What is the appropriate focused physical exam for a 55-year-old male presenting with cough and purulent sputum for the past 5 days?

Focused Physical Examination for a 55-Year-Old Male with Cough and Purulent Sputum

The focused physical examination for a 55-year-old male with cough and purulent sputum for 5 days should prioritize vital signs assessment and thorough respiratory examination to rule out pneumonia, as this is the most critical condition to exclude.

Vital Signs Assessment

• Temperature: Fever >38°C increases likelihood of pneumonia 1
• Heart rate: Tachycardia >100 beats/min is concerning for pneumonia 1
• Respiratory rate: Rate >24 breaths/min suggests pneumonia 1
• Blood pressure: To assess hemodynamic stability
• Oxygen saturation: To evaluate respiratory compromise

Respiratory Examination

Inspection

• Assess work of breathing, use of accessory muscles
• Note respiratory pattern and rate
• Observe for cyanosis or pallor
• Check for clubbing (suggests chronic respiratory disease)

Palpation

• Check for tactile fremitus (increased with consolidation) 1
• Assess chest expansion (asymmetry suggests pathology)
• Palpate for tenderness over sinuses (possible upper airway contribution)

Percussion

• Perform percussion over all lung fields
• Note any dullness (suggests consolidation) 2
• Compare symmetry between sides

Auscultation

• Listen for:
  • Focal crackles (suggests pneumonia) 1
  • Bronchial breath sounds (suggests consolidation) 1
  • Wheezes (suggests bronchospasm)
  • Rhonchi (suggests airway secretions)
  • Egophony (suggests consolidation) 1

Additional Focused Examination

Upper Respiratory

• Examine nasal passages for inflammation, discharge
• Examine oropharynx for erythema, postnasal drip
• Assess for sinus tenderness

Cardiac

• Auscultate heart sounds to rule out cardiac causes of cough
• Check for peripheral edema

Key Diagnostic Considerations

According to the American College of Radiology guidelines, the absence of the following findings significantly reduces the likelihood of pneumonia and may eliminate the need for chest radiography 1:

1. Heart rate >100 beats/min
2. Respiratory rate >24 breaths/min
3. Oral temperature >38°C
4. Focal consolidation, egophony, or fremitus on chest examination

Important Caveats

1. Physical examination alone is insufficient to definitively diagnose or exclude pneumonia. Studies show variable sensitivity (47-69%) and specificity (58-75%) among examiners 3.

2. The most valuable examination findings for detecting pneumonia are unilateral rales and rales in the lateral decubitus position 3.

3. In patients over 55 years old, a higher index of suspicion for pneumonia is warranted as they may present with fewer classic symptoms 1.

4. Purulent sputum alone is not an accurate distinction between pneumonia and acute bronchitis 1.

5. The physical examination findings in patients with bronchiectasis may reveal variable degrees of rhonchi, crackles, and clubbing, or they may be normal 1.

If any concerning features are present (abnormal vital signs or focal chest findings), chest radiography should be performed to rule out pneumonia, as this is the most important condition not to miss in a patient of this age with these symptoms.