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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Acute Cholecystitis
Robert L. Trowbridge, Nicole K. Rutkowski, Kaveh G. Shojania
Although the existing literature does not identify specific clinically useful combinations of...


Topics Discussed: cholecystitis, acute, clinical gestalt, summarizing the evidence

Excerpt: "Of 195 studies identified by our search, 17 evaluated the role of the clinical examination or basic laboratory test in patients with acute abdominal pain and possible acute cholecystitis and also met our inclusion criteria (Table 12-1).39-55 Twelve of these studies40,42-47,49,51-54 enrolled patients specifically suspected of having acute cholecystitis, with inclusion of many of these studies based on patient referral for radiology testing (ie, HIDA scan or right upper quadrant ultrasonography) for the confirmation of a clinical diagnosis. The remaining 5 studies39,41,48,50,55 enrolled patients presenting with abdominal pain and did not require a specific suspicion of acute cholecystitis for patient inclusion. Each of the 17 studies evaluated a variable number of clinical and laboratory findings included in the evaluation of suspected cholecystitis, ranging from 1 to 9 characteristics per study (Table 12-2).Measurements of laboratory characteristics and objective clinical signs such as temperature are assumed to have high precision, but the reproducibility of other aspects of the clinical examination for cholecystitis remains largely unknown. In fact, the only study identified as assessing the precision of some aspect of the clinical examination for biliary disease was an evaluation of the diagnostic value of iridology56 (iridologists believe that intricate neural connections between major organs and the iris permit diagnosis of general medical conditions through inspection of iris pigmentation patterns57,58). In this relatively well-designed study, the accuracy and precision of iridologic signs for the diagnosis of cholecystitis were barely distinguishable from values expected by chance alone ( = –0.06 to 0.28 for the 10 possible observer pairs)...."
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