Physical Examination

RPR Exchange: Results of a study of the reliability and predictive value of physical examination findings for diagnosing community-acquired pneumonia in children. James W. Mold, MD, MPH

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Abstract
Importance Community-acquired pneumonia (CAP) accounts for nearly 2 million pediatric outpatient and 375 000 emergency department (ED) visits annually in the US. Guidelines recommend relying on physical examination findings, not imaging, to diagnose CAP in youths who can be treated as outpatients.

Objective To determine the interrater reliability (IRR) of physical examination findings in youths diagnosed with CAP in EDs.

Design, Setting, and Participants This was a planned analysis from an ongoing prospective cohort study (pediatric CAP severity [PedCAPS]). Youths aged 3 months to 17 years with CAP were recruited at 7 academic pediatric EDs within the US from August 1, 2023, until May 24, 2025; participants had signs of lower respiratory tract infections, fever within 48 hours, and pneumonia on chest radiography, if performed. Youths with chronic pulmonary diseases (except asthma), sickle cell disease, immunodeficiency, cardiac disease, neurological disorders affecting respiration, and aspiration pneumonia were excluded, as were those hospitalized within the preceding 30 days or transferred from other EDs or hospitals.

Main Outcomes and Measures Two examiners evaluated the same patient within 60 minutes of each other and independently recorded their findings. IRR of physical examination findings was reported by raw agreement and Fleiss κ. A lower bound of the 95% CI of 0.4 for κ was considered acceptable reliability.

Results Among 252 youths with paired physical examinations (median [IQR] age, 5.7 [3.4-8.8] years; 127 female [50.4%]), the most frequent comorbidity was asthma (56 youths [22.2%]). In the overall study population, no physical examination finding met predefined significance for IRR. Wheezing (κ = 0.50; 95% CI, 0.39-0.62) and retractions (κ = 0.49; 95% CI, 0.37-0.60) had the highest IRR. In subanalyses of 124 youths discharged home and 128 youths who were hospitalized, IRRs of physical examinations were similar between the 2 groups.

Conclusions and Relevance In this study, individual auscultation findings, such as decreased breath sounds, crackles, or rhonchi, did not demonstrate sufficient reliability to be used alone for diagnosis.

Author/s:

Shubhada Hooli, Ron Reeder, Lauren Cutler, Laura F Sartori, Geoff Capraro, Amy Y. Cheng, Allison Cator, Matthew J. Lipshaw, Lilliam Ambroggio, Chris A. Rees, Son H. McLaren, Justin Moher, Leah Tzimenatos, Patrick S. Walsh, Chari D. Larsen, Richard M. Ruddy, Samir S. Shah, Nathan Kuppermann, Todd A. Florin

Management of Shoulder Pain in Primary Care: A Review

Mary Cervantes — Wed, 19 Aug 2026 17:54:00 +0000

Date Added:

August 19, 2026

Journal/Publication:

JAMA Internal Medicine

Publisher:

JAMA Intern Med

Publication Date:

August 17, 2026

URL:

Management of Shoulder Pain in Primary Care: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2026.3135

Keywords

Internal Medicine

Internal Medicine Practice

MeSH

clinical decision-making

Physical Examination

Physical Examination / methods

Overtreatment

primary health care

referral and consultation

Tendinopathy

A review of the management of patients with shoulder pain. James W. Mold, MD, MPH

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Importance Shoulder pain is a common and disabling condition most often managed in primary care. This review provides an evidence-based update on the diagnosis and management of shoulder pain to support clinical decision-making and improve patient outcomes.

Observations Shoulder pain arises from benign, self-limiting soft-tissue disorders or rare but serious causes. In primary care, most cases are nontraumatic and involve periarticular soft tissues. The subacromial region is the most frequent source of pain, and the term subacromial pain is preferred over overlapping and inconsistently defined labels such as rotator cuff tendinopathy or tear, impingement syndrome, or subacromial bursitis. Less commonly, pain originates from the glenohumeral joint, as in glenohumeral osteoarthritis or adhesive capsulitis. Assessment should focus on a detailed history and physical examination to assess pain patterns and movement limitation and to exclude serious causes, such as infection, malignant neoplasm, or nonshoulder referred pain. Once these are excluded, first-line treatment is similar for most patients and aligns with recommended care for other regional musculoskeletal concerns: education about the favorable natural history, symptom relief and activity modification if needed, and watchful waiting. Early imaging is not indicated in the absence of significant trauma or suspicious features, such as fever, unexplained weight loss, or history of malignant neoplasm, as structural abnormalities often do not correlate with symptoms, rarely alter management, and may lead to overdiagnosis and overtreatment. Specialist referral should be reserved for suspected serious pathology, such as infection, malignant neoplasm, fracture, or dislocation; significant functional or neurologic deficit; features suggestive of systemic inflammatory disease; or persistent or worsening pain and debility. High-certainty evidence indicates that subacromial pain does not benefit from surgical intervention.

Conclusions and Relevance Shoulder pain is the third most common musculoskeletal presentation in primary care. Although causes vary, the initial management is largely the same once serious conditions have been excluded. Most patients with subacromial pain will fully recover with minimal intervention and can be safely treated with supportive care. Imaging and referral to surgical subspecialists should be reserved for rare and carefully selected cases to avoid unnecessary intervention.

Author/s:

Romi Haas, Thomas Ibounig, MD, Buchbinder, Rachelle

A Simplified Approach to Evaluate and Manage Shoulder Pain

Erin Blanchette — Mon, 24 Mar 2025 16:18:35 +0000

Date Added:

March 24, 2025

Journal/Publication:

Journal of the American Board of Family Medicine

Publisher:

American Board of Family Medicine

Publication Date:

November 1, 2024

Issue:

Volume:

Pages:

1156-1166

URL:

A Simplified Approach to Evaluate and Manage Shoulder Pain

Type:

Best Local Practices

Format:

Article

DOI (1):

10.3122/jabfm.2024.240114R2

Keywords

PMID (1):

40118541

MeSH

Physical Examination / methods

A simplified algorithmic approach to the evaluation of shoulder pain. James W. Mold, MD, MPH

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With the lifetime prevalence of shoulder pain approaching 70%, accurate diagnosis and management remains essential. The shoulder is a complex joint with a vast range of motion making it susceptible to injury due to limited bony stabilization. This manuscript shares a simplified, novel approach to evaluating and managing atraumatic shoulder pain based on triaging symptoms on presence or loss of range of motion. In patients with loss of active and passive range of motion, the likely etiologies of pain include adhesive capsulitis or glenohumeral joint arthritis depending on imaging. In patients with preserved active and passive range of motion, implementing specific special testing can help pinpoint the diagnosis, and further guide appropriate management. Ultrasound plays an increasingly key role in diagnosing and managing shoulder pathology.

Author/s:

Kartik Sidhar, Hyung Jin Lim, Laurel Gutierrez

Tilt Table Testing

Alex Haga — Tue, 23 Apr 2024 17:41:24 +0000

Date Added:

April 23, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

April 11, 2024

URL:

Tilt Table Testing

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0004

Keywords

Cardiac Catheterization

PMID (1):

38602671

MeSH

hydrocortisone

Methacholine Chloride

Cardiac Catheterization

A summary and example of how to use tilt table testing in patients with syncope and various other fairly common symptoms. James W. Mold, MD, MPH

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A 43-year-old woman presented with a 1-year history of recurring symptoms of sudden onset of fatigue, palpitations, dyspnea, chest pain, lightheadedness, and nausea that were associated with standing and resolved with sitting. These symptoms began 1 month after mild COVID-19 infection. At presentation, while supine, blood pressure (BP) was 123/70 mm Hg and heart rate (HR) was 90/min; while seated, BP was 120/80 and HR was 93/min; after standing for 1 minute, BP was 124/80 and HR was 119/min. Physical examination results were normal. Oxygen saturation was 98% at rest while breathing room air. She had no oxygen desaturation during a 6-minute walk test but walked only 282 m (45% predicted). Complete blood cell count, morning cortisol, and thyrotropin blood levels were normal. Electrocardiogram (ECG), chest computed tomography, pulmonary function testing, methacholine challenge, bronchoscopy, echocardiography, and cardiac catheterization findings were normal. During tilt table testing, the patient experienced lightheadedness and nausea when moved from horizontal to the upright position. Results of the tilt table test are shown in the Table and Figure.

Author/s:

Chesire, W.P., Dudenkov, D.V., Munipalli, B.

Tilt Table Testing

Alex Haga — Tue, 23 Apr 2024 17:40:59 +0000

Date Added:

April 23, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

April 11, 2024

URL:

Tilt Table Testing

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.0004

Keywords

Cardiac Catheterization

PMID (1):

38602671

MeSH

hydrocortisone

Methacholine Chloride

Cardiac Catheterization

A summary and example of how to use tilt table testing in patients with syncope and various other fairly common symptoms. James W. Mold, MD, MPH

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Author/s:

Chesire, W.P., Dudenkov, D.V., Munipalli, B.

Approach to sialadenitis

Rowan Hutchins — Tue, 26 Sep 2023 05:00:00 +0000

Date Added:

September 26, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

August 1, 2023

Issue:

Volume:

Pages:

531-536

URL:

Approach to sialadenitis

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

https://doi.org/10.46747/cfp.6908531

Keywords

sialadenitis

family medicine

Family Physicians

PMID (1):

37582587

MeSH

Diagnostic Imaging

Physical Examination

Sialadenitis* / diagnosis

Sialadenitis* / etiology

Sialadenitis* / therapy

A concise review of the diagnosis and management of sialadenitis. James W. Mold, MD, MPH

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Objective To provide family physicians with a practical evidence-based approach to the management of patients with sialadenitis.

Sources of information MEDLINE and PubMed databases were searched for English-language research on sialadenitis and other salivary gland disorders, as well as for relevant review articles and guidelines published between 1981 and 2021.

Main message Sialadenitis refers to inflammation or infection of the salivary glands and is a condition that can be caused by a broad range of processes including infectious, obstructive, and autoimmune. History and physical examination play important roles in directing management, while imaging is often useful to establish a diagnosis. Red flags such as suspected abscess formation, signs of respiratory obstruction, facial paresis, and fixation of a mass to underlying tissue should prompt urgent referral to head and neck surgery or a visit to the emergency department.

Conclusion Family physicians can play an important role in the diagnosis and management of sialadenitis. Prompt recognition and treatment of the condition can prevent the development of complications.

Sialadenitis is inflammation or infection of the salivary glands that can present acutely or chronically. Sialadenitis can cause serious discomfort in everyday activities such as chewing food. There are numerous pathologies that can cause sialadenitis, which are reviewed below.

Author/s:

Moore, Jonah, Simpson, Matthew T.W., Cohen, Natasha, Beyea, Jason A., Phillips, Timothy

Geographic Tongue

Bethie Seay — Mon, 13 Sep 2021 05:00:00 +0000

Date Added:

September 13, 2021

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1503/cmaj.202855

MeSH

Glossitis, Benign Migratory

A good picture and quick summary about geographic tongue.

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A 37-year-old woman presented to the outpatient ear, nose and throat department with a 1-year history of intermittent burning and changes in appearance of her tongue. The patient had no history of bleeding, pain or concurrent skin or genital lesions, and she had no dermatologic history. A course of clotrimazole and vitamin B supplementation had been ineffective. On examination, she had well-defined annular lesions with central erythema and a raised white serpentine border involving the dorsal anterior two-thirds of her tongue (Figure 1). There was no fissuring. Based on her history, the appearance of her tongue and an otherwise normal physical examination, we diagnosed geographic tongue. We prescribed topical benzydamine, as required, for symptomatic relief of burning. At 6-month follow-up, she was free of symptoms, with patchy tongue changes.

Author/s:

Prasanth, V. J., Singh, A.

Diagnostic Accuracy of Symptoms, Physical Signs, and Laboratory Tests for Giant Cell Arteritis: A Systematic Review and Meta-analysis

Brian Desmarais — Thu, 20 Aug 2020 15:06:27 +0000

Date Added:

August 20, 2020

Journal/Publication:

JAMA Internal Medicine

Publication Date:

August 17, 2020

URL:

Diagnostic Accuracy of Symptoms, Physical Signs, and Laboratory Tests for Giant Cell Arteritis: A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.3050.

MeSH

Information Storage and Retrieval

This meta-analysis involving 68 studies calculated the likelihood ratios of various signs and symptoms of temporal arteritis (giant cell arteritis), which could be helpful when deciding when to refer patients for temporal artery biopsy.. James W. Mold, MD, MPH

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Abstract

Importance: Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest probability should be estimated remains unclear.

Objective: To evaluate the diagnostic accuracy of symptoms, physical signs, and laboratory tests for suspected GCA.

Data sources: PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were searched from November 1940 through April 5, 2020.

Study selection: Trials and observational studies describing patients with suspected GCA, using an appropriate reference standard for GCA (temporal artery biopsy, imaging test, or clinical diagnosis), and with available data for at least 1 symptom, physical sign, or laboratory test.

Data extraction and synthesis: Screening, full text review, quality assessment, and data extraction by 2 investigators. Diagnostic test meta-analysis used a bivariate model.

Main outcome(s) and measures: Diagnostic accuracy parameters, including positive and negative likelihood ratios (LRs).

Results: In 68 unique studies (14 037 unique patients with suspected GCA; of 7798 patients with sex reported, 5193 were women [66.6%]), findings associated with a diagnosis of GCA included limb claudication (positive LR, 6.01; 95% CI, 1.38-26.16), jaw claudication (positive LR, 4.90; 95% CI, 3.74-6.41), temporal artery thickening (positive LR, 4.70; 95% CI, 2.65-8.33), temporal artery loss of pulse (positive LR, 3.25; 95% CI, 2.49-4.23), platelet count of greater than 400 × 103/μL (positive LR, 3.75; 95% CI, 2.12-6.64), temporal tenderness (positive LR, 3.14; 95% CI, 1.14-8.65), and erythrocyte sedimentation rate greater than 100 mm/h (positive LR, 3.11; 95% CI, 1.43-6.78). Findings that were associated with absence of GCA included the absence of erythrocyte sedimentation rate of greater than 40 mm/h (negative LR, 0.18; 95% CI, 0.08-0.44), absence of C-reactive protein level of 2.5 mg/dL or more (negative LR, 0.38; 95% CI, 0.25-0.59), and absence of age over 70 years (negative LR, 0.48; 95% CI, 0.27-0.86).

Conclusions and relevance: This study identifies the clinical and laboratory features that are most informative for a diagnosis of GCA, although no single feature was strong enough to confirm or refute the diagnosis if taken alone. Combinations of these symptoms might help direct further investigation, such as vascular imaging, temporal artery biopsy, or seeking evaluation for alternative diagnoses.

Author/s:

van der Geest, Kornelis S. M., Sandovici , S., Brouwer, Elisabeth, Mackie, S.L.

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Brian Desmarais — Mon, 20 Jul 2020 16:29:20 +0000

Date Added:

July 20, 2020

Journal/Publication:

Canadian Medical Association Journal

Publication Date:

July 20, 2020

Issue:

Volume:

192

Pages:

E832-E843

URL:

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1503/cmaj.200021

MeSH

risk factors

fibrin fragment D

Fibrin Fibrinogen Degradation Products

tomography, x-ray computed

A guideline from Canada on diagnosis of acute aortic syndrome (dissection, thrombosis, or perforating ulceration of the aorta). James W. Mold, MD, MPH

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Not available.

Author/s:

Ohle, R., Yan, J.W., Yadav, K., Cournoyer, A., Savage, D.W., Jetty, P., Atoui, R., Bittira, B., Wilson, B., Gupta, A., Coffey, A., Callaway, Y., Middaugh, J., Ansell, D., Rubens, F., Bignucolo, S.J., Scott, T., McIsaac, S., Lang, E.

Clinical Practice Guideline: Ménière's Disease Executive Summary

John Bayhi — Mon, 18 May 2020 22:07:40 +0000

Date Added:

May 18, 2020

Journal/Publication:

Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery

Publisher:

Sage Publishing

Publication Date:

April 1, 2020

Issue:

Volume:

162

Pages:

415-434

URL:

Clinical Practice Guideline: Ménière's Disease Executive Summary

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1177/0194599820909439

Keywords

Meniett device

electrocochleography

endolymphatic hydrops

endolymphatic sac decompression

fluctuating aural symptoms

gentamicin

labyrinthectomy

sensorineural hearing loss

sodium-restricted diet

vestibular testing

PMID (1):

32267820

MeSH

A 2020 guideline for diagnosis and management of Meniere’s Disease from the American Academy of Otorhinolaryngology. James W. Mold, MD, MPH

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OBJECTIVE:

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many, and approaches typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE:

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Author/s:

Basura, GJ, Adams, ME, Monfared, A, Schwartz, SR, Antonelli, PJ, Burkard, R, Bush, ML, Bykowski, J, Colandrea, M, Derebery, J, Kelly, EA, Kerber, KA, Koopman, CF, Kuch, AA, Marcolini, E, McKinnon, BJ, Ruckenstein, MJ, Valenzuela, CV, Vosooney,A, Walsh, SA, Nnacheta, LC, Dhepyasuwan, N, Buchanan, EM

Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials

John Bayhi — Fri, 03 Jan 2020 17:40:28 +0000

Date Added:

January 3, 2020

Journal/Publication:

BMC Musculoskeletal Disorders

Publisher:

BioMed Central Ltd

Publication Date:

December 31, 2019

Issue:

Volume:

URL:

Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1186/s12891-019-3017-y

Keywords

chronic pain

Complementary Therapies

Craniosacral therapy

meta-analysis

systematic review

PMID (1):

31892357

MeSH

Craniosacral therapy is an apparently effective therapy, about which many of you may be unfamiliar, for patients with chronic pain syndromes. James W. Mold, MD, MPH

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OBJECTIVES:

To systematically assess the evidence of Craniosacral Therapy (CST) for the treatment of chronic pain.

METHODS:

PubMed, Central, Scopus, PsycInfo and Cinahl were searched up to August 2018. Randomized controlled trials (RCTs) assessing the effects of CST in chronic pain patients were eligible. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for pain intensity and functional disability (primary outcomes) using Hedges' correction for small samples. Secondary outcomes included physical/mental quality of life, global improvement, and safety. Risk of bias was assessed using the Cochrane tool.

RESULTS:

Ten RCTs of 681 patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain were included. CST showed greater post intervention effects on: pain intensity (SMD = -0.32, 95%CI = [- 0.61,-0.02]) and disability (SMD = -0.58, 95%CI = [- 0.92,-0.24]) compared to treatment as usual; on pain intensity (SMD = -0.63, 95%CI = [- 0.90,-0.37]) and disability (SMD = -0.54, 95%CI = [- 0.81,-0.28]) compared to manual/non-manual sham; and on pain intensity (SMD = -0.53, 95%CI = [- 0.89,-0.16]) and disability (SMD = -0.58, 95%CI = [- 0.95,-0.21]) compared to active manual treatments. At six months, CST showed greater effects on pain intensity (SMD = -0.59, 95%CI = [- 0.99,-0.19]) and disability (SMD = -0.53, 95%CI = [- 0.87,-0.19]) versus sham. Secondary outcomes were all significantly more improved in CST patients than in other groups, except for six-month mental quality of life versus sham. Sensitivity analyses revealed robust effects of CST against most risk of bias domains. Five of the 10 RCTs reported safety data. No serious adverse events occurred. Minor adverse events were equally distributed between the groups.

DISCUSSION:

In patients with chronic pain, this meta-analysis suggests significant and robust effects of CST on pain and function lasting up to six months. More RCTs strictly following CONSORT are needed to further corroborate the effects and safety of CST on chronic pain.

Author/s:

Haller, H, Lauche, R, Sundberg, T, Dobos, G, Cramer, H