Pneumonia physical examination

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Philip Marcus, M.D., M.P.H.[2]

Overview

Persons with symptoms of pneumonia need medical evaluation. Physical examination by a health care provider may reveal fever or sometimeslow 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. People who are struggling to breathe, who are confused, or who have cyanosis (blue-tinged skin) require immediate attention.

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) to further localize consolidation. The examiner may also palpate for increased vibration of the chest when speaking (tactile fremitus). The physical examination though not very sensitive and specific in diagnosis of community acquired pneumonia helps in determining the severity of illness and ruling out other differentials. Vital signs are useful in determining the severity of illness and have predictive values. However, high degree of suspicion should be kept in elderly as the presentation could be subtle in them.

Vital signs

• Fever
• Tachycardia > 125 beats/min
• Tachypnea
• Hypotension < 90 mm Hg
• Decreased oxygen saturation

Palpation

• Increased tactile fremitus

Percussion

• Dullness on percussion

Auscultation

• Decreased breath sounds
• Bronchial breath sounds
• Rhonchi
• Crackles, Rales
• Increased volume of whispered (vocal fremitus).

Combining findings

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:

• 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:

• 5 findings - 84% to 91% probability
• 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 comparing four prediction rules to physician judgment found that two rules, the one aboveand also, were more accurate than physician judgment because of the increased specificity of the prediction rules.