John L. Carpenter

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.

Adjunctive Corticosteroid Therapy for Tuberculosis: A Critical Reappraisal of the Literature

An extensive, although largely forgotten, literature addresses the utility of adjunctive corticosteroid therapy in the management of tuberculosis. Corticosteroid therapy probably improves neurological outcomes of, and decreases mortality due to, tuberculous meningitis of moderate severity. Although therapy for tuberculous pericarditis is simplified (with less need for operative intervention) by adjunctive corticosteroid administration and there are fewer deaths, the incidence of subsequent constriction is not changed. The signs and symptoms of typical reactivation tuberculous pneumonia, tuberculous pleurisy, and probably primary tuberculous disease (with lymphadenopathy) seem to decrease rapidly with corticosteroid therapy, although no differences in final outcomes have been observed. Corticosteroid regimens used in most studies varied greatly in duration and dosage and generally caused significant side effects. Corticosteroids do not appear to diminish the efficacy of adequate antimycobacterial therapy. Adjunctive corticosteroid therapy appears to offer significant short-term but (other than for tuberculous meningitis and effusive pericarditis) minimal long-term benefit for patients with tuberculosis.

Administration of a Parallel, Simultaneous Objective Structured Clinical Examination to Accommodate a Large Class of Students.

The use of an objective structured clinical examination (OSCE) to evaluate the clinical abilities of second‐year medical students at the end of an introduction to clinical medicine course in 2 successive years is reported. Due to the large number of students in our classes, two identical, simultaneous, parallel OSCEs were administered each year. Skills to be evaluated and cases used to measure these skills were determined by a modification of existing methods. The logistic feasibility of administering a large OSCE in this manner was confirmed. A thorough psychometric evaluation of the OSCE was performed, and findings were evaluated. When used in a pass‐fail context and calculated as a dependability index with cutoffs, the generalizability of the total OSCE and most individual skills measured was greater than .8 when the cutoff was 2 SD below the mean score. The number of cases required to achieve a generalizability of .8 for the total OSCE and each individual skill was fewer than 11. The potential for use...

Assessing the usefulness of using standardized patients in a clinical medicine course

No abstract available.

Using an Algebraic Inversion of the Dependability Index to Determine Pass/Fail Criteria for Clinical Performance Examinations

There has been considerable debate as to how to establish a pass/fail point for clinical performance examinations. Most standard setting techniques require considerable effort and may well be beyond the resources of most local institutions. At the University of Texas Southwestern Medical Center at Dallas we explored different pass/fail standards or criteria used in an OSCE given at the end of a second year Introduction to Clinical Medicine course. We compared the number of students who passed or failed for years 1990-1995 based upon using three different standards or cut scoring procedures: 1) a group or norm referenced cut point of two standard deviations below the mean, 2) an a priori estimated cut score based on 1991 group data applied to all OSCE scores, and 3) a cut point based upon an algebraic inversion dependability index of both 0.8 and 0.9. We found that the use of an estimated cut score as a reference in combination with algebraic inversion dependability index to be a most appropriate and simplest way to apply a standard setting process for pass/fail decisions. A well reasoned estimated score based upon faculty judgement and previous years test experience can serve as a useful benchmark.