For a 16‑year‑old female (5'5", 150 lb) with a three‑week worsening cough, wheeze, dyspnea, eczema, recent upper‑respiratory symptoms, and exposure to second‑hand smoke and cockroach allergens, what essential components of the physical examination are still missing?

Missing Components of the Physical Examination

You are missing spirometry with bronchodilator reversibility testing, which is the single most critical objective test needed to confirm asthma in this 16-year-old with classic symptoms of wheeze, dyspnea, and cough. 1

Critical Objective Testing Required

Spirometry and Bronchodilator Response

• The European Respiratory Society strongly recommends against diagnosing asthma based on symptoms and physical examination alone, even when classic features like recurrent wheeze, cough, and atopy (eczema) are present. 1, 2
• Spirometry is the first-line objective test for children aged 5-16 years under investigation for asthma, and most adolescents can successfully perform acceptable spirometry. 1, 2
• Bronchodilator reversibility testing showing ≥12% improvement in FEV1 after bronchodilator is a key diagnostic test required for asthma diagnosis. 1, 2
• Asthma should only be diagnosed when two or more recommended diagnostic tests are abnormal—symptoms and examination findings alone are insufficient. 1, 2

Fractional Exhaled Nitric Oxide (FeNO)

• If spirometry and bronchodilator testing are performed, FeNO testing should be considered as a second objective test, as elevated levels suggest eosinophilic airway inflammation. 1, 2
• This patient's combination of eczema, wheeze, and environmental allergen exposure (cockroach, secondhand smoke) makes eosinophilic inflammation highly likely. 2

Additional Physical Examination Components

Detailed Respiratory Examination

• Peak expiratory flow rate (PEFR) measurement should be documented, particularly given the audible wheeze and labored breathing on presentation. 3
• Pulse oximetry reading is documented (you note "v/a 112/82 HR 22" which appears incomplete—clarify if oxygen saturation was measured). 3
• Assess for signs of respiratory distress including use of accessory muscles, intercostal retractions, and nasal flaring during labored breathing. 3

Chest Auscultation Details

• While you note "audible wheeze," document specifically whether wheezing is inspiratory, expiratory, or both, and whether it is diffuse or localized. 3
• Document the quality of breath sounds (vesicular vs. diminished) and presence or absence of crackles, as these help differentiate asthma from other conditions. 3
• The presence of polyphonic expiratory wheeze is the characteristic finding in asthma. 3, 2

Nasal and Upper Airway Examination

• You documented sinuses as non-tender but did not describe the nasal mucosa appearance (pale/boggy vs. erythematous vs. normal), which helps assess for allergic rhinitis—a common comorbidity with asthma. 3
• The quality and quantity of nasal discharge should be documented if present. 3
• Assess for nasal polyps more thoroughly, as they can be associated with asthma. 3

Cardiovascular Examination Beyond Basics

• While you documented cap refill, you did not document heart sounds, presence or absence of murmurs, or jugular venous pressure. 3
• Assess for signs of cor pulmonale if severe chronic respiratory disease is suspected (though unlikely in this acute presentation). 3

High-Risk Features Present in This Patient

Atopic March Indicators

• This patient has eczema plus wheezing, which places her at high risk for persistent asthma throughout childhood and adolescence. 2
• The combination of eczema, respiratory symptoms, and environmental allergen exposure (cockroach, secondhand smoke) strongly suggests atopic asthma. 3, 2
• Family history of eczema further supports atopic predisposition. 3

Severity Assessment Missing

• You did not document whether the patient can speak in full sentences or only short phrases—this is a critical severity indicator. 3
• Respiratory rate of 22 is mildly elevated for a 16-year-old (normal 12-20), but you need to assess work of breathing more systematically. 3
• Document whether the patient appears anxious or has altered mental status, which would indicate severe exacerbation. 3

Common Pitfalls to Avoid

Do Not Rely on Clinical Diagnosis Alone

• The most important pitfall is proceeding with asthma treatment without objective confirmation via spirometry and bronchodilator testing. 1, 2
• While this patient has classic symptoms (wheeze, dyspnea, cough, eczema, environmental triggers), symptom improvement after empiric treatment should not be used to diagnose asthma. 3, 1

Chronic Cough Considerations

• Although this patient has wheeze in addition to cough, be aware that children with chronic cough (>4 weeks) as the only symptom are unlikely to have asthma and should be investigated according to chronic cough guidelines. 3, 1
• This patient's cough is accompanied by wheeze, dyspnea, and chest tightness, making asthma the leading diagnosis. 3, 2

Environmental History Already Documented

• You appropriately documented cockroach exposure and secondhand smoke—both are important asthma triggers. 3
• The recent upper respiratory infection may have triggered this exacerbation. 3

Immediate Next Steps

Before initiating treatment, obtain spirometry with bronchodilator reversibility testing and consider FeNO measurement to objectively confirm the diagnosis of asthma. 1, 2 If the patient is in significant distress, treat the acute exacerbation first, but ensure objective testing is completed once stabilized to confirm the diagnosis. 3, 1