Physical diagnosis versus modern technology. A review.

The role of physical diagnosis in an age of modern diagnostic technology has been evaluated by investigators assessing specific techniques in a number of areas, though there has been no systematic comprehensive study of the sensitivity, specificity, cost-benefit ratio, and reliability of physical diagnosis relative to technologic diagnostic tools. In a review of published studies comparing physical with nonphysical diagnostic techniques, the startling accuracy of physical diagnosticians in some areas contrasts sharply with the extremely poor correlation of physical findings with autopsy or imaging studies in others. In a time of constricting financial resources, physicians-and those who teach or judge physicians' skills-must begin to compare physical and nonphysical diagnostic techniques rigorously so that the best, safest, and least expensive diagnostic test is chosen in each clinical situation.

Syphilis evaluation and therapy: a study of current practices in a university hospital.

The incidence of syphilis, after declining for several years, increased by 23% in the first quarter of 1987. The authors reviewed the charts of 100 patients with syphilis in order to determine how such patients were managed in a university setting. Although 77 patients met Centers for Disease Control (CDC) indications for lumbar puncture, only 11 patients had the procedure. Most patients for whom treatment was indicated either were not treated or were treated with inadequate or incorrect medications. Only 30 patients received follow-up serologic tests, and of these, only one received follow-up at the intervals recommended by the CDC. This study indicates that physicians may either be unfamiliar or disagree with the current CDC guidelines for evaluation and management of patients with syphilis. Physicians should know these guidelines and document their reasoning if they choose not to follow them. Long-term follow-up of patients with syphilis is important to ensure effective treatment and to increase understanding of this disease.

A survey on the prevalence of alcoholism among the faculty and house staff of an academic teaching hospital.

We studied the extent of alcoholism among faculty and house staff of an urban, university-based teaching hospital. Of 569 questionnaires sent, 282 (50%) were returned and 271 of these were complete enough to be interpretable. Of those responding, 12 (4%) were classified as alcoholic and 26 (10%) as possibly alcoholic. There was no statistically significant difference in the prevalence of alcoholism in physicians from the different medical specialties or in regard to gender. Nevertheless, with 14% of the respondents to our questionnaire being classified as either alcoholics or possible alcoholics, it appears that this is a pervasive problem in our profession that deserves further study.

Preserving renal function in surgical patients.

Postoperative acute renal failure, especially associated with oliguria, carries a high rate of mortality and morbidity. This complication can frequently be avoided if physicians are knowledgeable about preventable or modifiable risk factors. Patients who have underlying renal disease, sepsis, volume depletion or other conditions associated with renal hypoperfusion, or who have severe liver disease, are at particular risk. Exposure to nephrotoxic agents and wide fluctuations of intravascular volume are key conditions that can usually be minimized. Managing patients with chronic advanced renal failure (creatinine clearance 10 to 25 ml per minute) requires close interaction between the internists, anesthesiologists and surgeons. Understanding associated metabolic and organ system disorders is necessary to prevent complications and preserve remaining renal function. Chronic renal failure should not be a contraindication to an elective or emergent surgical procedure.

Phlegmonous gastritis and Hemophilus influenzae peritonitis in a patient with alcoholic liver disease.

A patient with alcoholic liver disease and ascites had Haemophilus influenzae peritonitis and died in spite of vigorous antibiotic therapy. At autopsy, a phlegmonous gastritis was found as a likely cause of the peritonitis. Phlegmonous gastritis is an uncommon cause of unexplained gastrointestinal symptoms in alcoholics and in the elderly, and it may be pathogenetic in rare patients with bacterial peritonitis of unclear source.