First clinical judgment by primary care physicians distinguishes well between nonorganic and organic causes of abdominal or chest pain

Abstract

OBJECTIVE:To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. DESIGN:Prospective observational study. SETTING:General medical outpatient clinic in a university teaching hospital. PARTICIPANTS:One hundred ninety new, consecutive patients with a mean age of 44 years (SD ‫؍‬ 14 years, range 30-58 years) with a main complaint of abdominal or chest pain. MEASUREMENTS AND MAIN RESULTS:The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic" versus "organic" causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted" preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis ( n ‫؍‬ 131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively. CONCLUSIONS:A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted" preliminary diagnosis, suggesting that watchful waiting can be recommended in such cases. bdominal and chest pain are among the most frequent main complaints of patients in ambulatory care.

Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting

“…Finally, physicians' ratings were not assessed for interrater reliability, as each physician only rated his or her own patients. However, as Kroenke and colleagues [38] stated, "the primary care physician's gestalt about a symptom being medically unexplained is quite good and … few patients with symptoms initially judged to be somatoform were later found to have occult serious physical disorders at follow-up" (p. 271) [38,44]. Moreover, the single rating of the treating primary care physician is the normal case in reality and thus represents ecological validity.…”

Accuracy of General Practitioners’ Assessment of Chest Pain Patients for Coronary Heart Disease in Primary Care: Cross-sectional Study with Follow-up

“…Martina et al examined whether in patients with abdominal or chest pain, a non-organic tABlE 1. Baseline characteristics of chest pain patients (n = 1249) in relation to the general practitioners' provisional diagnosis of coronary heart disease (CHD) or no CHD after history taking and clinical examination CHD probability assessed by general practitioners* Baseline characteristic (n, %) no CHD (n = 235) low (n = 172) intermediate (n = 759) high (n = 83) P diagnosis could be reliably distinguished from an organic one; they found a diagnostic accuracy of 88% for organic origin of chest pain and 100% for non-organic pain (8). A study looking at GPs' ability to diagnose myocardial infarction found an unexpectedly low diagnostic accuracy, with a sensitivity of 44%, leading them to conclude that myocardial infarction should not be diagnosed on the basis of symptoms and signs alone (10).…”

“…The effectiveness of GPs' gatekeeping role, ie, identifying patients with CHD and protecting patients from overdiagnosis and treatment, depends on the accuracy of their provisional diagnosis after taking the patient's history and performing the basic clinical examination. So far, a limited number of studies have addressed this question (6)(7)(8)(9)(10). There is a need for additional data on GPs' management decisions after assumed CHD diagnosis, derived from a large and consecutively recruited sample of chest pain patients in primary care.…”

7 Abdominal pain, abdominal pain in women, complications of pregnancy and labour

“…History and examination has been shown to be very effective in distinguishing organic and non-organic causes of pain. 7 …”