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Three Part Question

In [patients with acute abdominal pain] does [clinical examination] accurately [detect/exclude serious pathology]?

Clinical Scenario

A 20 year old male patient presents to the accident and emergency department with a two day history of gradually worsening abdominal pain which has migrated from the umbilical region to the RLQ. On examination there are no other typical signs of appendicitis and you wonder how reliable clinical examination is in ruling out serious abdominal pathology.

Search Strategy

MEDLINE (1950-2008) and EMBASE search
[(exp abdominal pain OR abdominal pain.mp OR exp acute abdomen OR acute abdomen.mp OR exp peritonitis OR peritonitis.mp OR exp appendicitis OR appendicitis.mp) AND (exp physical examination OR clinical examination.mp OR medical examination.mp OR abdominal examination.mp)] LIMIT to humans and English Language

Search Outcome

1821 articles, of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

In all of the above studies, clinical examination was carried out by a surgeon rather than an accident and emergency physician. All of these studies have common finding with regards to the most useful signs and symptoms. In all studies, migration of pain from the periumbilical region to the RLQ, rebound tenderness, anorexia and a raised PMN count had a significance of >0.05. In all studies, migration of pain from the periumbilical region to the RLQ, rebound tenderness, anorexia and a raised PMN count had a significance of >0.05. Clinical examination is not accurate at identifying serious pathology. However, the available evidence does not include false negative data so it is difficult to say whether clinical evaluation is accurate at simply ruling out serious pathology. It is also the case that in patients with good signs, the clinical examination is far more accurate and therefore further investigations should possibly be reserved for patients with an equivocal diagnosis.

Clinical Bottom Line

Clinical examination alone does not appear accurate enough to exclude serious abdominal pathology. However, further research is required to substantiate this finding.

References

1. Nauta RJ, Magnant C. Observation versus operation for abdominal pain in the right lower quadrant. American Journal of surgery 1986;151:746-748.
2. Bjerregaard B, Brynitz S, Holst-Christensen J, Jess P, Kalaja E, Lund-Kristensen J, Thomsen C. The reliability of medical history and physical examination in patients with acute abdominal pain. Methods Inf Med 1983;22(1):15-8.
3. Jahn H, Mathiesen FK, Neckelmann K, Hovendal CP, Bellstrøm T, Gottrup F. Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg 1997 Jun;163(6):433-43.
4. Kalliakmanis V, Pikoulis E, Karavokyros IG, Felekouras E, Morfaki P, Haralambopoulou G, Panogiorgou T, Gougoudi E, Diamantis T, Leppäniemi A, Tsigris C. Acute appendicitis: the reliability of diagnosis by clinical assessment alone. Scandinavian Journal of Surgery 2005;94(3):201-6.