Evaluación del juicio clínico y las guías de decisión en la pesquisa de pacientes adultos con neumonía adquirida en la comunidad en la unidad de emergencia

Abstract

Acute respiratory infections in adults constitute a common health problem in the ambulatory care setting. Objective: To compare physician judgment with decision rules developed by Diehr, Singal, Heckerling and Gennis, for diagnosing community-acquired pneumonia in the emergency department. Design: Prospective observational investigation with preradiograph survey of physician's clinical diagnosis of pneumonia in immunocompetent adult patients presenting with fever or respiratory complaints. All patients had uniform clinical data collected, including chest radiographs and sufficient information to retrospectively apply the four clinical prediction rules. Setting: the emergency department of a major urban teaching hospital from Santiago, Chile. Participants: Adult patients presenting with recent history of acute cough, sputum production, chest pain, dyspnea or fever. Results: Of 325 patients, 112 (34%) had pneumonia. The sensitivity (0.79), specificity (0.66), positive predictive value (0.55) and negative predictive value (0.85) of physician judgment were very similar to the Diehr rule. The sensitivity of the Heckerling (0.84) and Gennis (0.92) rules exceeded that of physician judgment but specificities were lower (0.41 and 0.31, respectively). The accuracy of physician judgment (0.70) and the Diehr rule (0.69) exceeded that of the other decision rules. Conclusions: Physician's judgment prior to observation of radiography has moderate sensitivity and specificity to diagnose pneumonia in the emergency setting. The accuracy and specificity of physician judgment exceeded that of all four decision rules to diagnose pneumonia in adult patients