Pneumonia is suspected based on a constellation of symptoms and signs, but individual symptoms and clinical findings lack accuracy for precise diagnosis. 13 Attempts have been made to combine some of the symptoms and signs into a scoring system that predicts the probability of pneumonia, and four different decision rules were compared in a study of adult outpatients (Table59-2). The results of these attempts indicate that clinical criteria are most useful for "ruling out" pneumonia; that is, if a patient has none of the positive predictors, the probability of pneumonia is very low, from 1 to 4 percent. However, clinical criteria are inaccurate for "ruling in" pneumonia; even if a patient has all of the positive clinical predictors, these scoring systems predict pneumonia with a maximal probability of 40 to 50 percent. 13 Thus, for accurate diagnosis, a chest radiograph is required.

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