Clinical examination

1. Anamnesis

1. Was the onset of the cough sudden or insidious? What was its initiating event?
Did it start as an isolated symptom or occur with or follow other symptoms?

2. How long has the cough been present? Is it persistent or episodic? Seasonal or
perennial?

3. To determine the severity of the cough, ask: How frequent is a coughing

spell? How long does each coughing spell last? What is its effect on daily
activity or rest?

4. Is the cough productive or dry?

5. Is the cough the only symptom, or is it associated with other respiratory or

nonrespiratory symptoms?

6. In addition to an accurate smoking history, ask: To what respiratory irritants is

the patient exposed at home or at work? Is exposure accidental or intentional?

7. What are the precipitating or aggravating factors? What time of the day or
night is the cough or sputum production worse? Does it happen in supine
position, upon arising in the morning, with drinking or eating, with exercise,
or with breathing cold or dry air? Does the cough awaken the patient from
sleep?

8. Is there a past history (recent or old) of foreign body aspiration?

9. Has the pattern of the cough and the amount or other characteristics of the
sputum changed recently?

10. Can the patient locate the site of origin of the cough or the sputum, such as
from the throat or deeper in the chest?
 11. Has the patient had a similar problem with coughing in the past?

12. Does the cough have easily recognizable characteristics, as in croup or

whooping cough?

2. Physical Examination
a. Inspection
The following should be assessed:
1. Breathing pattern
Normal respiratory rate is 14–20/min in adults, and up to 44/min in infants
a. Bradypnea: respiratory rate < 14/min
b. Tachypnea: respiratory rate > 20/min, shallow breathing
c. Hyperpnea: respiratory rate > 20/min, deep breathing

2. Common abnormal patterns of breathing include:

a. Cheyne-Stokes breathing: alternating periods of deep breathing followed
by apnea
b. Results from a delay in detecting changes in ventilation and arterial carbon
dioxide pressure.
c. Common causes include: advanced heart failure, damage to respiratory
centers (e.g., stroke, traumatic brain injuries, metabolic encephalopathies),
and central sleep apnea
d. Ataxic breathing: irregular breathing in rhythm and depth
e. Obstructive breathing: prolonged exhalation

3. Increased effort of breathing

1. Tachypnea
2. Use of accessory muscles of respirations during inspiration
a. Sternomastoid muscles
b. Scalene muscles
 c. Pectoralis major

3. Trachea off midline

4. Tripod position: patients with emphysema and respiratory distress will
lean forward while sitting, resting with their hands on their knees.
4. Peripheral signs of respiratory dysfunction
1. Cyanosis: bluish discoloration of the skin and mucosa
2. Nail clubbing
5. Abnormalities in the shape of the thorax
1. The anteroposterior diameter of the thorax may increase in COPD,
leading to a “barrel chest” appearance.
2. Retraction of the intercostal spaces
3. Asymmetric movement may be associated with pleural disease,
phrenic nerve damage, or pleural effusion.
4. Kyphosis or scoliosis may lead to decreased forced vital capacity,
forced expiratory volume and overall respiratory function
6. Sputum production or secretions, if any
1. White and translucent: viral infection (for example, bronchitis that
presents with a typical early-morning cough)
2. White and foamy: pulmonary edema
3. Yellow-green: bacterial infection
4. Green: an indication of a pseudomonal infection
5. Grayish: pneumoconiosis, a waning bacterial infection
6. Blackish-brown: possibly old blood; should be further investigated
(can also be a harmless incidental finding)
7. Friable: tuberculosis, actinomycosis
8. Hemoptysis: see section below
b. Palpation
1. Evaluate areas of tenderness or bruising
2. Symmetry of chest expansion
a. Place both hands on the patient's back at the level of the 10 th ribs with
thumbs pointing medially and parallel to the rib cage.
b. As the patient inhales, evaluate for asymmetric movement of your
thumbs.
3. Tactile fremitus
a. Ask the patient to say “toy boat” and feel for vibrations transmitted
throughout the chest wall.
b. Can be asymmetrically decreased in effusion, obstruction, or
pneumothorax, among others
c. Can be asymmetrically increased in pneumonia

c. Percussion
1. Technique
a. Hyperextend the nondominant middle finger and place the distal
interphalangeal joint against the chest wall.
b. Strike the joint with the other middle finger and evaluate the elicited
sound.
c. Always percuss both sides of the chest at the same level. Often the
finding of asymmetry is more important than the specific percussion
note that is heard.
b. Physiological finding: resonant percussion note → a comparatively
hollow and loud note
c. Pathological findings
a. Hyper-resonant percussion note
a) Louder and hollower than normal
 b) Sign of increased air inside the thoracic cavity: emphysema,
bronchial asthma, pneumothorax
d. Assess diaphragmatic movement
a. Move downwards while percussing over both sides of the chest wall.
b. The transition point from resonant to dull percussion notes marks the
approximate position of the diaphragm.
c. Abnormally high transition points on one side may be seen in
unilateral pleural effusion and unilateral diaphragmatic paralysis.
d. The distance between the transition point on full expiration and the
transition point on full inspiration is the extent of diaphragmatic
excursion (normally 3.0-cm–5.5-cm).

c. Auscultation
Physiological breath sounds

a. Vesicular breathing
a. Soft and low pitched, through inspiration and part of expiration
b. Heard over both lungs
b. Bronchovesicular breathing
a. Intermediate intensity and pitch, through both inspiration and
expiration
b. Heard over 1st and 2nd intercostal spaces
c. Bronchial breathing
a. Loud and high pitched, through part of inspiration and all of expiration
b. Heard over the sternum
d. Tracheal breathing
a. Very loud and high pitched, through both inspiration and expiration
b. Heard over the neck
Diagnostic

1. Laboratory tests

a) Complete blood count: indicated in patients with chronic cough/red flag

symptoms if an infective etiology (e.g., neutrophilic leukocytosis in
pneumonia, lymphocytosis in TB) or allergic etiology (e.g., eosinophilia in
asthma) is suspected
b) Sputum examination
c) Sputum culture: suspected bacterial pneumonia, TB
d) Sputum examination for acid-fast bacilli: suspected TB
e) Nasopharyngeal swab/deep nasopharyngeal aspirate culture and PCR for
pertussis: indicated in patients with subacute/chronic cough, esp. if associated
with an inspiratory whoop and/or post-tussive vomiting
f) Blood culture: suspected pneumonia
g) Arterial blood gas analysis: patients with dyspnea and those with suspected
life-threatening causes of acute cough
h) Bronchoalveolar lavage
i) Inconclusive non-invasive diagnostic tests (e.g., in bronchiectasis, asbestosis,
bronchioloalveolar carcinoma)
j) Suspected infectious etiology in patients who are unable to expectorate
sputum for examination (e.g., tuberculosis, PCP, histoplasmosis, aspergillosis)

2. Imaging

a) Chest x-ray
b) Suspected pneumonia or TB
c) Chronic cough with abnormal physical examination findings or prolonged
history of nicotine abuse
 d) Red flag symptoms
e) X-ray of paranasal sinuses: patients with UACS secondary to suspected
sinusitis
f) Chest CT scan
g) Suspected bronchiectasis (diagnostic test)
h) Recurrent pneumonia
i) Chest x-ray findings suggestive of lung cancer (e.g., mass, hilar
lymphadenopathy)
j) Inconclusive chest x-ray findings in patients with foreign body aspiration
k) Bronchoscopy
l) Foreign body aspiration
m) Lung cancer
n) Suspected tracheoesophageal fistula

c. Pulmonary function tests

a) Spirometry: indicated to differentiate between obstructive lung disease (e.g.,

asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)
b) Bronchial challenge test (metacholine challenge test; bronchodilator
reversibility test): to differentiate asthma from other obstructive lung disease
c) Single-breath diffusing capacity: to differentiate between intrapulmonary
(e.g., interstitial lung disease) and extrapulmonary causes (e.g., pleural
effusion) of restrictive lung disease

Referensi

1. Bohadana A, Izbicki G, Kraman SS. Fundamental of lung auscultation. N Egl

J Med. 2014, 370(8)
2. Bickley L. Bates Guide to Physical Examination and History-Taking.
Lippincott Williams & Wilkins;2012
3. George L, Brightling CE. Eoshinophilic airway inflammation: role in asthma
and chronic obstructive pulmonary disease. The Adv Chronic Dis. 20016; 7(1)
4. Prifits KN, Eber E. Phaediatrcic Bronchoscopy. Prog Respir Res. 2010; 38.