Use of a committee review process to improve the quality of course examinations.

PURPOSE: In conjunction with curricular changes, a process to develop integrated examinations was implemented. Pre-established guidelines were provided favoring vignettes, clinically relevant material, and application of knowledge rather than simple recall. Questions were read aloud in a committee including all course directors, and a reviewer with National Board of Medical Examiners (NBME) item writing and review experience. This study examines the effectiveness of this process to improve the quality of in-house examinations. METHODS: Five hundred and twenty items were randomly selected from two academic years for initial comparison; 270 from 2000 to 2001, and 250 from 2001 to 2002. The first set of items represented the style, content and format when courses and tests were departmentally/discipline based, assembled by course directors, and administered separately. The latter group represented similar characteristics when courses and tests were organ-system-based, committee-reviewed and administered in an integrated examination. Items were randomized, blinded for year of origin, and rated by three NBME staff members with extensive item review experience. A five-point rating scale was used: one indicated a technically flawed item assessing recall of an isolated fact; five indicated a technically unflawed item assessing application of knowledge. To assess continued improvement, a follow-up set of 250 items from the 2002 to 2003 academic year was submitted to the same three reviewers who were not informed of the purpose or origin of this set of test items. RESULTS: The mean rating for items from 2000 to 2001 was 2.51 +/- 1.27; analogous values for 2001-2002 were 3.16 +/- 1.33, (t = 5.83; p < 0.0001), and in 2002-2003; 3.59 +/- 1.15 (t = 10.11; p<0.0001). CONCLUSION: Pre-established guidelines and an interdisciplinary review process resulted in improved item quality for in-house examinations.

Standardized patients' perceptions about their own health care.

BACKGROUND: There have been detailed descriptions on standardized patients (SP) programs' effects on students, curricula, and faculty, yet little attention has been paid to the consequences of participating on the SP's. PURPOSE: This study explored the perceptions of SPs toward their own health care in the context of having served as SPs. METHOD: All 180 SPs participating in Department of Medicine programs at 5 medical schools were surveyed. They completed the survey during SP activities, or it was mailed to them. SPs indicated their level of agreement or disagreement with 11 attitude statements related to their own health care after serving as an SP using a Likert scale, with 1 reflecting the most positive attitude and 5 the least positive. RESULTS: Responses to the attitudinal questions were obtained from 164 SPs (91%). SPs perceived that because of their participation as SPs they had a better understanding about medical history taking and physical examinations (1.9 +/- 0.9), communicated more effectively with their health care provider (1.8 +/- 0.9), and were more comfortable with both health care visits and physical examinations (2.2 +/- 0.9). There were no significant differences in results based on gender, age, race, or school. CONCLUSIONS: As a consequence of their participation, the SPs indicated a change in attitudes about their personal health care. They perceived improved understanding and ability to communicate and comfort with their own health care. Participation in SP programs seems to influence SPs by improving perceptions about their own health care interactions.

A man with vague rheumatic complaints.

A 52-year-old man presented with a four-month history of malaise, low-grade fever, decreased appetite, and a 20-pound weight loss. He complained of joint pain and swelling, proximal muscle weakness, exertional dyspnea, and a dry cough. He also noted that his fingers had turned white and then blue when chilled and red when rewarmed. He had not had pleuritic chest pain, dysphagia, dry eyes or mouth, rash, or skin photosensitivity.

Arthralgias following dilation and curettage.

A 36-year-old woman presented to the emergency department with right hip pain of one week's duration. An x-ray of the hip was unremarkable. She was diagnosed with trochanteric bursitis, given ibuprofen (800 mg tid) and crutches, and sent home. The next day, continual pain and progressive functional impairment prompted her to see an orthopedist. He concurred with the initial diagnosis and administered a corticosteroid injection into the right trochanteric bursa. Propoxyphene (65 mg q4h prn) was added to her medical regimen, and she was again sent home. Pain developed in the right sacroiliac area the next day. Within 24 hours, the right shoulder and right sternoclavicular joint were also involved, and the patient began having subjective fever and chilliness. She returned to the orthopedist and was immediately referred to a rheumatologist who ordered blood cultures and admitted her to the hospital.

Palpable purpura: an algorithmic approach.

Cutaneous vasculitis, secondary to drug reaction, infection or collagen vascular disease, is the most common identifiable cause of palpable purpura. Common causes of palpable purpura often can be identified during the patient's history and physical examination. When this condition occurs in a patient who has not had a known precipitating event, or when the cause is unclear from the history and physical examination, diagnosis may be based on findings of the laboratory investigations and skin biopsy. Many cases of palpable purpura are idiopathic and self-limited. When treatment is necessary, dapsone, colchicine or systemic corticosteroids are useful drugs.

D-penicillamine-induced myasthenia gravis: diagnosis obscured by coexisting chronic obstructive pulmonary disease.

D-penicillamine, a drug used to treat rheumatoid arthritis, Wilson's disease, and cystinuria, can cause myasthenia gravis. Fortunately, the myasthenia typically resolves after discontinuation of the drug. The diagnosis may be missed if weakness is blamed on a patient's underlying disease(s), in particular, rheumatoid arthritis. Reported here are the cases of two patients with chronic obstructive lung disease who were taking D-penicillamine for rheumatoid arthritis, then experienced increasing respiratory failure. At first, their problem seemed to stem from chronic lung disease, but further evaluation revealed the cause of the hypoventilation to be D-penicillamine-induced myasthenia gravis.

Performance of the Coumatrak system in a large anticoagulation clinic.

There is a need to monitor anticoagulation accurately, inexpensively, and rapidly. The accuracy and precision of a simple fingerstick method was studied in a large outpatient anticoagulation clinic using the Coumatrak method. The Coumatrak apparatus has been studied in the home setting, and three recent reports suggest that it is practical, accurate, and possibly superior to the standard method. These results differ from recently published studies. This technique was found to be less than acceptable in precision and accuracy. This method requires further study before it can be recommended for wide-spread use in making decisions for patient care.

Hodgkin's disease masquerading as sclerosing mediastinitis.

Cases in which fibrotic variants of Hodgkin's disease have been confused with sclerosing mediastinitis have rarely been reported. Sclerosing mediastinitis typically involves the superior/middle mediastinum and, in the United States, is most commonly due to histoplasmosis. We describe the case of a patient who came to us with fevers, a mixed anemia, and a posterior mediastinal mass that on pathologic examination appeared to be due to idiopathic sclerosing mediastinitis. Only inclusion of a biopsy specimen from a local celiac node, after a new porta hepatis mass was found, revealed the correct diagnosis of Hodgkin's disease of the nodular sclerosing type. With the correct diagnosis, early intervention and appropriate therapy resulted in clinical cure.

Case report: recurrent pneumothorax in a patient with rheumatoid arthritis.

Rheumatoid arthritis is a multi-system disease. Pulmonary manifestations and complications include pleural disease, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis. Pulmonary rheumatoid nodules, including rheumatoid pneumoconiosis (Caplan's Syndrome), can result in spontaneous pneumothorax. In this article, the authors present a patient with rheumatoid arthritis and recurrent spontaneous pneumothorax. Through investigation, a bronchopleural fistula caused by a rheumatoid nodule was revealed. The authors also discuss the potential pitfalls caused by a lung nodule in a patient with rheumatoid arthritis, including the overlap with bronchogenic carcinoma and confusion with tuberculosis.

Scurvy resembling cutaneous vasculitis.

Various conditions can imitate cutaneous vasculitis. Scurvy is a less appreciated cause of rash that can resemble vasculitis. Three patients were referred to our rheumatology service for "vasculitis," who subsequently were found to have scurvy. Findings included a purpuric skin rash, myalgias, and malaise. The patients had low vitamin C levels and findings on skin biopsy specimens indicative of scurvy. The three patients were on idiosyncratic diets deficient in vitamin C, and the two patients who allowed us to administer vitamin C therapy improved clinically. We emphasize the importance of a careful dietary history. Early recognition of scurvy is important because it can be treated specifically, and toxic treatment of vasculitis can be avoided.

The Ides of March. The match 1993 in perspective.

BACKGROUND: The total number of US medical school graduates who selected categorical programs in internal medicine in this year's match fell by 7.9%. Consequently, the program fill rate for US graduates declined for the eighth consecutive year, from 55.9% to 53.1%. Preliminary positions and international graduates continue to increase, though questions remain whether these residents serve as good role models to encourage student interest in internal medicine. METHODS: We reviewed the 1993 National Resident Matching Program data and several curricular reforms implemented in our internal medicine clerkship and residency program to evaluate whether such reform might enhance interest in general internal medicine. RESULTS: Reform in our internal medicine clerkship curriculum included increased emphasis on problem-based learning and exposure to generalist role models. This resulted in substantial increases on the average miniboard examination and a 22% increase in the number of students pursuing residency in internal medicine from the previous year. Residency curricular reform centered around enhanced ambulatory care teaching along with improved exposure to generalist role models. This resulted in a gradual increase in the number of residency graduates who were staying in general internal medicine from 21% in 1991 to 40% in 1993. CONCLUSIONS: Innovative curricular changes in our internal medicine clerkship and residency programs have led to enhanced interest in general internal medicine. Although our results are preliminary, such change is necessary, not only to continue program excellence, but for simple survival.

Case report: Castleman disease in association with POEMS.

Castleman disease, or angiofollicular lymph node hyperplasia, and POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, and Skin changes), are associated and can lead to a clinical conundrum. The physician caring for a patient with Castleman disease should be alert to the development of multiple endocrine deficiencies, including primary hypogonadism, diabetes mellitus, hypothyroidism, and adrenal insufficiency. Avoidance of treating hypothyroidism alone when there is concomitant subclinical adrenal insufficiency is important, to avoid precipitating an adrenal crisis. A better outcome may result from earlier recognition of the endocrinopathies of this syndrome. This article describes a patient with Castleman disease in whom the features of POEMS unfolded over the ensuing years.

Case report: the spectrum of autoimmune thyroid disease with urticaria.

Urticaria has many known etiologies. An association with autoimmune thyroid disease is described. One individual had the triad of urticaria, Hashimoto's thyroiditis, and rheumatoid arthritis, whereas the other individual had urticaria preceding Graves' disease by over 1 year.

Case report: hypothalamic tuberculoma associated with secondary panhypopituitarism.

Tuberculosis of the central nervous system remains quite rare in developed countries, accounting for only 0.53% of cases of tuberculosis in the United States. The most common form of intracranial tuberculosis is tuberculous meningitis; however, involvement may also take the form of a solid granulomatous mass (tuberculoma), which accounts for 15% to 30% of the neurosurgical cases in developing countries. An unusual case of a hypothalamic tuberculoma is presented in a man, who initially presented with signs and symptoms consistent with panhypopituitarism. Brain biopsy on two occasions confirmed caseating granuloma, and treatment with several antituberculous medications led to clinical improvement and radiographic resolution of the disease.

Cardiac tamponade due to Nocardia asteroides.

Pericarditis with hemodynamic compromise is a rare manifestation of infection with Nocardia asteroides. To our knowledge, only six cases have been reported previously. In contrast to other cases of pericardial disease due to Nocardia, culture of the pericardial fluid in our case was negative while culture of pericardial tissue led to the diagnosis. Surgical intervention and appropriate antibiotic therapy are essential in the treatment of Nocardia pericarditis.

Paraneoplastic syndromes for the primary care physician.

To summarize, we have reviewed the major endocrine, hematologic, neurologic, dermatologic, and miscellaneous paraneoplastic syndromes. These entities are of great importance to the primary care physician because, when recognized, they can permit early diagnosis of the neoplasm. Further, treatment can afford palliation of symptoms. We can expect more definite identification of the causes of the paraneoplastic syndromes in the future because more of the substances that are released by tumors will be identified and analyzed. We need to watch with anticipation for the development of specific treatments for the paraneoplastic syndromes as the causes are identified.

Erythromycin associated hearing loss in a patient with prior cis-platinum induced ototoxicity.

A case is reported of reversible sensorineural hearing loss associated with intravenous erythromycin treatment. Cis-platinum induced high frequency hearing loss developed nine months previously during treatment for stage IV papillary cystadenocarcinoma. Renal and hepatic function were normal; however, serum erythromycin levels were elevated. Clinical recovery promptly followed discontinuation of erythromycin.