Diagnosis and Admitting Orders - SRS Flashcards
HCC: A 55 y/o Afro-American male presents with chest pain. The pain is described as substernal and oppressive with radiation down the left arm. It is worse with exertion and relieved by rest. He also reports dyspnea, nausea, and “angor animi”.
PMH: Prior history is negative for hypertension or diabetes. He has hyperlipidemia for which he takes a statin (his only Med).
FH: His father died of an MI at age 50.
SH: Married with two children; Negative for smoking or ETOH.
Allergies: none.
PE: Vitals: BP is 142/90. Temperature is 37.5. Pulse 100. Respirations 22 b/m. HEENT: Negative. Heart: No murmurs, extra sounds or rubs. Lungs: Respirations rapid and shallow. No rales or wheezes. Abdomen: No masses or tenderness. MSK: thoracic somatic dysfunction. EKG is abnormal. Troponin is mildly elevated.
What is the best provisional diagnosis?
DDX?
- Acute Myocardial infarction
- SIRS
- ASHD
- Hyperlipidemia
What are the five systems that relate to somone with chest pain?
- Cardiovascular
- Pulmonary
- Musculoskeletal
- GI (Upper)
- CNS/Psychiatric
What are these signs pathognomonic for?
Tuberous sclerosis
Psoriasis plus chest pain may equal what?
MI
What are the steps of differential diagnosis?
1. Isolate pertinent data
- Isolate key features using semantic qualifiers, look for pathognomonic signs
- choose framework - anatomic, physiologic or mneumonic
- apply key features to framework for ddx
- develop a provisional diagnosis along with the differential.
What are the 7 chest pain differntials you DO NOT want to miss?
TEST QUESTION TOPIC
P4A3
- Pulmonary Embolus
- Pneumothorax
- Perforated esophagus
- Pericarditis
- Acute MI
- Aortic Aneurysm
- Acute Chest syndrome
What are the components of the standard admission orders?
Test question
- Diagnosis (primary/differential)
- Disposition (destination/condition)
- Drugs, home meds, O2
- Diet (IV fluids or other)
- Allergies
- Activity
- Assessment/nursing (vitals, weight, status, I and O etc)
- Analysis/evaluation/workup (labs, xrays, consultants)
- Alleviation/Treatment (new meds, procedures, PT/OT.OMM)
What are the D’s of the standard admission orders?
4
- Diagnosis (primary/differential)
- Disposition (destination/condition)
- Drugs, home meds, O2
- Diet (IV fluids or other)
What are the A’s of the standard admission orders?
- Allergies
- Activity
- Assessment/nursing (vitals, weight, status, I and O etc)
- Analysis/evaluation/workup (labs, xrays, consultants)
- Alleviation/Treatment (new meds, procedures, PT/OT.OMM)
Of the standard admitting orders, which is most important in facilitation of discharge?
Analysis*/evaluation/workup (labs, xrays, consultants)
Possibly a test question to this effect also
Why is analysis the most important part of the standard admission orders?
Critical for identifying the proper tests to establich diagnosis and optimal treatment protocol. If done right, then you will minimize patient stays, costs and maximize health.
Outline a possible standard admitting order protocol for the previous patient with MI.
- Diagnosis: NSTEMI
- Disposition: Admit to ICU
- Drugs: statin, O2, ASA
- Diet: Low sodium
- Allergies: None
- Activity: Beside commode
- Assessment/Nursing: Vitals q 2 hrs, Weigh daily,
- Analysis: Risk stratification (GRACE)
- Alleviation/treatment: if low risk - medical treatment with beta blocker, ACE inhibitor, ticagrelor, heparin, etc. If high risk – to cath lab
What does GRACE stand for?
Global Registry of Coronary Events Score
What are the components of the GRACE protocol?
- Age
- Heart rate (beats/min)
- Systolic blood pressure (mmHg)
- Creatinine (μmol/L)
- Killip class (no CHF to cardiogenic shock)
- Cardiac arrest at admission
- Elevated cardiac markers
- ST-segment deviation
Not sure if this is a test topic or not. He states both “Don’t worry about this, just know I like it better than TIMI”, and also that “you should listen up on this”.
What do GRACE risk scores range from?
What is a significant risk score according to GRACE?
2-372 is the range
score over 140 is very significant.
What are the 4 group causes of pulmonary HTN?
Group 1: Idiopathic Pulmonary arterial HTN (PAH)
Group 2: Pulmonary HTN owing to left-sided heart disease
Group 3: Pulmonary HTN owing to lung diseases and/or hypoxia (e.g. COPD)
Group 4: Chronic Thromboembolic pulmonary hypertension (CTEPH)
Likely Test question here
In what condition does acute chest syndrome arise?
Occurs in sicke cell anemia as a pulmonary illness
What is acute chest syndrome (ACS) defined by?
In sicke cell anemia, as a pulmonary illness defined by a new infiltrate on chest x-ray with at least one clincal sign or symptom (chest pain, cough, wheeze, tachypnea, fever)
In acute chest syndrome, what causes the diffuse extremity/bone pain?
Reduced blood flow to bone marrow causes painful ischemia and necrosis of the marrow.
Increased levels of what markers can be elevated during acute chest syndrome?
Increased serum levels of free fatty acids and the enzyme secretory phospholipase A2. The levels of phospholipase A2 will resemble those in a fat emboli syndrome.
What sort of admitting orders would you put together for a patient with acute chest syndrome?
- Diagnosis: Sickle Cell Acute Chest syndrome; Pneumonia; Pulmonary emboli, Hypoxia, AGA, bone infarction
- Disposition: ICU/critical
- Drugs: O2 at 2 liters/min
- Diet: Regular diet as tolerated. Dextrose 5% in 0.45 Na Cl IV at 80 cc/hr,
- Allergies
- Activity: Bedside commode
- Assessment/Nursing: Vitals q 4 hrs, Continous 02 sat, incentive spirometry.
- Analysis: Type and cross match for 6 units of packed RBCs (may need exchange transfusion), Spirometry, Repeat chest xray and EKG in AM, Deep cough sputum for gram stain and C and S.
- Alleviation and treatment: Ceftriaxone 1 gram IV daily, Albuterol 2 puffs four times a day, Prednisone 80 mg orally now and 40 mg daily x 4 days, O2 at 2-4 l/min, Rib raising four times daily.
Mostly just know the admitting order components here. Don’t necessarily expect tx of ACS and whatnot on the exam.
When there are multiple body systems involved the mneumonic approach to differential diagnosis can be applied with what mneumonic?
VINDICATED
What are the components of the mneumonic VINDICATED?
- Vascular
- Infectious, Inflammatory, or Infiltrative
- Neoplastic/Neuromuscular
- Degenerative, Deficiency
- Idiopathic, Intoxication (Drugs)
- Congenital
- Autoimmune, Allergic
- Traumatic
- Endocrine/metabolic, Environmental
- Depression (Anxiety)
Once again, what are the categories of pulmonary HTN?
He again reiterated that he wants us to know this.
Group 1, idiopathic pulmonary arterial hypertension (PAH).
Group 2, pulmonary hypertension owing to left-sided heart disease.
Group 3, pulmonary hypertension owing to lung diseases and/or hypoxia.
Group 4, chronic thromboembolic pulmonary hypertension (CTEPH).
