You are seeing Mr. Smith, a 60 year old man, in your outpatient clinic today for a worsening productive cough. Take a focused history of his complaint.
History
- Onset of cough
- Worsening cough
- Sputum production and volume
- Change in sputum color
- Presence of blood in sputum
- Associated shortness of breath
- Fever
- Chest pain
- Recent respiratory illnesses
- Smoking history (quantity in pack-years)
- Other drug use
- Personal history of lung disease
- Occupational history to airborne toxins/irritants
- Infectious contacts
- Exposure to environmental allergens
- Recent travel
- TB exposure history
Physical
Inspection
- Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
- Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
- Examines for thoracic deformities
Percussion/Palpation
- Percusses all anterior and posterior fields and comments on findings
- Uses percussion to estimate diaphragmatic excursion on the posterior chest
- Assesses fremitus in all anterior and posterior fields and comments on findings
- Evaluates chest expansion using palpation
Auscultation
- Instructs patient to breathe while auscultating; listens for at least one full breath at each location of auscultation
- Auscultates both lung fields in at least 5 different locations
- Auscultates posterior fields, and asks patient to cross arms in order to shift scapulae away from the lung fields
- Comments on of breath sounds and presence of adventitious sounds, e.g. crackles and wheezes
Case 1 – Productive Cough