Clinical Skills Flashcards
Shortness of Breath associated symptoms
RESPIRATORY and CARDIAC
> On exertion vs at rest? position? Paroxysmal nocturnal?
> + chest pain = MI, PE, infection
> + fever, chills, night sweats, weight loss = infection, cancer, emphysema
> + orthopnea, PND = CHF
> + stridor = large airway obstruction, croup
> + calf pain = deep vein thrombosis, PE
> + edema = CHF
> + cough = asthma, COPD, ILD
Cough associated symptoms
> Acute (<3wks), subacute, chronic (>8wks); time of day, exertion
+ sputum:
……… Frothy pink: Pulmonary edema
……… Rusty: pneumococcal pneumonia
……… Brown/black: chronic pneumonia, bronchitis, cancer
……… Yellow/green: CF, acute infection, lung abcess
……… Red jelly: Klebsiella infection
……… Blood: TB, cancer, PE
+ SOB = asthma, COPD, ILD
+ worse at night = CHF
+ Sour taste in mouth = GERD
+ Fever, weight loss, voice horsness = RED FLAGS
+ Brassy/barky cough = croup
Hoarsness associated symptoms
>
- Worse in the cold = asthma
Chest pain/tightness associated symptoms
Tightness = angina
Tearing/ripping pain (& back pain) = aortic dissection
> + Relieved promptly by nitroglycerin = angina
> + Better leaning forward = pericarditis
> + Worse on inspiration & stabbing pain = PE, pericarditis, pneumonia, pneumothorax, rib fracture
> + Worse with palpation = rib fracture, costochondritis
> + pain shooting down arms = MI
Stridor associated symtoms
>
- during inspiration = foreign body extra-thoracic
- Soft sound = epiglottitis
- Harsh = viral upper respiratory tract infection
- Brassy/barky cough = croup
Can’t miss diagnosis of chest pain
P → Pulmonary embolism: pleuritic chest pain, increased HR, SOB
E → Esophageal rupture: vomiting, epigastric pain, anxiety
T → Tension pneumothorax: tracheal deviation, sudden SOB, PCP
M → MI: retrosternal chest pain, radiating to arms/jaw, sweaty, low BP
A → Aortic dissection/rupture: tearing, upper back pain, BP diff right and left
C → Cardiac tamponade: SOB, Beck’s triad (low BP, JVD, muffled heart sounds)
Beck’s triad
- Low BP
- JVD
- Muffled heart sounds
CARDIAC TAMPONADE
Respiratory Exam
—INSPECTION—
> Work of breathing:
→ tripod, pursed lips
→ nasal flaring
→ accessory muscles
→ paradoxical breathing
→ tracheal tug
→ suprasternal
→ intercostal indrawing
→ able to complete sentences
> Rhythm of breathing:
→ Cheyne stokes: periodic breathing, gradually slower (CHF, ICP, CO poisoning
→ Kussmaul: rapid, deep laboured breathing (metabolic acidosis, DM)
→ Shallow: inhibited breathing (+ pleuritic chest pain = PE, pericarditis, pneumonia, rib fracture)
→ Cushing’s triad: irregular respiration, bradycardia, widened pulse pressure
> Assistive Equipment
Scars, medical devices
Cachexia and sarcopenia (muscle wasting)
Barrel chest, flail chest
Pectus excavatum, carinatum
Scoliosis, kyphosis
Central cyanosis
Peripheral cyanosis
Clubbing (chronic hypoxia, cyanotic heart disease, lung cancer, ILD)
Tar staining
—PALPATION—
>Laryngeal height (<4cm = hyperinflation)
>General (masses)
>Bilateral chest expansion (low in asthma, COPD, thoracic scoliosis)
>Tracheal deviation (away from pathology = tension, toward = collapse)
>Tactile fremitus (vibration high over consolidation, low over pleural effusion)
—PERCUSSION—
>Intercostal
>Diaphragmatic excursion
—AUSCULTATION—
>General
>Consolidation
>Forced expiration time (>9sec = COPD, asthma)
Rhythms of Breathing
→ Cheyne stokes: periodic breathing, gradually slower (CHF, ICP, CO poisoning
→ Kussmaul: rapid, deep laboured breathing (metabolic acidosis, DM)
→ Shallow: inhibited breathing (+ pleuritic chest pain = PE, pericarditis, pneumonia, rib fracture)
Cushing’s triad
- irregular respiration
- bradycardia
- widened pulse pressure
Resp sounds
FINE CRACKLES: on inspiration → distal lower process (fibrosis, CHF)
COARSE CRACKLES: on inspiration →proximal lower process (pneumonia, pulmonary edema, adult RDS)
STRIDOR: on inspiration → upper obstruction (croup, epiglottitis, bacterial tracheitis, retropharyngeal abscess, peritonsullar abscess, foreign body)
PLEURAL RUB: on expiration → pleural inflammation (effusion, PE, pleuritis)
WHEEZE: on expiration → lower distal airway diameter (asthma, COPD)
RHONCUS: on expiration → lower proximal airway diameter by mucus (pneumonia, CF)
Palpitations associated symptoms
**DDx: cardiac arrhythias, sinus tachycardia
>
- affected by sleeping = vagal tone-mediated Afib or long-QT syndrome
- Duration <5min = low likelihood arrhythmia
- Regular rapid-pounding sensation in neck = cardiac arrhythmia, AVNRT
- drugs that prolong QT = anti-arrhythmatics, antihistaminses, anti-depressants
Fatigue associated symptoms
>
- muscle weakness = neuromuscular etiology?
- acute infectious symptoms = influenza, EBV mononucleosis
- mood changes = psychiatric causes, depression
- unintentional weight loss = cancer
- hematological questions:
……. Adequate oxygenation: energy, SOB, exertional capacity, skin/colour changes, menorrhagia, trauma, easy bruising
……. Blood loss: hematemesis, hemoptysis, hematochezia, melena, hematuria, menorrhagia, trauma, easy bruising
……. Hematological-oncology: constitutional symptoms
Cardiac Exam
—INSPECTION—
> General: resp distress, diaphoresis, weight, consciousness, scars, pacemaker
> Eyes: conjunctiva pallor, icterus, arcus senilus (hyslipidemia)
> Head: pallor, central cyanosis
> Hands: splinter hemorrhages, janeway lesions, osler nodes, resp, cap refill, tremor (thyrotoxicosis)
> JVP: occludable, non-palapble, biphasic, low with elevation, high with AJR
> Abdomin: ascites, pulsations, scars
> Legs: edema, erythema, sacrs, vascular insufficiency
> Xanthoma: yellow deposits (hyperlipidemia)
> Coagulopathy: hematomas (petechiea, purpura, ecchymosis, telangiectasis)
—PALPATION—
> AJR
heaves, thrills
PMI (location, amplitude, duration, size; lean forward, left side)
Edema
Central and upper limb pulses
—AUSCULTATION—
> CV: S3 “montreal” loose & high volume; S4 “toronto” stiff & high pressure
Carotid bruits: duration, intensity, pitch
*Carotid upstroke: no delay between murmur onselt and carotid pusle (aortic stenosis or regurgitation)
Head and neck exam
