Renovascular Hypertension

Renovascular hypertension (RVH) is relatively common but underrecognized cause of resistant hypertension in clinical practice. Most patients with RVH have suboptimal control of hypertension in spite of being on multiple anti hypertensive medications. Prompt diagnosis and management is crucial to prevent long term morbidity and mortality. Initial evaluation by primary care physicians can expedite this to improve patient outcomes by co-managing hypertension specialists. In addition to pharmacologic and nonpharmacologic measures, some patients may benefit from angioplasty. This article discusses various definitions of hypertension, approach to diagnosis of RVH, and management. Data from clinical trials are discussed with evidence-based medicine practice recommendations.

Pocket-sized ultrasound as an aid to physical diagnosis for internal medicine residents: a randomized trial

BACKGROUND

Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded.

OBJECTIVE

We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice.

DESIGN

This was a randomized parallel group controlled trial.

PARTICIPANTS

Forty internal medicine residents in a single program at an academic medical center participated in the study.

INTERVENTION

Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice.

MAIN MEASURES

The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound.

KEY RESULTS

Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p = 0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group's 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % (p = 0.023).

CONCLUSIONS

The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice.

TRIAL REGISTRATION

clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2.