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Diagnosing pneumonia by physical examination: relevant or relic?
J E Wipf1, B A Lipsky, J V Hirschmann
1Veterans Affairs Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle 98108, USA. jwipf@washington.edu
Archives of Internal Medicine
|May 21, 1999
Summary
Chest physical exam findings for pneumonia show variable reliability among clinicians. Unilateral rales and lateral decubitus rales were most useful, but the exam alone cannot confirm or exclude pneumonia.
Area of Science:
- Pulmonology
- Internal Medicine
- Diagnostic Accuracy
Background:
- The diagnostic reliability of chest physical examination for pneumonia is not well-established.
- Interobserver agreement among clinicians in diagnosing pneumonia based on physical findings is largely unknown.
Purpose of the Study:
- To assess the accuracy of physical examination maneuvers in diagnosing pneumonia.
- To compare the interobserver reliability of these maneuvers among three physicians.
Main Methods:
- Fifty-two male patients with lower respiratory tract infection symptoms underwent a comprehensive lung physical examination by three blinded physicians.
- Examination findings and pneumonia diagnoses were recorded; chest x-rays served as the gold standard.
Main Results:
- Twenty-four patients had pneumonia confirmed by chest x-ray.
- Abnormal lung sounds were frequent in both pneumonia and non-pneumonia groups.
- Interobserver agreement was highest for rales in the lateral decubitus position (kappa ≈ 0.5) and wheezes.
- Clinical diagnosis sensitivity ranged from 47% to 69%, and specificity from 58% to 75%.
Conclusions:
- Interobserver agreement for physical examination findings varied significantly.
- Unilateral rales and rales in the lateral decubitus position were the most valuable maneuvers for detecting pneumonia.
- The traditional chest physical examination lacks sufficient accuracy to definitively diagnose or exclude pneumonia.