Volume 99, Issue 10

The accuracy and efficiency of recording information on a one-page standardized Outpatient Osteopathic SOAP Note Form (SNF) was compared with that obtained using the physician's progress notes (PPN). Use of the SNF in lieu of the PPN would assure the physician that proper clinical data were recorded to ensure proof of need and care in any instances of refused reimbursement. Moreover, standardized SNFs could be used to document and analyze present treatment protocols, enabling medical advances. Ten osteopathic physicians, who were skilled in osteopathic manipulative treatment (OMT), enrolled 300 patients. Initial and follow-up examinations totaled 959 visits (statistical cases); 76 statistical variables were compared. Essentially all information recorded in the PPN was recorded on the SNF. A significant difference (P < .05) was found between the PPN data set and the SNF data set in all but 17 of the 76 variables. Greater content of information almost always was found with the SNF data set. In addition, the SNF contained information not found in the PPN, most notably the severity and response to treatment of detected somatic dysfunctions. Participating physicians stated that the SNF takes about the same amount of time to fill in as the PPN. This makes the SNF a practical instrument for accurately and efficiently obtaining patient data in all physicians' offices. The validation study conducted demonstrated that the Outpatient Osteopathic SOAP Note Form easily and accurately reflected information recorded in the PPN and that data recorded may be used by physicians in their individual practices or for the conduct of osteopathic research.

Agenesis of the gallbladder is a relatively rare congenital anomaly with an incidence of only 0.01 % to 0.04%. Yet it continues to occur. The patient described in this case study was symptomatic and received a clinical diagnosis of cholecystitis after having an ultrasound examination that was read as indicating a small contracted gallbladder with stones. Only after an open surgical procedure and cholangiography was it discovered that the patient actually had a congenital absence of the gallbladder. Clinicians need to be aware of the potential for congenital absence of the gallbladder when interpreting tests and when findings are questionable, and to ensure no surprises, they should consider ordering other diagnostic tests before doing surgery.

A 43-year-old Asian woman who was initially seen because of hematemesis later had a gastric leiomyosarcoma cliagnosed. Epigastric palpation, computed tomography, and magnetic resonance imaging assisted in determining the size, borders, and location of the tumor while a second esophagogastroduodenoscopy revealed friable gastric mucosa with erosions. Biopsy specimens taken for frozen section during surgical abdominal exploration revealed a malignant gastric stromal tumor. An en bloc excision of the mass then followed, with the final pathologic diagnosis a gastric leiomyosarcoma. Metastases were later found in the liver, peritoneum, and mesentery. Differentiation of gastric leiomyosarcoma from other stromal tumors is difficult and requires standardized nuclear and cellular evaluation of atypia, necrosis, mitosis, and tumor doubling time. The most common symptoms at initial presentation are abdominal pain and gastrointestinal bleeding. Abdominal computed tomography remains more specific in suggesting gastric stromal tumors than esophagogastroduodenoscopy and upper gastrointestinal barium series. Lymph node involvement in gastric leiomyosarcoma is rare and affords the first line therapy of laparoscopic wedge gastrectomy with a good prognosis in tumors less than 6 cm in diameter. The prognostic factors include metastasis, size of the tumor, histologic grade, DNA ploidy of the tumor, and ulceration of overlying gastric mucosa.

Simple testicular cysts are extremely rare; only 20 cases have been reported in the literature. Sites include the tunica albuginea, tunica vaginalis, and testicular epidermis. Conservative enucleation is an effective treatment for these lesions once ultrasound examination establishes that the mass is cystic. Such Enucleation salvages testicular tissue. In the cases discussed, two patients were initially evaluated for vague testicular discomfort and one patient for male infertility. All were subsequently found to have benign testicular cysts. All the cysts were excised, and all patients remain disease-free. Included is a case series report of simple testicular cysts and a review of the literature.