From the Division of Community Pediatrics, The University of North Carolina at Chapel Hill (Dr Margolis), and Bassett Health Care, Cooperstown, NY (Dr Gadomski).
The Rational Clinical Examination section editors: David L. Simel,
MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical
Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.
Acute lower respiratory tract illness is common among children seen
in primary care. We reviewed the accuracy and precision of the clinical examination
in detecting pneumonia in children. Although most cases are viral, it is important
to identify bacterial pneumonia to provide appropriate therapy. Studies were
identified by searching MEDLINE from 1982 to 1995, reviewing reference lists,
reviewing a published compendium of studies of the clinical examination, and
consulting experts. Observer agreement is good for most signs on the clinical
examination. Each study was reviewed by 2 observers and graded for methodologic
quality. There is better agreement about signs that can be observed (eg, use
of accessory muscles, color, attentiveness; κ, 0.48-0.66) than signs
that require auscultation of the chest (eg, adventitious sounds; κ,
0.3). Measurements of the respiratory rate are enhanced by counting for 60
seconds. The best individual finding for ruling out pneumonia is the absence
of tachypnea. Chest indrawing, and other signs of increased work of breathing,
increases the likelihood of pneumonia. If all clinical signs (respiratory
rate, auscultation, and work of breathing) are negative, the chest x-ray findings
are unlikely to be positive. Studies are needed to assess the value of clinical
findings when they are used together.
Margolis P, Gadomski A. Does This Infant Have Pneumonia?. JAMA. 1998;279(4):308-313. doi:10.1001/jama.279.4.308