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Diagnostic Value of the Physical Examination in Patients with Dyspnea

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Diagnostic Value of the Physical Examination in Patients with Dyspnea REVIEW LEARNING OBJECTIVE: Readers will assess the diagnostic accuracy of physical signs in patients with dyspnea RICHARD A. SHELLENBERGER, DO BATHMAPRIYA BALAKRISHNAN, MD SINDHU AVULA, MD Associate Program Director, Internal Medicine Department of Pulmonary and Critical Care Medicine, Department of Internal Medicine, St. Joseph Residency Program, St. Joseph Mercy Ann Arbor Henry Ford Hospital System, Mercy Ann Arbor Hospital, Ann Arbor, MI Hospital, Ann Arbor, MI Detroit, MI ARIADNE EBEL, DO SUFIYA SHAIK, MD Department of Internal Medicine, Department of Internal Medicine, St. Joseph Mercy Ann Arbor Hospital, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI Ann Arbor, MI Diagnostic value of the physical examination in patients with dyspnea ABSTRACT aennec’s stethoscope has survived more L than 200 years, much longer than some of We reviewed the evidence for the diagnostic accuracy his contemporaries predicted. But will it sur- of the physical examination in diagnosing pneumonia, vive the challenge of bedside ultrasonography pleural effusion, chronic obstructive pulmonary disease, and other technologic advances? and congestive heart failure in patients with dyspnea and The physical examination, with its roots found that the physical examination has reliable diagnos- extending at least as far back as Hippocrates, tic accuracy for these common conditions. may be at a crossroads as the mainstay of diag- nosis. Physical signs can be subjective and lack KEY POINTS sensitivity and specificity. Modern imaging and laboratory studies may already be more trusted. Asymmetrical chest expansion, diminished breath sounds, If the physical examination is to survive, it egophony, bronchophony, and tactile fremitus can be must be accurate, reproducible, and efficient. used in combination to accurately diagnose pneumonia Needed is a simple, evidence-based approach and pleural effusion. to the physical examination that enhances its diagnostic accuracy while maintaining bedside No physical sign performs with a high degree of accuracy efficiency. for diagnosing early-stage chronic obstructive pulmonary Here, we analyze the accuracy of the physical disease. signs that are most effective in the clinical diag- nosis of 4 common cardiopulmonary conditions that often present with dyspnea: pneumonia, Inspiratory crackles, diminished breath sounds, and pleural effusion, chronic obstructive pulmonary cardiac dullness have high diagnostic value for advanced disease (COPD), and congestive heart failure. obstructive airway disease. ■ LIKELIHOOD RATIOS Congestive heart failure can be diagnosed at the bedside To grasp the significance of physical findings, by examining the jugular veins and palpating the point of it is necessary to understand the concept of maximal intensity. likelihood ratios, which are widely accepted measures of the accuracy of a test or clinical finding.1,2 The positive likelihood ratio is the probability of a disease being present when the test is positive or the clinical finding is pres- ent, while the negative likelihood ratio is the probability that the disease is present when the test is negative or the clinical finding is absent. They are calculated as follows1: Positive likelihood ratio = sensitivity / (1 – specificity) doi:10.3949/ccjm.84a.16127 Negative likelihood ratio = (1 – sensitivity) / specificity CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 12 DECEMBER 2017 943 Downloaded from www.ccjm.org on September 25, 2021. For personal use only. All other uses require permission. PHYSICAL EXAMINATION IN DYSPNEA ■ TABLE 1 PNEUMONIA Pneumonia is a common disease, with more Likelihood ratios and bedside estimates than 2 million cases annually in the United of probability States. It is most often diagnosed by stan- Likelihood ratio Approximate change in probability dard chest radiography, although comput- 0.1 −45% ed tomography can identify it earlier and with higher sensitivity and specificity.5 The 0.2 −30% amount of published data on physical exami- 0.3 −25% nation findings in pneumonia is surprisingly 0.4 −20% small. 0.5 −15% Asymmetry in chest expansion: 1 No change Specific, reproducible, but not sensitive 2 +15% The physical finding with the highest positive likelihood ratio for diagnosing pneumonia is 3 +20% asymmetry in chest expansion.6,7 4 +25% Chest expansion is typically examined 5 +30% posteriorly, with the thumbs placed together 6 +35% along the midline of the spine and the 4 fin- gers held together with the index finger below 8 +40% the 10th rib (Figure 1). As the patient takes a 10 +45% deep breath, the physician feels for asymmet- Values between 0 and 1 (negative likelihood ratios) decrease the probability of disease; ric movement of his or her thumbs. values greater than 1 (positive likelihood ratios) increase the probability of disease. In a 1984 study of 1,819 patients present- From McGee S. Simplifying likelihood ratios. J Gen Intern Med 2002; 17:647–650. ing to an emergency department with acute cough, Diehr et al6 evaluated several physical signs of pneumonia. Asymmetric chest expan- The amount Or more simply, they are calculated as the probability of the finding in patients with sion had a specificity and positive predictive of data on the disease, divided by the probability of the value of 100%, but its sensitivity was only same finding in patients without the disease.2 4.3%. Thus, it is not a good screening test, physical but it is a good diagnostic or confirmatory test. Thus, the higher the positive likelihood ratio, 8 examination the greater the probability that a patient who From these numbers, Metlay et al calculated in pneumonia has a positive finding actually has the disease. that the positive likelihood ratio was infinity Conversely, the lower the negative likelihood and the negative likelihood ratio was 0.96. is surprisingly 7 ratio, the lower the probability that a person McGee, on the other hand, calculated the small without the finding actually has the disease. A positive likelihood ratio of asymmetric chest likelihood ratio of 1 means the test or finding expansion at 44.1. McGee also found chest is no better than chance. expansion to be a highly reproducible find- Table 1 shows how the likelihood ratio of ing, with an interobserver agreement kappa 7 a test changes the posttest probability that a score of 0.85. (A kappa score of 1.0 would condition is present or absent, according to an indicate perfect interobserver agreement.) In- analysis by McGee.2 terestingly, chest radiographs interpreted for pulmonary infiltrates have an interobserver kappa score of only 0.38.7 Further studies of ■ STANDARDIZED TERMINOLOGY 3 this physical sign could shed more light upon The International Lung Sounds Association this area of uncertainty. has proposed standard terminology for de- scribing findings on chest auscultation, as the Other signs of pneumonia terminology used until now was considered None of the other physical signs studied for imprecise. For simplicity, respiratory sounds the diagnosis of pneumonia has as high a posi- can be described as either normal or abnormal tive likelihood ratio as asymmetric chest ex- (adventitious) (Table 2).4 pansion.6–12 944 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 12 DECEMBER 2017 Downloaded from www.ccjm.org on September 25, 2021. For personal use only. All other uses require permission. SHELLENBERGER AND COLLEAGUES TABLE 2 Auscultatory breath sounds Auscultatory breath sound Character Clinical correlation Normal (vesicular) breath sound Soft Diminished in hypoventilation, airway Nonmusical narrowing, pleural effusion, pneumothorax, Inspiration/expiration and lung destruction. Tracheal (tubular) breath sound Hollow Consolidation or compressed lung heard at the periphery Nonmusical (pneumonia, tumor, atelectasis) Inspiration/expiration Wheeze Musical and high-pitched Upper airway obstruction Inspiration/expiration Widespread airflow limitation Rhonchi Musical and low-pitched Airway narrowing by mucous thickening, Inspiration/expiration edema, or bronchospasm Fine crackles Short Heard in interstitial lung disease, Explosive congestive heart failure, fibrosis, pneumoco- Nonmusical niosis, pneumonia Mid to late inspiration Coarse crackles Short Indicates intermittent airway opening Explosive in chronic obstructive pulmonary disease Nonmusical Early inspiration Throughout expiration Stridor Musical Upper airway obstruction High-pitched Extrathoracic in inspiration Audible to unaided ear Intrathoracic in expiration Fixed lesions biphasic Squawk Short musical wheeze Pneumonia (acutely) Accompanying crackles Interstitial lung disease Pneumonitis Based on information in reference 4. Egophony is a high-pitched or nasal qual- (positive likelihood ratio 3.3 based on 1,118 ity of the patient’s voice heard on ausculta- patients)10 tion over lung tissue that is consolidated or Crackles have long been taught as a com- fibrosed, due to enhanced transmission of mon physical finding in pneumonia. Boha- high-frequency sound across fluid. It is often dana et al pointed out that “crackle” can be described as the “E-to-A change.” Although defined acoustically but does not suggest any listening for egophony is widely done and means or site of generation.4 Pooled data from easy to do, we calculate that this sign has a 4 studies in 3,647 patients6,10–12 result in a posi- positive likelihood ratio of only 6.8 based on tive likelihood ratio for crackles in the diag- pooled data from 3 trials with a total of 3,245 nosis of pneumonia of only 3.2. 6,10,11 patients. Diminished
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