To the Editor: Paulson et al. (Jan. 16 issue)1 propose an algorithmicapproach to the evaluation of right-lower-quadrant pain. Theapproach to the evaluation of suspected appendicitis has changedwith technology. Although the history and the physical examinationremain paramount, imaging studies, including computed tomographyand ultrasonography, have an increasingly important role incases of equivocal presentation. However, there is concern thatthe algorithmic approach may be skewed toward equivocal presentation,given evidence that the physical-examination skills of U.S.medical graduates in evaluating possible appendicitis are deficient.One study showed that only 5 of 113 examinees (4 percent) correctlyelicited the psoas sign,2 a sign with 95 percent specificity.1More emphasis should be given in the medical curriculum to instructionin physical-examination skills.3 The recommendation of diagnosticimaging for "equivocal cases" must bear in mind that the determinationof what is equivocal lies in the hands of the examiner.
Bernard M. Karnath, M.D. Join Y. Luh, M.D. University of Texas Medical Branch at Galveston Galveston, TX 77555-0566 bmkarnat{at}utmb.edu
References
Paulson EK, Kalady MF, Pappas TN. Suspected appendicitis. N Engl J Med 2003;348:236-242. [Free Full Text]
Ozuah PO, Curtis J, Dinkevich E. Physical examination skills of US and international medical graduates. JAMA 2001;286:1021-1021. [Free Full Text]
Schwind CJ, Boehler ML, Folse R, Dunnington G, Markwell SJ. Development of physical examination skills in a third-year surgical clerkship. Am J Surg 2001;181:338-340. [Medline]
The authors reply: As we state in our article, the history andphysical examination remain the diagnostic cornerstone in evaluatingpatients with pain in the right lower quadrant. However, inmany such patients, acute appendicitis remains a difficult diagnosisto establish, even for the most experienced physicians. Therate of error in managing right-lower-quadrant pain can approach40 percent in some groups of patients.1 With the judicious useof carefully performed diagnostic imaging, most patients withan equivocal clinical presentation can be given an accuratediagnosis of acute appendicitis or another disease that mimicsacute appendicitis or told they have a normal appendix. Promptuse of imaging can save patients unnecessary appendectomy, unnecessaryhospitalization for observation, and the associated costs.
We agree that teaching physical-examination skills should bea mainstay of any medical curriculum. The more difficult taskis to determine the best strategy for integrating appropriatediagnostic imaging with history taking, physical examination,and laboratory evaluation.
It has come to our attention that some of the values presentedin Table 1 of our article are incorrect. These values were basedin part on data in an article by Wagner et al., which were subsequentlycorrected.2,3 The correct values for the sensitivity and specificityof right-lower-quadrant pain are 84 percent and 90 percent,respectively, rather than 81 percent and 53 percent, as statedin Table 1 of our article. In addition, the correct values forthe sensitivity and specificity of anorexia are 68 percent and36 percent, respectively, rather than 84 percent and 66 percent,as stated in Table 1. We regret these errors.
Erik K. Paulson, M.D. Matthew F. Kalady, M.D. Theodore N.Pappas, M.D. Duke University Medical Center Durham, NC 27710 pauls003{at}mc.duke.edu
References
Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992;158:37-41. [Web of Science][Medline]
Wagner JM, McKinney P, Carpenter JL. Does this patient have appendicitis? JAMA 1996;276:1589-1594. [Free Full Text]
Wagner JM. Likelihood ratios to determine "does this patient have acute appendicitis?": comment and clarification. JAMA 1997;278:819-820. [Free Full Text]
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