1. The Rational Clinical Examination Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Does This Adult Patient Have Acute Meningitis?

2. The Rational Clinical Examination Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. Case Scenario 1 30-year-old man presents to emergency department (ED) 24-hour history of chills and a stiff neck Afebrile with normal mental status Full neck flexion but with cervical pain Kernig and Brudzinski signs absent

3. The Rational Clinical Examination Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. in cr ea si n g i m p a c tI n c r e a s i ng im pa ct LR: Impact on Likelihood of Disease LR = 1No Impact on Likelihood of Disease 0 LR = 0.3Less Likely LR = 0.2Less Likely LR = 0.1Less Likely LR = 0.01Less Likely LR = 3More Likely LR = 5More Likely LR = 10More Likely LR = 100More Likely

4. The Rational Clinical Examination Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. FindingLR+ (95% CI)LR– (95% CI) Fever0.82 (0.62-1.1)1.2 (0.94-1.5) Kernig sign (Thomas)0.97 (0.27-3.6)1.0 (0.94-1.1) Kernig sign (Uchihari)4.2 (0.23-77)0.92 (0.81-1.0) Brudzinski sign0.97 (0.26-3.5)1.0 (0.94-1.1) Jolt accentuation2.4 (1.4-4.2)0.05 (0.01-0.35) Test Characteristics: Examination Likelihood Ratios From Prospective Studies

5. The Rational Clinical Examination Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc. 1% Pretest probability in population presenting to ED If positive, posttest probability = 2% Jolt accentuation test LR+ = 2.4 Jolt accentuation test LR– = 0.05 If negative, posttest probability < 0.1% Likelihood Ratio

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