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Diagnostic tests are of crucial importance in clinical care and can help to determine the most appropriate treatment for individual patients, to monitor and modify ongoing treatment, and to determine prognosis. The critical details in deciding whether or how to use a diagnostic test are its precision and accuracy. Unfortunately, evidence to support these data is often difficult to find and frequently is not available at all. Further, although we are all taught that “a good history and physical examination” have considerable value, little evidence exists to support the diagnostic utility of the clinical findings.
In a primary care setting, 88% of all diagnoses were established by the end of the initial history and physical examination,1 and similar results have been observed in a general medicine clinic.2 However, despite the importance of the history and physical examination to the clinical setting, their accuracy and precision have rarely been subjected to rigorous evaluation. Using the definition of a high quality diagnostic study applied by such evidence-based journals as Evidence- Based Medicine and ACP Journal Club (independent blinded comparison with the reference standard among an appropriate spectrum of patients), few such studies of the clinical examination can be identified. JAMA began the Rational Clinical Examination series with the objectives of summarising the literature on elements of the clinical examination and drawing attention to those …