Cough and SOB lecture Flashcards
Tests to be thinking about
CXR PFT Bronchodilator Methacholine Sputum test Rapid strep Flu test Covid
Smoking hx?
COPD
Emphysema
Chronic Bronchitis
Cough
COPD Asthma Bronchitis PNA Allergic rhinitis HF exacerbation Pulm Embolism Lung CA Cocci TB Flu
Whenever you have edema and sx that are seemingly heart related, remember it can be a primary respiratory problem
bc when lungs aren’t functioning properly, causes R side of heart to back up and be under more pressure
any WBC over 10 (or 11) is
HIGH
Orthopnea
SOB when lying down
Paroxysmal nocturnal dyspnea
SOB that awakes the patient
Tx for PNA:
Azithro “Z pack” or
Doxy
5 days
for uncomplicated CAP
Everyone used to get Levaquin (Levofloxacin) for PNA,
BUT now we caution with FluoroQ bc
life threatening Hypoglycemia/coma
Delirium, agitation, memory impairment
Tendons, retinal detachment
Influenza season for PNA
September - May
Clinical pearls for PNA
Wet cough Fever SOB Pleuritic CP Chills
If you see PNA in the upper lobes
consider Aspiration PNA
Right upper lobe PNA
Aspiration
CAP important tests
CXR
Blood or sputum culture (sometimes)
Acute bronchitis
Cough
NO FEVER
normal lung exam
Tests for Acute bronchitis
CXR (if abnormal exam, SOB, or high fever)
Influenza sx
Sudden onset
High fever
severe Myalgia
September-May season
Influenza test
Typically Clinical dx
Can test
Aspiration PNA
Impaired mentation (dementia, prior stroke, substance abuse)
Test for Aspiration PNA
CXR: showing R upper lobe
TB sx
Long duration of sx
Risk factors for TB
TB testing
CXR w upper lobe cavitary lesions
Sputum for AFB (acid fast bacilli)
What is tx for COPD exacerbation?
ABX!!
Macrolide: Z pack
and
______
SOB when lying down
Orthopnea
JVD and S3 gallop
Crackles to mid lung fields
2+ pitting pedal edema bilaterally
Acute HF
CXR:
- Blunting of costophrenic angle
- Increased vascular marking
Sx: SOB when lying down, DOE, pitting edema
Acute HF
SOB complaint with a significant underlying Cardiac history, be thinking about
Heart Failure!!
Acute HF tx
Admit
Oxygen
IV Furosemide (Lasix) 20mg
Strict I and Os
IV dose of Furosemide is
DOUBLE of oral dose
Once pt is admitted for HF exacerbation, you can then add these thing
Ct diuresis, I/Os, Low salt
+
B-blockers
ACE-I if EF <40%
get a TEE (Echo cardiogram to see more about HF)
What were the 2 new meds that we can add in the hospital to treat Acute HF other than Lasix?
ACE-I
B-blocker
Class 1 HF:
sx only at activity levels that would make anyone tired
Class 4 HF:
sx of HF at REST!
HF meds
Loop diuretics
K sparing diuretic
B-blocker
ACE-I
B-blocker for HF
Metoprolol (Toprol XL)
Carvedilol (CoReg)
ACE-I for HF
Lisinopril (Zestril)
Clinical pearls for Heart Failure
Edema and Weight gain
Most common cause of diastolic dysfx HF
HTN
Common causes of L sided Heart Failure
CAD
HTN
Common causes of R sided Heart Failure
Left heart failure #1!!!
or
Severe pulm dz
Edema, JVD, and fatigue are seen in what side of HF?
Both!
LV or RV failure
Pulmonary edema is seen in what side HF?
think that the ____ isn’t working correctly, so what comes before it is going to get backed up
Left Ventricle Heart Failure
LV isn’t working right, so as a result the Lungs are getting backed up
Pulmonary edema
LV failure
S3 gallop is pathognomic of
Volume overload
occurs most commonly in decompensated HF
Pearl sx for HF
Hx of CAD, prior MI, HTN, PND
PE: S3 gallop, JVD, crackles
HF tests
CXR
BNP
TTE (echo)
Acute Coronary Syndrome (heart attack) important tests
EKG
Cardiac enzymes
Angiography
Arrhythmia tests to consider
EKG
Telemetry/ Holter monitor
Event monitor
Valvular heart dz
Hx of Rheumatic heart dz
Test to get with Valvular heart dz
TTE (echo)
cc: SOB recent surgery O2 sat 87% Tachycardic Tachypneic
PE?!?!
blood clot
Remember, PE for a Pulmonary Embolism is often
Normal
Tachy and Tachy
BUT no adventitious breath sounds and CXR is often normal
Why are CBC and BMP imp when ruling out PE?
Does she have acute Anemia?
Infection?
Platelets? need to know for anti-coag meds if warranted
D dimer are good at
RULING OUT
but not confirming
Tests to order if thinking about PE
EKG
CXR vs CTA chest**
Labs: CBC, BMP, cardiac markers, PT/INR, aPTT
Best test to r/o PE
CTA (CT angiography)
keep in mind, this requires Contrast
Need to make sure pt’s kidneys are working well b4 giving contrast
Check Cr levels
Post op Tachycardia Tachypneic O2 sat low PE unrevealing
Pulmonary Embolism!!
Tx for PE
Anti-coags
If someone just had surgery and now has a PE, who do you need to think about calling?
The surgeon!!
make sure you can give the pt Anti-coags, aka make sure their recent surgical site bleeding risk isn’t too high
Anti-coags that will work immediately
Heparin drip
Lovenox
DOAC
Heparin
very quick acting, and quick to leave body if stopped
bleeding risk goes away in about 4 hours of stopping
Warfarin (Coumadin)
takes DAYS to become therapeutic
If you have a pt who has a blood clot and you want to be able to REVERSE the bleeding of Anti-coag if needed (i.e. they just had recent surgery), use:
Heparin!
What are the only cases in which you would perform a procedure for PE?
If person is HemoDynamicalyl unstable- can do
Thrombolysis
Thrombectomy
Good starting dose for Warfarin (coumadin)
5 mg PO daily
What can you use as a BRIDGE when starting Warfarin (coumadin) therapy?
Lovenox is the bridge
What do you need to monitor when giving Warfarin (Coumadin)?
INR
Lovenox (the bridge) and DOACs have black and white dosing, BUT ______ is diff for each patient
Warfarin (coumadin) is highly dependent on pt
Variable dosing per person
Warfarin (Coumadin)
Black and white dosing
Lovenox (Enoxaparin)
DOACs
Two DOACs used most often
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Rivaroxaban
Xarelto
Apixaban
Eliquis
Xarelto tx
15 mg PO bidaily x3 weeks
then 20 mg PO daily
Eliquis tx
10 mg PO bidaily x1 week
then 5 mg bidaily
PE clinical pearls
If pt has PE, very good chance they also have DVT!!!
Sudden onset SOB and leg swelling
favor PE
other things like fever, cough, crackles, and wheezes DO NOT
COPD exacerbation, that is unexplained
what could be causing??
make sure it’s not due to an underlying PE!!
CXR of someone with PE
is NORMAL
Wells score
PE probability
Gold standard for PE diagnosis
Angiography,
but we use CT angiography instead of traditional
Takes time for _____ to get to therap range
Warfarin (coumadin)
If pt has underlying CA, what anticoag should we use?
Lovenox
or apixiban (eliquis)
How long to treat 1st PE/DVT when there was an identifiable risk factor
3 months
How long to treat 1st PE/DVT when it was idiopathic- dk what caused it
3-6 months
How long to treat recurring DVT/PE or inherited coagulopathy
Indefinitely
Tests for Asthma
PFT
Peak flow
Methacholine challenge
