Cough physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abiodun Akanmode,M.D.[2]

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Overview

once an in-depth history is taken from the patient, a detailed physical examination should be done when evaluating coughing patients.

Physical Examination

The sequence of examination of patients with cough follows the traditional inspection,palpation,percussion and auscultation.

Inpsection

This is the first step to any physical examination.

• Is the patient struggling to breathe, i.e. dyspnea?
• Does the patient look anxious or calm?
• What is the color of the patient's skin? E.g., the dark blue color indicates cyanosis.
• What is the patient's appearance: A cachexic appearance could suggest an underlying chronic disease.

The clinician's sense of smell should also be utilized, a strong smell of stale cigarette smoke in the patient's cloth could suggest chronic smoking even a foul-smelling diaper in kids could suggest fatty stool associated with cystic fibrosis and pancreatic insufficiency. Inspection should also check the fingers for finger clubbing and the chest wall for chest wall abnormalities such as barrel chest.

Palpation

Palpation in a coughing patient often includes feeling for the centrality of the trachea,a displaced trachea to the left or right could suggest a pneumothorax.Palpating for tactile fremitus by asking the patient to repeat the word ninety-nine(phrase often used) helps the examiner to identify areas of increased parenchymal density withing the lungs.Increased tactile fremitus is noted in conditions such as lobar pneumonia and decreased fremitus can be associated with pneumothorax or pleural effusion.

Percussion

This is usually done by the examiner tapping his dominant hand middle finger on his non-dominant hand middle finger while resting on the chest wall. The percussion note audible can be dull over areas of consolidation or hyperresonant with air trapping.

Auscultation

The stethoscope is used to achieve auscultation. With auscultation, different air movement patterns through the lungs and the airways can be heard depending on the location auscultated. The normal breath sounds are:

• Tracheal.
• Bronchial.
• Bronchovesicular.
• Vesicular.

The adventitious sounds are associated with different underlying illnesses.

• Stridor: This is best heard on inspiration. It is associated with airways narrowing. Stridor can be heard in croup.
• Crackles: Also referred to as rales is associated with popping open of the air-fluid menisci as the airways dilate with inspiration. The presence of crackles on auscultation usually indicates excess fluid within the airways, such as in pneumonia of pulmonary edema.
• Rhonchi: These are continuous bubbling sounds that can be heard at both inspiration and expiration.
• Wheeze: These are continuous musical sounds and are associated with conditions like bronchial asthma and are commonly heard more in expiration over inspiration.