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Background A clinical diagnostic support system (CDSS) can support medical students and physicians in providing evidence-based care. In this study, we investigate diagnostic accuracy based on the history of present illness between groups of medical students using a CDSS, Google, and neither (control). Further, the degree of diagnostic accuracy of medical students using a CDSS is compared with that of residents using neither a CDSS nor Google. Methods This study is a randomized educational trial. The participants comprised 64 medical students and 13 residents who rotated in the Department of General Medicine at Chiba University Hospital from May to December 2020. The medical students were randomly divided into the CDSS group (n = 22), Google group (n = 22), and control group (n = 20). Participants were asked to provide the three most likely diagnoses for 20 cases, mainly a history of a present illness (10 common and 10 emergent diseases). Each correct diagnosis was awarded 1 point (maximum 20 points). The mean scores of the three medical student groups were compared using a one-way analysis of variance. Furthermore, the mean scores of the CDSS, Google, and residents’ (without CDSS or Google) groups were compared. Results The mean scores of the CDSS (12.0 ± 1.3) and Google (11.9 ± 1.1) groups were significantly higher than those of the control group (9.5 ± 1.7; p = 0.02 and p = 0.03, respectively). The residents’ group’s mean score (14.7 ± 1.4) was higher than the mean scores of the CDSS and Google groups (p = 0.01). Regarding common disease cases, the mean scores were 7.4 ± 0.7, 7.1 ± 0.7, and 8.2 ± 0.7 for the CDSS, Google, and residents’ groups, respectively. There were no significant differences in mean scores (p = 0.1). Conclusions Medical students who used the CDSS and Google were able to list differential diagnoses more accurately than those using neither. Furthermore, they could make the same level of differential diagnoses as residents in the context of common diseases. Trial registration This study was retrospectively registered with the University Hospital Medical Information Network Clinical Trials Registry on 24/12/2020 (unique trial number: UMIN000042831).

Background To investigate whether speech recognition software for generating interview transcripts can provide more specific and precise feedback for evaluating medical interviews. Methods The effects of the two feedback methods on student performance in medical interviews were compared using a prospective observational trial. Seventy-nine medical students in a clinical clerkship were assigned to receive either speech-recognition feedback (n = 39; SRS feedback group) or voice-recording feedback (n = 40; IC recorder feedback group). All students’ medical interviewing skills during mock patient encounters were assessed twice, first using a mini-clinical evaluation exercise (mini-CEX) and then a checklist. Medical students then made the most appropriate diagnoses based on medical interviews. The diagnostic accuracy, mini-CEX, and checklist scores of the two groups were compared. Results According to the study results, the mean diagnostic accuracy rate (SRS feedback group:1st mock 51.3%, 2nd mock 89.7%; IC recorder feedback group, 57.5%–67.5%; F(1, 77) = 4.0; p = 0.049), mini-CEX scores for overall clinical competence (SRS feedback group: 1st mock 5.2 ± 1.1, 2nd mock 7.4 ± 0.9; IC recorder feedback group: 1st mock 5.6 ± 1.4, 2nd mock 6.1 ± 1.2; F(1, 77) = 35.7; p SRS feedback group: 1st mock 12.2 ± 2.4, 2nd mock 16.1 ± 1.7; IC recorder feedback group: 1st mock 13.1 ± 2.5, 2nd mock 13.8 ± 2.6; F(1, 77) = 26.1; p Conclusions Speech-recognition-based feedback leads to higher diagnostic accuracy rates and higher mini-CEX and checklist scores. Trial registration This study was registered in the Japan Registry of Clinical Trials on June 14, 2022. Due to our misunderstanding of the trial registration requirements, we registered the trial retrospectively. This study was registered in the Japan Registry of Clinical Trials on 7/7/2022 (Clinical trial registration number: jRCT1030220188).

Background The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician. Methods The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice. Results Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load). Conclusions Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.

Purpose Fundoscopic exams are conducted during outpatient consultations to assess intracranial disease and complications from chronic diseases. Low level of confidence in these skills which physicians have is one of the causes that implementation frequency is low. Research has not yet identified specific measures through which the healthcare system may increase the implementation of fundoscopic exams nor a qualitative process that enables physicians to gain confidence in their fundoscopic exam skills. We introduced a checklist and conducted a mixed-methods study. Methods This study is a before-and-after study, within an embedded-experimental mixed-methods design. We sampled 15 physicians in the department of general medicine at a university hospital assigned to initial consultation. We introduced a checklist to verify whether the fundoscopic exam was implemented. Measures are implementation ratio of the fundoscopic exam to the total number of indication cases, and Visual Analog Scale (VAS) values for the confidence in procedure are measured before and after the intervention. We obtained qualitative data from interviews and used the Modified Grounded Theory Approach. Results We observed significant increases in the implementation ratio (19.2% (29/151 cases) vs 64.8% (105/162 cases), p and , which is prevented by the checklist. The leads to a . Repeated executions result in . Conclusion The intervention increased the implementation ratio, thereby increasing successful experiences and confidence among physicians. The growth of confidence boosted motivations to implement fundoscopic exams.

A 73-year-old woman was referred to our department with a 2-month history of slight fever. Two weeks ago, she developed a fever of 38°C and right upper arm pain. Her right upper arm pain was induced by exertion, such as cooking and carrying heavy loads. She lost 3 kg (from 41 to 38 kg) of body weight in 2 months. Physical examination revealed a temperature of 37.9°C. Visual …

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.

A 16-year-old boy who was a non-smoker presented with a prolonged severe dry cough and malaise of 3 months in duration. Despite an increase in the patient's inflammatory marker levels, no respiratory lesions were radiologically or serologically detected. We suspected that the cough reflex pathway had been stimulated by large vessel vasculitis (LVV, a non-respiratory inflammatory condition) and diagnosed the patient with Takayasu arteritis. While inflammation of either the ascending pharyngeal or pulmonary artery have been reported to cause cough in patients with LVV, the present case shows that intense inflammation of the aortic arch and the starting portion of its main branches may stimulate a vagus nerve branch as a novel mechanism causing cough.

Objectives: The case history is an important part of diagnostic reasoning. The patient management problem method has been used in various studies, but may not reflect the actual reasoning process because a list of choices is given to the subjects in advance. This study investigated the contribution of the history to making the correct diagnosis by using clinical case simulation, in which students obtained clinical information by themselves. Methods: A prospective study was conducted. Ninety-four fifth-year medical students from Chiba University who underwent supervised clinical clerkships in 2009 were surveyed. Each student randomly selected 1 of 4 test cases and attempted to make a diagnosis through medical interview, physical examination, and laboratory tests, while the teacher acted as a patient. The student ranked the disease(s) diagnosed at each stage of the process. Diagnostic accuracy rates were compared using analysis of the χ2-test. Results: Sixty students (63.8%) made a correct diagnosis, which was based on the history in 43 students (71.7%), physical findings in 11 students (18.3%), and laboratory data in 6 students (10.0%). Compared with students who considered the correct diagnosis in their differential diagnosis after taking a history, students who failed to do so were 5.0 times (95%CI = 2.5-9.8) more likely to make a final misdiagnosis (χ2(1) = 30.73; p

We report a 54-year-old man with osteomalacia due to a bladder reconstruction performed 35 years previously. He had had slowly progressive chest and back pain for 18 months. Osteomalacia due to metabolic acidosis was suspected based on hyperalkalinephosphatasemia and a high serum chloride level, and the diagnosis was confirmed by bone scintigraphy. His symptoms and blood electrolyte levels were improved by oral medication, including sodium hydrogen carbonate. Measurement of the serum chloride level is simple and useful for evaluating acidosis, for which a regular blood test is essential in patients who have undergone bladder reconstruction.

We report a rare case of iliac vein compression syndrome caused by urethral calculus. A 71-year-old man had a history of urethral stenosis. He complained of bilateral leg edema and dysuria for 1 week. Physical examination revealed bilateral distention of the superficial epigastric veins, so obstruction of both common iliac veins or the inferior vena cava was suspected. Plain abdominal computed tomography showed a calculus in the pendulous urethra, distention of the bladder (as well as the right renal pelvis and ureter), and compression of the bilateral common iliac veins by the distended bladder. Iliac vein compression syndrome was diagnosed. Bilateral iliac vein compression due to bladder distention (secondary to neurogenic bladder, benign prostatic hyperplasia, or urethral calculus as in this case) is an infrequent cause of acute bilateral leg edema. Detecting distention of the superficial epigastric veins provides a clue for diagnosis of this syndrome.

We report a 38-year-old mestizo man with the sudden onset of left upper abdominal pain while climbing Mt. Fuji, which is the highest mountain in Japan. Enhanced computed tomography showed splenic infarction. Although his peripheral blood smear was normal, a hemoglobin S level of 40% established the diagnosis of sickle cell trait (SCT). This trait is common worldwide, but is not well recognized by doctors in Japan because no Japanese patients with SCT have been reported. However, in Japan it is important to consider SCT when assessing foreign patients with splenic infarction.

Kazutaka Noda, Masatomi Ikusaka, Yoshiyuki Ohira, Toshihiko Takada, Tomoko TsukamotoDepartment of General Medicine, Chiba University Hospital, Chiba, JapanObjective: Patient medical history is important for making a diagnosis of causes of dizziness, but there have been no studies on the diagnostic value of individual items in the history. This study was performed to identify and validate useful questions for suspecting a diagnosis of benign paroxysmal positional vertigo (BPPV).Methods: Construction and validation of a disease prediction model was performed at the outpatient clinic in the Department of General Medicine of Chiba University Hospital. Patients with dizziness were enrolled (145 patients for construction of the disease prediction model and 61 patients for its validation). This study targeted BPPV of the posterior semicircular canals only with a positive Dix–Hallpike test (DHT + BPPV) to avoid diagnostic ambiguity. Binomial logistic regression analysis was performed to identify the items that were useful for diagnosis or exclusion of DHT + BPPV.Results: Twelve patients from the derivation set and six patients from the validation set had DHT + BPPV. Binomial logistic regression analysis selected a "duration of dizziness ≤15 seconds" and "onset when turning over in bed" as independent predictors of DHT + BPPV with an odds ratio (95% confidence interval) of 4.36 (1.18–16.19) and 10.17 (2.49–41.63), respectively. Affirmative answers to both questions yielded a likelihood ratio of 6.81 (5.11–9.10) for diagnosis of DHT + BPPV, while negative answers to both had a likelihood ratio of 0.19 (0.08–0.47).Conclusion: A "duration of dizziness ≤15 seconds" and "onset when turning over in bed" were the two most important questions among various historical features of BPPV.Keywords: benign paroxysmal positional vertigo, likelihood ratio, diagnosis, screening, prediction rules

In January, 2007, a 58-year-old woman presented to our department with a 2-year history of severe paroxysmal hip pain. She had a 30-year history of anorexia nervosa. The pain originated near the pubis and radiated to the right or left hip, with right-sided pain being more frequent. The pain often occurred after urination or defecation, and lasted from several minutes to several hours. She could not walk because of the severity of the pain, and had to lie supine with the aff ected thigh fl exed to obtain some relief. Our patient had presented to emergency departments several times, receiving a diagnosis of psychogenic pain or osteoarthritis because of degenerative changes shown on hip radiographs. On examination, she was asymptomatic but severely emaciated with a height of 159 cm and weight of 32 kg (body-mass index 12·7 kg/m2). There was no tenderness, swelling, or restricted movement of her hip joints, making the diagnosis of degenerative arthritis unlikely. Just after examination, left-sided pain occurred on urination. Emergency CT of the pelvis showed intrusion of the bowel into the left obturator canal (fi gure). Her pain soon subsided, and elective surgery was scheduled. After 1 month, severe right-sided pain occurred and she had an emergency laparotomy. Bilateral obturator hernia was diagnosed and mesh repair surgery done. In August, 2009, at 32-month follow-up she had not experienced any pain since the operation. Obturator hernia is most common in emaciated elderly women between 70 and 90 years old. Women are aff ected six times more frequently than men because they have a wider pelvis with a larger obturator canal. Emaciation is an important risk factor because the loss of preperitoneal fat overlying the obturator canal increases the risk of herniation. Obturator hernia is relatively rare, with a reported incidence of 0·073% of all abdominal hernias and bilateral obturator hernia has an incidence of only 0·013%. The hernia is more common in multiparous women and Asians, and occurs less frequently on the left side because the sigmoid colon can cover the left obturator foramen, preventing herniation. The usual presention is with the clinical features of acute small bowel obstruction, but obstruction can also be partial and resolve spontaneously. Approximately one third of the patients have a history of intermittent previous attacks. Patients can present with groin, thigh, knee, or hip pain due to compression of the obturator nerve by the hernia (Howship-Romberg sign), which is seen in 15–50% of patients. The pain is exacerbated by extension, abduction, or medial rotation of the thigh, while fl exion usually relieves it. Our patient with bilateral hernia was relatively young, but she had severe emaciation due to anorexia nervosa. Bowel herniation induced the HowshipRomberg sign, resulting in her curious paroxysmal hip pain. Diagnosis of obturator hernia is challenging, although CT or ultrasonography can be useful, the correct diagnosis is made preoperatively in only 21·5% to 31·3% of cases. Diffi culty in establishing the diagnosis leads to a high mortality rate of up to 25%, so early accurate diagnosis is crucial. Although obturator hernia is a rare disease, it must be considered when any underweight woman, not only the elderly, complains of unexplained pain in the groin, thigh, knee, or hip.

Objective Carnett's test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles. It is useful for differentiating abdominal wall pain from intra-abdominal pain. However, no study has reported its association with psychogenic abdominal pain. We evaluated its diagnostic usefulness in psychogenic abdominal pain. Methods Two physicians performed Carnett's test on each patient, but only one received the medical history. The other physician only conducted the test. Based on the final diagnosis, patients were categorized into 3 groups: psychogenic pain, abdominal wall pain, or intra-abdominal pain. Each group was analyzed in association with the results of Carnett's test conducted by the blinded physician. Patients A total of 130 outpatients with the chief complaint of abdominal pain who had abdominal tenderness. Results There were 22 patients with psychogenic abdominal pain, 19 with abdominal wall pain and 62 with intra-abdominal pain. In patients with psychogenic pain or abdominal wall pain, Carnett's test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p

Kiyoshi Shikino, Masatomi Ikusaka, Yoshiyuki Ohira, Masahito Miyahara, Shingo Suzuki, Misa Hirukawa, Kazutaka Noda, Tomoko Tsukamoto, Takanori Uehara Department of General Medicine, Chiba University Hospital, Chiba, Chiba Prefecture, Japan Background: This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. Methods: The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. Results: For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P

Takanori Uehara,1,2 Masatomi Ikusaka,1 Yoshiyuki Ohira,1 Mitsuyasu Ohta,1,2 Kazutaka Noda,1 Tomoko Tsukamoto,1 Toshihiko Takada,1 Masahito Miyahara11Department of General Medicine, Chiba University Hospital, 2Division of Rotated Collaboration Systems for Local Healthcare, Graduate School of Medicine, Chiba University, Chiba, JapanPurpose: To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine.Participants and methods: Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A “correct” diagnosis was one where the predicted disease matched the final diagnosis code.Results: A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, -3.6) (χ2=22.27, P