Bedside diagnosis for neurological residents in neurological emergencies: a retrospective analysis.
BACKGROUND
Critical assessment of diagnostic accuracy is indispensable to resident training and medical education, especially in regard to our situation of the extremely low rate of autopsy. Recent setup of advanced technology for neurological diagnosis has resulted in a tendency to overuse these tools at the expense of using classic bedside diagnostic approach. Disclosing the common errors of daily practices among neurological residents necessitates implementing this pioneer study.


METHODS
The tentative diagnosis of each patient, as performed by neurological residents after finishing bedside diagnostic processes, was assessed by final diagnosis concluded from clinical syndrome and/or the results of laboratory studies. The overall rate of diagnostic error and the frequency of diagnostic inaccuracy in various disease entities were evaluated. The reason for the diagnostic error was determined by reviewing the records regarding the entire diagnostic process.


RESULTS
1336 consecutive patients from January 1990 to December 1990 were recruited for this study. The initial bedside diagnosis was correct in 901 (67%) patients. No definite final diagnosis could be obtained in 169 (13%) patients. The diagnoses were incorrect in 266 (20%) patients. The highest rate of inaccuracy was found in the diagnosis of subdural hematoma (56%). The other common diseases of high rate of diagnostic inaccuracy were myasthenia gravis (50%), subarachnoid hemorrhage (42%), Guillain-Barré syndrome (40%), traumatic disorders (39%), herniation of intervertebral disc (33%), metabolic encephalopathy (30%), infection of central nervous system (30%), intracranial neoplasm (24%), drug overdose or intoxication (22%), and mixed neurological and metabolic encephalopathy (21%). The explored reasons for diagnostic inaccuracy were errors of reasoning (38%), inadequate data base (35%), and inadequate fund of knowledge (27%).


CONCLUSIONS
This study confirmed that the basic methods of bedside diagnosis with a standardized sequence of history taking, physical examination and diagnostic reasoning are currently still the most fundamental process of achieving an accurate diagnosis in neurological emergencies. No shortcut or mechanical substitute is available for clinical diagnosis.
Wei
S C
SC
Department of Neurology, China Medical College, Taichung, R.O.C.
Tsai
J J
JJ
D003951:Diagnostic Errors; D004630:Emergencies; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D009422:Nervous System Diseases / Q000175:diagnosis*; D012189:Retrospective Studies