Review

Diagnostic value of the physical examination in patients with dyspnea

Richard A. Shellenberger, DO, Bathmapriya Balakrishnan, MD, Sindhu Avula, MD, Ariadne Ebel, DO and Sufiya Shaik, MD
Cleveland Clinic Journal of Medicine December 2017, 84 (12) 943-950; DOI: https://doi.org/10.3949/ccjm.84a.16127

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Checking for asymmetry in chest expansion, a specific but not sensitive sign of pneumonia and of pleural effusion. Left, expiration; right, inspiration.

    From Diaz-Guzman E, Budev MM. Accuracy of the physical examination in evaluating pleural effusion. Cleve Clin J Med 2008; 75:297–303.

  • Figure 2
    Figure 2

    Algorithmic approach to physical examination for suspected pneumonia vs pleural effusion.

Tables

  • TABLE 1

    Likelihood ratios and bedside estimates of probability

    Likelihood ratioApproximate change in probability
     0.1−45%
     0.2−30%
     0.3−25%
     0.4−20%
     0.5−15%
     1No change
     2+15%
     3+20%
     4+25%
     5+30%
     6+35%
     8+40%
     10+45%

    • Values between 0 and 1 (negative likelihood ratios) decrease the probability of disease; values greater than 1 (positive likelihood ratios) increase the probability of disease.

    • From McGee S. Simplifying likelihood ratios. J Gen Intern Med 2002; 17:647–650.

  • TABLE 2

    Auscultatory breath sounds

    Auscultatory breath soundCharacterClinical correlation
    Normal (vesicular) breath soundSoft
    Nonmusical
    Inspiration/expiration    		Diminished in hypoventilation, airway narrowing, pleural effusion, pneumothorax, and lung destruction.
    Tracheal (tubular) breath sound heard at the peripheryHollow
    Nonmusical
    Inspiration/expiration    		Consolidation or compressed lung (pneumonia, tumor, atelectasis)
    WheezeMusical and high-pitched
    Inspiration/expiration    		Upper airway obstruction
    Widespread airflow limitation
    RhonchiMusical and low-pitched
    Inspiration/expiration    		Airway narrowing by mucous thickening, edema, or bronchospasm
    Fine cracklesShort
    Explosive
    Nonmusical
    Mid to late inspiration    		Heard in interstitial lung disease, congestive heart failure, fibrosis, pneumoconiosis, pneumonia
    Coarse cracklesShort
    Explosive
    Nonmusical
    Early inspiration
    Throughout expiration    		Indicates intermittent airway opening in chronic obstructive pulmonary disease
    StridorMusical
    High-pitched
    Audible to unaided ear    		Upper airway obstruction
    Extrathoracic in inspiration
    Intrathoracic in expiration
    Fixed lesions biphasic
    SquawkShort musical wheeze
    Accompanying crackles    		Pneumonia (acutely)
    Interstitial lung disease
    Pneumonitis

    • Based on information in reference 4.

  • TABLE 3

    Signs of pneumonia

    SignsPositive likelihood ratioNegative likelihood ratio
    Asymmetric chest expansion644.11.0
    Egophony6,10,11  6.80.9
    Dullness to percussion6,10–12  5.70.9
    Bronchophony10  3.30.9
    Crackles6,10–12  3.20.7
    Diminished breath sounds10–12  2.50.7
  • TABLE 4

    Signs of pleural effusion

    SignPositive likelihood ratioNegative likelihood ratio
    Dullness to percussion138.70.31
    Asymmetric chest expansion148.10.29
    Diminished tactile fremitus145.70.21
    Diminished vocal resonance146.50.27
  • TABLE 5

    Signs of congestive heart failure

    SignsPositive likelihood ratioNegative likelihood ratio
    Jugular venous pressure ≥ 8 cm23,26  9.70.3
    Jugular venous pressure ≥ 12 cm23,2410.40.1
    Abdominojugular reflux28–30  8.00.3
    Displaced apical impulse31–3410.30.7
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