The patient history and clinical examination often sufficed for patients presenting to the emergency department, according to a study published as a research letter online Aug. 8 in Archives of Internal Medicine . The authors suggested that the decision to order advanced imaging studies, such as CT, be based on clinical data for this population.
Previous, but dated, studies have established the clinical utility of the patient history and physical examination. Researchers from Department of Medicine A, Kaplan Medical Center, Rehovat and the Hebrew University Hadassah Medical School in Jerusalem, sought to re-assess their utility and designed a prospective study of 442 adult patients admitted from the ED with general medicine symptoms.
A senior resident completed the history and physical exam and reviewed ancillary tests completed in the ED, including chest x-ray, ECG, hematology and chemistry tests and urinalysis as well as charts from previous admissions. At that point, she diagnosed the patient and identified the modalities most helpful in informing the diagnosis. The diagnosis was sealed and not revealed to other researchers. A hospital physician repeated the procedure.
A final diagnosis was made at least one month after discharge. The primary outcome of the study, wrote Liza Paley, MD, of Hebrew University Hadassah Medical School, was the diagnosis of the senior resident or physician compared with the final diagnosis. Secondary outcomes included the value of various tests and imaging studies and the prevalence and impact of imaging studies, other than chest x-ray, performed in the ED.
Mean patient age was 66.9 years, 51 percent were male and many had comorbidities, particularly hypertension, diabetes and coronary disease.
Of the patients in the study, 15.5 percent had an ancillary imaging study, 11.8 percent underwent CT and 3.7 percent were referred for ultrasound.
Diagnostic accuracy was high for both the resident and physician at 80.1 percent and 84.4 percent, respectively.
“The patient’s history emerged as the key element in formulating diagnosis either alone (approximately 20 percent of cases), in combination with the patient’s examination (another 40 percent, approximately), or in addition to basic tests with or without the physical examination (33 percent),” according to Paley and colleagues.
Imaging was used infrequently, she noted, and CT was considered valuable in one of three patients.
The researchers stated that the results confirmed the enduring value of basic clinical methods, and reiterated that 90 percent of all correct diagnoses were achieved on the basis of a history, physical and basic tests (excluding imaging).
“Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation,” Paley et al concluded.
For more on CT imaging in the ED, read “Credit or Blame? CT Propels Imaging in the ED” in the September issue of Health Imaging & IT .