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

You are seeing Mr. Alexander, a 55 year old male, in the ER for a one week history of worsening and debilitating chest pain. Take a focused history of his complaint.

History

• Onset and duration of chest pain
• Location of pain
• Severity of pain
• Alleviating factors
• Aggravating factors, especially activity
• Frequency of chest pain
• Radiation of pain
• Association with shortness of breath
• Diaphoresis
• Palpitations
• Nausea/vomiting
• Symptoms of syncope
• Personal history of coronary artery disease and myocardial infarction
• TIA/Stroke
• Diabetes
• Dyslipidemia
• Hypertension
• Smoking history (quantity in pack-years)
• Family history of heart disease
• Effect on daily activities/occupation
• Patient’s concern as to the cause of the pain

Physical Examination

Inspection/Palpation

• Inspects precordium for scars, pulsations
• Palpates for the presence of thrills, heaves
• Palpates PMI and comments on size, amplitude, duration, and location

Carotid/JVP

• Examines JVP and comments on its estimated height
• Palpates the carotid arteries bilaterally
• Auscultates the carotid arteries for bruits

Auscultation

• Auscultates in all 4 areas of precordium with bell and diaphragm
• Comments on presence of murmurs, extra heart sounds
• Auscultates the lungs

Please assess the volume status of Mr. Kennedy, a 61 year old male, and comment on your findings.

Physical Examination

Vitals

• Assesses heart rate by palpating the radial pulse
• Measures blood pressure while supine
• Assesses orthostatic changes by measuring blood pressure and heart rate with patient standing
• Comments on vital signs findings of a patient who is hypovolemic

JVP

• Observes JVP with correct patient position (30 degrees head-up-tilt); adjusts patient accordingly if JVP is not initially evident
• Confirms JVP by changing angle of head of bed
• Occludes JVP to confirm location
• Comments on the multiple waveforms of the JVP
• Comments on the JVP height

Peripheral Vasculature

• Comments on capillary refill
• Comments on skin turgor, mottling
• Comments on mucus membranes
• Examines for peripheral edema
• Comments on peripheral temperature

You are seeing Mrs. Diaz, a 68 year old female, who is in your office because she says she has recurrent episodes of ‘fainting.’ Take a focused history of her complaint.

History

Syncope

• Onset of syncope
• Timing of syncope
• Frequency
• Duration of syncopal episodes
• Activity surrounding syncope
• Changes in position before syncope
• Distinguishes if true syncope, i.e. full loss of consciousness

Pre-syncopal signs and symptoms

• Distinguishes syncope from dizziness and vertigo
• Chest pain before syncope
• Shortness of breath
• Palpitations
• Focal neurologic deficits (vision, numbness, weakness)
• Systemic neurologic deficits

Post-syncopal signs and symptoms

• Post-ictal confusion
• Incontinence
• Weakness
• Personal history of heart disease
• Personal history of seizure
• Cardiac risk factors
• Family history of heart disease, seizure disorders