ABSTRACT
BACKGROUND: Clinical diagnosis of pneumonia is a concern when a patient presents with recent cough--new or worsened--together with fever as the chief complaint. Given this presentation, the doctor would benefit from having access to software that specifies, first, what diagnostic indicators experts typically use in that diagnosis; then, upon entry of those facts, what experts' typical probability of pneumonia is in such a case; and finally, how much this probability might change upon adding the facts from chest radiography. METHODS: We specified a set of 36 hypothetical presentations of this type by patients 20-70 years of age, involving a comprehensive set of clinical-diagnostic indicators. Members of three separate expert panels independently set the probability of pneumonia in each of these cases, and also the range of possible post-radiography probabilities. A logistic function of the diagnostic indicators was fitted to the medians of the probabilities. RESULTS: The median probability of pneumonia was a joint function of the patient's age and current rate of cigarette smoking; history as to the cough's duration, the fever's maximum, dyspnea (including whether on effort only) and rigors; and physical examination as to temperature, signs of upper respiratory infection, prolongation of expiration, dullness on percussion and some auscultation findings. Non-contributory were history of wheezing, pain on inspiration, type of sputum and signs of cold or influenza. This probability function, and the post-radiography functions based on the same indicators, are accessible at http://www.evimed.ch/pneumonia. INTERPRETATION: The expert inputs to clinical diagnosis that were derived and made readily accessible provide for expertly clinical diagnosis of pneumonia, relevant for decisions about radiography and treatment without it.
Subject(s)
Diagnosis, Differential , Pneumonia/diagnosis , Surveys and Questionnaires , Adult , Aged , Algorithms , Canada , Europe , Expert Testimony , Female , Humans , Logistic Models , Male , Middle Aged , Pneumonia/diagnostic imaging , Pneumonia/physiopathology , Radiography , United StatesSubject(s)
Aging/physiology , Decision Making , Informed Consent , Mental Competency/psychology , Aged , Aged, 80 and over , Canada , Female , Geriatric Assessment , Humans , Male , Patient Rights , Personal Autonomy , Physician-Patient Relations , Terminal CareABSTRACT
Whipple's disease is a multisystem infectious disease caused by the bacterium Tropheryma whippelii. A case with an unusual presentation is reported. A 66-year-old man presented with a febrile vasculitic rash on his forearms. An extensive rheumatological, hematological and infectious workup gave negative results, apart from mild anemia and eosinophilia. An abdominal computed tomography revealed a retroperitoneal lymphadenopathy, and a skin biopsy revealed an eosinophilic vasculitis. This diverted the work toward ruling out a lymphoma or a vasculitic process. A lymph node biopsy was then performed and showed a diffuse neutrophilic inflammation with abundant foamy macrophages, fat necrosis and lipogranuloma formation. These findings were considered to be nonspecific and no further pathological investigation was carried out. After a course of corticosteroids, diarrhea and weight loss predominated and subsequently a diagnosis of Whipple's disease was confirmed on a small-bowel biopsy. Lymph node involvement was then confirmed on re-evaluation using the appropriate stains.
Subject(s)
Eosinophilia/complications , Skin Diseases, Vascular/complications , Vasculitis/complications , Whipple Disease/diagnosis , Aged , Eosinophilia/diagnosis , Humans , Male , Skin Diseases, Vascular/diagnosis , Vasculitis/diagnosis , Whipple Disease/complicationsSubject(s)
Clinical Competence , Education, Medical, Graduate/standards , Education, Medical, Undergraduate/standards , Interprofessional Relations , Canada , Education, Medical, Graduate/trends , Education, Medical, Undergraduate/trends , Female , Hospital Units , Hospitals, Teaching , Humans , Internship and Residency , Male , Program Evaluation , Teaching/organization & administrationSubject(s)
Dictionaries, Medical as Topic , Terminology as Topic , Concept Formation , Medicine , Physician's RoleSubject(s)
Dictionaries, Medical as Topic , Health , Terminology as Topic , Concept Formation , Public HealthSubject(s)
Dictionaries, Medical as Topic , Disease , Terminology as Topic , Concept Formation , Medicine , Philosophy, MedicalSubject(s)
Dictionaries, Medical as Topic , Disease/etiology , Terminology as Topic , Concept Formation , Health , MedicineSubject(s)
Dictionaries, Medical as Topic , Disease , Terminology as Topic , Concept Formation , Disease Progression , MedicineSubject(s)
Diagnosis , Dictionaries, Medical as Topic , Prognosis , Terminology as Topic , Concept Formation , Health , MedicineSubject(s)
Physician's Role , Terminology as Topic , Concept Formation , Dictionaries, Medical as Topic , Disease , Health , MedicineSubject(s)
Disease , Public Health , Terminology as Topic , Community Medicine , Concept Formation , Dictionaries, Medical as Topic , Medicine , MorbidityABSTRACT
A Charter on Medical Professionalism (CMA) has just recently been developed internationally, and the Canadian Medical Association is calling for public dialogue on medical professionalism now that reforms in the Canadian system of health care are imminent. We posit that good practices are at issue; we outline the essence of these in general and also specifically in the knowing, teaching and intervening components of practice. We also see challenges not to, but in, medical professionalism - first and foremost in the profession's definition of good practices and the payer's confinement of insurance coverage to these.
