The Lost Art of the History and Physical

Approach to Loss of Consciousness: Distinguishing Epileptic Seizures, Psychogenic Nonepileptic Seizures, and Syncope

Transient loss of consciousness (TLOC) is a common emergent neurological issue, which can be attributed to syncope, epileptic seizures, and psychogenic nonepileptic seizures. The purpose of this article is to outline an approach to diagnosing the most common etiologies of TLOC by focusing on the importance of the history and physical examination, as well as targeted diagnostic tests.

Interobserver Reliability of the Respiratory Physical Examination in Premature Infants: A Multicenter Study

OBJECTIVE

To measure the inter-rater reliability of 7 visual and 3 auscultatory respiratory physical examination findings at 36-40 weeks' postmenstrual age in infants born less than 29 weeks' gestation. Physicians also estimated the probability that each infant would remain hospitalized for 3 months after the examination or be readmitted for a respiratory illness during that time.

STUDY DESIGN

Prospective, multicenter, inter-rater reliability study using standardized audio-video recordings of respiratory physical examinations.

RESULTS

We recorded the respiratory physical examination of 30 infants at 2 centers and invited 32 physicians from 9 centers to review the examinations. The intraclass correlation values for physician agreement ranged from 0.73 (95% CI 0.57-0.85) for subcostal retractions to 0.22 (95% CI 0.11-0.41) for expiratory abdominal muscle use. Eight (27%) infants remained hospitalized or were readmitted within 3 months after the examination. The area under the receiver operating characteristic curve for prediction of this outcome was 0.82 (95% CI 0.78-0.86). Physician predictive accuracy was greater for infants receiving supplemental oxygen (0.90, 95% CI 0.86-0.95) compared with those breathing in room air (0.71, 95% CI 0.66-0.75).

CONCLUSIONS

Physicians often do not agree on respiratory physical examination findings in premature infants. Physician prediction of short-term respiratory morbidity was more accurate for infants receiving supplemental oxygen compared with those breathing in room air.

To round or not to round: that is the question!

Bedside rounding and clinical examination has been an integral part of medical education and patient care for centuries. With the advent of computers and regulatory requirements for documentation by insurance carriers and third party providers, bedside rounding time has consistently decreased over the past several decades. Several studies have attempted to address the most effective way of bedside rounding, but no definite conclusion has been reached. We suggest multi-center broad base studies of key stakeholders to address this challenging issue.