FEATURE

Bedside Medicine- A Forgotten Art.

Prof. B. M. Hegde,
hegdebm@gmail.com

Fatigue:

This is a non specific symptom but an important one in heart failure patients. To get at the bottom of this symptom on the bed side could be quite taxing as anything from anxiety to cancer could cause this, fatigue syndrome being another confounding diagnosis.

However some questions are in order to get at the truth.

• How long have you been having this problem? Fatigue is one of the earliest signs of progressive cardiac failure especially of the right heart variety.

• Is it worsening as the days go by?

• What exactly do you mean by fatigue?

• How much can you do routinely?

• In what way do you think your daily routine is affected by this fatigue?

System review:

A thorough examination of the cardiovascular system requires the patient to be comfortable and co-operative. One needs to do a cursory general examination with special reference to signs that are secondary to heart disease in other systems. Good light, undressing down to the waist and a nurse to help are very useful. In fact, a good doctor could make out a lot as the patient walks into his room in any outpatient set up or his behavior in bed in the ward. There will be the details in the video tape of the actual details of the examination demonstrated.

• The following points should be noted by the examining doctor before proceeding further.

• Is s/he comfortable?

• Is s/he cyanosed?

• Is s/he breathless at rest?

• Does s/he understand commands correctly?

• Does s/he lie flat in bed comfortably?

• Does s/he look well nourished or does he look famished?

• Does s/he look pale or jaundiced?

• Is s/he anxious?

• Is s/he co-operative or confused?

• Does s/he have ankle swelling?

Take Home message:

1) A careful history is a must be begin the examination. This should give away the diagnosis to a great extent.

2) Examination should be methodic, lest one should miss any important clue to refine the diagnosis obtained from the history.

3) Remember to examine other systems to rule out congestive cardiac failure-ankle oedema, liver enlargement, increased jugular venous pressure, basal pulmonary rales, and ascites.

Examination of the Respiratory System.

The respiratory system examination should precede, as always, with a short history of the prominent symptoms like:

• Cough.

• Spit.

• Fever with or without chills.

• Blood in the spit.

• Wheeze.

• Breathlessness.

• Ankle oedema.

• Upper respiratory problems like common cold, feverish cold, sore throat and, ‘Flu like illness.

• Chest pain on breathing.

History taking:

One could presume that there is no respiratory illness without cough. History of cough, thus, assumes central role in history. The duration of the cough, its relation to posture, its severity, whether it is dry or productive, its association with wheeze, and its association with any additional sounds like a whoop would assist in the final diagnosis. Next in significance is the spit that comes out. A detailed history of the spit and, if possible, a personal examination of the spittoon that the patient uses could also be is use. In the case of cough due to pulmonary oedema in the early stages the diagnosis could be made if one gets an opportunity to see the spittoon that has not been cleaned for a few hours. In case of pulmonary oedema the alveoli contain the oedema fluid which gets mixed with the surfactant present there. The surfactant does not allow the bubbles formed there due to churning of the fluid during coughing to collapse. Even when kept in the spittoon for some hours the spit dries up leaving behind the rings of the remains of the bubbles. This does not happen in any other condition- a sine qua non of pulmonary oedema. 

The other details of the spit are the quantity per spit and over a period of twenty four hours. Its relation to posture is very important in large lung abscesses. The colour of the spit and its smell also are important. Presence of blood in the sputum needs further enquiries about the type of blood-fresh or discoloured. That does make a difference. Occasionally, small lung debris might also be seen in the spit. Large amounts of pussy sputum suggest the possibility of either bronchiectasis or lung abscess. The three layered sputum that the textbooks describe is rarely seen outside the textbooks! 

Wheezing sound that is audible suggests severe bronchospasm. But mild wheeze could only be assessed by auscultation. If the patient complains of wheezing, which is not obvious, one needs to go deep into the story. First difference is between perennial wheeze as compared to paroxysmal wheeze characteristic of bronchial asthma. In the latter case the factors that bring on a wheeze are as important as the wheeze itself.

The symptom that is next in order of importance is the sputum that the patient brings out. Its quantity, quality, color, presence of blood-fresh or old- as also its relation to posture are of importance. Frank haemoptysis, lot of blood in the sputum is a grave symptom needing immediate action. It is one of those urgent situations in medicine as occasionally the patient might even bleed to death, very rarely though. Commonly it is blood tinged sputum that is the pr4esenting feature. This could be a feature of many serious illnesses, the common among them being pulmonary tuberculosis and malignancy in the lungs. In extreme situations of gross pulmonary oedema as seen in acute left heart failure the sputum could be “prune juice” like. This is more of a jargon than reality. Usually the sputum in pulmonary oedema, as described in earlier chapter, has a very characteristic feature in that the sputum in the mug dries up in discreet rings as the bubbles in the fresh sputum never break, thanks to surfactant, in the alveoli. The bubbles dry as rings. The sputum could occasionally also have mild discolourations due to RBCs in it.

Fever is the next common symptom in respiratory disease and denotes infection in the lungs either bacterial or viral as the case may be. The classical textbook description of the evening rise of temperature is usually seen in tuberculosis. High temperature could be a feature of some pneumonias while low grade fever is seen in atypical pneumonias of viral aetiology. That said, we must be prepared to encounter any or all these infections without any rise in temperature: this happens when the patient’s immune system is depressed.

Usual questions to be asked:

1) What is your main complaint?

2) How long have you been suffering from this?

3) Did it all start suddenly or did the symptoms develop and increase gradually over a period of time?

4) Were there remissions in between?

5) What are the drugs that you are taking at the moment?

6) Did any of your medicines change the course of your symptoms? If so which one was the medicine and what was its effect on the course of the disease so far.

7) Did you have fever? Describe the fever……….

Let us no take the symptoms one by one and go into them in some details.

Contd. in next issue......