SGEM#298: What’s the Signs and the Symptoms of Pneumonia?

Date: July 13th, 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com. He has a great new blog post about increasing diversity in medicine using something called the BSAP approach and an interesting Broome Doc podcast with Dr. Casey Parker called EBM 2.0.   Reference: Ebell et al. Accuracy of Signs and Symptoms for the Diagnosis of Community‐acquired Pneumonia: A Meta‐analysis. AEM July 2020 Case: A 67-year-old woman with no previous health problems presents with fever, cough, and myalgias. You are working with a medical student on their very first rotation, and you want to spend some time teaching them about the history and physical exam. However, being an evidence-based medicine enthusiast, you wonder what aspects of the patient’s presentation are going to be truly helpful in making a diagnosis.  Background: Depending on the time of year, fever and cough can be one of the most common presentations seen in the emergency department. It is important not to miss pneumonia in the sea of viral illnesses. We have covered various aspects of this issue a number of times on the SGEM: SGEM#287: Difficult to Breathe – It Could Be Pneumonia SGEM#286: Behind the Mask – Does it need to be an N95 mask? SGEM#263: Please Stop, Prescribing – Antibiotics for Viral Acute Respiratory Infections SGEM#216: Pump It Up – Corticosteroids for Patients with Pneumonia Admitted to Hospital SGEM#120: One Thing or Two for Community Acquired Pneumonia? Antibiotic overuse is a significant problem, and ordering chest x-rays (CXR) on everyone is inefficient, expensive, and adds potentially unnecessary risk from radiation. Thus, it is important to know how accurate the history and physical exam is for identifying patients with pneumonia. A prior meta-analysis demonstrated that the combination of normal vital signs and normal lung exam effectively rules out pneumonia (Marchellow eat al JABFM 2019), and that a physician’s overall clinical impression is moderately accurate (Dale et al BrJGP 2019). However, there has not been a meta-analysis looking at the evidence for individual signs and symptoms for pneumonia in the last decade. Clinical Question: What is the accuracy of individual signs and symptoms for diagnosing community acquired pneumonia? Reference: Ebell et al. Accuracy of Signs and Symptoms for the Diagnosis of Community‐acquired Pneumonia: A Meta‐analysis. AEM July 2020 Population: Adolescents and adults presenting with symptoms of respiratory infection or clinically suspected pneumonia in the outpatient setting Intervention: Any clinical sign or symptom (including vital signs) for pneumonia Comparison: Outcome: Radiologically confirmed pneumonia (using CXR as the gold standard) Dr. Mark Ebell This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Mark Ebell is a Family Physician and Professor at the University of Georgia in Athens. He is a co-founder of POEMs, editor-in-chief of Essential Evidence, deputy editor of American Family Physician, and co-host of the podcast Primary Care Update and POEM of the Week.   Authors’ Conclusions: “While most individual signs and symptoms were unhelpful, selected individual signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics. Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Unsure. The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivit...