In a general practice setting, 20 of 402 patients with cough were diagnosed with pneumonia by chest x-ray. The sensitivity and specificity of clinical diagnosis varied with the prevalence of pneumonia. For example, if the baseline prevalence of pneumonia was 5%, the presence of crackles raised the probability to 10% and their absence decreased the probability to 3%. Most individual findings were insufficient to diagnose pneumonia. Other physical findings (rhonchi, crackles, decreased breath sounds, dullness to percussion, and bronchial breath sounds) yielded LR+s from 1.5 to 3.5, respectively. In one study, the absence of any vital sign abnormalities reduced the likelihood of pneumonia substantially (LR− = 0.18), but did not rule out the diagnosis completely. Regarding the physical examination, tachypnea, tachycardia, and fever had LR+s between 1.5 and 2.4 in an ambulatory setting. No single feature was sufficient to either rule in or rule out the diagnosis. For most elements of history, both the positive and negative likelihood ratios (LR+, LR−) were in the indeterminate range of 0.5 to 2.0. Nine symptoms (cough, dyspnea, sputum production, subjective fever, chills, night sweats, myalgias, sore throat, and rhinorrhea) and 3 items in the past medical history (asthma, immunosuppression, and dementia) were associated with pneumonia. The most reliable findings (dullness to percussion and wheezing) had only fair agreement among examiners (kappa approximately 0.5). In a study by Spiteri and associates, 2 24 physicians examined 24 patients with a variety of respiratory conditions: only 4 had pneumonia on chest x-ray. 1 Although no study specifically addressed the interobserver reliability of the history and physical examination findings in pneumonia, other studies of chest findings typically found variable reproducibility. Subjects were community-dwelling adults with acute cough who were seen in ambulatory settings, and who had an average pneumonia prevalence of 7% (range, 3%–38%). In each of the 4 studies, the reference standard for the diagnosis of pneumonia was a new infiltrate on chest radiograph. Metlay and colleagues 1 found only 4 high-quality, prospective cohort trials evaluating the sensitivity and specificity of the clinical history and physical examination in pneumonia. Practice guidelines for the management of community-acquired pneumonia in adults.Infectious Diseases Society of America. Bartlett JG, Dowell SF, Mandell LA, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Gonzales R, Bartlett JG, Besser RE, et al. Diagnosing pneumonia by physical examination: relevant or relic? Arch Intern Med 1999 159:1082-7.ĥ. Wipf JE, Lipsky BA, Hirschmann JV, et al. Relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard. Diagnosis of pneumonia in adults in general practice. Reliability of eliciting physical signs in examination of the chest. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination.
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