Reading material for ex.2 p.185.

Read the two texts and explain the meaning of the words in green type:

I.Diagnosing Pneumonia Using Physical Examination

 
Although chest radiographs can confirm physical examination findings, little is known
about the utility of the physical examination alone in predicting pulmonary disease or
in distinguishing among pulmonary conditions. Increasing time constraints on patient
visits and the immediate availability of radiography have led physicians to question
the need for a detailed lung examination when lower respiratory infection is
suspected.

Patients who presented to the emergency department with signs of lower respiratory
infection, including an acute cough and copious or dark-colored sputum, were eligible
for the study. Each patient was examined sequentially by at least two or three board-
certified physicians who had no knowledge of the patient's history, vital signs or
radiographic findings. The physicians were not allowed to ask the patient questions.
Patients were examined in the sitting and right- and left-lateral decubitus positions. In
the sitting position, patients were examined for rales, rhonchi, wheezing, tactile
fremitus and other signs consistent with pneumonia. In the left and right lateral
decubitus positions, patients were examined for rales. Chest radiographs were
obtained for all patients and were considered the gold standard* for confirming the
diagnosis; physical findings were considered correct if they were present in the same
general areas as infiltrates on the chest radiographs.

Fifty-two male patients, who were generally elderly with a history of smoking and
asthma or chronic obstructive pulmonary disease, were enrolled in the study. Of
these, 24 had pneumonia confirmed by chest radiographs, and 28 did not have
pneumonia. The latter group was believed to have some type of bronchitis. In four of
the patients with pneumonia, the chest radiographs were interpreted as “possible
pneumonia.” Most cases of pneumonia were located in the right lower lobe of the
lung.

Physical examination of the chest took about 10 minutes. The two most frequent
abnormal findings in all patients were rales in the sitting position (22 to 65 percent)
and bronchial breath sounds (8 to 43 percent). Other chest findings were uncommon.
Physician consistency was highest for rales. Overall, sensitivity and specificity of
physical findings varied considerably among physicians, as well as for a given
physician in eliciting findings between the right and left lungs. The most consistently
helpful maneuvers were auscultating for rales with the patient in the sitting position
(highest sensitivity) and performing auscultatory percussion for egophony and rales
in the left-lateral decubitus position (highest specificity).

The authors conclude that the physical examination had moderate sensitivity and
specificity in determining the presence of pneumonia and identifying the affected site.
Physical examination alone was not sufficiently accurate to confirm or exclude the
diagnosis of pneumonia. Chest radiographs remain the best way to confirm the
diagnosis.

gold standard* In medicine and statistics, a gold standard test is usually the

diagnostic test or benchmark that is the best available under reasonable conditions.
Other times, a gold standard is the most accurate test possible without restrictions.

BARBARA APGAR, M.D., M.S.

Wipf JE, et al. Diagnosing pneumonia by physical examination. Relevant or relic? Arch Intern
Med. May 24, 1999;159:1082–7.

II. Physical Exam for Pneumonia

Topic Overview

When you visit your doctor for suspected pneumonia , he or she will check:

 Your heart rate. It may be faster if you have a fever or are dehydrated .

 Your temperature. You usually have a fever in pneumonia.
 Your breathing. Fast, shallow breathing; difficulty breathing; and shortness of breath
often are symptoms of pneumonia.
 Whether you have chest pain.
 Your oxygen level.
 Other symptoms, if you have any. For example, rash may develop in some people who
have pneumonia. Other symptoms may include fatigue, muscle aches, nausea, vomiting,
cough, and dehydration. Complications of pneumonia may include stiff neck (a symptom
of meningitis ), swollen joints, and abdominal (belly) pain.

Your doctor also will listen to your chest for:

 Crackling or bubbling noises (rales) made by movement of fluid in the tiny air sacs of
the lung.
 Dull thuds heard when the chest is tapped (percussion dullness), which indicate that
there is fluid in a lung or collapse of part of a lung.
 Sounds made by rubbing of swollen (inflamed) lung tissue on the lining of the lung
cavity (pleural friction rub).
 Lack of breath sounds in a certain area of the chest, which may mean that air is not
entering an area of the lung.
 Wheezing, which usually means inflammation or spasm is present in the bronchial
tubes.
 "E" to "A" changes in the lungs (egophony). Your doctor may have you say the letter
"E" while he listens to your chest. Pneumonia may cause the "E" to sound like the letter
"A" when heard through a stethoscope.