Day 2: Pathophysiology Flashcards
Doc thought process
- subjective complaints and risk factors
- differential diagnoses
- objective evaluation
- final diagnosis
Pertinent positive
specific symptoms that raise the physician’s suspicions for that disease
Pertinent negative
symptoms NOT present that cause doc to doubt certain diagnoses
CAD
MAJOR DDX FOR CP
Etiology: narrowing of coronary arteries, causing angina (CP due to heart ischemia)
1. catch phrase: “chest pain with physical exertion”
2. CC: CP or chest pressure (worse with exertion, improved with rest)
3. Associated Meds: ASA 324 mg PO, NTG .4 mg SL
4. Dx by: cardiac catheterization, not Dx in ED
5. a) CAD greatest risk factor for MI
b) stress test or cardiac cath assess severity of CAD
c) pt has CAD if they have PMHx Angina, MI, CABG, cardiac stents, or angioplasty
d) EVERY patient complaining of CP should receive ASA, unless given PTA or contraindicated due to bleeding or allergy
MI (STEMI, non-STEMI)
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR CP
Etiology: acute blockage of coronary arteries results in ischemia and infarct of the heart muscle
1. Catch phrase: CP with diaphoresis, N/V, and SOB
2. Risk factors: CAD, HTN, HLD, DM, Smoker, FHx of CAD < 55 y.o.
3. CC: CP or chest pressure
4. Dx by: EKG (STEMI) or elevated Troponin (non-STEMI)
5. Assoc. Med: ASA, NTG, B-blocker, Thrombolytic (Heparin)
6. Note: Acute MI pt must receive ASA 324 mg ASAP. STEMI pt must get to Cath-lab w/in 90 min of arrival. Document ED arrival and depart times
CHF
CRITICAL CARE DDX
MAJOR DDX FOR SOB
Etiology: heart enlarged, inefficient, and congested with excess fluid
1. catch phrase: SOB w/pedal edema and orthopnea
2. CC: SOB: worse lying flat (orthopnea), Paroxysmal Nocturnal Dyspnea (PND), DOE
3. PE: rales, JVD
4. Assoc med: Diuretics (lasix, furosemide) -> urinate extra fluid
5. Dx by: CXR or elevated BNP (B-type natriuretic peptid)
6. note: think of CHF as fluid traffic jam in the heart; fluid backs up in neck (JVD) and down the legs (pedal edema)
A-Fib
Etiology: electrical abnormalities in the “wiring” of the heart causes top of heart (atria) to quiver abnormally
- CC: palpitations
- risk factors: Paroxysmal A-Fib, chronic A-Fib
- PE: irregularly irregular rhythm, tachycardia
- Dx by: EKG(ECG)
- Assoc meds: coumadin (warfarin), blood thinner
- Note: ED concern is Rapid Ventricular Response (RVR). These pts will often be “cardioverted”, put back into NSR
Non-cardiac causes of CP
- Pericarditis: inflammation of the sac surrounding the heart
- Pleurisy: inflammation of the sac surrounding the lungs
- Costochondritis: irritation of the ribs causing CP, worsened by pressing on the sternum
- Chest Wall Pain: irritation of the chest wall causing pain with palpation of the chest
- Pleural Effusion: fluid collecting around the lungs causing SOB or CP
PE
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR CP OR SOB
Etiology: blood clot becomes lodged in pulmonary artery, blocks blood flow to lungs
1. Catch phrase: pleuritic CP w/Tachycardia and hypoxia
2. risk factors: known DVT, PMHx of DVT or PE, FHx, recent surgery, cancer, A-fib, Immobility, Pregnancy, BCP, smoking
3. CC: SOB or pleuritic CP (worse w/deep breaths)
4. Dx by: CTA chest (CT chest w/IV contrast) or VQ scan. D-dimer aids in detecting clots, but cannot diagnose a PE
PNA (pneumonia)
CORE MEASURE
MAJOR DDX FOR FEVER/SOB/CP
Etiology: infiltrate (bacterial infection) and inflammation inside the lung
1. catch phrase: productive cough with fever
2. risk factors: elderly, bedridden, recent chest injury, recent surgery
3. CC: SOB or productive cough
4. Assoc. Sx: cough with sputum, fever, chest pain
5. Assoc. Meds: Rocephin and Zithromax (Abx)
6. Dx by: CXR
7. Note: Community Acquired Pneumonia (CAP) protocol applies to pt’s with PNA. Document Abx, vital signs, SaO2, mental status, and blood cultures
PTX (Pneumothorax)
CRITICAL CARE DX
Etiology: collapsed lung due to trauma or spontaneous small rupture of the lung
1. CC: SOB and one-sided CP (sudden onset, often trauma pt’s)
2. PE: absent breath sounds unilaterally
3. Dx by: CXR
4. Note: document % lung collapsed (e.g. 20% PTX)
COPD
Etiology: long-term damage to lung alveoli (emphysema) along with inflammation and mucous production (chronic bronchitis)
- risk factors: smoking
- CC: SOB
- PE: decreased breath sounds, wheezing, rales
- Assoc Meds: Home O2 (document how much they use @ baseline)
- Dx by: CXR and hx of smoking
Asthma
Etiology: constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a “bronchospasm”
- CC: SOB/wheezing (improved with nebulizer “breathing treatments” (bronchodilators)
- PE: wheezes (inspiratory or expiratory)
- Dx by: clinical
- Note: Doc will ask: 1. Do you have a home nebulizer (machine)? 2. Have you been on steroids recently? 3. Hx of hospitalization for asthma 4. Hx of intubation?
Pulmonary Summary
PE : Pleuritic CP w/tachycardia and hypoxia : Dx by CTA Chest w/contrast
PTX: Unilateral CP and SOB : Dx by CXR
PNA: SOB w/productive cough : Dx by CXR
COPD: SOB with Hx smoking: CXR w/hx smoking
Asthma : wheezing with Hx of Asthma : Dx clinically
Ischemic CVA
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR WEAKNESS/NUMBNESS
Etiology: blockage of the arteries supplying blood to brain resulting in permanent brain damage
1. C: unilateral focal neurological deficits: 1-sided weakness/numbness or changes in speech/vision
2. risk factors: HTN, HLD, DM, HxTIA/CVA, smoking, FHx CVA, Afib
3. PE: neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits
4. Dx by: clinically, potentially normal CT head
5. Note: always document date and time they were “last known well” as well as source of this information. used to assess eligibility for tPA, a blood thinner that can reverse CVA
Document tPA considered and not indicated due to: onset greater than 3 hours or unknown, unreliable time of onset; symptoms are rapidly improving
Hemorrhagic CVA
CRITICAL CARE DDX
MAJOR DDX FOR HA
Etiology: traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in brain
1. CC: HA (sudden onset, “worst of life”)
2. assoc. Sx: changes in speech, vision, sensation, or motor strength, AMS, Sz
3. PE unilateral neurological deficits
4. Dx by CT head or LP
5. Note: document tPA not indicate due to hemorrhage
TIA
Etiology: vascular changes temporarily deprive a part of the brain of O2, Sx usually last less than 1 hr
- CC transient focal neurological deficit (change in speech, vision, strength, or sensation)
- Dx clinically
- note: Document tPA considered and not indicated due to resolved symptoms
Meningitis (bacterial vs. viral)
CRITICAL CARE DX
MAJOR DDX FOR HA
Etiology: inflammation and infection of the meninges; the sac surrounding the brain and spinal cord
1. CC HA
2. Assoc Sx: fever, neck pain, neck stiffness, AMS
3. PE: meningismus, Nuchl rigidity
4. Dx by LP
Spinal Cord Injury
CRITICAL CARE DX
MAJOR DDX FOR TRAUMA, WEAKNESS, OR NUMBNESS
Etiology: injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury
1. CC nck pain or back pain, bilat. extremity weakness
2. PE: midline bony tenderness, deformities, or step-offs, Bilat. extremity weakness, numbness, decreased rectal tone
3. Dx by CT: C-spine, T-spine, L-spine
4. Note: document if spine is often immobilized w/C-collar
Sz
MAJOR DIAGNOSIS FOR SYNCOPE Etiology: abnormal electrical activity in brain leading to abnormal physical manifestations. Often caused by epilepsy, EtOH withdrawals, or febrile sz in pediatric pts 1. CC: Sz activity, syncope 2. Assoc Sx: injuries(bite tongue) confusion, headache, incontinence 3. PE: somnolent, confused (post-ictal) 4. Note: Doc will ask: a. has pt had similar sz in past? b. does pt have hx of sz 3. what was the date of their last sz d. what sz med do they take
Bell’s Palsy
Etiology: inflammation or viral infection of the facial nerve causes one-sided weakness of face
- CC: facial droop, sudden onset
- Assoc. Sx: jaw or ear pain, increased tear flow of one eye
- Pert. Neg: no extremity weakness, no changes in speech or vision
- PE: unilateral weakness of the upper and lower face
- Dx clinically
- remember to document the absence of other FND
HA
etiology: various causes including hypertensive HA, recurrent dx migraines, sinusitis, etc
1. CC: HA (gradual onset), pressure, throbbing
2. Pert. Neg: no fever, no neck stiffness, no numbness/weakness, no change in speech or vision
3. Note: always remember to doc if HA is similar or dissimilar to any prior HA.
AMS
etiology: multiple causes: most common are hypoglycemia, infection, intoxication, and neurological
1. risk factors: diabetic, elderly, demented, EtOH use, drug use
2. CC: confusion, decreased responsiveness, unresponsive
3. Dx by: case dependent
4. Note: AMS is generalized and usualy caused by things that affect the whole brain (drugs, low blood sugar)