A recent review of the pulmonary clinical examination 5 confirmed the paucity of data on the usefulness of physical examination in diagnosing community-acquired pneumonia. To our knowledge, interobserver reliability and accuracy in diagnosing pneumonia based solely on physical examination (ie, without prior knowledge of clinical history or radiologic findings) have not been previously studied. 4 Patients with pneumonia had coarse crackles, most often pan-inspiratory, which differed from the findings in the other conditions. performed as a bedside ritual." 3Ĭomputerized analyses of lung sounds have confirmed distinct findings in each of 4 diseases: idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. In fact, some believe that auscultation, once considered a sophisticated art that helped guide diagnostic and therapeutic decisions, is "now. Increasing constraints on the time available to evaluate patients and ready access to chest radiographs have led clinicians to question the need for a detailed lung examination when lower respiratory infection is suspected. Furthermore, teachers seldom emphasize the difficulty of eliciting chest physical signs. Surprisingly, neither the utility of the physical examination in predicting pulmonary disease nor its value in distinguishing among different pulmonary conditions has been well studied. 1, 2 Although chest physical examination findings can be confirmed with chest x-ray results, objective data on clinician accuracy and reproducibility of physical examination findings are limited. INTRODUCED NEARLY 200 years ago, auscultation and percussion of the chest are considered essential in the physical examination and are taught to every medical student. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%.Ĭonclusions The degree of interobserver agreement was highly variable for different physical examination findings. Relatively high agreement among examiners (κ ≈ 0.5) occurred for rales in the lateral decubitus position and for wheezes. Abnormal lung sounds were common in both groups the most frequently detected were rales in the upright seated position and bronchial breath sounds. Twenty-eight patients did not have pneumonia. Results Twenty-four patients had pneumonia confirmed by chest x-ray films. Chest x-ray films were read by a radiologist. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Methods Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lower respiratory tract infection (cough and change in sputum) were prospectively examined. Objectives To determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the interobserver reliability of the maneuvers among 3 examiners.
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