Clinical approach to the diagnostic evaluation of progressive neuromuscular diseases

This article has reviewed the clinical approach to the diagnostic evaluation of progressive neuromuscular diseases with an emphasis on relevant neuromuscular history, family history, clinical examination findings, laboratory studies, and a brief discussion of the role of muscle biopsy. Molecular genetic and immunocytochemistry studies of muscle have been major advances in the diagnostic evaluation of the neuromuscular disease patient; however, all diagnostic information must be interpreted within the context of relevant clinical information. In some instances, a precise diagnosis is not medically possible; however, the accurate characterization of an individual patient within the most appropriate NMD clinical syndrome often allows the clinician to provide the patient and family with accurate prognostic information and anticipatory guidance for the future. After synthesizing all available clinical and diagnostic information, the physiatrist or neurologist may at times determine that an NMD patient has an inappropriate diagnosis warranting further diagnostic evaluation. This issue focuses on the rehabilitation of progressive neuromuscular diseases with an emphasis on optimization of health, prevention or minimization of complications, and enhancement of quality of life. Appropriate rehabilitation approaches require an accurate diagnosis. In addition, patient quality of life in NMD depends on access to current and accurate information. The first step in providing accurate information and appropriate treatment is constantly ensuring that NMD patients have appropriate diagnoses based on a through evaluation of clinical information and appropriate application of current medical science and available diagnostic technology.     

Diagnostic imaging of heel pain and plantar fasciitis

Heel pain or calcaneodynia is a common clinical complaint which has a myriad of causes ranging from plantar fasciitis to stress fracture. In many instances, the etiology of the heel pain is difficult to ascertain simply on the basis of history and physical examination. Therefore, the clinician may enlist various diagnostic imaging modalities to clarify the source of pain. Of all the imaging techniques, magnetic resonance imaging (MRI) has proven its worth in the diagnosis of heel pain. This article outlines the various causes of heel pain and their associated imaging findings.     

Pain assessment and evaluation of patients who have neuropathic pain

Pain assessment and physical examination are the first crucial steps in diagnosis of neuropathic pain disorders because these are still solely diagnosed on clinical grounds. The physical examination should be conducted in such a way that all of the positive sensory phenomena, such as allodynia, hyperalgesia, hyperpathia, summation, and after-sensation are elicited. Other physical examination findings should corroborate the diagnostic impression of neuropathic pain. Specific pain diagnosis should then lead to more specific therapy.     

Clinical methods for diagnostic confirmation of stroke subtypes

Clinicians faced with a patient having a sudden-onset, focal neurological deficit must answer three fundamental questions: is it a stroke?, is it ischemia or hemorrhage? and what kind of ischemic stroke is it? Clinical information (that is, history and examination) is immediately available to every physician, and its role in answering these questions is extremely important, even though a 100% certainty can only be obtained with instrumental diagnostic tools. In fact, when diagnosis is based on properly designed clinical criteria, the percentage of diagnostic mistakes is quite low. Clinical methods are still the best way of orientating topographic and etiologic diagnosis, as well as prognosis. In addition, time might be saved if randomization in clinical trials could be done using clinical methods before complex investigations are applied.     

The assessment of light intensity preference in psychiatric patients: a questionnaire

PROBLEM: Psoas abscesses are really rare so that the diagnostic onset is commonly very late. The differential diagnosis to other retroperitoneal processes is therefore important. METHOD: In a period of observation of 6 years 21 patient were treated with psoas abscesses. The evaluation of 16 records was done retrospectively under consideration of etiology, history, clinical examination, lab results and x-ray/CT/MRI etc. RESULTS: With the knowledge of the anatomy of the ilio-psoas muscle the clinical examination gives us important information about the diagnosis of psoas abscess. The history and the clinical examination precede the further diagnostics and are condition for high rates of sensitivity and specificity. Lab results indicate an absedation without being specific. The exclusive position of radiological diagnostics is undisputed. Ultrasound, x-ray and leucocyte marked bonescan are proven to be helpful in cases of unknown location of the abscesses. Method of choice seems to be the contrast enhanced CT-scan. The differential diagnosis includes gastrointestinal or renal disorders as well as pathology of bone or joints. In our cases differential diagnosis was complicated since the diagnostic onset was delayed and the initial therapy was not adequate. The diagnosis "abscess of the psoas" does not imply a general regime for therapy therefore an individual treatment in consideration of percutaneous and operative drainage has to be recommended. In selected cases a combination therapy is advised. CONCLUSION: In every case of retroperitoneal symptoms the differential diagnosis of an abscess of the psoas has to be regarded. The diagnosis is subtil and requires clinical and laboratory examinations as well as contrast enhanced computerscan. The therapy follows operative measures. The technique has to be individually decided.     

Right upper quadrant abdominal pain. Diagnosis in patients without evident gallstones

Right upper quadrant abdominal pain is often of biliary origin. Negative results on an ultrasound examination do not exclude biliary pathology. A logical diagnostic approach to the patient should be based on clues obtained from careful history taking, physical examination, and review of routine laboratory studies. Endoscopy, radiography, and nuclear medicine studies may identify specific causes for pain. The use of sophisticated tests, such as endoscopic retrograde cholangiopancreatography with sphincter manometry, may enable diagnosis in refractory cases. Therapy specific for a correctly diagnosed cause provides rewarding results and avoids unnecessary and unsuccessful procedures.     

Differential diagnosis in patients with disorders of the patellofemoral joint

Anterior knee complaints are difficult diagnostic problems. It cannot be overstated that the most important information available is to be found in the patient's history. Onset, quality, and quantity of symptoms must be assessed. This information is then synthesized to determine the specific functional disabilities resulting from the patient's anterior knee disorder. Once a history is obtained, a consistent, methodical physical examination can be performed to narrow the differential diagnosis. Radiographic evaluation is used to further hone the differential or to confirm the most likely diagnosis. Ultimately, a specific working diagnosis is selected and treatment is tailored to changing the underlying structural or biomechanical abnormalities that led to the patient's complaints.     

MR of the spine with a fast T1-weighted fluid-attenuated inversion recovery sequence

Much is unclear about the pathophysiological mechanisms underlying painful temporomandibular disorders. In addition to various other theories, masticatory muscle dysfunction and pain have also been attributed to primary central nervous system hyperactivity. We assessed this possibility in a study using recent neurophysiological techniques. From among outpatients whose diagnosis of temporomandibular disorders had been obtained in stomatognathic facilities, we studied 10 patients with bilateral pain and 15 patients with unilateral pain, in whom electromyographic examination of the trigeminal reflexes disclosed normal findings except for absence or amplitude asymmetry of the jaw jerk. Transcranial magnetic stimulation yielded masseter motor evoked potentials of normal latency and amplitude, but five patients had to exert a near-maximum contraction to obtain their responses. The masseter silent periods elicited by the double-shock technique recovered normally. Because these tests measure the excitability of the masticatory system (including motor cortex, corticobulbar and corticoreticular connections, reticular interneurones and lower motoneurones), the lack of facilitation in these patients' responses excluded central hyperactivity as the primary cause of their masticatory dysfunction and pain.     

Primary bone and metastatic tumors of the cervical spine

Cervical spine tumors, whether primary bone tumors or metastatic tumors, are rare. The possibility of tumors existing must be considered in the differential diagnosis of patients with persistent neck pain, with or without neurologic symptoms, particularly in those with significant pain at night. The clinical presentation is extremely variable, though a history of malignancy should always raise the concern for recurrence. The evaluation and diagnostic assessment includes a thorough physical examination. Radiographic imaging is usually initiated with plain radiographs and additional advanced imaging obtained as indicated. Using appropriate biopsy principles and techniques, tissue is obtained for histologic determination of the suspected lesion before surgical intervention. Treatment options are extremely variable and depend on many factors, including tumor type, location, and patient preference. Treatment warrants a multidisciplinary approach from experienced physicians and is most successfully accomplished in referral centers. Oncologic staging using the Enneking staging system, followed by surgical staging using the Weinstein, Boriani, Biagini system, will aid in the accurate characterization of the tumor load, maximize surgical goals, assure use of appropriate terminology, and provide optimal communication among treatment centers regarding tumor characteristics, treatment efforts, and results.     

Iliopsoas bursitis and tendinitis. A review

This review examines the diagnosis and management of iliopsoas bursitis and/or tendinitis. It is a relatively uncommon and unrecognised cause of anterior hip pain and anterior snapping hip. In view of its pathology, iliopsoas bursitis might be better referred to as iliopsoas syndrome. It can usually be diagnosed by history and physical examination, though real time ultrasound may be useful in confirming the diagnosis. Magnetic resonance and computerised tomography imaging have limited roles in its diagnosis, but may identify other pathology or surgical lesions. Nonoperative management has not been well established. Surgical management does not guarantee treatment success. There is a need for further research into both diagnostic and treatment options for those patients with iliopsoas bursitis/tendinitis.     

Ultrastructural changes in liver damage induced by carbon tetrachloride in spontaneously hypertensive rats and Wistar-Kyoto rats

The establishment of a better local area medical centre containing hospitals and clinics is thought to be a very important issue. The medical information system, which should be accepted by both hospitals and clinics, has been studied using graphic user interface (GUI) and a three dimensional structure. Our system files medical records and blood examination data as well as diagnostic images, which may be the first attempt in the world. It has been favourably evaluated by physicians through clinical evaluation.     

Psychotherapy for children. Generalities

Child psychotherapy has limited use in an institution. Through play one can appreciate the conflicts and suggest solutions, either verbally or through the play itself. As a framework one can use a dynamic concept of development and learning, and an educational approach. First one must elaborate a clinical history, do a physical examination and apply psychological tests in order to make a good diagnosis. The approach and treatment should be interdisciplinary. The institutional difficulties for this type of work are mentioned.     

Clinical reasoning and decision making in the practice. A woman with abdominal complaints

A female patient aged 28 years suffered from recurrent episodes of diarrhoea. Giardia lamblia was isolated once. By rigorous application of basic clinical skills, such as thorough history taking and physical examination, together with laboratory tests the correct diagnosis was established (in this patient systemic lupus erythematosus). Two important aspects of clinical reasoning, viz. returning to the patient when new information becomes available (cyclic way of working) and pattern recognition ensured a fruitful diagnostic process.     

Does this patient have appendicitis?

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.     

Pulmonary infections in immunocompromised patients who do not have acquired immunodeficiency syndrome: a systematic approach

Immunocompromised patients are susceptible to infections by organisms that infect individuals with normal immunity and by organisms that affect only those with abnormalities in their immune system. Using the radiographic findings and incorporating clinical information allows for the creation of a useful list differential diagnoses. The nature of the immune defect must be defined because defects in the different parts of the immune system are associated with infections by specific organisms. The time interval since transplantation provides a diagnostic clue because infections tend to occur at certain time intervals after transplantation. An epidemiologic history provides a history of exposure to organisms that may produce pneumonia. Consideration of the therapy the patient has received provides additional clues to the cause of the pneumonia. The physical examination and laboratory studies may provide an indication of the cause of the infection. Organisms tend to produce infections that have a typical rate of clinical development. Classifying the presentation as acute, subacute, or chronic provides additional etiologic clues. Correlating the clinical information with the radiographic findings generates a list of the most likely causative organisms. The list is useful in deciding on additional diagnostic tests and guiding therapy.     

Differentiation between Crohn's disease and ulcerative colitis

In the last several decades, the incidence of CD has been rising. This trend in part has been due to the clinical recognition of isolated CD. The differentiation can usually be made based on careful clinical history, physical examination, and diagnostic testing. The most reliable, sensitive method for differentiating these two diagnoses is colonoscopy. The ability to obtain directed endoscopic colonic biopsy specimens gives an even greater diagnostic yield. In many situations, observation of the clinical course and repeated diagnostic evaluations result in further clarification of the disease process involved. The importance of establishing an accurate diagnosis becomes most relevant when surgery is indicated. Once surgery has been performed, evidence of recurrent disease at the site of an ileostomy, ileal pouch, or ileorectal anastomosis establishes the disease as CD. In the absence of recurrent disease after colectomy, the difference becomes one of academic interest.     

Migraines and other headaches: an approach to diagnosis and classification

Headache is a symptom that accounts for over 18 million visits to physicians each year. In an effort to resolve inconsistencies and problems with the differentiation of specific types of headache, the International Headache Society (IHS) has established a classification system. For each major type of headache, the IHS classification specifies diagnostic criteria and recognized subtypes where appropriate. Migraine headaches are commonly encountered in clinical practice. Recognition and accurate diagnosis of migraine headache depend on a thorough history, appropriate physical examination and diagnostic testing.     

A biopsychosocial formulation of pain communication.

We present a detailed framework for understanding the numerous and complicated interactions among psychological and social determinants of pain through examination of the process of pain communication. The focus is on an improved understanding of immediate dyadic transactions during painful events in the context of broader social phenomena. Fine-grain consideration of social transactions during pain leads to an appreciation of sociobehavioral events affecting both suffering persons as well as caregivers. Our examination considers knowledge from a variety of perspectives, including clinical health psychology, social and developmental processes, evolutionary psychology, communication studies, and behavioral neuroscience. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain

STUDY DESIGN: A controlled clinical trial. OBJECTIVES: To examine the long-term effect of an informative approach to low back pain. SUMMARY OF BACKGROUND DATA: In management and prevention of low back pain, back school based on an ergonomic approach have played in important role. The effect of such informative interventions is not clear. METHODS: A 5-year follow-up study was done on patients included in a previous study. The outcome was measured by return to work or still on sick leave. The patients were allocated to an intervention group (n = 245) and a control group (n = 244). Only the intervention group was called in for examination and intervention and answered a battery of tests for psychological and health factors. The intervention apart from the clinical examination consisted of education in an "mini back school." The program was based on a new medical model for low back pain. RESULTS: Forty-seven (19%) of the patients in the intervention group, compared with 84 patients (34%) in the control group, were still on sick leave after 5 years (P < 0.001). There were fewer recurrences of sick leave (P < 0.03) in the intervention group than in the control group. Based on Internal Health Locus of Control, number of children, and income, 75% were correctly classified as nonreturners in the intervention group. CONCLUSIONS: This study indicates that subchronic low back pain may be managed successfully with an approach that includes clinical examination combined with information for patients about the nature of the problem, provided in a manner designed to reduce fear and give them reason to resume light activity.     

Usefulness of transesophageal echocardiography in predicting mortality and morbidity in stroke patients without clinically known cardiac sources of embolus

Shoulder pain is encountered commonly in older people. Most of the conditions are amenable to nonoperative treatment, but a clear understanding of the anatomy and those conditions encountered most commonly is essential. A careful history and physical examination, as well as limited diagnostic tests, point to a clear diagnosis in the majority of patients. Most often, conservative measures are effective. Steroid injections are often helpful for both diagnostic and therapeutic reasons. A small percentage of patients do not respond to conservative management and require operative intervention.