Impact of clinical experience on quantification of clinical signs at physical examination.

PURPOSE: Although physical examination is a fundamental component of medical decision making, relatively few studies have evaluated how physicians quantify clinical signs and whether different methods of assessment have different effects on clinical practice. OBJECTIVES: To evaluate a possible impact of clinical experience when attending physicians, medical residents and medical students quantify qualitative signs of physical examination in a teaching hospital. SETTING: Hospital das Clínicas, University of São Paulo, Brazil. SUBJECTS: A total of 244 randomly selected physicians and medical students completed a reliable and consistent eight-item questionnaire. MAIN OUTCOME MEASURES: To compare how they quantified clinical signs of cyanosis, anaemia, jaundice, oedema and dehydration, why they used the method(s) they described, and whether the method used could affect diagnosis, further testing or patient management. A chi-square test was used to calculate differences between the groups. RESULTS: Whilst the majority of those surveyed tended to use a four-level evaluation for these clinical signs, attending staff physicians were more likely to employ two-level evaluations than were residents or medical students. For all five signs, attending physicians' use of dichotomous evaluations was significantly higher than that of residents or medical students: anaemia (P = 0.004), cyanosis (P < 0.001), oedema (P = 0.005), dehydration (P < 0.001) and jaundice (P = 0.002). CONCLUSION: Although medical students and residents are routinely taught to use a four-level evaluation for these clinical signs, many of those surveyed tend to abandon this experience for a dichotomous approach. Given that the clinicians in this survey tended not to change their initial approach to a patient based on the intensity of this semi-quantitative method, increased emphasis on teaching dichotomous approach evaluations in medical school should be encouraged.

Blood pressure behaviour in chronic daily headache.

The objective was to examine the association between high blood pressure (BP) and chronic daily headache using 24-h ambulatory blood pressure monitorization (24-h ABPM). This was a cross sectional study in an out-patient clinic. Women were selected among patients referred for first evaluation, 62 with chronic daily headache and 57 without chronic daily headache. The main outcome measures were mean office systolic and diastolic blood pressure (BP), mean systolic and diastolic daytime and night-time BP and BP load, and mean systolic and diastolic nocturnal fall. Office systolic BP was 138.2 mmHg for women with chronic daily headache and 141.7 mmHg for women without headache (P = 0.36). Office diastolic BP was 88.9 mmHg for women with headache and 92.7 mmHg for women without headache (P = 0.17). Mean daytime and mean night-time systolic BP was, respectively, 122.2 mmHg and 108.8 mmHg for women with headache and 122.9 mmHg and 109.5 for women without headache (P = 0.82 and P = 0.80, respectively). Mean daytime and mean night-time diastolic BP was, respectively, 78.6 mmHg and 65.4 mmHg for women with headache and 79.9 mmHg and 67.1 mmHg for the women without headache (P = 0.80 and P = 0.45, respectively). There was no difference between the two groups regarding systolic and diastolic BP load and nocturnal systolic and diastolic fall. No significant difference in BP values was observed in women with chronic daily headache compared with women without headache using 24-h ABPM.

Avaliação de atividade de busca de alto risco para doença cardiovascular. Uma experiência na semana do coraçäo - 1993 / Evaluation of a search for subjects in high risk for cardiovascular disease. An experience of the heart week - 1993

Objetivo - testar a eficácia da prevençäo primária na detecçäo de subpopulaçöes de alto risco para doenças cardiovasculares em uma populaçäo de baixa renda familiar, detectando casos de hipertensäo arterial, diabetes metllitus e hipercolesterolemia, no Distrito de Saúde do Butantä (Säo Paulo, SP). Métodos - Durante a semana do coraçäo de 1993 foram estudados 156 indivíduos acima dos 40 anos, sendo 126 (80,8 por cento) mulheres, com média de idade de 53 anos e tiveram seus fatores de risco cardiovaslares quantificados. Resultados - O percentual de fatores de risco foi: fumantes (19,2 por cento), obesidade (27,8 por cento), hpercolesterolemia (50 por cento), diabetes mellitus (15,2 por cento) e hipertensäo arterial sistêmica (HAS) (25,8 por cento). O diagnóstico de HAS e diabetes mellitus era desconhecido, respectivamente, entre 46,4 por cento e 22,2 por cento das mulheres e em 45 por cento e 50 por cento dos homens. Conclusäo - a utilizaçäo da Semana do Coraçäo como atividade para busca de alto ric em populaçào de baixa renda é uma atividade exequível, porém limitada a mulheres, obesos, hipertensos, hipercolesterolêmicos e diabéticos, näo atingindo os fumantes.

Purpose - To test the efficaccy of primary prevention in detecting a cluster of cardiovascular risk factors in a low income population and unaware individuals with hypertension, diabetes mellitus and hypercholesterolemia in the district of Butantã (São Paulo, Brazil). Methods - We studied 156 people older than 40 yearsold, 126 (80.8%) female, mean age 53 years and observed their cardiovascular risk factors. Results - The proportion of unaware hypertensive patients was of 46.4% among hypertensive women and 40.0% among hypertensive men; and about diabetes, the proportion of unawareness was 22.2% among diabetic women and 50.0% among diabetic men, although the total number of diabetics and of hypertensive men was very small. Conclusion - People with the following attributes: female, overweight, hypertensive and with glucose intolerance were those with more concern about health and prevention. In other hand, men and smokers were absent of those activities showing a low self-concern with health and disease