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Diagnosing Pneumonia by Physical Examination
Relevant or Relic?
Joyce E. Wipf, MD;
Benjamin A. Lipsky, MD;
Jan V. Hirschmann, MD;
Edward J. Boyko, MD, MPH;
Julie Takasugi, MD;
Renee L. Peugeot, RN, MS;
Connie L. Davis, ARNP, MS
Arch Intern Med. 1999;159:1082-1087.
Background The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown.
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.
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. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist.
Results Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (  0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%.
Conclusions The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.
From the Medical Service (Drs Wipf, Lipsky, Hirschmann, and Boyko and Mss Peugeot and Davis) and the Radiology Service (Dr Takasugi), Veterans Affairs Puget Sound Health Care System, Seattle, Wash; and the Departments of Medicine, (Drs Wipf, Lipsky, Hirschmann, and Boyko) and Radiology (Dr Takasugi), University of Washington, Seattle.
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