What are the good and bad physical assessment findings in a patient with Upper Respiratory Infection (URI) symptoms and underlying conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Physical Assessment Findings in URI with Underlying Asthma/COPD

Critical "Bad" Findings Requiring Immediate Action

In patients with URI symptoms and underlying asthma or COPD, you must immediately identify signs of acute respiratory failure, which carries significant mortality risk and demands urgent intervention. 1

Red Flag Vital Signs and Mental Status

• Drowsiness or altered mental status - indicates CO2 narcosis and impending respiratory failure 1
• Oxygen saturation <88% with significant hypoxemia 1
• Tachycardia >100 bpm - suggests respiratory distress or pulmonary embolism 2
• Respiratory rate - elevated rates indicate increased work of breathing 2

Concerning Respiratory Examination Findings

• Paradoxical bronchospasm after bronchodilator use - can be life-threatening and requires immediate discontinuation 3
• Quiet or diminished breath sounds - positive likelihood ratio >5.0 for significant COPD, indicates severe airflow limitation 2
• Prolonged expiratory phase - suggests airflow obstruction and predicts presence of asthma/COPD 2
• Wheezing - predictive value for chronic airways disease, especially with other risk factors 2
• Hyperresonance on percussion - positive likelihood ratio >5.0 for COPD 2

Signs of Advanced Disease or Complications

• Cyanosis (central) - indicates severe hypoxemia 2
• Signs of hyperinflation - barrel chest, use of accessory muscles 2
• Weight loss - associated with more severe impairment and worse prognosis 2
• Peripheral edema - suggests cor pulmonale (right heart failure) 4
• Raised jugular venous pressure - indicates right ventricular dysfunction 4
• Right ventricular heave - palpable sign of cor pulmonale 4

"Good" Findings Suggesting Lower Risk

Reassuring Physical Examination

• Normal breath sounds throughout all lung fields 2
• Normal respiratory rate and effort at rest and with minimal exertion 2
• Oxygen saturation >92% on room air 1
• Alert mental status without confusion or drowsiness 1
• Absence of accessory muscle use 2
• Normal cardiac examination without signs of right heart strain 4

Findings Suggesting Simple URI Rather Than Exacerbation

• Absence of wheezing on both history and examination - likelihood ratio 0.02 for airflow obstruction when combined with no smoking history 5
• Normal expiratory phase duration 2
• Stable weight and nutritional status 2
• No increase in baseline sputum volume or purulence 2

Algorithmic Approach to Physical Assessment

Step 1: Assess for Immediate Life Threats

1. Mental status - drowsiness mandates arterial blood gas and immediate intervention 1
2. Oxygen saturation - if <88%, obtain chest x-ray immediately and target 88-92% oxygen therapy 1
3. Respiratory distress - accessory muscle use, inability to speak in full sentences 2

Step 2: Differentiate URI from Exacerbation

Consider underlying chronic lung disease if ≥2 of the following present: 2

• Wheezing on examination
• Prolonged expiration
• Smoking history (>40 pack-years has likelihood ratio of 12 for airflow obstruction) 5
• History of allergy

If ≥2 present: perform spirometry to confirm chronic airways disease 2

Step 3: Assess Disease Severity

• Measure functional dyspnea using modified Medical Research Council scale 2
• Document BMI - values <21 kg/m² associated with increased mortality 2
• Assess exercise tolerance - ask about breathlessness with daily activities 2
• Evaluate sputum characteristics - persistent large volumes (>30 mL/24h) or purulence suggests bronchiectasis or bacterial infection 2

Step 4: Screen for Complications

Obtain chest x-ray if any of the following: 1

• Drowsiness or altered mental status
• Severe hypoxemia
• Signs of consolidation on examination
• Suspected pneumothorax (sudden worsening in patient with bullous disease)
• Signs of heart failure (peripheral edema, elevated JVP)

Consider pulmonary embolism if: 2

• History of DVT or prior PE
• Immobilization in past 4 weeks
• Malignant disease
• Hemoptysis

Common Pitfalls to Avoid

Physical Examination Limitations

• Physical examination alone has poor sensitivity for detecting moderate COPD - normal examination is common in mild disease 2
• Do not rely on physical examination to exclude cor pulmonale - it has poor sensitivity for moderate right heart dysfunction 4
• Obesity can mask physical findings of both respiratory disease and cor pulmonale 4

Dangerous Assumptions

• Never assume stable chronic disease without assessing for acute changes - blood-streaked sputum during exacerbations is common, but always consider alternative diagnoses like malignancy 2
• Do not overlook nocturnal symptoms - daytime sleepiness and heavy snoring suggest obstructive sleep apnea, which worsens pulmonary hypertension 2
• Awake oxygen saturation does not predict nocturnal hypoxemia - consider overnight oximetry if cor pulmonale present despite only moderate daytime hypoxemia 4

Critical Assessment Errors

• Failure to recognize CO2 narcosis - drowsiness in COPD patients is a medical emergency, not simple fatigue 1
• Inappropriate oxygen therapy - excessive oxygen in acidotic patients worsens acidosis; target 88-92% saturation 1
• Missing paradoxical bronchospasm - worsening after bronchodilator requires immediate discontinuation and alternative therapy 3