#236 Physical Exam Series: Approach to Shortness of Breath

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.
 
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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.