Practice corner: using clinical prediction rules.

نویسنده

  • Thomas McGinn
چکیده

S c e n a r i o On inpatient teaching rounds, we recently discussed the admission of a 45-year-old woman with chest pain. This patient presented to the emergency department after an episode of chest pain lasting approximately 30 minutes. The pain was pleuritic in nature, located on the right side of her chest, and was associated with shortness of breath. The patient reported no palpitations, diaphoresis, nausea, or vomiting. She had no relevant medical history, was taking oral contraceptives, and had no family history of cardiac or thromboembolic disease. Her vital signs, including oxygen saturation, were normal, as were the physical examination results. The working diagnosis was pulmonary embolus (PE), and she was started on intravenous heparin and scheduled for a ventilation-perfusion (V/Q) scan to be done within the next half hour. After interviewing the patient with a team (2 residents, 3 interns, and 2 medical students) and reviewing the data, I asked the team to individually record their best estimate of the probability that this patient had PE. At first, the team was reluctant, in particular the third-year residents, but with encouragement, all members of the team scribbled down their best estimate. The probabilities were reviewed and were found to range from 5% to 80%. The importance of accurately determining the pretest probability of disease is highlighted in Figure 1. For our patient, resident 1 estimated the patient’s pretest probability of PE as being high (i.e., 80%). This pretest probability combined with a low-probability V/Q scan result (likelihood ratio = 0.4) gives a 61.5% probability of PE (1). This post test probability is not sufficient to either rule in or rule out the diagnosis of PE and would prompt the resident to order further diagnostic tests, such as spiral computed tomography or pulmonary angiography, to better clarify the diagnosis. Resident 2 estimated the patient’s pretest probability as being low (i.e., 5%). When combined

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عنوان ژورنال:
  • ACP journal club

دوره 137 2  شماره 

صفحات  -

تاریخ انتشار 2002