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Does This Patient Have Community-Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination Joshua P

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Does This Patient Have Community-Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination Joshua P Does This Patient Have Community-Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination Joshua P. Metlay, MD, PhD; Wishwa N. Kapoor, MD, MPH; Michael J. Fine, MD, MSc Community-acquired pneumonia is an important cause of acute respiratory chitis, upper respiratory tract infection, symptoms (eg, cough) in the ambulatory care setting. Distinguishing pneumo- asthma, and sinusitis.1 Though pneumo¬ nia from other causes of respiratory illnesses, such as acute bronchitis and up- nia may represent a small proportion of all the accu¬ per respiratory tract infections, has important therapeutic and prognostic impli- acute respiratory illnesses, cations. The reference standard for is chest rate identification ofthis subgroup is im¬ diagnosing pneumonia radiography, because of the distinct but it is on portant very likely that many physicians rely the patient's history and their physi- therapeutic and prognostic features of cal examination to diagnose or exclude this disease. A review of published this illness. studies of are no in- patients suspected of having pneumonia reveals that there In the preantibiotic era, mortality dividual clinical findings, or combinations of findings, that can rule in the diag- from pneumococcal pneumonia was con¬ nosis of pneumonia for a patient suspected of having this illness. However, sistently higher than 20% for all cases, some studies have shown that the absence of any vital sign abnormalities or any rising to more than 60% for bacteremic abnormalities on chest auscultation substantially reduces the likelihood of cases.2 Since the introduction of antibi¬ pneumonia to a point where further diagnostic evaluation may be unnecessary. otics no one has reported results from studies antibiotic This article reviews the literature on the appropriate use of the history and large-scale comparing physical examination in diagnosing community-acquired pneumonia. therapy to nonantibiotic therapy for pa¬ JAMA. tients with pneumonia. As a result, such 1997;278:1440-1445 therapy is universally recommended and has become a standard of care for all CLINICAL SCENARIO—DOES last 2 days, she has noted increasing spu¬ patients with pneumonia. No such stan¬ THIS PATIENT HAVE PNEUMONIA? tum production with her cough and dard exists for alternative respiratory worsening fatigue. She has felt warm but infections such as bronchitis3 or the com¬ A woman comes to has documented fever or 53-year-old your not any night mon cold.4 Moreover, inappropriate use office with a cough ofmore than 1 week's sweats. On physical examination, her of antibiotics for these alternative res¬ duration. She was in excellent health un¬ oral is 38.3°C her temperature (101°F), piratory infections may be an important til 7 days ago when she developed a non¬ heart rate is 110 beats per minute, and determinant of the rise in antibiotic re¬ mild sore and auscultation of her chest productive cough, throat, reveals inspi- sistance among common respiratory myalgia. She recalls no past history of ratory crackles on the left side. pathogens.5·6 asthma or chronic obstructive pulmo¬ In terms of prognosis, patients with and she does not smoke. nary disease, WHY IS THIS AN IMPORTANT continue to have an overall home from work forthe pneumonia Despite staying QUESTION TO ANSWER WITH high mortality from this illness, ranging A CLINICAL EXAMINATION? from as low 5% in studies of hospitalized and ambulatory patients to as high as Physicians commonly encounter pa¬ 37% in studies of ad¬ From the General Internal Medicine Unit, Department tients with simi¬ patients requiring of General respiratory complaints mission intensive care units.7 This Medicine, Massachusetts Hospital and Har- lar those in the clinical scenario. In to per¬ vard Medical School, Boston (Dr Metlay), and the Divi- to sistently high mortality underscores the sion of General Internal Medicine, Department of Medi- 1994, there were over 10 million visits to Center cine, for Research on Health Care, University of primary care physicians by adults with a Pittsburgh, Pittsburgh, Pa (Drs Kapoor and Fine). Dr chief of Metlay is now with the Division of General Internal complaint cough, representing Medicine, Department of Medicine, University of Penn- over 4% of all visits to physicians that The Rational Clinical Examination section editors: sylvania Medical Center, Philadelphia. year. Pneumonia 5% David L. Simel, MD, MHS, Durham Veterans Affairs Reprints: Michael J. Fine, MD, MSc, Montefiore Uni- represented only Medical Center and Duke Medical Cen- of all causes for these visits and was University versity Hospital, 8 East Room 824, 200 Lothrop St, ter, Durham, NC; Drummond Rennie, MD, Deputy Pittsburgh, PA 15213 (e-mail: [email protected]). the fifth leading diagnosis, after bron- Editor (West), JAMA. Downloaded from jama.ama-assn.org at HINARI on August 27, 2011 need for physicians to choose carefully HOW TO ELICIT THESE SYMPTOMS can yield abnormal auscultatory findings between home or hospital therapy for all AND SIGNS in as many as 50% of normal subjects.16 patients with pneumonia.8 For these rea¬ Finally, both percussion and ausculta¬ sons, physicians need to know how opti¬ Patients with community-acquired tion of the chest should proceed in a sys¬ mally to use their clinical examination to pneumonia present with a large number tematic fashion, with an examination of identify patients at suitable risk for of possible symptoms. In a study of more symmetric areas on both the anterior pneumonia to require further, definitive than 1800 patients with community- and posterior chest wall. diagnostic testing. acquired pneumonia, these presenting Chest is the reference radiography symptoms ranged from typical respira¬ METHODS standard for diagnosing community- tory complaints, including productive acquired pneumonia and provides addi¬ cough, dyspnea, and pleuritic chest pain, Literature Search tional information on the prognosis of pa¬ to predominately systemic complaints We searched English-language medi¬ tients with this illness,9 as well as the of fatigue, anorexia, and myalgias. More¬ cal literature to determine the precision presence of coexisting conditions such as over, the pattern ofpresenting symptoms of the clinical examination in patients bronchial obstruction or pleural effu¬ varied considerably among patients, par¬ with community-acquired pneumonia sions.10 Moreover, chest radiography is ticularly among elderly patients with and the accuracy of the examination in highly reliable,11 safe, generally avail¬ pneumonia who less frequently reported diagnosing patients suspected of having able, and relatively inexpensive, so that a wide range of symptoms.14 As a result, this illness. We searched MEDLINE it is a standard part of the evaluation of careful history taking in a patient sus¬ from 1966 through October 1995 based any patient with suspected pneumonia. pected of having community-acquired on an initial search strategy similar to It is possible that some physicians con¬ pneumonia should consider a broad that used by other authors in this series. tinue to diagnose and manage patients range of possible symptoms, including (The search strategy is available on re¬ with pneumonia without the aid of chest both respiratory and nonrespiratory quest.) The initial retrieval oftitles (n=7 radiography, while other physicians rou¬ symptoms. for precision, n=140 for diagnostic accu¬ tinely obtain chest radiographs for all pa¬ In contrast, the examination of the racy) was reviewed by 2 of us (J.P.M., tients suspected ofhaving pneumonia. We chest in patients with suspected pneu¬ M.J.F.). Articles that focused on hospi¬ do not know the proportion of physi¬ monia is traditionally carried out in a tal-acquired pneumonia, pediatrie pneu¬ cians who choose these alternative strat¬ structured manner, proceeding through monia, or acquired immunodeficiency egies. Therefore, the aims of this article the 4 steps of inspection, palpation, per¬ syndrome-related pneumonia were ex¬ are both to assess the validity of the cussion, and auscultation. The chest is cluded. The remaining articles were re¬ former approach (diagnosing pneumo¬ inspected for signs of asymmetric chest trieved, as well as any potentially eli¬ nia without chest radiography, using his¬ expansion, defined as a visible difference gible articles identified through review tory and physical examination alone) and in excursion between the 2 sides of the ofthe article reference lists (n=7 for pre¬ to identify elements of the clinical ex¬ chest. The chest wall is palpated while cision, =52 for diagnostic accuracy). amination that might improve the effi¬ the patient speaks in order to assess the A set of explicit inclusion and exclu¬ ciency of the latter approach (ordering transmission of sound, or tactile fremi¬ sion criteria were applied to each re¬ chest radiographs for all patients with tus. Percussion over symmetric areas of trieved article. Inclusion criteria re¬ suspected pneumonia). the anterior and posterior chest wall de¬ quired that the study be an original tects diminution in the resonance of the of the or of the PATHOPHYSIOLOGY OF study accuracy precision percussion note, or dullness to percus¬ history and/or physical examination in COMMUNITY-ACQUIRED sion. auscultation ofthe as¬ the of commu¬ PNEUMONIA Finally, lung determining diagnosis sesses the intensity of normal breath nity-acquired pneumonia. Exclusion cri¬ In patients with community-acquired sounds, the transmission of spoken teria consisted of studies of (1) patients pneumonia,
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