What comprehensive history and physical exam should be performed on an adult (≥40 years) with suspected or known chronic obstructive pulmonary disease?

Complete History and Physical Examination for COPD

History Taking

Core Symptom Assessment

The diagnosis of COPD should be suspected when patients over 40 years present with progressive dyspnea that worsens with exercise and persists over time, chronic cough (often intermittent and initially dismissed as "smoker's cough"), chronic sputum production for ≥3 months in 2 consecutive years, wheezing, chest tightness, or recurrent lower respiratory infections. 1, 2, 3

Smoking and Exposure History

• Quantify tobacco exposure in pack-years (packs per day × years smoked); a smoking history >40 pack-years has a positive likelihood ratio of 12 for airflow obstruction 3, 4
• Document occupational exposures to dusts, vapors, fumes, or gases 1, 2, 3
• Assess environmental exposures including smoke from home cooking/heating 3
• A smoking history >55 pack-years combined with wheezing on auscultation and patient-reported wheezing virtually confirms airflow obstruction (likelihood ratio 156) 3

Past Medical and Family History

• Document childhood respiratory conditions (wheeze, bronchitis, pertussis, pneumonia, tuberculosis) as these suggest alternative diagnoses 1, 3
• Record history of atopy or asthma 1, 3
• Obtain family history of COPD, alpha-1 antitrypsin deficiency, or chronic respiratory disease 2, 3
• Document age of symptom onset and pattern of progression 3

Functional Impact Assessment

• Record specific exercise tolerance (e.g., distance walked, stairs climbed) to establish baseline for monitoring future changes 1, 5
• Assess impact on activities of daily living and work absenteeism 3
• Document exacerbation history and prior hospitalizations for respiratory disorders 3

Comorbidity Screening

• Screen for cardiac risk factors (age >65, orthopnea, history of MI, hypertension, atrial fibrillation) as heart failure commonly mimics COPD exacerbations 5, 6
• Assess for depression, a common and often overlooked comorbidity 2
• Evaluate social circumstances and available support systems 2

Physical Examination

Vital Signs and Anthropometrics

• Measure respiratory rate, oxygen saturation at rest and with exertion, weight, height, and BMI at every visit 1, 5
• Document pulse rate (>100 bpm may suggest pneumonia or exacerbation) 5

Respiratory System Examination

A normal physical examination is common in mild COPD and does not exclude significant disease; characteristic signs typically appear only when lung function is already markedly impaired. 1, 3, 5

Signs of Hyperinflation

• Loss of cardiac dullness on percussion 1
• Decreased cricosternal distance (<3 finger breadths) 1
• Increased anteroposterior diameter of the chest 1
• Hyperresonance on percussion (positive likelihood ratio >5.0 when combined with diminished breath sounds) 1

Auscultatory Findings

• Diminished or quiet breath sounds (positive likelihood ratio >5.0 for COPD) 1
• Wheezes (rhonchi), especially on forced expiration 1
• Prolonged expiratory phase 1

Signs of Advanced Disease

• Central cyanosis (though its absence does not exclude hypoxemia) 1
• Weight loss (but consider occult malignancy) 1
• Peripheral edema indicating cor pulmonale 1
• Raised jugular venous pressure, right ventricular heave, loud pulmonary second sound, tricuspid regurgitation (signs of pulmonary hypertension, often masked by hyperinflation) 1

Signs of Hypercapnia (During Acute Exacerbations)

• Flapping tremor (asterixis) 1
• Bounding pulse 1
• Drowsiness or confusion 1
• Note: High PaCO₂ can occur in stable severe COPD without these signs 1

Functional Assessment

• Assess maximal laryngeal height (distance from thyroid cartilage to suprasternal notch during full inspiration; reduced in COPD) 4
• Measure breathlessness using the modified Medical Research Council (mMRC) dyspnea score 1
• Perform functional capacity testing with timed walking distances or walking speed, as exercise tests predict mortality particularly well in COPD 1

Airway Assessment (If Considering Bronchoscopy)

• Evaluate mouth opening, Mallampati score, thyromental distance (normal >3 finger breadths), and cervical spine mobility 1

Critical Diagnostic Pitfall

Physical examination and clinical impression alone have very limited diagnostic value (likelihood ratio 0.59 for ruling out airflow obstruction); COPD must NEVER be diagnosed without spirometric confirmation showing post-bronchodilator FEV₁/FVC <0.70. 3, 4, 7 The absence of smoking history, no wheezing on history, and no wheezing on examination essentially excludes airflow obstruction (likelihood ratio 0.02) 3, but spirometry remains mandatory for definitive diagnosis 2, 3.

Immediate Investigations Required

Mandatory Testing

• Post-bronchodilator spirometry (after 400 mcg albuterol or equivalent) showing FEV₁/FVC <0.70 confirms persistent airflow limitation and establishes the diagnosis 2, 3, 5
• Chest radiography to exclude alternative diagnoses (pneumonia, pulmonary edema, pneumothorax, lung masses) and identify concomitant diseases 1, 5

Additional Testing as Indicated

• Arterial blood gas analysis if hypoxemia or hypercapnic respiratory failure suspected 5
• CT chest if emphysema quantification, bronchial wall thickening assessment, or lung cancer suspected 1, 5
• Alpha-1 antitrypsin screening in all patients ≤40 years with confirmed COPD 2
• Laboratory investigations for vasculitis or connective tissue disorders if nonmalignant central airway obstruction suspected 1