title: The rational clinical examination. Does this patient have aortic regurgitation?
abstract: OBJECTIVE
  To review evidence as to the precision and accuracy of clinical examination for aortic regurgitation (AR).
  
  
  METHODS
  We conducted a structured MEDLINE search of English-language articles (January 1966-July 1997), manually reviewed all reference lists of potentially relevant articles, and contacted authors of relevant studies for additional information. Each study (n = 16) was independently reviewed by both authors and graded for methodological quality.
  
  
  RESULTS
  Most studies assessed cardiologists as examiners. Cardiologists' precision for detecting diastolic murmurs was moderate using audiotapes (kappa = 0.51) and was good in the clinical setting (simple agreement, 94%). The most useful finding for ruling in AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8-32.0 [95% confidence interval [CI], 2.8-32 to 16-63] for detecting mild or greater AR and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 grade A studies). The most useful finding for ruling out AR is the absence of early diastolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater AR and 0.1 [95% CI, 0.0-0.3] for moderate or greater AR) (2 grade A studies). Except for a test evaluating the response to transient arterial occlusion (positive LR, 8.4 [95% CI, 1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display poor sensitivity and specificity for AR.
  
  
  CONCLUSIONS
  Clinical examination by cardiologists is accurate for detecting AR, but not enough is known about the examinations of less-expert clinicians.
authors.affiliation: Department of Medicine, University of Toronto and the University Health Network, Ontario, Canada.
authors.forename: N K
authors.initials: NK
authors.lastname: Choudhry
authors.forename: E E
authors.initials: EE
authors.lastname: Etchells
mesh_terms: D001022:Aortic Valve Insufficiency / Q000175:diagnosis*; D003971:Diastole; D006326:Heart Auscultation; D006337:Heart Murmurs / Q000150:complications / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D008875:Middle Aged; D008946:Mitral Valve Stenosis / Q000175:diagnosis; D010808:Physical Examination; D011674:Pulse; D051437:Renal Insufficiency / Q000150:complications