About egophony.

Egophony is a change in timbre (Ee to A) but not pitch or volume. It is due to a decrease in the amplitude and an increase in the frequency [corrected] of the second formant, produced by solid (including compressed lung) interposed between the resonator and the stethoscope head. This explains certain difficulties in learning this valuable but currently neglected sign as well as in understanding certain physiologic false-positive occurrences.

The medical complications of drug addiction and the medical assessment of the intravenous drug user: 25 years later.

Purpose: To review changes in the medical complications of drug abuse that have occurred since the authors reviewed them 25 years ago.

Data Source: Manual search of the internal medicine and subspecialty literature of the past three decades that was selected by the authors.

Study Selection: Selected studies were of three types--baseline studies for the period ending in 1968, studies after 1968 that emphasized changes from baseline, and studies after 1968 that emphasized change (or the absence of change) and the manner in which clinicians conceptualized problems.

Words--10 years later.

Certain phrases in the medical language have lost their meaning and in some cases now suggest the exact opposite of the facts. These are "anemia of chronic disease," "liver function tests," "the prevalence," "S1 was present," "S1 is normal," "neurologic syncope," "orthostatic hypotension," "the neck veins were distended," "hospital-acquired pneumonia," and "right-sided backward failure." I suggest a different and more clinically useful way of looking at these phrases.

Contemporary use of the disease concept: III. A pedantic failure to change behavior regarding the problem of anemia.

The frequency with which house staff noticed their patients to be anemic, the frequency with which they tried to find out why the patients were anemic, and the diagnostic accuracy of such endeavors were measured. Next, an intervention was conducted in which the teams were lectured on the subject of anemia, given reading materials on the subject, and given social encouragement to solve the problem. At follow-up no improvement was found in any of the outcome variables.

Why medicine residencies?

Over the last several decades the context of the medicine residency has changed. These changes are described and attributed in considerable degree to bureaucratic impositions. I consider it paradoxic that there is finally a move afoot to reverse the changing nature of medicine residencies, yet this effort appears in the form of yet another bureaucratic imposition.

Why perform a routine history and physical examination?

Science uses two types of data--one for generating hypotheses and a second for testing hypotheses. In clinical medicine the history and physical examination generate the data used for making hypotheses about what could possibly be wrong with the patient; but the various laboratory and imaging procedures are used for hypothesis-testing, ie, deciding which of the possible problems is actually the one bothering the patient. Although comparisons between physical examination maneuvers and imaging procedures may tell something about the precision of the former, in general such comparisons can tell little about the intrinsic worth of one versus the other, because these two different types of procedures generate data with two completely different types of usage.

Contemporary use of the disease concept: II. The question of anemia.

Of 105 admissions to a medical service, 64 involved anemia (defined as a hematocrit value of less than 38%) at some time during the admission. Chart review revealed that the disease concept was not being used, as most of the anemias were unnoticed or undiagnosed, and most of the diagnoses that were made were incorrect.

A modest proposal: board certification for medical educators (or quis custodiet ipsos custodes?).

So that medical educators themselves will not be deprived of the benefits of certification, a brief written examination is offered as a first step. While the examination questions initially appear to be as obscure as those found on other certifying examinations, on further consideration they are found to be illustrative of certain basic concepts of medical education that are thought to be enduring, though not currently popular.

An internist looks at the fundus oculi.

The ophthalmoscope is the only convenient device permitting the in vivo inspection of both neural tissue and the arterial and venous blood columns within the retinal vessels. Many findings of little interest to ophthalmologists are, when integrated into the total clinical examination, of great use to internists during the process of making a specific diagnosis. Even after the diagnosis has been made, some ophthalmoscopic signs are uniquely useful in evaluating the chronicity, severity, prognosis, and/or the vasculopathic effects of the disease.

On pulsus paradoxus.

An abnormal amount of pulsus paradoxus may be produced in normal volunteers, for teaching purposes, by having them inspire and expire against resistance.