#236 Approach to Shortness of Breath: Physical Exam Series
The Curbsiders Internal Medicine Podcast
The Role of the Physical Exam in Hypothesis-Driven Exams
To understand how the physical exam affects the diagnosis, it's helpful to understand the concepts of pretest probability, likelihood ratios, and post-test probability. Using Fagin's Nomogram, a clinician can then take the pretest probability of a diagnosis, use the likelihood of ratio of an exam maneuver, and then determine the post- test probability to make a diagnosis. In this episode, we pulled data from four sources: The McGee's Evidence-Based Physical Diagnosis Textbook, JAMA Rational Clinical Exam Series, Jack State of the Art Review and the Role of the Clinical Exam in Patients with Heart Failure.
Learn which exam maneuvers are worthwhile and which ones are worthless in your approach to shortness of breath. In our evidence based series on the physical exam, we discuss the approach to the dyspneic patient with Dr. Brian Garibaldi (Hopkins, SBM), associate professor of pulmonary and critical care medicine at Johns Hopkins, and co-president of the Society of Bedside Medicine. We discuss the physical exam’s effect on our differential diagnosis, maneuvers that are commonly taught, and some simple tests with great data that may go overlooked. Be prepared, this episode may take your breath away!
Credits
- Written and Produced by: Justin Berk, MD, MPH, MBA and Sam Masur, MD
- Infographic: Sam Masur, MD, Beth Garbitelli
- Cover Art: Beth Garbitelli
- Hosts: Stuart Brigham, MD; Matthew Watto, MD, FACP; and Paul Williams, MD, FACP
- Editor:Justin Berk MD; Clair Morgan of nodderly.com
- Guest(s): Brian Garibaldi, MD
Sponsors:
National Internal Medicine Day
Help ACP celebrate National Internal Medicine Day on October 28th. Visit https://www.acponline.org/NIMD20 to learn how you can show your internal medicine pride. Be sure to tag @ACPInternists and use the hashtags #NationalInternalMedicineDay, #IMProud, and #IMEssential.
VCU Health CE
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. Note: A free VCU Health CloudCME account is required in order to seek credit.
Time Stamps
- Sponsor – National Internal Medicine Day, The American College of Physicians
- Sponsor – VCU Health Continuing Education
- 00:00 Intro, disclaimer, guest bio
- Sponsor – National Internal Medicine Day, The American College of Physicians
- 03:47 Introduction to evidence-based exam, pre-test probability, and likelihood ratios
- 05:29 Case from Kashlak Memorial
- 06:51 Dr. Garibaldi’s initial maneuvers for the dyspneic patient
- 11:33 Recapping the exam maneuvers
- 14:05 Likelihood ratios for common maneuvers
- 18:25 Over 6/Under 6 maneuvers
- 25:30 Recap of Dr. Garibaldi’s go-to maneuvers
- 28:19 Role of labs and diagnostic imaging
- 31:03 Role of point-of-care ultrasound (POCUS)
- 34:10 Friday at 5pm
- 36:31 Take home points
- 39:25 Outro
- Sponsor – VCU Health Continuing Education
Links*
- Stanford 25: Teaching and promoting bedside exam skills to students, residents and healthcare professionals both in person and online
- The 5 Minute Moment at the Society of Bedside Medicine
- The POCUS Atlas: Evidence Based Point of Care Ultrasound
Goal
Listeners will feel confident how to optimally use the physical exam to guide clinical decision-making in patients presenting with dyspnea.
Learning objectives
After listening to this episode listeners will…
- Describe the effectiveness of the exam when it comes to aiding diagnosis in a patient with dyspnea
- Identify specific exam maneuvers that can aid clinical decision-making
- Identify exam maneuvers that may not offer more information compared to imaging such as POCUS
Disclosures
This episode was made with assistance from the Society of Bedside Medicine and funding from the New York Academy Medicine. Dr Garibaldi reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Citation
Masur S, Garibaldi BT, Watto M, Williams P, Brigham S, Berk J. #236 Physical Exam Series: Approach to Shortness of Breath. The Curbsiders Internal Medicine Podcast. https:/www.thecurbsiders.com/episode-list. Original Air Date October 12, 2020.
References
- Mochizuki K et al. Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study. Acute Med Surg. Nov 2016. doi:10.1002/ams2.252
- Sarkar M et al. Physical signs in patients with chronic obstructive pulmonary disease. Lung India. 2019. doi:10.4103/lungindia.lungindia_145_18
- Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293(5):257. doi:10.1056/NEJM197507312930513
- Simel, David, et al. Rational Clinical Examination, McGraw-Hill Professional Publishing, 2009. ProQuest Ebook Central
- McGee, Steven. Evidence-based physical diagnosis [4th edition] Elsevier, 2018. Clinical Key
- Benbassat, J., Baumal, R. Narrative Review: Should Teaching of the Respiratory Physical Examination Be Restricted Only to Signs with Proven Reliability and Validity?. J GEN INTERN MED 25, 865–872 (2010). https://doi.org/10.1007/s11606-010-1327-8
- Al Deeb M et al. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014;21(8):843-852. doi:10.1111/acem.12435
- Yousefifard et al. Screening Performance Characteristic of Ultrasonography and Radiography in Detection of Pleural Effusion; a Meta-Analysis. Emerg (Tehran). 2016;4(1):1-10.
- Martindale et al. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016;23(3):223-242. doi:10.1111/acem.12878
- Caldentey et al. Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (atrial fibrillation and chronic heart failure). JACC Heart Fail 2014.. doi:10.1016/j.jchf.2013.10.004
Tags
Physical exam, dyspnea, shortness of breath, auscultation, PMI, percussion, heart failure, wheeze, POCUS, COPD, JVD, hepatojugular reflux, observation, asymmetry, Brian Garibaldi, practice, pallor, lung, heart, hands.
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