Diagnostic Accuracy Of Clinical Examination Research Articles

Clinical Examination and Diagnosis of Nasal Bone Fracture; Is There Really a Need for X-ray Nasal Bone?

Objective: To evaluate the role of clinical examination in diagnosing nasal bone fracture. Methodology: This Prospective Observational study was carried out in the departments of Otolaryngology-Head and Neck Surgery and Radiology at the Pakistan Institute of Medical Sciences, Islamabad, from Jan 2022 to Dec 2023. About 1000 patients of nose trauma patients coming to ENT emergency were evaluated clinically by thorough nose examination by ENT surgeon and radiologically by X-ray nasal bone both lateral and anteroposterior view. Based on examination if nasal bone fracture was suspected patient was referred to radiology department for X-ray nasal bone which was reported by radiologist if the bone is fractured or not. The clinical findings were correlated with X-ray reports to find out if there really is a need for X-ray nasal bone for diagnosing nasal bone fracture. The diagnostic accuracy of clinical examination was calculated. Results: When clinical and radiological findings were compared regarding the diagnosis of nasal bone fracture a statistically significant association was found between the two (p=<0.001) showing patients with clinical suspicion of fracture actually had fracture on X-ray. The diagnostic accuracy of clinical examination was very high with Positive Predictive Value, Negative Predictive Value, Sensitivity, Specificity, False Negative Rate and False Positive Rate being 96.1%, 93%, 88.5%, 97.7%, 11.5% and 2.3% respectively. Conclusion: We concluded that almost all patients with suspected nasal bone fracture actually had fractures on X-ray. Fractured nasal bone can correctly be diagnosed clinically by ENT surgeon and there is no real need for X-ray nasal bone just for diagnosing nasal bone fracture.

Rotator Cuff Tears: Correlation Between Clinical Examination, Magnetic Resonance Imaging and Arthroscopy.

Background Arthroscopy in diagnosing a rotator cuff injury has surgical and anaesthesia-related risks. Magnetic resonance imaging (MRI), a non-invasive procedure, is expensive, and lacks dynamic components making it less favourable. Clinical examination narrows the diagnosis, but lacks diagnostic accuracy due to overlapof clinical signs and symptoms. We aimed to determine the diagnostic accuracy of clinical examination and MRI in rotator cuff tears by correlating it with arthroscopy. Methods This prospective, cross-sectional validation study included patients (N=28) with shoulder pain with clinical characteristics suggestive of rotator cuff tears. Clinical diagnoses and MRI were done preoperatively, following which each patient underwent arthroscopic surgery. Shoulder arthroscopy findings were correlated with those of clinical examination and MRI. Results The mean age of patients was 50.21±9.66 years, with 60.71% being males. Clinical examination was 100% sensitive and 73.8% specific for detecting rotator cuff tears. MRI was 92.85% sensitive and 98.8% specific in detecting rotator cuff tears. Shoulder MRI demonstrated a higher agreement with arthroscopy than clinical results for subscapularis, supraspinatus, infraspinatus, teres, and biceps tendon appearance. Conclusion MRI results in identifying rotator cuff pathologies are comparable with arthroscopy. Clinical examination findings are variable due to an examiner's bias and therefore its diagnostic scope is limited. However, clinical examination with MRI together might accurately identify the rotator cuff injury.

Diagnostic accuracy of clinical examination for identification of life-threatening torsos injuries: a meta-analysis.

Diagnostic accuracy of clinical examination for identification of life-threatening torsos injuries: a meta-analysis.

Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients

BackgroundTimely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy.MethodsRetrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis.ResultsAmong 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16–89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62–2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988–0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986–0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63–8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision.ConclusionsClinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.

A Comparative Analysis of Pre Operative and Operative Findings in Non Traumatic Acute Abdomen: A Prospective Observational Study

Acute abdomen remains the important cause of morbidity and mortality in emergency. It requires careful history taking and thorough evaluation of symptoms, clinical examination and judicious use of radiological investigation which simplify the evaluation of disease. Aim and Objectives: To assess the accuracy of radiological diagnosis in comparison to postoperative diagnosis in non-traumatic cases of acute abdomen. Materials and Method: A prospective observational study of non-traumatic acute abdomen was carried out at Sahyadri Narayana Multispeciality Hospital, Shimoga, Karnataka. Total of 78 cases of acute abdomen patients were evaluated and operated over a period from December 2018 to February 2020 and included in the study group. Pediatric age group (12 years and below), traumatic cases (blunt and penetrating), acute abdomen in pregnancy and gynecological causes of acute abdomen, urological cases, and conservatively managed cases were excluded from the study. Detailed history was taken and relevant physical examination performed. All patients underwent hematological and biochemical investigations, appropriate radiological investigation (USG, AXR and CT-scan) were performed based on clinical suspicion. Clinical and radiological diagnosis based on clinical examinations and radiological investigations was compared with post-operative diagnosis based on operative findings. Result: The most common age group was 20-60 years with male preponderance. Pain in abdomen was commonest symptom followed by vomiting, anorexia and fever. Tenderness was commonest clinical sign observed followed by rebound tenderness, tachycardia and guarding/rigidity. Acute appendicitis was the most common cause of acute abdomen followed by perforation peritonitis and intestinal obstruction. The overall diagnostic accuracy of clinical examination in acute abdomen was 81.8% and if radiological imaging techniques combined with this, the accuracy raised up to 94%. Conclusion: The study strongly suggested that with thorough history taking and proper clinical examination, clinical diagnosis was successfully achieved in 82% of patients. Radiological investigations help in confirming clinical suspicions and giving added information of underlying pathology with accuracy of 94%. Keywords: Abdomen Injury; Radiological Investigations; Trauma; Diagnostic Test; Perforation.

Comparison of diagnostic value of two-dimensional ultrasound and clinical examination in fetal weight estimation.

Background:Estimation of fetal weight during pregnancy plays an important role in prenatal and intrapartum care and is more important in pregnancies after 37 weeks to determine the type of delivery. The aim of this study was to compare and evaluate the accuracy and diagnostic value of two-dimensional ultrasound and clinical examination in estimating fetal weight and pregnancy outcomes.Materials and Methods:This cross-sectional study was conducted on 300 pregnant women without abnormal fetuses and pregnancies after 37 weeks; mothers who had a normal delivery or cesarean section were evaluated by the available method. The weight of the fetus was estimated before and after delivery, using ultrasound and clinical examination. Newborns were classified into five groups based on their fetal weight. Analysis of collected data was performed with SPSS software.Results:The mean age of the patients was 31 years and the mean weight of the neonates was 3450 g. At a weight of less than 3000 g, ultrasound and clinical evaluation were strongly correlated with the actual weight of the infant, but at weights of more than 3500 and 4000 g, weight estimation with ultrasound was highly accurate, and clinical examination had poor accuracy. In lower weights, square errors were fewer in both ultrasound and clinical examination, in comparison with higher weights. In higher weights, ultrasound is more reliable, and the diagnostic accuracy of clinical examination is reduced.Conclusion:Estimation of fetal weight with prenatal ultrasound is highly accurate. Clinical examination is more accurate in determining the weight of small fetuses and does not pay much attention to the diagnosis of macrosomic fetuses and even leads to overestimation, while ultrasound is much more accurate in diagnosing fetal macrosomia.

Assessment of the Diagnostic Accuracy of Baseline Clinical Examination and Ultrasonographic Imaging for the Detection of Lymph Node Metastasis in Patients With High-risk Cutaneous Squamous Cell Carcinoma of the Head and Neck

Patients with cutaneous squamous cell carcinoma (SCC) of the head and neck may develop lymph node metastasis; therefore, additional workup of the regional lymph nodes in these patients should be considered. However, there is uncertainty regarding the value of baseline ultrasonographic imaging in addition to clinical examination for the detection of metastasis. To assess the diagnostic accuracy of clinical examination and baseline ultrasonography for the detection of metastasis among patients with high-risk cutaneous SCC of the head and neck and to assess the accuracy of ultrasonography when baseline clinical examination produces negative results. This diagnostic study was conducted among a retrospective cohort of 233 patients with 246 high-risk cutaneous SCC tumors of the head and neck. The study included all patients with high-risk cutaneous SCC of the head and neck who received clinical examination and baseline ultrasonographic imaging of their lymph nodes at the Erasmus Medical Center Cancer Institute, a tertiary referral hospital for patients with skin cancer in Rotterdam, the Netherlands, between January 1, 2015, and December 31, 2017. Data were analyzed from October 13, 2020, to September 29, 2021. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Fine-needle aspiration cytologic biopsy and 6 months of follow-up per patient were used as the reference standards. Among 233 patients (176 men [75.5%]; median age, 79.1 years [IQR, 71.5-83.7 years]; data on race and ethnicity were not collected) with 246 high-risk cutaneous SCC tumors of the head and neck, 20 metastases were cytologically confirmed at baseline, and 2 metastases were detected during 6 months of follow-up, yielding a 9% metastasis rate. The sensitivity of clinical examination was 50% (95% CI, 28%-72%), and the specificity was 96% (95% CI, 93%-98%). The PPV and NPV were 55% (95% CI, 36%-72%) and 95% (95% CI, 93%-97%), respectively. In the total cohort, ultrasonography had a sensitivity of 91% (95% CI, 71%-99%) and a specificity of 78% (95% CI, 72%-83%), with a PPV of 29% (95% CI, 23%-35%) and an NPV of 99% (95% CI, 96%-100%). In the group of patients with negative results at baseline clinical examination, 9 of 11 metastases were detected by ultrasonography, with 82% sensitivity (95% CI, 48%-98%); specificity was 79% (95% CI, 73%-84%), PPV was 17% (95% CI, 12%-23%), and NPV was 99% (95% CI, 96%-100%). In this diagnostic study, among a cohort of patients with high-risk cutaneous SCC of the head and neck, baseline ultrasonography was more sensitive than clinical examination alone for the detection of lymph node metastasis. In the setting of a negative result at baseline clinical examination, ultrasonography had high sensitivity for detecting nodal metastases, but this sensitivity should be evaluated against the high rate of false-positive findings.

Accuracy of clinical examination and magnetic resonance in assessment of chondral lesion of knee joint by arthroscopy

Introduction: The knee joint has a unique anatomical structure in the human body. The localization between the two longest bones in the human body – femur, and tibia – makes it prone to injuries, trauma, and other pathologies. Clinical examination of the joint is still the primary method in evaluating the condition of the patient's knee. The study aims to determine the diagnostic accuracy of clinical examination and magnetic resonance (MR) in assessing chondral lesions of knee joint using arthroscopy as a reference standard.Patients and methods: The examination was conducted on 94 patients (58 males and 36 females) with knee injuries. Clinical examination indicated a primary chondral lesion of knee cartilage in eight patients (five men and three women), with an average age of 45.75. Besides the clinical examination, the diagnostics were performed using MR imaging by Siemens of 0.5 Tesla, and arthroscopy was performed using Storz arthroscope.Results: Our research has generated the following values of clinical and MR results for chondral lesions: Sensitivity (Se) = 12.5%, Specificity (Sp): could not be calculated, Positive Predictive Value (PPV) = 100%, Negative Predictive Value (NPV) = 0% and Accuracy (ACC) = 12.5%. The accuracy of clinical and intraoperative results for chondral lesion was: Se =100%, Sp: could not be calculated, PPV = 100%, NPV: could not be calculated, and ACC = 100%. MR imaging and arthroscopy findings of chondral lesion showed: Se = 100%, Sp = 0%, PPV = 12.5%, NPV: could not be calculated and ACC = 12.5%. In comparing the clinical sign and MRand intraoperative result, Positive Predictive Value for patients with chondral lesion was maximal (100%), while comparing MR with the intraoperative result, Positive Predictive Value was 12.5%. In comparison between clinical sign and intraoperative results, the accuracy for patients with chondral lesion was 100%, while comparing the clinical sign with MR result and MR with the intraoperative result, the accuracy was 12.5%.Conclusion: Our examinations have shown that MR examination is not currently as valid for diagnosing injury of chondral cartilage of knee as the medical community or patients have anticipated it.

The Validation of Clinical Examination and MRI as a Diagnostic Tool for Cruciate Ligaments and Meniscus Injuries of the Knee Against Diagnostic Arthroscopy.

Background: This study was conducted to compare the accuracy of MRI findings and clinical examination of ligamentous and meniscal injuries of the knee, taking arthroscopy as a standard diagnostic tool in knee injuries. Methods: All patients with knee injuries attending the outpatient department or emergency of our hospital underwent clinical examination. Out of them, 60 patients with knee injuries were subjected to clinical examination, MRI, and then arthroscopy. The findings of these diagnostic tools in respect to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and meniscus injuries were validated, compared, and analyzed using various statistical tools. The accuracy, sensitivity, negative predictive value (NPV), positive predictive value (PPV), and specificity were calculated and an agreement between various tests was established using kappa statistics.Results: The accuracy of clinical examination in our study was 88% for ACL tears, 85% for meniscal tears, and 100% for PCL tears. The kappa measure of agreement between arthroscopy and clinical finding and MRI for ACL was 0.610 and 0.698, respectively, which was statistically significant. MRI (98.1) was found to be a more sensitive test for detecting ACL injury than clinical examination (90.4%) resulting in higher diagnostic accuracy (98.3%), while diagnostic accuracy of clinical examination and MRI was found to be 100% for PCL injuries. Hence, MRI is an excellent screening tool for ligamentous and meniscal injuries of the knee joint. We can avoid diagnostic arthroscopy in patients with knee injuries having equivocal clinical and MRI examinations and can proceed for therapeutic arthroscopy to deal with such injuries. Conclusions: For the assessment of ligamentous and meniscal injuries, MRI is an accurate and noninvasive modality. It can be used as a first-line investigation but arthroscopy remains the gold standard.

Could a careful clinical examination distinguish physiologic phimosis from balanitis xerotica obliterans in children?

The diagnosis of balanitis xerotica obliterans (BXO) in children may be challenging, since clinical examination only could lead to an underestimation of its incidence. The aim of this retrospective and single-centre study is to assess the diagnostic performance of clinical examination, together with clinical history, in identifying BXO. Ninety-seven children underwent circumcision for phimosis from 2015 to 2019. Histology was routinely performed. Cohen’s kappa coefficient, sensitivity, specificity, predictive values, likelihood ratios and accuracy of macroscopic appearance of the foreskin, steroid administration and past medical history were estimated. Forty-eight patients (50%) were affected by BXO; 31 of them (69%) presented with suggestive clinical signs. A strictured or whitish urethral meatus was detected during surgery in nine cases (19%); this was associated to allergic or immune diseases (p = 0.046). Foreskin appearance alone mildly correlated with histology (k = 0.494; p < 0.001) and it showed a diagnostic accuracy of 75%. The specificity and positive predictive value of abnormal macroscopic findings at examination, together with a positive clinical history for other allergic or immune diseases, and/or for balanitis, were 100% and the positive likelihood ratio was greater than 10. Conversely, sensitivity decreased to 4.5% (95% CI 0–11%).Conclusion: Foreskin appearance together with clinical history could predict BXO with certainty. However, since the absence of a positive medical history could not exclude the diagnosis, foreskin histology is still highly recommended.What is Known:• Occurrence of balanitis xerotica obliterans may be underestimated in children and it could lead to long-term complications.• The diagnostic accuracy of clinical examination is controversial.What is New:• Clinical signs together with patients’ medical history present high specificity and positive predictive values but low sensitivity.• When suggestive clinical aspects are present, patient should be referred to surgery avoiding prolonged conservative treatment; and preputial histology is highly recommended.

Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies.

Visual inspection via laparoscopy is considered the gold standard for the diagnosis of deep infiltrating endometriosis. Laparoscopy is an invasive procedure; therefore, it would be beneficial to patients if accurate non-invasive modalities were available for the diagnosis of deep infiltrating endometriosis. The purpose of the current review and meta-analysis was to assess the diagnostic accuracy of clinical examination, transvaginal ultrasound (TVUS), transrectal ultrasound (TRUS) and MRI as alternative methods for diagnosis of deep infiltrating endometriosis. A systematic search of the Medline, Scopus, Embase and Cochrane library databases, between their inception and September 2019, was performed. The quality of trials was assessed using the quality assessment of diagnostic accuracy studies-2 tool. Meta-analyses were conducted to obtain the pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio for each of the three imaging modalities and clinical examination. A total of 30 studies with 4,565 participants were included in the review. Physical examination had a pooled sensitivity of 71% and a specificity of 69%, with an average diagnostic accuracy [area under the curve (AUC) =0.76]. TVUS had a pooled sensitivity of 76% and a specificity of 94%, with higher diagnostic accuracy than physical examination (AUC =0.92). TRUS had a pooled sensitivity of 91% and a specificity of 80% with an AUC of 0.93. MRI had a pooled sensitivity of 82% and a specificity of 87% with higher diagnostic accuracy than physical examination (AUC =0.91). All the imaging modalities had good clinical utility, as indicated by the Fagan plot. The present analysis demonstrates that the imaging modalities TVUS, TRUS and MRI may be highly useful alternatives to laparoscopy for diagnosis of deep infiltrating endometriosis and that these techniques have a high sensitivity and specificity.

Comparative study of clinical examination and MRI in relation to arthroscopy in Ligamnentous and meniscal knee injuries

Objective: To determine sensitivity, specificity and accuracy of clinical examination and MRI in detecting ligamentous and meniscal knee injuries in relation to arthroscopy. Material and methods: It was a prospective, study conducted on 30 patients who presented to the department of Orthopaedics, with suspected ligamentous/ meniscal knee injuries, and underwent detailed clinical examination followed by MRI and arthroscopy of the knee. Patients with injuries less than 2 weeks, degenerative lesions of the knee and patients with contraindications to MRI were excluded. Results: Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of clinical examination for anterior cruciate ligament injuries was 91.6, 83.3, 95.6 71.4 and 90 percent respectively and of MRI was 95.8, 66.6, 92, 80 and 90 percent respectively. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of clinical examination for medial meniscal injuries was 61.5, 88.2, 80, 75 and 76.6 percent respectively and MRI was 92.3, 94.1, 92.3, 94.1 and 93.3 percent respectively. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of clinical examination for lateral meniscal injuries was 50, 95.8, 75, 88.5 and 86.6 percent respectively and of MRI was 83.3, 95.8, 83.3, 95.8 and 93.3 percent respectively. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of both clinical examination and MRI for posterior cruciate ligament injuries was 100 percent. Conclusion: In cases of suspected ACL injuries, carefully performed clinical examination can give equally reliable diagnosis as MRI. MRI is more sensitive than clinical examination in diagnosing meniscal injuries and reduces number of missed tears. Negative MRI scans in meniscal injuries is useful in ruling out an injury thus minimizing the number of unnecessary arthroscopies.

A Bayesian Network Analysis of the Diagnostic Process and Its Accuracy to Determine How Clinicians Estimate Cardiac Function in Critically Ill Patients: Prospective Observational Cohort Study.

BackgroundHemodynamic assessment of critically ill patients is a challenging endeavor, and advanced monitoring techniques are often required to guide treatment choices. Given the technical complexity and occasional unavailability of these techniques, estimation of cardiac function based on clinical examination is valuable for critical care physicians to diagnose circulatory shock. Yet, the lack of knowledge on how to best conduct and teach the clinical examination to estimate cardiac function has reduced its accuracy to almost that of “flipping a coin.”ObjectiveThe aim of this study was to investigate the decision-making process underlying estimates of cardiac function of patients acutely admitted to the intensive care unit (ICU) based on current standardized clinical examination using Bayesian methods.MethodsPatient data were collected as part of the Simple Intensive Care Studies-I (SICS-I) prospective cohort study. All adult patients consecutively admitted to the ICU with an expected stay longer than 24 hours were included, for whom clinical examination was conducted and cardiac function was estimated. Using these data, first, the probabilistic dependencies between the examiners’ estimates and the set of clinically measured variables upon which these rely were analyzed using a Bayesian network. Second, the accuracy of cardiac function estimates was assessed by comparison to the cardiac index values measured by critical care ultrasonography.ResultsA total of 1075 patients were included, of which 783 patients had validated cardiac index measurements. A Bayesian network analysis identified two clinical variables upon which cardiac function estimate is conditionally dependent, namely, noradrenaline administration and presence of delayed capillary refill time or mottling. When the patient received noradrenaline, the probability of cardiac function being estimated as reasonable or good P(ER,G) was lower, irrespective of whether the patient was mechanically ventilated (P[ER,G|ventilation, noradrenaline]=0.63, P[ER,G|ventilation, no noradrenaline]=0.91, P[ER,G|no ventilation, noradrenaline]=0.67, P[ER,G|no ventilation, no noradrenaline]=0.93). The same trend was found for capillary refill time or mottling. Sensitivity of estimating a low cardiac index was 26% and 39% and specificity was 83% and 74% for students and physicians, respectively. Positive and negative likelihood ratios were 1.53 (95% CI 1.19-1.97) and 0.87 (95% CI 0.80-0.95), respectively, overall.ConclusionsThe conditional dependencies between clinical variables and the cardiac function estimates resulted in a network consistent with known physiological relations. Conditional probability queries allow for multiple clinical scenarios to be recreated, which provide insight into the possible thought process underlying the examiners’ cardiac function estimates. This information can help develop interactive digital training tools for students and physicians and contribute toward the goal of further improving the diagnostic accuracy of clinical examination in ICU patients.Trial RegistrationClinicalTrials.gov NCT02912624; https://clinicaltrials.gov/ct2/show/NCT02912624

The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I

PurposeClinical examination is often the first step to diagnose shock and estimate cardiac index. In the Simple Intensive Care Studies-I, we assessed the association and diagnostic performance of clinical signs for estimation of cardiac index in critically ill patients.MethodsIn this prospective, single-centre cohort study, we included all acutely ill patients admitted to the ICU and expected to stay > 24 h. We conducted a protocolised clinical examination of 19 clinical signs followed by critical care ultrasonography for cardiac index measurement. Clinical signs were associated with cardiac index and a low cardiac index (< 2.2 L min−1 m2) in multivariable analyses. Diagnostic test accuracies were also assessed.ResultsWe included 1075 patients, of whom 783 (73%) had a validated cardiac index measurement. In multivariable regression, respiratory rate, heart rate and rhythm, systolic and diastolic blood pressure, central-to-peripheral temperature difference, and capillary refill time were statistically independently associated with cardiac index, with an overall R2 of 0.30 (98.5% CI 0.25–0.35). A low cardiac index was observed in 280 (36%) patients. Sensitivities and positive and negative predictive values were below 90% for all signs. Specificities above 90% were observed only for 110/280 patients, who had atrial fibrillation, systolic blood pressures < 90 mmHg, altered consciousness, capillary refill times > 4.5 s, or skin mottling over the knee.ConclusionsSeven out of 19 clinical examination findings were independently associated with cardiac index. For estimation of cardiac index, clinical examination was found to be insufficient in multivariable analyses and in diagnostic accuracy tests. Additional measurements such as critical care ultrasonography remain necessary.

The Role of Clinical Examination in Predicting Relevant MRI Findings in Acute Knee Injuries: A Retrospective Study.

The objective of this study was to delineate the usefulness of clinical examination and magnetic resonance imaging (MRI) in acute knee injuries. We aim to establish whether the time period post acute knee injury is related to the diagnostic accuracy of clinical examination and to investigate the strength of specific clinical examination findings in predicting a clinically relevant MRI abnormality. Seventy patients were referred to fracture clinic with an acute knee injury who subsequently went on to be investigated with MRI over 12 months. These patients were retrospectively analyzed looking at the time period they were reviewed, the components that were assessed at physical examination, and the results of their eventual MRI scan looking for any correlation. A greater proportion of patients who were examined at 2 weeks had relevant positive findings on MRI scan, p = 0.03. Range of movement and lateral joint line tenderness were not associated with a positive MRI scan at any period after injury. The presence of a moderate to large effusion was not associated with an MRI abnormality if the examination was within 2 weeks of injury but was if present 2 weeks after injury, p = 0.0001. Range of movement should not form part of the decision making on whether an injury should be investigated with MRI. Joint effusion in isolation within 2 weeks after injury should not be an indication for MRI but a repeat clinical examination in 2 weeks, where if still present, should be investigated with MRI.

Clinical examination for diagnosing circulatory shock.

In the acute setting of circulatory shock, physicians largely depend on clinical examination and basic laboratory values. The daily use of clinical examination for diagnostic purposes contrasts sharp with the limited number of studies. We aim to provide an overview of the diagnostic accuracy of clinical examination in estimating circulatory shock reflected by an inadequate cardiac output (CO). Recent studies showed poor correlations between CO and mottling, capillary refill time or central-to-peripheral temperature gradients in univariable analyses. The accuracy of physicians to perform an educated guess of CO based on clinical examination lies around 50% and the accuracy for recognizing a low CO is similar. Studies that used predefined clinical profiles composed of several clinical examination signs show more reliable estimations of CO with accuracies ranging from 81 up to 100%. Single variables obtained by clinical examination should not be used when estimating CO. Physician's educated guesses of CO based on unstructured clinical examination are like the 'flip of a coin'. Structured clinical examination based on combined clinical signs shows the best accuracy. Future studies should focus on using a combination of signs in an unselected population, eventually to educate physicians in estimating CO by using predefined clinical profiles.

Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain.

BackgroundThe diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP.Methods and FindingsIn a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR.ConclusionCombinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP.

ARTHROSCOPIC DETERMINATION OF ACCURACY OF CLINICAL EXAMINATION IN INJURIES WITH INTERNAL DERANGEMENT OF KNEE

Abstract Background: For the diagnosis of knee injuries some investigations along with detailed history and clinical examination such as arthrography and arthroscopy are required, which increase the authenticity of diagnosis. Objective: To determine diagnostic accuracy of pre-operative clinical diagnosis with arthroscopic diagno-sis in internal derangement of knee. Methods: This was a Comparative cross sectional study. Conducted at Department of Orthopaedic Sur-gery and Traumatology (DOST) Unit - 1, King Edward Medical University, Mayo Hospital Lahore. Total 45 patients having symptomatic knee injuries, were inclu-ded in this study. After taking informed consent from these patients, a clinical diagnosis of medial meniscus tear (MMT), lateral meniscus tear (LMT), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament(MCL) and lateral collateral ligament (LCL) injury of knee was made, confirmation with magnetic resonance imaging (MRI) was done and those patients having positive clinical and MRI findings of above mentioned injuries arthro-scopy was carried out and then findings of both clini-cal examination and arthroscopy were compared to find out the diagnostic accuracy of clinical examinat-ion. Data was analyzed with the help of SPSS version 20. Results: Mean age of all 45 patients was 29.51 ± 8.72 years. Minimum and maximum age of patients was 18 and 48 years respectively. Clinical examination is 70.83% sensitive and 19.05% specific for medial meniscus tear. Clinical examination has 50% Positive predictive value and 36.36% Negative predictive value. For the diagnosis of Lateral Meniscal tear, clini-cal examination is 16.67% sensitive and 89.47% speci-fic. While clinical examination has 20% positive pre-dictive value and 87.5% negative predictive value. For ACL rupture diagnosis clinical examination is 72.73% sensitive and 66.67% specific. While clinical examina-tion has 85.71% positive predictive value and 47.06% negative predictive value. Conclusion: Results of this study clearly revealed that diagnostic accuracy of clinical examination for the diagnosis of internal derangement of knee shows vari-ability. Clinical examination findings have high sensi-tivity for diagnosis of MMT and ACL injuries while it shows very low sensitivity for LMT. While specificity of clinical examination for diagnosing LMT and ACL was high but for MMT was low. Key Words: Arthroscopy, Clinical Examination, Internal derangement, Knee.

English

The goal of the study was to evaluate the status of clinical diagnosis as well as diagnostic accuracy of easily available imaging techniques (X-ray, US, CT, etc.) in acute abdomen in a rural based teaching hospital. Here we present a prospectively conducted study including 118 patients presenting with features of acute abdomen irrespective of their age, sex, religions, marital and social status. After thorough history taking and clinical examinations, a straight x-ray abdomen, a chest x-ray, USG whole abdomen, CT scan of abdomen (if required), MRI (if required) were done. A provisional diagnosis was made on the basis of imaging findings. Then operative findings were noted if any surgery was required. Then a comparison was done to know that in what percentage of cases the diagnosis made by the available imaging techniques matched with the final diagnosis made on the basis of clinicopathological and operative findings. In our study among 45 cases of laparotomy other than appendicectomy, 39 cases were accurately diagnosed by x-ray (86.66%), USG was diagnostic in 36 cases (80%) and if both were used the sensitivity was raised up to 91%. So it is evident that x-ray is the only and most useful investigating modality in a case of acute abdomen. The overall diagnostic accuracy of clinical examination in acute abdomen is 71% and if imaging techniques are combined with this, the sensitivity raises up to 94.3%. INTRODUCTION: Acute abdomen can be defined as ‘a syndrome induced by wide variety of pathological conditions that require emergent medical or more often surgical treatment.’ 1 Many diseases, some of which are not surgical or intra-abdominal, can produce acute abdominal pain and tenderness. Therefore this challenging clinical scenario requires a thorough and expeditious work-up to determine the need for operative intervention and to initiate appropriate therapy. Approach to a patient with acute abdomen must be orderly and thorough. Clinical examination should suggest the probable cause and guide the choice of initial diagnostic tests. Supplementary laboratory and radiological investigations are indispensible for diagnosis of many surgical conditions, exclusion of medical causes and assistance for preoperative preparations. Now the availability and reliability of these diagnostic studies vary in different hospitals. Beside the wide clinic-pathological spectrum of acute abdomen, our study has focused over the aspect of diagnostic accuracy of available imaging techniques in this rural based teaching hospital. The importance of good history and examination in the assessment of acute abdomen was demonstrated in the 1970s by Late Tim de Dombal from Leeds and Tony Gunn from Scotland. USG since its use by Puylaert et al in 1986 for diagnosing acute abdomen preoperatively has shown itself to be a discerning modality for diagnosing acute abdominal pathology. It is as good as laparoscopy in diagnosing acute abdominal conditions and unlike laparoscopy it has no contraindications such as previous laparotomy & the procedure does not involve general anesthesia. 1 It is easily available, less

Usefulness of hand-held echocardiography (VScan, GE) in bedside outpatients cardiology consultations in addition to physical examination: preliminary results from a multicentric Italian study

Aims While patient history taking and physical examination remain the cornerstones of patient evaluation in clinical practice, there has been a decline in the accuracy of the latter. Hand-held echocardiographic devices have recently been introduced and could potentially improve the diagnostic accuracy of clinical examination. The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination. Methods and results: One hundred fifty-one patients, referred for initial cardiology outpatient consultations, were studied in 6 Cardiologic Centres in Italy. Each patient was submitted to physical examination followed by VScan (GE Healthcare) assessment. Scanning time, the number of examinations with abnormal results after physical examination and the VScan, and the information obtained by physical examination alone and followed by the VScan (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed. The main consultation motives were: dyspnea (28%), chest pain (24%), arrhythmias (19%), shock (5%), syncope (5%), before surgery cardiologic evaluation (25%). The scanning time with the VScan was184±83 seconds. Its use after physical examination led to diagnosis in 106 patients (70%) and to an additional 25 patients (16%) being released from the outpatient clinic. After physical examination followed by VScan assessment, only 37 patients (24%) were sent to the echocardiography lab for further examination. The VScan modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the VScan in 18 patients (11%) and no referral determined by the VScan in 58 patients (29%). The main diagnoses made with VScan were: increase of left and or right ventricular chambers, atrial dilation, left ventricular hypertrophic or dilative remodeling, previous myocardial infarction, low Left Ventricular ejection fraction, mitral or aortic valvular insufficiency or stenosis, pericardial effusion. Conclusions: The VScan utilization caused a negligible increase in the duration of consultations. It showed incremental value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.