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

Medical Outpatient Clinic, Department of Internal Medicine, University Hospital, Basel, Switzerland.
Journal of General Internal Medicine (Impact Factor: 3.45). 09/1997; 12(8):459-65. DOI: 10.1046/j.1525-1497.1997.00083.x
Source: PubMed


To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain.
Prospective observational study.
General medical outpatient clinic in a university teaching hospital.
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.
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.
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.

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Available from: Edouard Battegay, Sep 17, 2014
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    • "Although the sensitivity and specificity of a history and physical may not match that of an abdominal CT scan, there is no risk, minimal time lost, and essentially no cost. In fact, in this evidencebased era, one observational study has revealed that, based on history and a physical alone, physicians were able to correctly differentiate between organic and nonorganic causes of abdominal pain nearly 80% of the time [4]. Furthermore, historical features such as pain location have been shown in prospective investigation to be specific for certain disease states [5]. "
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    • "Also, somatizing patients may resist efforts to attribute their symptoms to nonphysical causes strenuously , which makes it difficult for the practitioner to explore emotional underpinnings openly or offer psychologic treatments. Although a chronic history of unexplained symptoms builds the strongest case for somatization, follow-up studies of selected symptoms, such as fatigue , dizziness, chest pain, abdominal pain, palpitations, and back pain, have confirmed the clinician's initial judgment that a symptom is unexplained usually is correct and that the delayed emergence of serious diagnoses that were not suspected initially is rare [14] [15] [16] [17] [18] [19] [20]. Somatization is associated with increased health care use, functional impairment , provider dissatisfaction, and psychiatric comorbidity. "
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  • No preview · Article · Aug 1997 · Journal of General Internal Medicine
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