Stanley L. Wiener

The diagnostic usefulness of the history of the patient with dyspnea

The diagnostic usefulness of the medical history may depend on the type of problem confronted. It has been suggested that dyspnea is an example of a condition the causes of which cannot be easily distinguished based on identification in the history of stereotypical disease patterns presented in standard texts. To evaluate this assertion, faculty members independently interviewed 146 consecutively admitted patients with dyspnea, and following the history of the present illness, made a diagnosis. After discharge of the patients, another faculty member, using preselected criteria, independently reviewed each record to make a final diagnosis. History-based diagnoses predicted final diagnoses 74% of the time. Therefore, the history appeared to be useful in identifying the primary diagnosis for most dyspneic patients admitted to the hospital. However, it is not known whether this identification provides sufficient rationale for therapy or leads to more efficient use of laboratory tests.

Outbreak of acute pulmonary hîstoplasmosis in members of a wagon train.

In August 1980, an outbreak of acute pulmonary histoplasmosis occurred among participants in a wagon train as it traveled through eastern Tennessee. Of the 85 people on the train 69 (81 percent) had evidence of infection with Histoplasma capsulatum. Fifty-four people had symptomatic disease. The source of infection was traced to the site of a former winter blackbird roost in Charleston, Tennessee, that had been partially cleared five years earlier to make a park. Fourteen of 25 soil samples from this site were culture-positive for H. capsulatum. This is the first reported outbreak to involve a large migrant group. The outbreak is unusual in that exposure occurred without excavation, construction or tree-cutting at the site.

Accuracy of precordial percussion in detecting cardiomegaly

STUDY OBJECTIVE To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse. DESIGN Descriptive study. SETTING Hospitals and clinics of a university medical center. PATIENTS Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results. MEASUREMENTS AND MAIN RESULTS Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases. CONCLUSIONS Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.

Campylobacter fetus ssp jejuni: Isolation from patients with gastroenteritis

Within a seven-month period, Campylobacter fetus ssp jejuni was isolated in East Tennessee from 18 patients with gastroenteritis; 83% of these patients had bloody diarrhea. Absence of other enteric organisms such as Salmonella, Shigella, and Yersinia implicated C fetus ssp jejuni as the causative agent. A fourfold increase in titer by tube agglutination from four of eight patients studied supported the pathogenicity of this organism. Treatment with erythromycin alleviated gastroenteritis symptoms within 24 to 48 hours, with concurrent disappearance of the organism from the feces. An isolation rate of 8% in our patients indicates that C fetus ssp jejuni is more common as a cause of human diarrhea than Salmonella or Shigella. The severity of the C fetus ssp jejuni gastroenteritis poses a possible reclassification from diarrhea or gastroenteritis to acute dysentery syndrome.

Medical readiness education and training exercises by United States army medical personnel in Kenya

Medical Readiness Education and Training Exercises (MEDRETEs) enable United States military medical personnel to sharpen their skills in diagnosis and treatment of common illnesses in rural third world populations. We report our experiences on MEDRETEs conducted during recent exercises in the Republic of Kenya involving United States and Kenyan forces. Respiratory, musculoskeletal, and eyes, ears, nose, and throat conditions comprised 55% of cases. In 73% of cases, the final diagnosis and the chief complaint were in the same diagnostic category. In asymptomatic patients, 17% had physical findings suggestive of significant disease. Anecdotal experiences demonstrated the importance of the local environment and social customs in the genesis of certain illnesses and symptoms.