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Variations and Tendencies in the Clinical Decision-Making of MDH Hospital Staff

                                              in Patients with Acute Nontraumatic RLQ Abdominal Pain  


Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg




Background of Study:


             This paper is part of the quality assurance activities of  Manila Doctors Hospital on patients with acute  nontraumatic right lower quadrant (RLQ) abdominal pain.




            To gather data on the present practice or manner of decision-making of MDH medical staff on clinical diagnosis and use of ancillary diagnostic procedures in patients with acute nontraumatic RLQ abdominal pain.  To document overall variation, if present; variations among different levels of medical staff; variations abmong the different specialties; and overall tendencies.


Research Design: Descriptive-Survey



            Various clinical scenarios and a questionnaire were created and samples of MDH medical staff were asked to answer.  Responses were analyzed using measures of central tendencies and dispersions.



            A total of 98 sets of responses was gotten from 20 consultants, 21 residents, and 20 interns.


            There were marked variations overall; between and among consultants, residents, and interns; and between and among different specialties in the clinical diagnosis and use of ancillary diagnostic procedures.


             There were tendencies towards the following:


1. In the absence of cues for an alternative nonappendicitis diagnosis, placing greatest weight on a combination of direct tenderness, rebound tenderness, and guarding for a clinical diagnosis of acute appendicitis.  Corollary to this, placing more weights on the presence of  two or more kinds of tenderness than on a single kind.


2. Using shifting pain from epigastric or periumbilical area to the RLQ as an important cue in the clinical diagnosis of acute appendicitis. Corollary to this, nonreliance on shifting LLQ to RLQ as a cue for the clinical diagnosis of acute appendicitis.


3. In the presence of cues for an alternative nonappendicitis condition,  not to consider strongly a

appendicitis diagnosis.   However, in the presence of rebound tenderness and guarding, to consider strongly an appendicitis diagnosis together with the nonappendicitis one.


4. To routinely elicit cough, Rovsing, psoas, and obturator signs and perform rectal examination. Not to routinely perform internal examination in patients with RLQ pain.


5. Uncertainty in clinical diagnosis in the majority of cases that would prompt request for ancillary diagnostic procedure.


6. To routinely perform ancillary diagnostic procedure, especially CBC and urinalysis.         


7. For surgeons not to routinely do all kinds of maneuvers in the physical examination and request for CBC and urinalysis.


8. Not to perform observation as an ancillary diagnostic procedure.


9. No clearcut  trend on where to put more weights on: direct or rebound tenderness; rebound tenderness or guarding.




            The data-gathering showed marked variations in the clinical decision-making of medical staff of Manila Doctors Hospital which would justify the development of an evidence-based clinical practice guideline.  Hopefully, this guideline will not only resolve the variations but will reduce the confusion among patients and health care providers alike.  The ultimate impact of the guideline will be a better health care outcome.