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ARTICLE |

The Science of the Art of the Clinical Examination FREE

David L. Sackett, MD, MSc Epid, FRCPC; Drummond Rennie, MD
[+] Author Affiliations

Reprint requests to Henderson General Division, Room 408; McMaster Clinic, 711 Concession St, Hamilton, Ontario, Canada L8V 1C3 (Dr Sackett).


JAMA. 1992;267(19):2650-2652. doi:10.1001/jama.1992.03480190092040
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Our first moments with a patient are packed with visual, auditory, and tactile information that determines both the effectiveness and the costs of our subsequent care. Of all the diagnoses that ever will be made, most are made during the history, and most of the rest during the physical examination. For example, Crombie1 documented that 88% of diagnoses in primary care were established by the end of a brief history and some subroutine of the physical examination. Similarly, Sandler2 found that 56% of patients in a general medical clinic had been assigned correct diagnoses by the end of their history, and that this figure rose to 73% by the end of their physical examination. Even when patients are referred to

See also pp 2638 and 2645. specialty centers after exhaustive workups elsewhere, attention is appropriately refocused on the clinical examination: the patient's "story" and the physical examination. Indeed,

REFERENCES

Crombie DL.  Diagnostic process. J Coll Gen Pract . 1963;;6:579-589.
Sandler G.  The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J . 1980;;100(pt 1):928-931.
Diamond GA, Forrester JS.  Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med . 1979;;300:1350-1358.
Sox HC Jr, Hickam DH, Marton HI, et al.  Using the patient's history to estimate the probability of coronary artery disease: a comparison of primary and referral practices. Am J Med . 1990;;89:7-14.
Levin BE.  The clinical significance of spontaneous pulsations of the retinal vein. Arch Neurol . 1978;;35:37-40.
Marton KI, Sox HC Jr, Wasson J, Duisenberg CE.  The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med . 1980;;140:191-195.
Bayes T.  An essay toward solving a problem in the doctrine of chance. Philosophic Trans R Soc . 1763;;53:370-418.
Griner PF, Panzer RJ, Greenland P. Clinical Diagnosis and the Laboratory: Logical Strategies for Common Medical Problems . Chicago, Ill: Year Book Medical Publishers Inc; 1986;.
McNeil BJ, Abrams HL. Brigham and Women's Hospital Handbook of Diagnostic Radiology . Boston, Mass: Little Brown & Co Inc; 1986;.
Sox HC Jr, ed. Common Diagnostic Tests: Use and Interpretation . Philadelphia, Pa: American College of Physicians; 1987;.
Huhns LR, Thornbury JR, Fryback DG. Decision Making in Imaging . Chicago, Ill: Year Book Medical Publishers Inc; 1989;.
Petersdorf R.  Is the establishment defensible? N Engl J Med . 1983;;309:1053-1057.
Oxman AD, Guyatt GH.  Guidelines for reading literature reviews. Can Med Assoc J . 1988;;138:697-703.
Sackett DL.  A primer on the precision and accuracy of the clinical examination. JAMA . 1992;;267:2638-2644.
Hull R, Hirsh J, Sackett DL, et al.  Combined use of leg scanning and impedance plethysmography in suspected venous thrombosis: an alternative to venography. N Engl J Med . 1977;;296:1497-1500.

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Crombie DL.  Diagnostic process. J Coll Gen Pract . 1963;;6:579-589.
Sandler G.  The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J . 1980;;100(pt 1):928-931.
Diamond GA, Forrester JS.  Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med . 1979;;300:1350-1358.
Sox HC Jr, Hickam DH, Marton HI, et al.  Using the patient's history to estimate the probability of coronary artery disease: a comparison of primary and referral practices. Am J Med . 1990;;89:7-14.
Levin BE.  The clinical significance of spontaneous pulsations of the retinal vein. Arch Neurol . 1978;;35:37-40.
Marton KI, Sox HC Jr, Wasson J, Duisenberg CE.  The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med . 1980;;140:191-195.
Bayes T.  An essay toward solving a problem in the doctrine of chance. Philosophic Trans R Soc . 1763;;53:370-418.
Griner PF, Panzer RJ, Greenland P. Clinical Diagnosis and the Laboratory: Logical Strategies for Common Medical Problems . Chicago, Ill: Year Book Medical Publishers Inc; 1986;.
McNeil BJ, Abrams HL. Brigham and Women's Hospital Handbook of Diagnostic Radiology . Boston, Mass: Little Brown & Co Inc; 1986;.
Sox HC Jr, ed. Common Diagnostic Tests: Use and Interpretation . Philadelphia, Pa: American College of Physicians; 1987;.
Huhns LR, Thornbury JR, Fryback DG. Decision Making in Imaging . Chicago, Ill: Year Book Medical Publishers Inc; 1989;.
Petersdorf R.  Is the establishment defensible? N Engl J Med . 1983;;309:1053-1057.
Oxman AD, Guyatt GH.  Guidelines for reading literature reviews. Can Med Assoc J . 1988;;138:697-703.
Sackett DL.  A primer on the precision and accuracy of the clinical examination. JAMA . 1992;;267:2638-2644.
Hull R, Hirsh J, Sackett DL, et al.  Combined use of leg scanning and impedance plethysmography in suspected venous thrombosis: an alternative to venography. N Engl J Med . 1977;;296:1497-1500.
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