Variations
and Tendencies in the Clinical Decision-Making of MDH Hospital Staff
in
Patients with Acute Nontraumatic RLQ Abdominal Pain
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.
Objectives:
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
Methodology:
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.
Results:
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.
Conclusion:
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.