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{{Pneumonia}}
{{Pneumonia}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; [[Philip Marcus, M.D., M.P.H.]][mailto:pmarcus192@aol.com]
{{CMG}}; {{AE}} {{HQ}}, [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
Persons with symptoms of pneumonia need medical evaluation. [[Physical examination]] by a health care provider may reveal [[fever]] or sometimes[[hypothermia|low body temperature]], an [[tachypnea|increased respiratory rate]], [[hypotension|low blood pressure]], a [[tachycardia|fast heart rate]], or a low [[oxygen saturation]], which is the amount of oxygen in the blood as indicated by either [[pulse oximetry]] or [[arterial blood gas|blood gas analysis]]. People who are struggling to breathe, who are confused, or who have [[cyanosis]] (blue-tinged skin) require immediate attention.  
[[Physical examination]] may reveal [[fever]] or sometimes [[hypothermia|low body temperature]], an [[tachypnea|increased respiratory rate]], [[hypotension|low blood pressure]], a [[tachycardia|fast heart rate]], or a low [[oxygen saturation]], which is the amount of oxygen in the blood as indicated by either [[pulse oximetry]] or [[arterial blood gas|blood gas analysis]]. Patients who have difficulty breathing, who are confused, or who have [[cyanosis]] (blue-tinged skin) require immediate attention. [[Auscultation]] findings include lack of normal breath sounds, the presence of crackling sounds ([[rales]]), or increased loudness of whispered speech (whispered pectoriloquy) with areas of the lung that are stiff and full of fluid, called consolidation. Vital signs are useful in determining the severity of illness and have predictive values. However, a high degree of suspicion should be kept in elderly as the presentation could be subtle in them.


Listening to the lungs with a [[stethoscope]] ([[auscultation]]) can reveal several things. A lack of normal breath sounds, the presence of crackling sounds ([[rales]]), or increased loudness of whispered speech (whispered pectoriloquy) can identify areas of the lung that are stiff and full of fluid, called "consolidation." The examiner may also feel the way the chest expands ([[palpation]]) and tap the chest wall ([[Percussion (medicine)|percussion]]) to further localize consolidation. The examiner may also palpate for increased vibration of the chest when speaking (tactile fremitus).<ref name=metlay>Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. ''JAMA'' 1997; 278:1440. PMID 9356004</ref>
==Physical Examination==


The physical exam findings for pneumonia are as follows:<ref name="MusherThorner2014">{{cite journal|last1=Musher|first1=Daniel M.|last2=Thorner|first2=Anna R.|title=Community-Acquired Pneumonia|journal=New England Journal of Medicine|volume=371|issue=17|year=2014|pages=1619–1628|issn=0028-4793|doi=10.1056/NEJMra1312885}}</ref><ref>{{cite web|url=http://www.who.int/mediacentre/factsheets/fs331/en/|title= WHO Pneumonia Fact Sheets}}</ref><ref name="MandellWunderink2007">{{cite journal|last1=Mandell|first1=L. A.|last2=Wunderink|first2=R. G.|last3=Anzueto|first3=A.|last4=Bartlett|first4=J. G.|last5=Campbell|first5=G. D.|last6=Dean|first6=N. C.|last7=Dowell|first7=S. F.|last8=File|first8=T. M.|last9=Musher|first9=D. M.|last10=Niederman|first10=M. S.|last11=Torres|first11=A.|last12=Whitney|first12=C. G.|title=Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults|journal=Clinical Infectious Diseases|volume=44|issue=Supplement 2|year=2007|pages=S27–S72|issn=1058-4838|doi=10.1086/511159}}</ref>


===Combining findings===
*Physical examination of patients with pneumonia is usually remarkable for: shortness of breath, cough, fever, and difficulty breathing.
One study created a prediction rule that found the five following signs best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room<ref name="pmid2221647">{{cite journal |author=Heckerling PS, Tape TG, Wigton RS, ''et al'' |title=Clinical prediction rule for pulmonary infiltrates |journal=Ann. Intern. Med. |volume=113 |issue=9 |pages=664-70 |year=1990 |pmid=2221647 |doi=}}</ref>:
*Temperature > 37.8 degrees C (100 degrees F)
*Pulse > 100 beats/min
*Crackles
*Decreased breath sounds
*''Absence'' of asthma


The probability of an infiltrate in two separate validations was based on the number of findings:
===Appearance of the Patient===
*5 findings - 84% to 91% probability
*Patients with pneumonia usually appear normal or in distress.
*4 findings - 58% to 85%
*3 findings - 35% to 51%
*2 findings - 14% to 24%
*1 findings - 5% to 9%
*0 findings - 2% to 3%


A subsequent study<ref name="pmid1952308">{{cite journal |author=Emerman CL, Dawson N, Speroff T, ''et al'' |title=Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients |journal=Annals of emergency medicine |volume=20 |issue=11 |pages=1215-9|year=1991 |pmid=1952308 |doi=}}</ref> comparing four prediction rules to physician judgment found that two rules, the one above<ref name="pmid2221647"/>and also<ref name="pmid2745948">{{cite journal |author=Gennis P, Gallagher J, Falvo C, Baker S, Than W |title=Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department |journal=The Journal of emergency medicine |volume=7 |issue=3|pages=263-8 |year=1989 |pmid=2745948 |doi=}}</ref>, were more accurate than physician judgment because of the increased specificity of the prediction rules.
===Vital Signs===
{|style="float:right"
|
{| style="border: 0px; font-size: 85%; margin: 3px; width:200px;" align=center
|valign=top|
|+ '''Criteria for Tachypnea'''<ref name="Russell2001">{{cite journal|last1=Russell|first1=G.|title=Community acquired pneumonia|journal=Archives of Disease in Childhood|volume=85|issue=6|year=2001|pages=445–446|issn=00039888|doi=10.1136/adc.85.6.445}}</ref>
! style="background: #4479BA; color:#FFF;  width: 100px;" | Age
! style="background: #4479BA; color:#FFF;  width: 100px;" | Breaths/min
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  < 2 months
| style="padding: 5px 5px; background: #F5F5F5;" | > 60
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  2-12 months
| style="padding: 5px 5px; background: #F5F5F5;" | > 50
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  1- 5 years
| style="padding: 5px 5px; background: #F5F5F5;" | > 40
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  > 5 years
| style="padding: 5px 5px; background: #F5F5F5;" | > 20
|}
|style="width: 600px"|         
|}
* [[Decreased oxygen saturation]]
* [[Fever]]
* [[Hypotension]] < 90 mm Hg
* [[Tachycardia]] > 125 beats/min
* [[Tachypnea]]
 
===Skin===
* Skin examination of patients with pneumonia is usually normal.
 
===HEENT===
* HEENT examination of patients with pneumonia is usually normal.
 
===Neck===
* Neck examination of patients with pneumonia is usually normal.
 
===Lungs===
====Palpation====
* Increased tactile fremitus
 
====Percussion====
* Dullness on percussion
 
====Auscultation====
* Decreased breath sounds
* Bronchial breath sounds
* [[Rhonchi]]
* Crackles, [[Rales]]
* Increased [[vocal fremitus]]
 
===Heart===
* Cardiovascular examination of patients with pneumonia is usually normal.
 
===Abdomen===
Abdominal examination of patients with pneumonia is usually normal.
 
===Back===
* Back examination of patients with pneumonia is usually normal.
 
===Genitourinary===
* Genitourinary examination of patients with pneumonia is usually normal.
 
===Neuromuscular===
* Neuromuscular examination of patients with pneumonia is usually normal.
 
===Extremities===
* Extremities examination of patients with pneumonia is usually normal.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


[[Category:Diseaase]]
[[Category:Pneumonia]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Infectious disease]]
[[Category:Pneumonia|Pneumonia]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
 
[[Category:Pediatrics]]
{{WH}}
[[Category:Disease]]
{{WS}}

Latest revision as of 23:45, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Priyamvada Singh, M.D. [3]

Overview

Physical examination may reveal fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a fast heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry or blood gas analysis. Patients who have difficulty breathing, who are confused, or who have cyanosis (blue-tinged skin) require immediate attention. Auscultation findings include lack of normal breath sounds, the presence of crackling sounds (rales), or increased loudness of whispered speech (whispered pectoriloquy) with areas of the lung that are stiff and full of fluid, called consolidation. Vital signs are useful in determining the severity of illness and have predictive values. However, a high degree of suspicion should be kept in elderly as the presentation could be subtle in them.

Physical Examination

The physical exam findings for pneumonia are as follows:[1][2][3]

  • Physical examination of patients with pneumonia is usually remarkable for: shortness of breath, cough, fever, and difficulty breathing.

Appearance of the Patient

  • Patients with pneumonia usually appear normal or in distress.

Vital Signs

Criteria for Tachypnea[4]
Age Breaths/min
< 2 months > 60
2-12 months > 50
1- 5 years > 40
> 5 years > 20

Skin

  • Skin examination of patients with pneumonia is usually normal.

HEENT

  • HEENT examination of patients with pneumonia is usually normal.

Neck

  • Neck examination of patients with pneumonia is usually normal.

Lungs

Palpation

  • Increased tactile fremitus

Percussion

  • Dullness on percussion

Auscultation

Heart

  • Cardiovascular examination of patients with pneumonia is usually normal.

Abdomen

Abdominal examination of patients with pneumonia is usually normal.

Back

  • Back examination of patients with pneumonia is usually normal.

Genitourinary

  • Genitourinary examination of patients with pneumonia is usually normal.

Neuromuscular

  • Neuromuscular examination of patients with pneumonia is usually normal.

Extremities

  • Extremities examination of patients with pneumonia is usually normal.

References

  1. ↑ Musher, Daniel M.; Thorner, Anna R. (2014). "Community-Acquired Pneumonia". New England Journal of Medicine. 371 (17): 1619–1628. doi:10.1056/NEJMra1312885. ISSN 0028-4793.
  2. ↑ "WHO Pneumonia Fact Sheets".
  3. ↑ Mandell, L. A.; Wunderink, R. G.; Anzueto, A.; Bartlett, J. G.; Campbell, G. D.; Dean, N. C.; Dowell, S. F.; File, T. M.; Musher, D. M.; Niederman, M. S.; Torres, A.; Whitney, C. G. (2007). "Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults". Clinical Infectious Diseases. 44 (Supplement 2): S27–S72. doi:10.1086/511159. ISSN 1058-4838.
  4. ↑ Russell, G. (2001). "Community acquired pneumonia". Archives of Disease in Childhood. 85 (6): 445–446. doi:10.1136/adc.85.6.445. ISSN 0003-9888.

Template:WH Template:WS

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