October 12, 2020

#236 Approach to Shortness of Breath: Physical Exam Series

41 minutes

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