Diagnosing pneumonia by physical examination - Relevant or relic?

Background: The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown. Objectives: To determine the accuracy of various physical examination maneu vers in diagnosing pneumonia and to compare the interobserver reliability o f the maneuvers among 3 examiners. Methods: Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lo wer respiratory tract infection (cough and change in sputum) were prospecti vely examined. A comprehensive lung physical examination was performed sequ entially by 3 physicians who were blind to clinical history, laboratory fin dings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist. Results: Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were co mmon in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement amo ng examiners (kappa approximate to 0.5) occurred for rales in the lateral d ecubitus position and for wheezes. The 3 examiners' clinical diagnosis of p neumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%. Conclusions: The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination mane uvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not suff iciently accurate on its own to confirm or exclude the diagnosis of pneumon ia.