Pneumonia physical examination: Difference between revisions
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==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. | 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. | ||
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> | 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> | ||
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. | 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, a high degree of suspicion should be kept in elderly as the presentation could be subtle in them. | ||
==Physical examination== | ==Physical examination== | ||
===Vital signs=== | ===Vital signs=== | ||
Revision as of 18:41, 18 September 2012
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753Associate Editor(s)-In-Chief: Priyamvada Singh, M.D. [2]
Overview
Persons with symptoms of pneumonia need medical evaluation. Physical examination by a health care provider 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. 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).[1] 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, a high degree of suspicion should be kept in elderly as the presentation could be subtle in them.
Physical examination
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).[3]
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[2]:
- 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[3] comparing four prediction rules to physician judgment found that two rules, the one above[2]and also[4], were more accurate than physician judgment because of the increased specificity of the prediction rules.
References
- ↑ 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
- ↑ 2.0 2.1 Heckerling PS, Tape TG, Wigton RS; et al. (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647.
- ↑ Emerman CL, Dawson N, Speroff T; et al. (1991). "Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients". Annals of emergency medicine. 20 (11): 1215–9. PMID 1952308.
- ↑ Gennis P, Gallagher J, Falvo C, Baker S, Than W (1989). "Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department". The Journal of emergency medicine. 7 (3): 263–8. PMID 2745948.