the Patient Self-Determination Act in a hospital setting: an initial evaluation. Arch Intern Med. 1995; 155:502-10. 11. Fried T, Rosenberg R, Lipsitz L. Older community-dwelling adults' attitudes toward and practices of health promotion and advance planning activities. J Am Geriatr SOC. 1995; 43545-9. 12. Cugliari A, Miller T, Sobal J. Factors promoting completion of advance directives in the hospital. Arch Intern Med. 1995; 155:1893-8. 13. Perry E, Buck C, Newsome J, Berger C. Messana J. S w a m R. Dialysis staff influence patients in formulating their advance directives. Am J Kidney Dis. 1995; 25:262-8. 14. Richter K. Langel ABSTRACTObjective: To assess the cardiovascular physical examination skills of emergency medicine (EM) housestaff and attending physicians. Methods: Prospective, cohort assessment of EM housestaff and faculty performance on 3 valvular abnormality simulations (mitral regurgitation, mitral stenosis. and aortic regurgitation) conducted on the cardiology patient simulator, "Harvey." Participants examined each of the 3 study disease simulations and proposed a diagnosis (session I). They were then given a cardiac examination form and repeated the programmed simulations (session 11). The examination form was used to prompt physicians to interpret 23 separate cardiac findings for each simulation in a multiple-choice format.Results: Forty-six EM housestaff (PGY 1-3) and attending physicians were tested over a 2-month study period. Physician responses did not differ significantly among the different levels of postgraduate training. The overall correct response rates for participants were 59% for aortic regurgitation, 48% for mitral regurgitation, and 17% for mitral stenosis. For aortic regurgitation, recognition of a widened pulse pressure and recognition of diastolic decrescendo murmur were associated with a correct diagnosis (p < 0.01). For mitral regurgitation, comect assessment of the contour of the holosystolic murmur predicted a correct diagnosis (p < 0.001). For mitral stenosis, proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (p c 0.001). Conclusion: Housestaff and faculty had difficulty establishing a correct diagnosis for simulations of 3 common valvular heart diseases. However, accurate recognition of a few critical signs was associated with a correct diagnosis in each simulation. Training programs may need to focus attention on selected key components of the cardiovascular examination to facilitate teaching of physical diagnosis.

This report describes two cases of pyogenic sacroiliitis with remarkably similar histories. The initial diagnosis is often overlooked because of its rarity and poorly localized signs and symptoms. Clinical and radiological findings, as well as treatment measures, are discussed. Familiarity with this type of septic arthritis is essential if prompt and appropriate therapy is to be rendered.

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