Clinical PracticeRELIABILITY OF ELICITING PHYSICAL SIGNS IN EXAMINATION OF THE CHEST
Abstract
Agreement between 24 physicans on the presence or absence of respiratory signs was investigated. The physicians were divided into six sets of 4; each set examined 4 patients with well-defined chest signs. There was generally poor agreement about particular signs. Overall, the 4 physicians in a set were in complete agreement only 55% of the time. Some signs such as wheezing seemed to be more reliably elicited than others such as whispering pectoriloquy. Comparison of diagnoses based on the clinical findings with the correct diagnoses supported by investigations showed that 28% of physicians' diagnoses were incorrect. The more often the examiners differed from the majority on the presence or absence of a sign, the more likely they were to make an incorrect diagnosis. A ranked order of the reliability with which chest signs are elicited would improve the teaching of chest medicine.
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Cited by (186)
Respiratory symptoms and signs
2023, Medicine (United Kingdom)2016 marked the 200th anniversary of Laennec's invention of the stethoscope, with his subsequent publication on auscultatory sounds for clinical diagnosis (1819). Combined with percussion, the ‘inventum novum’ developed by Auenbrugger and described in 1761 formatively improved the diagnosis of thoracic diseases through clinical signs. Today, history and examination remain pivotal to accurate diagnosis. The key symptoms of respiratory disease are breathlessness, chest pain, wheeze, cough and associated sputum production, although non-respiratory conditions can also produce these symptoms. Other symptoms directly representative of respiratory disease, or associated with the consequences, include haemoptysis, fever, fatigue, air hunger and decreased exertional tolerance. A systematic approach to history-taking should include all primary symptoms, with their time-course, characteristics, severity and trajectory. A review of non-respiratory associations and pharmaceutical and historical aspects of respiratory symptoms should precede a thorough review of clinical signs. Further questioning or examination for clarification then leads to an assimilation of the information, synthesis with clinico-pathophysiological knowledge of respiratory diseases, and formulation of a differential diagnosis. From meta-analyses, auscultation of the lungs has a low to intermediate diagnostic sensitivity for various pathologies, increasing as the prevalence does. However, it has very good specificity. Lung imaging (i.e. chest radiography, lung ultrasound, computed tomography) and lung function testing underpin the post-test diagnostic likelihood from the elicited clinical features. On examination, based on the model of inspection, palpation, percussion and auscultation, there are a few classical patterns of the most important focal abnormalities. There can, however, be an absence of clinical signs. This article reviews the key features of respiratory symptoms and signs and tips on how best to elicit them, and discusses patterns of clinical features suggesting certain diagnoses.
Continuous Monitoring Versus Intermittent Auscultation of Wheezes in Patients Presenting With Acute Respiratory Distress
2022, Journal of Emergency MedicineAuscultation for an extended period of time using a wearable stethoscope enables objective computerized analysis and longitudinal assessment of lung sounds. However, this auscultation method differs from bedside auscultation in that clinicians are not present to optimize the quality of auscultation. No prior studies have compared these two auscultation methods.
The aim of this study was to compare intermittent auscultation using a conventional stethoscope with continuous auscultation using a wearable stethoscope for wheeze detection in patients who present with acute respiratory distress.
Patients presenting to the emergency department with acute respiratory distress were enrolled. The Strados Remote Electronic Stethoscope Platform (RESP™) was used for continuous auscultation, and intermittent auscultation was performed using a U.S. Food and Drug Administration–cleared electronic stethoscope. A recording was made with an electronic stethoscope. Subsequently, continuous recording was made using RESP™, which continued until the patient was admitted or discharged from the emergency department. The number of captured wheezes in each recording was counted and validated by two board-certified physicians.
From May 2018 to May 2019, 43 patients were enrolled in the study. Three patients were excluded from analysis due to incomplete audio recording data. The mean length of recording was 62.3 min for continuous auscultation and 0.7 min for intermittent auscultation; 77.5% (31 of 40) of intermittent recordings contained wheezes, in contrast to 85% (34 of 40) of continuous recordings.
Extending the duration of auscultation using a wearable stethoscope in a noisy clinical environment showed comparable performance to standard of care intermittent auscultation in identifying patients who have wheezes.
Respiratory symptoms and signs
2020, Medicine (United Kingdom)Laennec's invention of the stethoscope in 1816, and description of auscultatory sounds for clinical diagnosis remain important today. History and examination are pivotal to accurate diagnosis, helped by confirmatory investigations. The key symptoms of respiratory disease are breathlessness, chest pain, cough with associated sputum production, and wheeze. Non-respiratory conditions also produce such symptoms. A systematic approach to history-taking should include all primary symptoms, their time course, characteristics, severity and trajectory. A review of non-respiratory and pharmaceutical associations, and historical aspects of respiratory symptoms, should precede a thorough review of clinical signs. Hence, a checklist of ‘pulmonary risk factors’ completes a thorough evaluation. After clinical evaluation, assimilation of information, and synthesis with clinicopathophysiological knowledge of respiratory diseases, allows formulation of a differential diagnosis. Classical patterns of the most important focal abnormalities, if present, include consolidation, collapse, pneumothorax, pleural effusion, or interstitial lung patterns. Clinical signs can change during the time course of the illness. The pre-test likelihood ratio of a diagnosis may then inform the post-test likelihood following investigations. This article reviews the key features of respiratory symptoms and signs, outlines tips on how best to elicit these, and discusses patterns of clinical features in the context of differential diagnosis.
Why Physiology Is Critical to the Practice of Medicine: A 40-year Personal Perspective
2019, Clinics in Chest MedicinePoint of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED
2017, American Journal of Emergency MedicinePrimary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED.
Eligible patients 2–17 years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥ 1 of the following findings: ≥ 3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart.
A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p = 0.03), prolonged ED length of stay (30% vs. 9%, p = 0.04) and admission rate (30% vs 0%, p = 0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84–1.00).
This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice.
Utility of physical examination and comparison to echocardiography for cardiac diagnosis
2017, Indian Heart JournalTo find out the accuracy of cardiac auscultation using non-digital stethoscope in physical diagnosis of cardiac diseases.
We enrolled 104 consecutive patients with abnormal cardiac auscultatory findings attending cardiology clinic and not previously evaluated by echocardiography. One time detailed cardiac physical examination followed by echocardiography within 1 month was undertaken. Agreement between two methods was calculated using mean pair percentage agreement, kappa statistics (κ) and calculation of 95% confidence interval (CI) for kappa statistics.
Using kappa statistics, there was almost perfect agreement between cardiac auscultation and echocardiography for the detection of mitral stenosis (κ = 0.865; CI 0.76–0.97) and ventricular septal defect (κ = 0.872; CI = 0.73–1.01). Substantial agreement was noted for aortic stenosis (κ = 0.752; CI = 0.56–0.94), pulmonary stenosis (κ = 0.647; CI = 0.33–0.97) and atrial septal defect (κ = 0.646; CI = 0.32–0.97), while moderate agreement was found for mitral regurgitation (κ = 0.470; CI = 0.30–0.64), aortic regurgitation (κ = 0.456; CI = 0.25–0.66) and tricuspid regurgitation (κ = 0.575; CI = 0.38–0.77).
For combined mitral stenosis and mitral regurgitation lesions, almost perfect agreement was found for mitral stenosis (κ = 0.842; CI = 0.691–0.993) while fair agreement noted for mitral regurgitation (κ = 0.255; CI = −0.008 to 0.518).
Careful clinical auscultation using a stethoscope remains a valuable tool for cardiac diagnosis. Decision on initial diagnosis and management of valvular and congenital heart diseases should be based on clinical examination and integrating such information with echocardiography as required.