Case 1 – Shortness of Breath
You are seeing Mrs. Chan, an 81 year old female, in the ER for a one week history of progressive shortness of breath. Take a focused history of her complaint.
History
- Onset and duration of shortness of breath
- Progression of shortness of breath
- Alleviating factors
- Orthopnea
- Asks about nighttime symptoms and paroxysmal nocturnal dyspnea
- Association with cough
- Chest pain
- Palpitations
- Leg swelling
- Nocturia
- Abdominal distension
- Syncope, pre-syncope
- Presence of fever, chills, and other systemic symptoms
- Adherence to medications, diet
- Personal history of CHF, CAD, MI, and CVA
- Smoking history (quantity in pack-years)
- Occupational history
- Diabetes
- Dyslipidemia
- Hypertension
- Current medications
- Family history of heart disease
- Effect on daily activities
Physical Examination
Inspection
- Inspects patient, comments on respiratory status
- States that weight should be measured for BMI/fluid overload status
- Volume Status
- Examines lower extremities for pitting edema
- Examines JVP and comments on its estimated height
- Measures pulse, comments on rate and rhythm
- Evaluates patient’s orthostatic vitals
- Examines the abdomen for ascites and a pulsatile liver, indicating right heart failure
Pre-cordium/Carotid
- Palpates for the presence of thrills, heaves
- Palpates PMI and comments on size, amplitude, duration, and location
- Auscultates in all 4 areas of precordium with bell and diaphragm
- Comments on presence of murmurs, extra heart sounds
- Examines carotid arteries for bruits
Respiratory
- Percusses posterior chest, comments on dullness
- Auscultates all lung fields, commenting on presence of crackles, wheezes or other adventitious breath sounds
