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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION

OSCE 5: Cough

This video format is designed to help you prepare for objective structured clinical examinations, or

OSCEs.

So Ms. Chen, tell me what is your average weight that you keep.

You are going to observe and participate in a clinical encounter of a 45‐year‐old woman who comes to

the office with a complaint of a cough. As you observe the encounter, you will be asked to answer

questions while the image on the screen freezes. These questions will allow you to practice the skills of

history taking and physical examination skills as well clinical reasoning as you develop your assessment

or differential diagnosis, and plan—that is, an appropriate next diagnostic workup.

You will have time to record your findings and receive feedback.

Health History

Ms. Chen, tell me your special concerns.

I have been coughing for a week and just can’t seem to stop. I can hardly sleep at night.

Have you been bringing up any phlegm or sputum?

I’ve been coughing up a yellow‐green mucus, sometimes with pink streaks that seem to be blood.

What diagnoses are you considering at this time?

Pneumonia.

Bronchitis.

Sinus infection.

Tuberculosis.

How much pink streaking are you seeing at any one time?

Just a tinge, but maybe 3 or 4 times a day.

Have you had any fevers or chills?

Yes, I checked my temperature yesterday and it was 101°F.

What about shortness of breath?

I do feel shortness of breath when I’m working outside, but not when I’m working at my desk.

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Have you noticed any wheezing?

Just once in a while when I’m going up the stairs fast, or when I’m doing heavy work in the yard.

Have you had any of these symptoms before, or had any asthma?

No, not since I was a kid. I did have some mild asthma when I was in elementary school but luckily I

never had to go the hospital.

Any pain in your chest when you take a deep breath?

No, no pain when I breathe in or out.

You mentioned that you’re coughing a lot at night. Are you using any extra pillows?

Well, the last few nights I have been using two pillows instead of one. It seems to help me clear my

head.

Have you had any acid taste, or reflux?

No, not really.

How about any recent colds?

Well, actually last week I came down with a runny nose and a sore throat, but then my symptoms got

worse.

Have you had any sinus congestion?

Well, my sinuses do feel full a lot. Um…I first feel a drip in the back of my throat, um…but now the worst

thing is the cough.

What about allergies when you’re outside?

Pollen and golden rod get me every spring and fall. Right now my spring allergies are almost over.

And what do you do for those?

Antihistamines usually help. Um…I do try to cut down on my smoking, but right now my symptoms now

are much worse than usual, especially with the bad cough and phlegm.

Do you have pets at home?

Yes, we have two cats. I’ll admit right now that they sleep in our bedroom.

Well, animal fur picks up allergens, you may want to consider having them sleep in a different part of

the house, or even outside.

Can you tell me if you still smoke cigarettes?

I’ve smoked two packs a day for the last 10 years. I’ve tried to stop but I work as a dispute mediator.

With all that stress I just can’t seem to quit.

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Have you had any weight loss or night sweats?

No, my weight is fine, and no night sweats.

Has anyone around you been ill? Or have you been exposed to tuberculosis?

My family and co‐workers are fine. When I was a kid though, my grandmother told me she had

tuberculosis in her 20s.

Have you been checked for tuberculosis, with a skin test like a tine test or PPD?

I did have one of those PPDs about 10 years ago when I started my current job, and it was negative.

Have you had a chest x‐ray?

No, I’ve never had a chest x‐ray.

What about any recent travel? Have you been out of the country?

Well, I did go to Shanghai a few months ago to visit my cousins…um, however this cough is much more

recent. No other travel.

I’d like to go back to the pink streaks in your sputum that you mentioned. Are you taking any

medications right now, such as aspirin or ibuprofen?

Right now I’m taking a decongestant over the counter and some ibuprofen maybe twice a day or so. I’m

not on any regular medication.

Okay, let’s talk about your general health. Do you drink alcohol?

Well, a glass of wine, 3 times a week.

Have you ever used any oral, nasal, or injection drugs such as marijuana, cocaine, amphetamines, or

heroin?

No, never, even though I know people who do.

To be thorough, given your cough, I need to ask about your sexual activity. What is your sexual

preference, men, women, or both?

Men.

Now, just a few questions about your past health…I see you are 45. Have you ever had any problems

with your heart or lungs?

No, I’m still able to work out even with the smoking. I just had that asthma a few times when I was in

grade school.

How about any surgery?

No, no surgery. I’ve never even been to the hospital.

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Okay, is there anything else that you would like me to know?

No, I think you’ve covered everything.

Okay, let’s start your physical examination.

Physical Examination

With the patient’s health history in mind, and after good hand hygiene, you are ready for the physical

examination.

Okay, your temperature is up a little at 101.5°F. Your blood pressure is 130 over 88. Your heart rate is

100 and you’re breathing at about 22 breaths a minute, which is higher than normal.

What regions of the physical examination are important in this patient?

Head and neck, heart and lungs, extremities.

Okay, first I’d like to check your head and neck.

Examine the ears.

Palpate the sinuses.

Examine the throat and mouth.

Palpate the anterior and posterior cervical lymph nodes.

Okay, your ears look fine but your throat is a little red, otherwise it’s okay. Now I’d like to check your

lungs.

Percuss the lungs.

There is some dullness here over the base of your left lung. Can you say “99” for me a few times?

Palpate for tactile fremitus.

Auscultate the lungs.

[RALES AND RHONCHI SOUNDS]

Can you say “99” for me a few times?

99…99…99…

Listen for bronchophony, or louder transmitted voice sounds, which are abnormal.

Good, now can you whisper the number “99”?

[WHISPERING] 99…99…99…

Listen for whispered pectoriloquy, or louder whispered sounds, which are abnormal.

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Okay. Can you say the letter “E” for me 2 or 3 times?

Eeeee…Eeeee…

Listen for egophony, or “E to A” changes, which are abnormal.

Okay, you can stop.

How am I doing?

I’m hearing some changes from consolidation in your left lower lung. Let’s continue the examination and

then we can talk more. Can you lie back for me?

Auscultate the anterior chest.

Check the neck veins for jugular venous pressure.

Palpate the carotid upstroke…

…and listen for bruits.

Listen to the heart in the six positions.

Listen to the abdomen.

Palpate the abdomen.

Inspect and palpate the calves and ankles for tenderness and swelling.

Diagnostic Considerations

List your diagnostic considerations in order of importance and explain your rationale.

Press pause and list your answers. Resume when you are ready to receive feedback.

Community acquired pneumonia: This 45‐year old smoker has a productive cough, mild shortness of

breath, and fever. On physical examination she has an elevated temperature and a mildly elevated

respiratory rate and dullness, increased tactile fremitus, rhonchi, and E to A changes in the left lower

lobe of her lungs, all features suspicious for the lung consolidation of community‐acquired pneumonia.

Rapid onset of symptoms and pleuritic chest pain are also characteristic, and 25‐50% of patients have an

accompanying pleural effusion. Risk factors include COPD, cardiovascular disease, diabetes, and

smoking.

Atypical community‐acquired pneumonia: Atypical pneumonia frequently presents with a persisting

non‐productive “dry hacking cough,” low‐grade fever, and absence of pleuritic chest pain. Lung

examination findings are variable, but may be normal. Clinical features do not clearly distinguish atypical

from typical pneumonias. This patient’s symptoms, especially fever, productive cough, and positive lung

findings, make this diagnosis less likely.

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Bronchitis: In acute bronchitis, which is usually self‐limiting, cough typically follows an upper respiratory

infection and persists for more than 5 days. Sputum production is variable and may be blood‐tinged.

The chest examination is normal. In chronic bronchitis look for chronic cough with sputum, often seen in

smokers. Unlike this patient, chronic cough lasts for more than 8 weeks. Note that symptoms and

findings suggesting sinus infection or GERD are minimal.

Pulmonary tuberculosis: This patient’s blood‐tinged sputum raises the possibility of pulmonary

tuberculosis from Mycobacterium tuberculosis; however, in tuberculosis cough is usually present for

more than 2 to 3 weeks and hemoptysis is usually a late symptom reflecting cavitation. Actual sputum

may not be present. Initially patients are often asymptomatic then progress to constitutional symptoms

such as weight loss, anorexia, fatigue, fever, chills, night sweats, and cough. The lung examination may

be normal except for crackles, or rales.

Lung cancer: Lung cancer is unlikely in this patient due to the acute onset of cough with productive

sputum, fever, and confirming lung examination findings. However, the possibility arises since this

patient is a smoker with a cough and blood‐tinged sputum though not hemoptysis. Lung cancer

symptoms usually appear late, including cough, hemoptysis, chest pain, and dyspnea but symptoms also

arise from metastatic spread. Cigarette smoking causes roughly 90% of lung cancers.

Diagnostic Workup

List 5 next steps in your diagnostic workup.

Press pause and list your answers. Resume when you are ready to receive feedback.

O2 saturation: In an office setting, pulse oximetry helps identify hypoxia when the oxygen saturation

falls below 90%, particularly in smokers and patients with COPD or known lung disease. It is important to

note that the oxygen saturation can be high even when the more important indicator of oxygenation,

the pO2, is considerably lower due to the S‐shape of the oxyhemoglobin dissociation curve. In more

seriously ill patients an arterial blood gas is indicated.

Chest x‐ray: Chest x‐ ray is the gold standard for diagnosis of pneumonia. Although it does not identify

the causative pathogen, focal infiltrates with pleural effusion suggest bacterial infection. Interstitial

infiltrates are common in mycoplasma, chlamydia, and viral infection. Cavitation with air‐fluid levels is

suspicious for abscesses from staphylococci, anaerobes, or gram negative bacilli. Cavities without air‐

fluid levels are seen in tuberculosis and fungal infection. Chest x‐ray also helps identify cough related to

heart failure, COPD, and malignancy

Complete blood count with differential and metabolic profile: These standard tests identify the rise in

white blood cell count and neutrophils, elevation of CO2, anemia, and renal and liver disease that

influence antibiotic therapy.

Sputum culture and gram stain: Collecting a sputum culture and gram stain before starting therapy is

controversial, but can help guide therapy in severely ill patients.

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Blood cultures: Blood cultures and urine testing for legionella and pneumococcal antigens are

recommended for patients with severe pneumonia.

Summary

In sum, the patient is a 45‐year‐old dispute mediator with cough productive of yellow‐green and

occasional blood‐tinged sputum for a week, fever, mild shortness of breath and occasional wheezing,

and a 10‐year history of smoking 2 packs of cigarettes a day. There is a remote history of travel and TB

exposure, which do not contribute to the current clinical presentation. On examination her temperature

is 101.5°F; blood pressure, 130 over 88; heart rate, 100; and respiratory rate, 22. She has dullness,

decreased breath sounds, and egophony in the left lower lobe.

Diagnostic considerations include Community‐acquired pneumonia, which is most likely, atypical

community‐acquired pneumonia, acute bronchitis, pulmonary tuberculosis, and lung cancer.

The diagnostic workup includes O2 saturation, chest x‐ray, CBCd and metabolic profile, sputum culture

and gram stain, and blood cultures.

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