Shadow Health Focused Exam: Cough and Respiratory Assessment Guide (with Practice Cases)
10 min read In this guide
- What the Shadow Health Focused Exam: Cough evaluates
- Subjective questions for acute, subacute and chronic cough
- A step-by-step Shadow Health respiratory assessment
- Normal and adventitious breath sounds explained
- Two practice cases (COPD and medication-related cough) with documentation
- Patient education, common mistakes and FAQs
Why the cough focused exam matters
Cough is one of the most common reasons people visit a healthcare provider. It protects the airways by clearing mucus and irritants, but a persistent or changing cough can signal infection, asthma, chronic obstructive pulmonary disease (COPD), heart failure, reflux, medication side effects or, less commonly, lung cancer or tuberculosis. The Shadow Health Focused Exam: Cough asks you to characterize the cough, identify associated symptoms and risk factors, and perform a thorough respiratory assessment (Jarvis & Eckhardt, 2024). For a quick comparison with other focused exams, see our Shadow Health Focused Exams: Complete Guide.
Step 1: Classify the cough
| Type | Duration | Common causes |
|---|---|---|
| Acute | Less than 3 weeks | Viral upper respiratory infection, acute bronchitis, pneumonia, asthma flare, aspiration |
| Subacute | 3–8 weeks | Post-infectious cough, pertussis, asthma, sinus drainage |
| Chronic | More than 8 weeks (adults) | Upper airway cough syndrome (postnasal drip), asthma, reflux, COPD, ACE inhibitor use, smoking, bronchiectasis, lung cancer, heart failure, tuberculosis |
Step 2: Subjective data for cough
- Onset and duration: “When did the cough start? Did it begin with a cold?”
- Character: dry or productive; barking, hacking or whooping
- Sputum: color (clear, white, yellow, green, rust), amount, thickness, odor, blood (hemoptysis)
- Timing: worse at night, in the morning, after meals, when lying down, with exercise or cold air
- Associated symptoms: fever, chills, shortness of breath, wheezing, chest pain, runny nose, sore throat, heartburn, hoarseness, weight loss, night sweats, leg swelling, orthopnea
- Triggers and exposures: smoke, vaping, dust, pets, mold, pollen, chemicals at work, sick contacts, recent travel, tuberculosis exposure
- History: asthma, COPD, allergies, reflux, heart failure, previous pneumonia; immunizations (influenza, pneumococcal, COVID-19, pertussis)
- Medications: especially ACE inhibitors (such as lisinopril), inhalers and how they are used, over-the-counter cough remedies
- Smoking history: type, amount and years; calculate pack-years (packs per day × years smoked)
- Impact: sleep, work, exercise, urinary leakage with coughing
Step 3: The Shadow Health respiratory assessment
Inspection
- Respiratory rate, rhythm, depth and effort; ability to speak in full sentences
- Use of accessory muscles, nasal flaring, retractions, pursed-lip breathing, tripod position
- Chest shape (for example, an increased anteroposterior diameter, or “barrel chest,” in long-standing COPD)
- Skin and lip color; finger clubbing
Palpation
- Tenderness, masses, crepitus
- Symmetric chest expansion
- Tactile fremitus: increased over consolidation (pneumonia), decreased over air or fluid (pneumothorax, effusion, emphysema)
Percussion
- Resonant: normal lung
- Dull: consolidation, effusion or mass
- Hyperresonant: air trapping (emphysema) or pneumothorax
Auscultation
With the diaphragm, listen to a full breath at each site, moving side to side from the apices to the bases on the posterior, lateral and anterior chest (Ball et al., 2023).
| Sound | Description | Possible meaning |
|---|---|---|
| Vesicular | Soft, low-pitched; heard over most lung fields | Normal |
| Bronchovesicular | Medium pitch; between the scapulae and near the sternum | Normal in these areas |
| Bronchial | Loud, high-pitched; over the trachea | Abnormal if heard over peripheral lung (consolidation) |
| Crackles (rales) | Discontinuous popping sounds, usually on inspiration | Pneumonia, heart failure, pulmonary fibrosis |
| Wheezes | Continuous high-pitched musical sounds, often expiratory | Asthma, COPD, narrowed airways |
| Rhonchi | Low-pitched snoring sounds that may clear with coughing | Secretions in larger airways (bronchitis) |
| Stridor | High-pitched inspiratory sound from the upper airway | Airway obstruction; emergency |
| Pleural friction rub | Grating sound with breathing | Pleural inflammation |
| Diminished or absent sounds | Reduced air movement | Emphysema, effusion, pneumothorax, atelectasis |
Also check oxygen saturation, temperature and heart rate, and, if relevant, peak expiratory flow. Examine the nose, throat and lymph nodes for upper respiratory causes, and look for leg edema and jugular venous distention if heart failure is possible.
Red flags in a cough exam
Report promptly: coughing up blood; shortness of breath at rest or inability to speak in full sentences; oxygen saturation below the patient’s baseline or expected range; stridor; high fever with chest pain; unexplained weight loss or night sweats; a long-term smoker with a new or changed cough; possible tuberculosis exposure.
Practice case 1: chronic productive cough
Original practice case for learning; not taken from Shadow Health and not an answer key.
Patient: James Porter, 66, retired construction worker. “My cough is worse and I get winded walking to the mailbox.”
Subjective: morning cough with thick white sputum for “years,” worse over the past week with yellow-green sputum and increased shortness of breath; smoked 1 pack a day for 40 years (40 pack-years), still smokes half a pack daily; uses an albuterol inhaler “when I remember” and sometimes sprays it without inhaling deeply; worked around dust and fumes; no fever, chest pain, blood in sputum or leg swelling; last influenza vaccine two years ago.
Objective: T 99.1°F, HR 96, RR 24, BP 138/84, SpO2 90% on room air. Sitting forward, using accessory muscles, pursed-lip breathing; speaks in short phrases. Increased anteroposterior chest diameter. Hyperresonance to percussion. Diminished breath sounds bilaterally with scattered expiratory wheezes and rhonchi that partially clear with coughing. Prolonged expiration. No edema.
Clinical reasoning
- Cues: long smoking history, chronic productive cough, worsening dyspnea, change in sputum color, low oxygen saturation, accessory muscle use, barrel chest, hyperresonance, wheezes, poor inhaler technique.
- Analysis: findings are consistent with COPD with a likely acute exacerbation, possibly triggered by infection. COPD is characterized by persistent respiratory symptoms and airflow limitation, most often caused by smoking (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2025).
- Priority and actions: impaired gas exchange is the priority. Report findings promptly; anticipate bronchodilator therapy and further evaluation; position upright; coach pursed-lip breathing; teach correct inhaler technique with teach-back; offer smoking cessation support; recommend vaccinations.
Sample documentation
Subjective: 66-year-old male reports chronic morning productive cough with white sputum for years, worsening × 1 week with yellow-green sputum and increased exertional dyspnea. 40 pack-year smoking history; currently smokes ½ pack/day. Uses albuterol inhaler intermittently with incorrect technique. Occupational dust and fume exposure. Denies fever, hemoptysis, chest pain or edema. Last influenza vaccine 2 years ago.
Objective: T 99.1°F, HR 96, RR 24, BP 138/84, SpO2 90% on room air. Sitting upright leaning forward; accessory muscle use; pursed-lip breathing; speaks in short phrases. Increased AP diameter. Hyperresonant to percussion bilaterally. Diminished breath sounds throughout with scattered expiratory wheezes and rhonchi, partially clearing with cough; prolonged expiratory phase. No lower-extremity edema. Findings reported to provider.
Practice case 2: dry cough after a medication change
Patient: Carmen Diaz, 54. “I have this tickly dry cough that won’t go away.”
Subjective: dry, tickling cough for 6 weeks; no sputum, fever, shortness of breath or heartburn; nonsmoker. Started lisinopril for high blood pressure about two months ago.
Objective: vital signs normal; SpO2 99%; lungs clear to auscultation; throat without redness.
Reasoning: a dry cough that began after starting an ACE inhibitor, with a normal exam, suggests a medication-related cough. Report it to the provider, who may consider an alternative medication. Teach the patient not to stop her blood pressure medicine on her own. This case shows why the medication history is essential in a cough exam.
Patient education opportunities
- Smoking and vaping cessation, with referral to support programs
- Correct inhaler and spacer technique, using teach-back
- Recognizing worsening symptoms and following an action plan for asthma or COPD
- Vaccinations: influenza, pneumococcal, COVID-19 and pertussis, as recommended
- Hydration, rest, cough etiquette and hand hygiene during infections
- Avoiding triggers such as smoke, dust and allergens
Common mistakes in the cough focused exam
- Not asking about sputum color, amount and blood
- Forgetting the medication history (ACE inhibitors) and smoking pack-years
- Listening through clothing or only on the anterior chest
- Not comparing side to side at each level
- Skipping percussion and tactile fremitus
- Missing education on inhaler technique and smoking cessation
Sample interview flow for the cough exam
Example questions you might type, in a logical order. Adapt the wording to each patient.
- “Hello, I’m [name], the nurse who will be examining you today. Can you confirm your name and date of birth?”
- “Tell me about your cough. When did it start?”
- “Is it dry, or do you cough anything up? What color is it, and how much?”
- “Have you noticed any blood when you cough?”
- “Is it worse at certain times, like at night, in the morning, after meals or with exercise?”
- “Do you have fever, chills, shortness of breath, wheezing or chest pain?”
- “Any runny nose, sore throat, heartburn or a sour taste in your mouth?”
- “Have you been around anyone who is sick, or traveled recently?”
- “Do you smoke or vape, or have you in the past? How much and for how long?”
- “Are you exposed to dust, fumes, mold or pets at home or work?”
- “Do you have asthma, COPD, allergies or heart problems?”
- “What medications do you take, including inhalers? Can you show me how you use your inhaler?”
- “Which vaccines have you had recently, such as flu or pneumonia vaccines?”
- “How is the cough affecting your sleep and daily life?”
Cough and respiratory exam checklist
- Classify the cough as acute, subacute or chronic
- Characterize sputum, timing, triggers and associated symptoms
- Calculate pack-years and review medications such as ACE inhibitors
- Inspect breathing pattern, effort, accessory muscles, chest shape and clubbing
- Palpate expansion and tactile fremitus
- Percuss for resonance, dullness or hyperresonance
- Auscultate anterior, lateral and posterior fields side to side
- Check oxygen saturation and teach inhaler technique, vaccinations and smoking cessation
Frequently asked questions
How do I calculate pack-years?
Multiply the number of packs smoked per day by the number of years smoked. For example, one pack a day for 40 years equals 40 pack-years, and half a pack a day for 20 years equals 10 pack-years.
What is the difference between crackles and rhonchi?
Crackles are brief popping sounds caused by fluid in small airways or alveoli, often heard in pneumonia or heart failure. Rhonchi are lower-pitched, snoring sounds caused by secretions in larger airways and may clear after coughing.
Should I examine the heart in a cough exam?
Yes, briefly. Heart failure can cause cough, crackles and shortness of breath, so listen to the heart and check for edema and jugular venous distention when appropriate.
What does tactile fremitus tell me?
Fremitus is the vibration you feel on the chest wall when the patient speaks. It increases when lung tissue is consolidated, as in pneumonia, and decreases when air or fluid separates the lung from the chest wall, as in pneumothorax, pleural effusion or emphysema.
When is a cough an emergency?
Coughing up significant blood, severe shortness of breath, inability to speak in full sentences, stridor, bluish lips or low oxygen saturation require immediate reporting and emergency care.
More in the series: Shadow Health Focused Exam: Chest Pain, Shadow Health Special Populations Focused Exams and Shadow Health Documentation.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Global Initiative for Chronic Obstructive Lung Disease. (2025). Global strategy for prevention, diagnosis, and management of COPD: 2025 report. https://goldcopd.org
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
