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The rational clinical examination in emergency care

BMJ 2008; 337 doi: (Published 15 December 2008) Cite this as: BMJ 2008;337:a2374
  1. Kevin Mackway-Jones, professor
  1. 1Emergency Department, Manchester Royal Infirmary, Manchester M13 9WL
  1. kevin.mackway-jones{at}

    We should tell patients that even highly sensitive tests miss some cases

    Understanding the patient’s history and interpreting the clinical examination can be challenging in emergencies. Although the immediate presenting problem may be clear—“I’ve hurt my hand” or “I have a cough”—confounding factors such as pain and anxiety may obfuscate the symptoms and mask the signs. In these circumstances a rational approach to clinical assessment is essential.1

    The Ottawa ankle rules are probably the most well known and frequently used clinical decision support rules for use in emergencies.2 3 Evidence based approaches have, however, been developed to help in many other emergency situations, including head injury in adults and children,4 5 neck injury,6 knee injury,7 mandibular trauma,8 and risk assessment after self harm.9

    In the linked study (doi:10.1136/bmj.a2428), Appelboam and colleagues extend this work with the results of the SWEET study—a multicentre prospective diagnostic cohort study that investigates a simple clinical test (extension of the …

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