First Clinical Judgment by Primary Care Physicians
Distinguishes Well Between Nonorganic and Organic
Causes of Abdominal or Chest Pain
Benedict Martina, MD, Bruno Bucheli, MD, Martin Stotz, MD,
Edouard Battegay, MD, Niklaus Gyr, MD
nosis based solely on patient history and physical examina-
tion in medical outpatients with abdominal or chest pain.
To evaluate the accuracy of a preliminary diag-
Prospective observational study.
General medical outpatient clinic in a university
tients with a mean age of 44 years (SD
58 years) with a main complaint of abdominal or chest pain.
One hundred ninety new, consecutive pa-
14 years, range 30–
MEASUREMENTS AND MAIN RESULTS:
nosis, established on the basis of patient history and physical
examination, was compared with a final diagnosis, obtained af-
ter 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 diagno-
sis 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 pre-
dicted 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 ad-
dition, final nonorganic diagnosis (
with long-term follow-up by obtaining information from pa-
tients 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 pa-
tients that had been misdiagnosed as having abdominal pain
of nonorganic causes. Compared with follow-up, the diagnos-
tic accuracy for nonorganic abdominal and chest pain at
chart completion was 93% and 98%, respectively.
The preliminary diag-
131) was compared
organic abdominal or chest pain based on patient history and
physical examination proved remarkably reliable. Accuracy
was almost complete in patients with an “undoubted” prelim-
A preliminary diagnosis of nonorganic versus
inary diagnosis, suggesting that watchful waiting can be
recommended in such cases.
ganic diagnosis; patient history.
J GEN INTERN MED 1997;12:459–465.
abdominal pain; chest pain; outpatients; nonor-
bdominal and chest pain are among the most fre-
quent main complaints of patients in ambulatory
A substantial percentage of these complaints do
not have readily discernible organic causes. Nonorganic
diagnoses are made in up to 60% of patients in primary
care that present with abdominal pain,
mately 80% of patients with chest pain.
workup in patients with abdominal or chest pain sus-
pected of having nonorganic causes may identify only a
few patients with organic causes and may therefore have
a very low diagnostic yield.
tional and sometimes costly investigations might be un-
There are a few studies on the diagnostic accuracy of
physicians’ initial assessments of nonorganic versus or-
ganic diagnoses in patients with abdominal or chest pain
in primary care.
However, most of these studies are
not prospective, and none are with patients in general
medical clinics that include a long-term follow-up. Fur-
thermore, it is not entirely clear how diagnostic accuracy
varies with the degree of certainty that the primary care
physician attaches to the initial diagnosis. Consequently,
primary care physicians are often mired in doubt about
whether to rely on their initial and preliminary diagnosis
of a nonorganic cause of pain or whether to initiate more
The aim of this prospective study was to appraise the
quality of the physician’s initial diagnostic assessment
based on patient history and physical examination for pa-
tients presenting in general medical outpatient clinics
with abdominal or chest pain. Two comparisons were per-
formed. Initial diagnoses characterized as “undoubted” or
“probable” were compared with (1) the final diagnosis es-
tablished after workup and completion of the chart, and
(2) long-term follow-up results.
and in approxi-
This suggests that addi-
Received from the Medical Outpatient Clinic, Department of In-
ternal Medicine, University Hospital, Basel, Switzerland.
Dr. Battegay was a SCORE fellow of the Swiss National Sci-
ence Foundation (grant 32-31,948.91).
Address correspondence and reprint requests to Dr. Martina:
Medical Outpatient Clinic, University Hospital, CH-4031 Basel,
Martina et al., First Diagnosis in Abdominal or Chest Pain
Setting and Medical Staff
The Medical Outpatient Clinic is a division of the De-
partment of Internal Medicine of the University Hospital
Basel. This teaching hospital provides primary, secondary,
and tertiary care for a region with approximately 200,000
inhabitants. Each year about 20,000 general internal medi-
cal consultations for approximately 5,000 new patients are
provided by the Medical Outpatient Clinic, which is open to
the public without referral. Approximately 80% of the cases
are primary care walk-in patients; 20% of the patients are
referred to the clinic by physicians of other departments, by
general practitioners, or by specialists in town.
The medical staff consists of 14 residents in internal
medicine, most of whom have undergone more than 4 years
of postgraduate clinical training, and three supervising at-
tending physicians. A recent evaluation at our clinic set the
duration of the first consultation at 35 minutes (range 20–
75 minutes). This consultation usually consists of taking a
careful patient history and a general physical examination.
All 1,032 new and consecutive general internal medi-
cine outpatients were prospectively evaluated and screened
for the study during the 3-month inclusion period from
April through June 1992. Outpatients who were seen in
subspecialty clinics were not evaluated for inclusion into
the study. Of 1,032 patients, 190 fulfilled inclusion crite-
ria; i.e., they had abdominal or chest pain as their main
complaint or symptom. These 190 patients were included
in the present study.
Preliminary Diagnosis (Initial Assessment)
For all patients, routine patient history and physical
examination were performed by one of 14 residents ac-
cording to standard protocol. When necessary, interpret-
ers helped to obtain the history from patients speaking
foreign languages. Patients were subsequently presented
to an attending physician (A) who checked directly with
patients when necessary to confirm elements of the his-
tory or physical examination. Attending physician A and
resident together reached a preliminary diagnosis. The pre-
liminary diagnosis was immediately recorded onto a stan-
dardized form and was rated as “undoubted” or “proba-
ble.” An “undoubted” preliminary diagnosis was based on
characteristic and specific findings allowing a diagnosis
with a very high level of confidence by the involved physi-
cians. A preliminary diagnosis based on vague or nonspe-
cific findings or a mere suspicion was called “probable.”
Further workup included routine laboratory testing
and all measures deemed necessary to reach a diagnosis
that might benefit the patient. Results of the individual
diagnostic workup and immediate follow-up visits over a
mean duration of 2 weeks were recorded. The most fre-
quently performed investigations in patients with ab-
dominal pain were stool culture for parasites or bacteria,
abdominal ultrasound, gastroduodenal endoscopy, and
colonic endoscopy. The most frequently performed inves-
tigations in patients with chest pain were chest radiogra-
phy and treadmill ergometry. In addition to treadmill er-
gometry, myocardial perfusion scintigraphy was done
particularly in patients with angina-like chest pain or car-
diovascular risk factors.
Based on the diagnosis, reasons for abdominal or chest
pain were classified as being of nonorganic versus organic
causes. Nonorganic causes of abdominal pain were un-
specific pain symptoms such as nonulcer dyspepsia and
irritable bowel syndrome. Organic causes of abdominal pain
were gastritis, peptic ulcer, parasitoses, enteritis, motility
disorders due to alcohol consumption, cholelithiasis, chole-
cystitis, pancreatitis, and diverticulitis. Nonorganic causes
of chest pain were unspecific chest pain symptoms and
anxiety disorders. Organic causes of chest pain were cor-
onary heart disease of any stage, pleuritis, tracheobron-
chitis, esophageal reflux, chest wall trauma, and tumors.
“Gold Standard” Diagnosis
A final diagnosis was established by the resident and
attending physician A when patients were discharged from
the care of the Medical Outpatient Clinic, i.e., after test re-
sults were entered into the chart and a diagnosis was made.
Subsequently, all diagnoses were analyzed together by at-
tending physician B and the resident. A second diagnosis
was reached, however, because attending physician B was
not blinded to the study aims or the preliminary diagnosis;
subsequently, another independent attending physician (C),
who was blinded to the aims of the study and the prelimi-
nary diagnosis, reviewed all charts and made the final di-
agnosis. The second and third “final” exact diagnoses were
compared using the Kappa test.
noses were reevaluated and classified as being either non-
organic or organic by consensus between attending physi-
cians B and C. This final consensus decision served as
the gold standard to assess sensitivity, specificity, accu-
racy, and the likelihood ratio of the preliminary diagnosis.
Thereafter, final diag-
Follow-up of Patients with Nonorganic Causes of
Pain at Final Diagnosis
Patients with nonorganic abdominal or chest pain
were contacted after a mean of 29 months (range 18–56
months) after their first consultation to verify the diagno-
sis. Telephone interviews or, if necessary, ambulatory
checkup examinations at our institution were executed.
To reach as many patients as possible, telephone calls
were repeated. When needed, specially trained interpret-
ers helped to recruit as many patients as possible for fol-
Volume 12, August 1997
low-up. The patients were asked about new complaints,
change of complaints, further investigations, intervening
treatments, and hospitalizations during the follow-up ob-
servation period. In all cases with suspected new diag-
noses, the responsible general practitioner was contacted
to confirm or reject alternative diagnoses.
Of 1,032 consecutive new patients in the general Med-
ical Outpatient Clinic screened for the study, 190 fulfilled
the inclusion criteria; i.e., they had either abdominal pain
112) or chest pain (
78) as their main complaint.
The mean age was 44 years (SD
male, and 89 were female.
14); 101 patients were
Definition of the Gold Standard
Interobserver agreement between attending physi-
cians B and C on the final diagnosis as well as separation
into nonorganic or organic was excellent, with a
in both instances. Subsequently, all 190 patients were
classified by consensus by the two attending physicians B
and C as having a nonorganic (
59) final diagnosis.
131) or organic (
Accuracy of Preliminary Diagnoses Based on
History and Physical Examination Alone
We investigated whether a preliminary diagnosis of
nonorganic versus organic cause of pain was reliable, i.e.,
whether it compared favorably with the diagnosis when
the patient’s case was considered closed (see the gold
pain as their main complaint, 47 (41%) had upper abdom-
inal pain, 30 (27%) had lower abdominal pain, and 35
(31%) had diffuse nonlocalized abdominal pain. The pre-
liminary diagnosis was nonorganic for 51 patients and or-
ganic for 61 patients. After the final diagnosis, an organic
cause was found in 46 (41%) of 112 patients (Table 1A).
9), peptic ulcer disease (
4) were the most frequent organic findings. Sixty-
six (59%) of 112 patients were considered to have a nonor-
ganic cause of their pain (Table 1A).
The actual preliminary diagnosis compared with the
actual final diagnosis was not correct in 31 (28%) of 112
patients. As many as 19 of these 31 patients were ulti-
mately diagnosed with a nonorganic cause of their pain;
i.e., most erroneous judgments occurred in patients that
were initially diagnosed as having a pain of organic origin
and were ultimately classified as having a pain of nonor-
ganic origin. In 8 other patients an organic cause other
than the previously suspected one was discovered, e.g., a
peptic ulcer instead of cholelithiasis. Only 4 patients had
Of the 112 patients with abdominal
6), and amebia-
an organic final diagnosis when a pain of nonorganic ori-
gin had originally been supposed (one urinary infection,
one appendicitis, one peptic ulcer, and one enteric amebi-
asis). In 2 of the patients with a wrong preliminary nonor-
ganic diagnosis, the correct diagnosis was made within an
hour after the preliminary diagnosis on the basis of rou-
tine laboratory testing (diagnosis of acute appendicitis af-
ter leukocyte count and abdominal ultrasound, urinary
infection after urinalysis). In the remaining 2 patients, a
correct diagnosis was made within 2 days; upper endos-
copy led to the diagnosis of nonbleeding peptic ulcer, and
positive stool tests to the diagnosis of amebiasis.
All 31 preliminary diagnoses that turned out to be
wrong had been characterized as “probable” by the treating
physicians. In other words, the confidence of the treating
physicians in the reliability of their diagnosis was low. Con-
sequently, further workup was solicited that resulted in the
final, correct diagnosis in all of these cases. In 40 (38%) of
112 cases the preliminary diagnosis had been rated as “un-
doubted.” In these cases the diagnosis was always correct
when compared with the final diagnosis (Tables 2 and 3).
Hence, 81 (72%) of all 112 patients with abdominal pain had
an exact final diagnosis correctly assessed on the basis of
history and physical examination alone (Table 3). The cor-
responding sensitivity, specificity, and accuracy are excel-
lent for an “undoubted” preliminary diagnosis and inter-
mediate for a “probable” preliminary diagnosis (Table 2).
pain, 65 (83%) had unspecific complaints of musculoskel-
etal origin or other symptoms that were classified as non-
organic in final diagnosis (Table 1B). In one third of these
patients further investigations such as treadmill ergome-
try or chest radiography were used to exclude potential
organic causes of chest pain. Only 13 patients with chest
pain (17%) received a final diagnosis of organic disease
Of 78 patients complaining mainly of chest
Table 1A. Preliminary Diagnosis of Nonorganic Versus
Organic Abdominal Pain Compared with Final Diagnosis
Eight patients had organic causes of pain, different from the one
Table 1B. Preliminary Diagnosis of Nonorganic Versus
Organic Chest Pain Compared with Final Dignosis
Martina et al., First Diagnosis in Abdominal or Chest Pain
(Table 1B): 4 patients (5%) had symptomatic coronary
heart disease, and 9 (12%) had an other organic final di-
agnosis, most frequently pleuritis (
2), or esophageal reflux (
Of the 78 patients, 69 (88%) had a correct prelimi-
nary diagnosis on the basis of history and physical exam-
ination alone. In 55 (80%) of these patients, the prelimi-
nary diagnosis had been considered “undoubted,” and in
14 (20%) “probable.” Final diagnosis did not correspond
to preliminary diagnosis in only 9 (12%) of the patients
(Table 3). In 8 of these 9 patients, preliminary diagnosis
was made with little confidence, analogous to the results
in patients with abdominal pain. Thus, the preliminary
diagnosis was rated as “probable” organic disorder, mostly
angina pectoris, in these patients. These 8 patients re-
ceived a final diagnosis of nonorganic chest pain. A single
patient received an “undoubted” preliminary diagnosis of
angina pectoris based on the patient’s history of myocar-
dial infarction and a history of percutaneous translumi-
nal coronary angioplasty (PTCA). However, thallium scin-
tigraphy did not reveal any ischemia, which led to a final
diagnosis of nonorganic cause of pain despite the patient’s
history of coronary heart disease. Interestingly, this pa-
tient was later found to have coronary pain (successful
PTCA, see below) in the follow-up investigation.
Thus, all nonorganic preliminary diagnoses were cor-
rect in 56 of 78 patients with chest pain (Tables 2 and 3).
No organic cause of pain was missed. This means a speci-
ficity of nonorganic preliminary diagnosis of 100% (Table
2). Similar to abdominal pain, an exceedingly high speci-
ficity and sensitivity was reached when the treating physi-
cians rated the cause of chest pain as “undoubted” or-
ganic or nonorganic (Table 2).
Follow-up Examination of Patients with
Nonorganic Abdominal or Chest Pain
Missing an organic cause of pain that is not immedi-
ately apparent on standard workup might have dire conse-
quences for a patient. It would therefore be of great ad-
vantage to know whether a first clinical judgment of a
nonorganic cause of pain is reliable in the long term. To that
end and to assess the final diagnosis serving as gold stan-
dard, we conducted a long-term follow-up of 131 patients
with a nonorganic abdominal or chest pain at final diag-
nosis gold standard.
Thirty-eight patients (29%) could not be reached for
follow-up investigation. Most of these predominantly
young patients (e.g., students and expatriates) had moved
away. Their diagnostic and demographic characteristics
are given in Table 4. Of 131 patients, 93 (71%) could be
reached for a follow-up examination after a mean of 29
months (range 18–56 months). Of these patients, 46 had
nonorganic abdominal pain and 47 had nonorganic chest
pain as their final diagnosis (Table 5). Patients had a tele-
phone interview or checkup investigation at our institu-
tion. They were asked about new diagnoses and about the
evolution of their pain symptoms.
Nonorganic Abdominal Pain.
could be followed, pain had resolved completely in 15
(33%), improved in 10 (21%), remained unchanged in 15
(33%), and worsened in 6 (13%) (Table 5). In three pa-
tients who originally had a final diagnosis of nonorganic
abdominal pain, the follow-up investigation revealed an
organic diagnosis. Two patients had gastric ulcer, and
one underwent surgery for diverticulosis of the colon.
Thus, accuracy in patients diagnosed as having nonor-
ganic abdominal pain at final diagnosis was 92% when
compared with long-term follow-up.
Of the 46 patients that
Nonorganic Chest Pain.
pain that could be followed, pain had resolved completely in
Of the 47 patients with chest
Table 2. Quality of the Preliminary Diagnosis
Preliminary Diagnosis of
Preliminary Diagnosis of
Likelihood ratio (95% CI)
Table 3. Comparison of Final Diagnoses According to
Confidence in Preliminary Diagnosis
Eight patients had organic causes of pain different from the one
Volume 12, August 1997
17 (36%), improved in 13 (28%), remained unchanged in 11
(23%), and worsened in 6 (13%) (Table 5). The gold standard
and diagnosis was correct in 98%. In one patient a final di-
agnosis of nonorganic chest pain had been made because of
a negative result on thallium scintigraphy. A month later
coronary heart disease was detected at coronary angiogra-
phy, and PTCA abrogated the pain. Interestingly, the pre-
liminary diagnosis was “undoubted” organic cause of pain.
Abdominal pain, chest pain, fatigue, back pain, head-
ache, and dyspnea are the most frequent symptoms in
In the collective patients screened
for our study, abdominal pain and chest pain were the
most common complaints. This case mix of outpatients
compares well with general internal practitioners in the
and other regions.
85% of complaints have no discernible organic cause; i.e.,
they are “nonorganic” in origin.
diagnose a nonorganic cause of pain early in order to pre-
vent unnecessary workup and cost.
patients can be diagnosed reliably and early with a nonor-
ganic cause of pain, although this may be more difficult
than in pain of organic origin. To appraise whether a non-
organic diagnosis can be distinguished reliably from an
organic one by clinical means alone, we prospectively
studied 190 consecutive general medical outpatients with
abdominal or chest pain.
In outpatients, 40% to
It may be crucial to
It matters whether
A clinical judgment based on patient history and
physical examination alone correctly predicted final diag-
nosis at completion of the chart in both abdominal (72%)
and chest pain (88%). When a distinction between nonor-
ganic and organic pain, but not a precise diagnosis, was
made, accuracy increased to 79% for abdominal pain and
remained at 88% for chest pain. These findings match
other reports on the pivotal diagnostic contribution of
careful history taking and physical examination alone in
various patient populations.
Medical practitioners often rely on experience and
feelings that are described as “probable” or “undoubted.”
Here we provide some evidence concerning the adequacy
of such terms in the context of nonorganic versus organic
abdominal and chest pain. The preliminary diagnosis was
almost completely accurate when residents, together with
their supervising attending physicians, felt very confident
about their preliminary diagnosis. Accuracy of an “un-
doubted” preliminary diagnosis was 99% compared with
the final diagnosis. Conversely, the accuracy of a “proba-
ble” preliminary diagnosis of abdominal pain and chest
pain compared with the final diagnosis was only 68% and
One might argue that patients with an “undoubted”
preliminary diagnosis only rarely had additional investi-
gations to dispel their initial diagnosis. However, the fol-
low-up investigation of patients with nonorganic final di-
agnosis after an average of 29 months (range 18–56
months) did not identify any erroneous judgment in the
subset of patients with “undoubted” diagnoses. Diagnos-
tic accuracy for both undoubted and probable nonorganic
final diagnoses after completion of the chart (gold stan-
dard) in patients with abdominal and chest pain was 93%
and 98%, respectively, as compared with the follow-up in-
vestigation. This is comparable to a report of 100 patients
followed for nonorganic abdominal pain who were as-
sessed with an equally high diagnostic accuracy of 95%.
Our study did not aim to discern whether patient his-
tory or physical examination contributed more to diag-
nostic accuracy. However, patient history influences diag-
nostic evaluation more than physical examination does,
the latter revealing crucial information in approximately
20% or less of all cases.
revealed an improvement of nonorganic abdominal pain
Our follow-up investigation
Table 4. Description of Patients with Nonorganic Diagnoses by Follow-up Status
( SD)Male Female
Preliminary Diagnosis of Abdominal Pain
Preliminary Diagnosis of Chest Pain
93 71 45
144548 160 18 1231196
28 21 42
Table 5. Outcome at Long-Term Follow-up of 93 Patients
with Nonorganic Abdominal or Chest Pain
Martina et al., First Diagnosis in Abdominal or Chest Pain
in approximately 50% of the patients. Similarly, nonor-
ganic abdominal pain,
other gastrointestinal complaints,
and miscellaneous symptoms
half of all cases after a prolonged observation period. Non-
organic chest pain in our patients improved in 64%. Simi-
lar results were reported in patients with atypical chest
pain and normal coronary arteries.
cost and high-quality care is ongoing. Patient wishes for in-
terventions have to be considered.
as others’ 24 suggest that lower cost is not necessarily asso-
ciated with low quality of care. We conclude that only diag-
noses of nonorganic pain that are rated as “probable” need
further investigations and workup.
Our study has several limitations. First, our consecu-
tive outpatients with abdominal or chest pain are better
suited for the study of nonorganic causes of pain than or-
ganic ones. The number of our patients with organic diag-
noses is relatively small, heterogeneous, and represents a
limited number of diseases with a low number of cases in
each category of disease. This, and the high prevalence of
poorly circumscribed complaints of abdominal and chest
pain in daily medical practice,1,8 led us to focus on the re-
liability of diagnoses for nonorganic causes of pain.
Second, each patient had his or her individual
workup; e.g., investigations such as treadmill ergometry
or endoscopy were performed only when clinically indi-
cated. Individualization of workup has also been de-
scribed in other similar studies that reflect conditions of
daily medical practice.1,3 Third, a shortcoming of any in-
vestigation like ours is the lack of a totally reliable gold
standard. In our study the final diagnosis served as a gold
standard to measure the quality of the preliminary diag-
nosis. However, standardized and more aggressive inves-
tigations may have somewhat altered the final diagnosis.
To assess the gold standard, we performed a follow-up in-
vestigation of nonorganic diagnosis. It was possible to
reach 71% of the patients. It appeared that our gold stan-
dard was very good, 93% for abdominal pain and 98% for
Fourth, screening for psychiatric conditions was not
performed. A number of nonorganic diagnoses in our pa-
tients could have been better circumscribed and defined
with questionnaires such as the PRIME–MD patient ques-
tionnaire.25 We did not strive to make a specific diagnosis
in patients with pain of nonorganic origin. Yet, further psy-
chological workup and care are clearly necessary in these
With these limitations in mind, our study still indi-
cates that an “undoubted” preliminary nonorganic diag-
nosis is highly precise and reliable. The specificity of
100% shows that no organic diagnosis was missed. Thus,
watchful waiting with little or no additional laboratory or
other investigations is appropriate in these cases.
In conclusion, this study demonstrates that the first
judgment of experienced physicians based on careful pa-
tient history and physical examination alone is reliable in
medical outpatients with abdominal or chest pain. Reli-
improved in approximately
The search for low-
Yet our data, as well
ability increases with the confidence with which the diag-
nosis can be made. In patients that have been confidently
diagnosed with a nonorganic cause of pain, there does not
seem to be a need for additional workup. Avoiding unnec-
essary workup may contribute to high-quality and low-
cost ambulatory medicine. Further studies to evaluate the
appropriate investigations are required in ambulatory
care patients with nonorganic complaints.
The authors thank H.C. Bucher, MD, MPH, and M. Battegay,
MD, for discussing and expertly reviewing the manuscript. Mrs.
F. Vogel and S. Jaquemet are acknowledged for their out-
standing secretarial assistance.
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