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errors in eliciting and understanding respiratory signs

Reflecting on the examination process highlights 2 areas of concern. Firstly, any treatment decisions are based on subjective findings making it relevant to consider the reproducibility of the findings for further healthcare professionals involved in the patient’s care. Kalantri et al (2007) stated that clinician to clinician errors in eliciting and understanding respiratory signs are common and risk reducing the validity of the test. Looking specifically at the respiratory assessment Spiteri (1988) found that percussion had a Cohen Kappa co efficient of 0.52 making it the most reproducible part of the respiratory exam. The research also determined tactile fremitus had a co efficient of 0.01 making it almost an even probability that two clinicians would reach the same conclusion. In contrast Kalantri et al (2007) found an excellent inter observer correlation between all respiratory signs however their study only looked at the actions of two clinicians. Perhaps of more importance is the significance of the findings. To base a treatment decision on a finding that has both low sensitivity and specificity is potentially unwise. Rebound tenderness is a commonly used test for appendicitis however Williams et al (2009) found it to be positive in 30% of proven appendicitis patients. A clear dichotomy of thought is occurring as most emergency clinicians believe it to be pathognomonic for surgical disease (Bemelman and Kievit, 1999, Liddington and Thomson, 1991). Murphy’s sign, another stalwart of the abdominal exam, has a sensitivity of 97% however has been demonstrated to diminish in the elderly, an important caveat that if unknown could create a false sense of security (Mcgee 2018). Utilising a black and white approach to a physical finding is clearly not best practise. The clinician has a responsibility to be aware of the reliability and reproducibility of the examination to ensure appropriate decisions are made. Establishing objectivity through further testing is therefore essential.

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