The Rational Clinical Examination
David L. Simel, Drummond Rennie
David G. Bundy, Julie S. Byerley, E. Allen Liles, Eliana M. Perrin, Jessica Katznelson, Henry E. Rice
Limitations of the Literature
abdominal pain, appendectomy, appendicitis, acute, approach to medical literature, child, conduct considerations, diagnostic imaging, diagnostic process, likelihood ratio, mantrels, pediatrics, physical examination, primary studies, prior probability, pyrexia, summarizing the evidence
"Forty-two studies met our inclusion criteria and were
assigned a level of evidence. Of these, 25 studies were level 3
or better (level 1: n = 1; level 3: n = 24) and
are included in this analysis (Table 60-4). One additional study
provided precision data only.Abdominal pain is a nearly universal finding in pediatric appendicitis.
Since the presence of abdominal pain was an inclusion criterion
in the majority of the articles we included, we could not evaluate
the independent significance of abdominal pain as a presenting symptom.
Whether the duration of pain was more or less than 24 hours did
not affect the likelihood of appendicitis in either unselected children
with abdominal pain (level 1 study) or select groups of children
undergoing further evaluation for appendicitis (level 3 studies)
(Table 60-5). In the level 3 studies, presence of RLQ pain had minimal
impact on the likelihood of appendicitis (summary LR, 1.2; 95% CI,
1.0-1.5); absence of RLQ pain, however, did decrease the
likelihood (summary LR, 0.56; 95% CI, 0.43-0.73).
Presence of pain that began midabdominally and migrated to the RLQ
was more useful (LR range, 1.9-3.1), while absence of this
pain evolution had a similar LR compared with that for the absence
of RLQ altogether (LR range for absence of RLQ migratory pattern, 0.41-0.72)...."
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