Search

A 56-year old female runner is not able to run without tripping over anymore. Only whilst running her right foot repeatedly and involuntary makes an outward twist, which impedes her from continuing. She was diagnosed with Runner's Dystonia based on her presentation and virtually normal physical neurologic examination at rest.

In this article we extracted potential safety risks of supervising medical interns based on disciplinary cases filed since 2010 at Dutch Medical Disciplinary Boards. The main risks lie in the remote supervision of medical interns. The history and physical examination of complex patients (for example very ill patients or patients with a physical or mental disability) may require a direct form of supervision. Further, the management of medical records by interns requires a proper supervision. There is also a risk of a complaint in patients who do not want an intern to be present during their anamnesis or physical examination.

A 66-year-old man is evaluated in the Emergency Department for abdominal pain and vomiting since 2 days. Medical history showed esophageal resection because of an esophageal carcinoma. On physical examination there was tenderness of the right hemi-abdomen. A CT-angiography-chest/abdomen proved intrathoracically located small intestines with signs of ischemia.

Chronic itch, defined as an itching sensation that persists for more than 6 weeks, is a common complaint that is associated with a high burden of disease. Chronic itch can occur due to a variety of skin diseases, but can also feature as prominent symptom in various internal, neurologic, and psychiatric disorders. Importantly, chronic itch can be drug-related. Determining the underlying cause can be challenging, yet it is an essential step in the management of chronic itch. When generalized chronic itch presents with no primary skin lesions and/or secondary skin lesions, the diagnostic work-up should consist of a detailed history and physical examination with an initial limited screening of laboratory tests. Subsequent additional screening should be dictated by clinical suspicion. In 8% of patients, no underlying cause can be identified: pruritus of unknown origin. The management of chronic itch of unknown origin preferably follows a multimodal approach.

Constipation is an everyday complaint in general practice and in secondary care. In a limited number of situations, constipation is an alarm signal of a serious condition. In this postgraduate learning article, we discuss possible causes, the role of history and physical examination, additional diagnostics and treatment of constipation.

To determine the inter-rater reliability and validity of the Netherlands Triage Standard (NTS) for paediatric triage.A cross-sectional study using fictional cases for telephone and physical triage.An expert panel established in advance the urgency of 40 cases concerning emergency help requests from non-referred children (the reference standard). These requests were presented in an online survey to triagists from three general practitioner (GP) out-of-hours practices, three ambulance dispatching centres and three hospital emergency departments. Triagists assessed all cases, using the NTS. We determined the agreement on degrees of urgency between different triagists and compared them with the reference standard. The outcome measure for inter-rater reliability was the intraclass correlation coefficient (ICC). The outcome measures for validity were the degree of agreement with the reference standard, under-triage and over-triage, and sensitivity and specificity in identifying high-urgency (U0-U2) versus low-urgency cases (U30U5).In total, 116 triagists participated in the study (response: 86%). The ICC was 0.73 among all triagists, and was highest in the out-of-hours GP cooperatives. There was 62.3% agreement with the reference standard, 17.4% under-triage and 20.2% over-triage. Of the divergent urgencies, 77% differed by only one urgency category. The sensitivity was 85.2% and the specificity 89.7%. The sensitivity and specificity of triage by the GP out-of-hours practices (82.7% and 92.7%, respectively) were almost the same as that by the hospital emergency departments (79.6% and 92.5%, respectively). Triage by the ambulance dispatching centres had relatively high sensitivity (93%), but relatively low specificity (82.4%).The results of the study contribute to the evidence that the NTS is a reliable and valid triage standard for paediatric patients. The urgency assessments by triagists in the GP out-of-hours practices, ambulance dispatching centres and hospital emergency departments were broadly in agreement. Results were limited by cases being on paper and triage only on anamnestic characteristics.

Point of care ultrasonography (POCUS) is a specific form of ultrasonography that aims to quickly rule in or out specific abnormalities with a high impact on diagnostic or therapeutic management as an adjunct to physical examination. As such, it is of great value to every physician who performs physical examinations, especially if there is an acute problem that may involve several organ systems.

Here we present the case of a 64-year-old female patient with a painful thumb. This case demonstrates how, with proper physical examination, a correct diagnosis of 'skier's thumb' with concomitant Stener lesion can be made. This condition is a tear of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint with an interposition of the UCL and the aponeurosis adductor pollicis muscle. It is usually treated surgically.

Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.

Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.

Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.

Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis.A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis.This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics.

Abdominal pain Abdominal pain can be part of a variety of abdominal and non-abdominal conditions. Individual symptoms and signs from history taking and physical examination have limited discriminatory value for a clear diagnosis. Additional laboratory testing strategies and imaging techniques can provide more guidance in this respect. In this article, we will answer specific practical questions with respect to abdominal pain. Topics discussed include various abdominal conditions, diagnostic markers, the diagnostic value of imaging techniques and new treatments for irritable bowel syndrome.

Identification and interpretation of abnormal walking patterns is important, for the diagnosis as well as the treatment of the underlying condition. Since walking pattern changes can often be clinically observed at an early stage, their identification can help with timely diagnosis. Clinical training makes use of comprehensive descriptions of walking abnormalities that list all possible characteristics of a classic syndrome. However, patients rarely present at the office with all clinical symptoms of a specific disease, certainly not in the earliest stages. Especially in the beginning, patients often display only one or at best a few abnormal walking characteristics. None of these individual characteristics is specific for a certain disease, but may instead be seen in combination with several different disorders. For this reason, we have developed a practical diagnostic approach which allows making a differential diagnosis for each abnormal walking characteristic. Focused history taking and physical examination can then be used to make an accurate diagnose or to refer the patient for further diagnostics.

Previous studies showed that general practitioners (GPs) have problems in diagnosing asthma accurately, resulting in both under and overdiagnosis. To support GPs in their diagnostic process an asthma diagnostic consultation service (ADCS) was set up.We evaluated the performance of this ADCS by analysing the (dis)concordance between the GPs working hypotheses and the ADCS diagnoses and possible consequences this had on the patients' pharmacotherapy.In total 659 patients were included in this study. At this service the patients' medical history was taken and a physical examination and a histamine challenge test were carried out. We compared the GPs working hypotheses with the ADCS diagnoses and the change in medication this incurred.In 52% (n = 340) an asthma diagnosis was excluded. The diagnosis was confirmed in 42% (n = 275). Furthermore, chronic rhinitis was diagnosed in 40% (n = 261) of the patients whereas this was noted in 25% (n = 163) by their GP. The adjusted diagnosis resulted in a change of medication for more than half of all patients. In 10% (n = 63) medication was started because of a new asthma diagnosis. The 'one-stop-shop' principle was met with 53% of patients and 91% (n = 599) were referred back to their GP, mostly within 6 months. Only 6% (n = 41) remained under control of the ADCS because of severe unstable asthma.In conclusion, the ADCS helped GPs significantly in setting accurate diagnoses for their patients with an asthma hypothesis. This may contribute to diminish the problem of over and underdiagnosis and may result in more appropriate treatment regimens.

The relation between cancer and thrombosis is well known. In fact, the presence of an occult malignancy in patients with unprovoked venous thromboembolism (VTE) is named after a famous 19th century French physician; it is called Trousseau's sign. In this commentary, I elaborate upon findings from a recent individual patient data meta-analysis on Trousseau's sign. This study demonstrated that extensive screening to unmask an occult malignancy in unprovoked VTE is no better than 'simple' history taking and physical examination, alongside age-specific and gender-specific national cancer screening e.g. for colorectal carcinoma, breast cancer and/or prostate cancer. Listening to what the patient has to say and a good physical examination remain the cornerstone for modern medicine, a finding Trousseau would no doubt have appreciated.

The guideline entitled 'Functional abdominal pain in children' has been developed by a multidisciplinary working group on behalf of the Dutch Pediatric Association in 2015. - History and physical examination are essential in diagnosing pediatric functional abdominal pain. Additional diagnostic testing is of limited value when alarm symptoms are absent. - Reassurance and education of both the child and parent(s), are the cornerstones in the treatment of pediatric functional abdominal pain. - In case of persisting symptoms, hypnotherapy or cognitive behavioral therapy can be started. There is no evidence for any pharmacological treatment.

Physical examination of a 68-year-old woman showed dimpling of the left breast, which was only visible when she lifted her arms. Dimpling of the skin of the breast is an important sign of breast cancer that can easily be missed.

The aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children presenting to ERs with physical injury.A large multicentre study with a 6-month follow-up in 4 ERs in The Netherlands.Participants were 4290 children aged 0-7 years, attending the ER because of physical injury. All children were systematically tested with an easy-to-use child abuse checklist (index test). A national expert panel (reference standard) retrospectively assessed all children with positive screens and a 15% random sample of the children with negative screens for physical abuse, using additional information, namely, an injury history taken by a paediatrician, information provided by the general practitioner, youth doctor and social services by structured questionnaires, and 6-month follow-up information. Our main outcome measure was physical child abuse; secondary outcome measure was injury due to neglect and need for help.4253/4290 (99%) parents agreed to follow-up. At a prevalence of 0.07% (3/4253) for inflicted injury by expert panel decision, the positive predictive value of the checklist was 0.03 (95% CI 0.006 to 0.085), and the negative predictive value 1.0 (0.994 to 1.0). There was 100% (93 to 100) agreement about inflicted injury in children, with positive screens between the expert panel and child abuse experts.Rare cases of inflicted injury among preschool children presenting at ERs for injury are very likely captured by easy-to-use checklists, but at very high false-positive rates. Subsequent assessment by child abuse experts can be safely restricted to children with positive screens at very low risk of missing cases of inflicted injury. Because of the high false positive rate, we do advise careful prior consideration of cost-effectiveness and clinical and societal implications before de novo implementation.

The Dutch College of General Practitioners practice guideline on 'Sexual problems' describes the diagnostics and management of common sexual problems. An adequate sexual anamnesis is essential in order to obtain a good picture of the patient's symptoms and of any underlying causes. Additional physical or other medical examination is of limited value. The provision of information and advice are central to the treatment of sexual problems. Attention should be paid to the different aspects of sexual functioning: physical, psychological, relational and sociocultural, and to gender differences. In many cases, management is determined by the causal factor, for instance comorbidity, sexual trauma or relational problems. In other cases, a more specific problem is diagnosed, and management is based on this.

Soft tissue swelling of the leg is a relatively uncommon occurrence in children, and is often benign. In adults, 1% of malignancies originate in soft tissue, whereas for children the figure is 8%. Based on medical history and physical examination alone, it is difficult to differentiate between benign and malignant soft tissue tumours.A 15-year-old girl presented to her GP with a swelling in the left thigh, without alarming symptoms. The GP suspected the lesion to be benign and she was asked to return if the swelling increased in size. Five months later, when the lesion was excised, it proved to be a granular cell tumour. The second case concerns a 12-year-old boy who presented to his GP with a swelling of the lateral malleolus, which had developed after impact against a door five years ago. The boy was referred to the surgical department where after excision it was shown to be a dermatofibrosarcoma protuberans.In paediatric cases when diagnosis is inconclusive, including cases involving possible growth of the swelling, suspicions raised during physical examination, or unusually lengthy recovery after trauma, awareness is important. Imaging diagnostics or even tissue excision with histopathology may be indicated to allow the correct diagnosis to be made.

In the present article the complex aetiology of periodontal diseases is explained. Furthermore risk factors are identified for making mistakes in diagnosis and failing treatment of periodontal infections. This includes patient and treatment factors such as incomplete anamnesis, improper screening and documentation as well as insufficient plaque and smoking control, improper use of antibiotics and insufficient pocket-elimination and maintenance care. The use of a strict diagnostic and treatment protocol including evaluation is emphasized in order to obtain optimal treatment results. Patients should minimally expect to be regularly screened by their dentist or dental hygienist for periodontal diseases, to be informed about the further diagnostic steps and possible treatment options and to get periodontal care organised. Providers of oral health care can, in this way, reduce the risk of negligent practice and significantly limit their liability.

An otherwise healthy 15-month-old boy presented with a pruritic rash that had gradually developed since birth, leaving brown pigmentation. Darier's sign was positive and the diagnosis of juvenile urticaria pigmentosa was made. Juvenile urticaria pigmentosa usually shows spontaneous remission before puberty. Progression to systemic mastocytosis is extremely rare.

Tot in de twintigste eeuw was het bekijken van de uitgestoken tong voor de arts een routinezaak bij vrijwel alle ziekten. Vreemd genoeg deed de middeleeuwse arts dat niet. Men was het er wel over eens dat dit lichaamsdeel bestond uit zacht wit (!) vlees, dat vol zat met aderen en zenuwen. De functie van de tong was ook duidelijk. Deze moest met behulp van het speeksel het voedsel tussen de kiezen brengen en daarnaast was de tong belangrijk voor de smaakgewaarwording en vond men de tong ook van belang voor de klankvorming van de spraak.

Balance disorders in the elderly often have several contributing causes. The search for these causes focuses on vision, proprioception, coordination and medication. The peripheral vestibular system is often overlooked. This is probably due to the fact that most clinicians overlook the vestibular system, when complaints of vertigo are missing. However, dysfunction of the vestibular system may cause imbalance without vertigo. Three cases are presented. One case illustrates several contributing causes leading to imbalance. Two other cases illustrate causes of vestibular dysfunction resulting in imbalance without vertigo: a bilateral vestibulopathy and benign paroxysmal positional vertigo. Symptoms, examination and treatment are discussed. All patients with imbalance should undergo a Head Impulse Test and Dix-Hallpike maneuver.

Pituitary adenoma is the main cause of hyperprolactinaemia; however, physicians should be aware that the pituitary is not always to blame. There are many other physiological and pathological causes for hyperprolactinaemia, and the contribution of stress, medication and the presence of macroprolactin should not be overlooked. We describe three patients - a 19-year-old female, a 28-year-old female and a 20-year-old male - in whom hyperprolactinaemia was due to medication use, physical stimulation of the nipple and a combination of macroprolactianaemia with a microadenoma, respectively. The first two case reports show that conducting a thorough patient history can prevent unnecessary imaging and laboratory costs. The third case illustrates that macroprolactinaemia and true hyperprolactinaemia may coexist. While early screening for macroprolactinaemia in an asymptomatic patient can save money, finding macroprolactinaemia in a symptomatic patient still warrants further workup.

Pneumomediastinum is characterized by the presence of free air in the mediastinum. This can be a sign of a severe underlying disorder that requires urgent intervention. However, pneumomediastinum is also associated with other causes that can be treated conservatively. Here, we describe three patients who presented with a primary or spontaneous pneumomediastinum and a secondary pneumomediastinum due to traumatic or iatrogenic perforation. Recognition of the underlying cause of pneumomediastinum is essential for further diagnostic studies and patient management. Unnecessary investigations and interventions, which may cause further harm to and hospitalization of the patient, can thereby be prevented.

A 27-year old woman was admitted to the emergency room after her left ankle rolled inward during a volleyball game. On physical examination a bony prominence on the lateral side of the left foot was noticeable, without neurovascular injury. An X-ray (anterior-posterior view) showed a subtalar dislocation without associated fractures.

The aim of a diagnostic work-up in patients with acute sore throat is to exclude serious causes of tonsillitis and, in cases of a pharyngotonsillitis, to assess the degree of illness and the risk of complications. A diagnostic work-up aimed at the distinction between a viral or bacterial cause of pharyngotonsillitis does not determine initial treatment policy. Pharyngotonsillitis usually has a benign natural course; patient information and analgesia are usually sufficient treatment. Complications of an infection with group A streptococci are rare; diagnostic work-up for this bacterial cause is, therefore, not recommended. Antibiotics are only useful in cases of severe pharyngotonsillitis, increased risk of complications or a peritonsillar infiltration. The antibiotic of choice is a narrow spectrum penicillin; however, amoxicillin/clavulanate is indicated in patients with peritonsillar infiltration. If there is discrepancy in adults between the severity of symptoms and findings on physical examination, the possibility of epiglottitis should be considered.

If a child cries with an asymmetrical mouth it can be a sign of a nerve compression or a developmental defect in a facial muscle. In the latter case, a 22q11 deletion can be the cause, and multiple organs might be involved.A 2-month-old infant was referred to the paediatric outpatient clinic because he had an asymmetrical mouth when crying or laughing. There were no further symptoms. Genetic investigations and ultrasounds of the heart and kidneys were performed to exclude an underlying syndrome caused by a 22q11 deletion. These revealed no significant findings. It appeared to be a case of isolated 'asymmetric crying facies' as a result of hypoplasia of the depressor anguli oris muscle.An asymmetrical mouth in an infant can be a part of a genetic syndrome, in which there can be anomalies in multiple organ systems. For this reason, additional investigations are essential in cases of 'asymmetric crying facies'.

Patients with transient loss of consciousness are often seen by a variety of specialists. Even if typical signs occur, it can be difficult to identify specific causes. We discuss two patients with complex presentations. The first patient was diagnosed with sleep syncope, a relatively unknown type of reflex syncope. The prodromal symptoms of discomfort and the subsequent loss of consciousness occurred while the patient was in bed or got up to go to the toilet due to abdominal symptoms. The onset in supine position was misleading, since this is a well-known alarm symptom of a possible cardiac cause. The second patient had vasovagal syncope followed by a psychogenic pseudosyncope. This resulted in frequent loss of consciousness of long duration with typical and atypical triggers and uncommon syncopal signs, including eye closure. These conflicting symptoms can be a pitfall and clinical expertise is required to identify the type of syncope.

A 41-year-old woman presented to our emergency department after she tripped over a doorstep. Physical examination showed swelling and a stepladder deformity of the left little finger. Radiographs confirmed dorsal dislocation in both interphalangeal joints. Closed manual reduction under local anaesthesia restored position and function of the finger.

When there are no strings visible during an IUD (intrauterine device) check-up and ultrasound does not show an IUD in the uterine cavity, expulsion is commonly assumed. If the patient has abdominal pain further investigation is advised. This case shows that this policy does not cover every eventuality.The patient is a 32-year-old gravida 2, para 2. One month after IUD insertion she developed abdominal pain. The strings of the IUD were not visible with a speculum and ultrasound revealed an empty uterine cavity. Over the next few years the abdominal pain decreased but she developed atypical symptoms that were interpreted as psychosocial in origin. Two years later she presented with new abdominal symptoms and we referred her to a gynaecologist. An abdominal overview X-ray image revealed the IUD, which was removed laparoscopically.If there are no strings visible at an IUD check-up, perforation of the uterus needs to be considered. An abdominal overview X-ray image, which is relatively cheap and non-invasive, can then easily be taken.

Dit onderzoek is een retrospectieve analyse, waarin de onderliggende diagnoses worden vergeleken in twee groepen kinderen met een achterstand in de ontwikkeling (oa): 45 moeilijk lerende kinderen (mlk; iq 70-80) en 68 kinderen met een milde mentale retardatie (mmr; iq 50-70). Daarnaast worden geassocieerde medische problemen vergeleken met die bij kinderen die regulier basisonderwijs volgen. Resultaten: Het aantal oorzakelijke diagnoses (55%) was in beide groepen gelijk en gelijkelijk verdeeld over erfelijke, verworven of familiaire oorzaken. Genetische syndromen kwamen frequent voor in beide groepen (27%). Diagnoses kwamen merendeels tot stand dankzij anamnese en lichamelijk onderzoek door een multidisciplinair team. Kinderen met een achterstand hadden significant vaker dan kinderen in het regulier onderwijs geassocieerde medische problemen (35%); deze betroffen vooral epilepsie, gedrag, gehoor en groei. Voor motorische revalidatie werd 70% verwezen, voor psychiatrische behandeling 15% en voor genetische advisering 60%. Conclusie: Bij kinderen met een onverklaarde achterstand in de ontwikkeling kon, zowel in mlk als in mmr, in een op de twee een diagnose worden gesteld. Kinderen in deze studie met een milde ontwikkelingsachterstand werden vaker dan gezonde kinderen door geassocieerde medische problemen gehinderd. Er is geen goede reden om de diagnostiek te beperken tot kinderen met een mentale retardatie (iq

A 83-year-old male was admitted to the Emergency Department with acute haematochezia and abdominal pain. At digital rectal examination multiple soft distensions were palpable. Sigmoidoscopy revealed ischaemia of the rectum with severe gangrene. The patient was discharged after fluid resuscitation. Follow-up sigmoidoscopy 4 weeks later showed a fully recovered rectum.

A 5-year-old girl with generalized verrucous hyperkeratosis consulted the dermatologist for diagnosis and therapy. Further physical and mental development were normal. Gene analysis of keratin 1 and 10 was negative. According to the clinical findings, the diagnosis ichthyosis hystrix was made. Treatment with oral vitamin-A was suggested to the family.

It has been suggested that chronic dizziness in older people may constitute a multifactorial geriatric syndrome. Considering dizziness to be a geriatric syndrome with multiple contributory factors may provide additional leads for treatment. A structured history, followed by physical examination and additional tests if necessary, can yield clues to factors that may contribute to dizziness. To illustrate such a multifactorial approach, we present two patients with chronic dizziness. In both cases, the general practitioner considered multifactorial dizziness with several treatable contributory factors. By treating these contributory factors, the frequency of dizziness and dizziness-related impairment decreased temporarily in one patient and permanently in the other.