical diagnosis in an outpatient setting was evaluated as an alternative to an inpatient-oriented course. A comparison of the ability of 12 students trained in an outpatient setting to examine hospitalized patients with that of students trained in the traditional inpatient-oriented program revealed no difference between the two groups. These results are consistent with the hypothesis that the clinical status of the patient and the clinical setting have little impact on students' acquisition of physical diagnosis skills. Thus, the ambulatory care setting can provide an effective alternative for inpatient-oriented physical diagnosis programs. This finding has implications for curriculum planners who are seeking ways to restructure fundamental courses that emphasize development of primary care skills.

Resident education in primary care: how residents learn.

The process of resident education in an internal medicine practice was examined through interviews with 14 residents, who discussed their educational experience while caring for 10 patients. These retrospective evaluations provided insights about how the residents learned when caring for their patients. The study results suggest that resident education in this setting depends upon feedback provided through residents' use of educational resources or through their participation in elements of patient care. These essential elements of resident education were identified: treating and following patients, having cases reviewed by consultants and supervisors, encountering and recognizing diseases, and reading about problems. The study results provide a conceptual model of resident education upon which to base future research projects that should focus on patient selection and organizational aspects of the residents' practice.

Faculty supervision of residents in an internal medicine practice.

This study examines the supervision of residents by faculty members in an outpatient internal medicine practice. For the study, the investigators developed a methodology to analyze the cognitive content and the focus of residents' thoughts during conversations between faculty members and residents. The residents also identified characteristics of productive and less productive exchanges with the faculty. The study shows that both residents and faculty members use the majority of their part of conversations to present information. Residents in early training appear to be more challenged by diagnostic issues, while residents later in training are more concerned with therapy and management. The study results suggest that effective supervision may relate more to the ability of faculty members to display their reasoning as they present information to residents than to the quantity and types of questions they pose to residents.

Consultations in internal medicine: a training program resource.

At the Milton S. Hershey Medical Center of the Pennsylvania State University an internal medicine consulting resident sees all medical consultation requests not directed to a specific subspecialty division. An audit of a nine-month experience on the consult service was compared with that of a general medicine ward service. The audit revealed that consulting residents were exposed to a quantitatively and qualitatively different spectrum of medical problems than were found on the ward service. The interdisciplinary aspects of the experience expand the consulting internist's fund of knowledge and complement outpatient exposure to other specialties, such as surgery and obstetrics-gynecology. Chief medical residents at 36 university medical centers were surveyed regarding the nature of the internal medicine consultation programs in their institutions. The survey indicated that half the programs were service oriented rather than educational and were not felt to be of profit to the medicine residents.

Sleep apnea precipitated by pharyngeal surgery in a patient with myotonic dystrophy.

A patient was seen for evaluation of excessive daytime sleepiness, which was exacerbated following complications secondary to surgical reconstruction of the pharynx for a submucous cleft palate. She underwent recordings in the sleep laboratory and was found to have sleep apnea. Also, a thorough clinical and laboratory assessment established the diagnosis of myotonic dystrophy. Following tracheostomy, both the patient's sleep apnea and daytime hypersomnia were eliminated. Our case demonstrates that surgical procedures involving the upper airway should be approached with considerable caution in patients with myotonic dystrophy and only after the presence of associated sleep apnea has been carefully excluded. An original finding is the suggestion of a decrease in the number of T-cell lymphocytes in a patient with myotonic dystrophy.