Objective : The outpatient diagnostic processes of novice and trained residents were compared, as to the working diagnosis time and the correct tentative diagnosis rate after history taking to the final diagnosis.
Methods : Three physicians who had received outpatient training in our department for ≥2 years were defined as “trained residents”, and another three physicians participated in this study from their first day of training at the outpatient clinic were defined as “novice residents”. The study was done at Chiba University Hospital in Japan. The working diagnosis time was defined as the time for the physicians to make a tentative diagnosis for each patient based on history taking, and was calculated from the starting and ending times entered into a computer. By comparing the working diagnoses and the final diagnoses, the correct diagnosis rate was determined for each physician.
Results : The correct diagnosis rates for trained residents were 87%, 87%, and 85%, respectively. These rates were significantly higher than those of novice residents, which were 73%, 69%, and 55%, respectively (all P<0.001). The working diagnosis times of trained residents were significantly shorter than those of novice residents (all P<0.001). The trained residents still made mostly correct diagnoses after a long time, while the novice residents made more wrong diagnoses as time passed.
Conclusion : The working diagnosis time was shorter and the correct diagnosis rate was higher in the trained resident group than the novice resident group. Trained residents were able to eventually make a correct diagnosis, even when they failed to make the correct diagnosis initially. On the other hand, the correct tentative diagnosis rate was generally lower for novice residents, and the rate was markedly lower when patients had diseases that could not be diagnosed at an early stage.

A 51-year-old woman presented with a 3-month history of left-sided chest pain. The pain was colicky, without associated tenderness, and involved the T5-8 thoracic dermatomes. We suspected referred pain from peptic ulcer, and upper gastrointestinal endoscopy revealed multiple ulcers in the middle-third of the gastric lesser curvature. As the patient was on non-steroidal anti-inflammatory drug (NSAID) treatment for tension headaches, NSAID-induced peptic ulcer was diagnosed. Proton-pump inhibitor (PPI) treatment resulted in prompt pain relief. There are few reports of chest pain as the sole presenting symptom of peptic ulcer. Nevertheless, although rare, peptic ulcer should also be considered in the differential diagnosis of chest pain.

A 51-year-old man was emergently admitted for acute renal failure. Blood tests showed a high serum creatinine level and metabolic alkalosis. He had a history of recurrent vomiting starting one month prior to admission to our hospital, and had circumferential thickening of the cardia on upper gastrointestinal endoscopy and CT. He underwent total gastrectomy and was given a diagnosis of scirrhous gastric carcinoma at the pylorus. After total gastrectomy, acute renal failure and metabolic alkalosis showed amelioration. We report this very rare case with metabolic alkalosis and acute renal failure resulting from pyloric stenosis caused by scirrhous gastric carcinoma.

Background: Taking a good history is important for the diagnosis of abdominal pain. We investigated questionnaire items that were significantly correlated with causes of abdominal pain requiring hospitalization. We also studied the combination of responses that could exclude severe disease.
Method: Between February 2006 and December 2007, 296 of 317 patients with abdominal pain who attended our Outpatient Department completed a questionnaire for their abdominal pain. They included 32 patients requiring hospitalization (severe group) and 264 other patients (mild group). The percentage of positive responses to each questionnaire item was compared between the two groups, and those showing a significant difference were employed for logistic regression analysis.
Results: The following 4 responses were selected: “It is less than 7 days since the onset of pain” (odds ratio [OR], 2.8; 95% confidence interval [95% CI], 1.2-6.4); “The pain is exacerbated by walking” (OR, 2.8; 95% CI, 1.3-6.2); “The pain is accompanied by weight loss” (OR, 3.8; 95% CI, 1.5-9.8); and “The pain wakes me at night” (OR, 2.3; 95% CI, 1.1-5.2). If a patient had none of these responses, the predictive value was 0.03 for severe disease.
Conclusions: Our findings suggested that pain reported within 7 days, exacerbation by walking, nocturnal awakening, and associated weight loss are features of abdominal pain that predict severe disease. Conversely, severe disease can be almost completely excluded in patients negative for all 4 features.

Physical examination is an important skill that is indispensable for physicians’ practice, but clinical practice tends to be a case dependent experience. In addition, there is not enough opportunity to systematically train the physical examination skills. Hypothesis is driven according to the clinical context. Our objective is to improve hypothesis-driven physical examination skills. Fifth and sixth grade medical students launched an interest group “General Medicine Interest Group” at Chiba University. Flipped classroom and peer teaching were adopted to the General Medicine Interest Group. The educational approach of incorporating flipped classroom and peer-assisted learning was considered useful for improving students’ motivation and physical examination skills. We will report on the activities and their effectiveness.

In this revision, we have attempted to align the Model Core Curriculum for Medical Education competency, "problem-solving ability based on specialized knowledge," with the "Standards of National Examination for Medical Practitioners." The major diseases and syndromes in "Essential Fundamentals" correspond to the basic diseases in Table 1 of the Core Curriculum, symptoms, physical and laboratory examinations, and treatment in "General Medicine" correspond to the items in Table 2 of the Core Curriculum, and the diseases in "Medical Theory" correspond to the diseases in PS-02 of the Core Curriculum. The validity of the diseases in the Core Curriculum was verified using the evaluation results of the examination level classification of the "Research for Revision of National Examination Criteria." Approximately 690 diseases were conclusively selected. This revision mentions the number of diseases in the Core Curriculum for the first time. Hopefully, this will lead to a deeper examination of diseases that should be studied in medical schools in the future.