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

Martina, Benedict ; Bucheli, Bruno ; Stotz, Martin ; Battegay, Edouard ; Gyr, Niklaus

In: Journal of General Internal Medicine, 1997, vol. 12, no. 8, p. 459-465

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    Objective: To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. Design: Prospective observational study. Setting: General medical outpatient clinic in a university teaching hospital. Participants: 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. Measurements and main results: 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. Conclusions: 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