Dyspnea HYHO

Question 1

Diagnostic pathway for dyspnea complaint

Answer 1

1. H/E + walking oximetry + peak flow assessment
2. Further testing = CXR, spirometry, ECG, CBC, CMP
3. Chest CT, lung volumes, DLCO, tests of NM function, echo, cardiac stress test
4. Cardiopulm exercise testing and referral

Question 2

DDx for dyspnea

Answer 2

• Anemia (oximetry might not be low)
  Pt presents w/ pallor, bounding pulses, fatigue, dyspnea and sx of HF and/or angina
  *Get CBC

Question 3

PE findings for COPD

Answer 3

• barrel chest
• limited rib motion
• lung expansion w/ limited exhalation
• Hyperresonance on percussion (hyperinflation), decreased breath sounds, wheezing, prolonged expirations

Question 4

How do tactile fremitus and transmitted voice sounds respond in COPD

Answer 4

Both are decreased

Question 5

General causes of dyspnea

Answer 5

85% = cardio or pulm etiology

Smoking, occupational lung dz, medications

Question 6

COPD tx

Answer 6

1. Short-acting bronchodilators for rescue (SABA or SAMA)
2. Long-acting bronchodilators for persistent sx (LAMA > LABA)
   STOP SMOKING

Question 7

How does stopping smoking help?

Answer 7

Accelerated decline in FEV1 dose dependent relationship with pack-years

Question 8

1* prevention for COPD

Answer 8

Flu vax annually
Pneumococcal vax (PCV13) followed by PPSV23 (pneumovax) at least a year later
Tdap

Question 9

3* prevention for COPD

Answer 9

Smoking cessation

Question 10

COPD complications

Answer 10

• Progressive hypoxia
• COPD exacerberations (more as FEV1/FVC drops < 50%)
• many exacerbations related to infection
• Respiratory failure

Question 11

How does stable angina present?

Answer 11

Discomfort as tightness, squeezing, heavy, pressure that can radiate to shoulder, neck, jaw, back
NOT pain

Question 12

What does a finding of reproducible chest pain on palpation indicate?

Answer 12

Probably not a cardiovascular cause

Question 13

How do you listen for S3 and S4?

Answer 13

Pt in left lateral decubitus position
Use BELL @ apex and LSB
(also done for MR)

Question 14

What is included in PE for stable angina?

Answer 14

• S3/S4 auscultation
• Palpate for PMI
• Auscultate for carotid bruits
• Evaluate peripheral pulses
• Assess for edema

Question 15

Diagnostic data in stable angina?

Answer 15

• ECG likely normal when Asx
  (previous ECG findings may be present though)
• Cardiac stress test - may see ST depressions during increased cardiac workload or dyspnea sx

Question 16

What to do if pt is suspected of having IHD, but no confounding features on ECG?

Answer 16

Do treadmill exercise test

Question 17

Contraindications for exercise stress test?

Answer 17

• Unstable angina w/in 48 h
• Unstable rhythm
• Severe AS
• Acute myocarditis
• Uncontrolled HF
• Severe PAH
• Active infective endocarditis

Question 18

Short term tx for stable angina?

Answer 18

• Pt education (reduced energy expenditure in early am and after meals)
• Lifestyle modification (stop smoking, weight loss, cholesterol management)

Question 19

What is a high risk factor for coronary events?

Answer 19

Inability to exercise more than 6 minutes

Question 20

2* prevention for stable angina

Answer 20

Assess pt for other CV sx

- Screen for thyroid dysfunction, anemia (things that increase cardiac workload)

Question 21

3* prevention for stable angina

Answer 21

• Cardiac rehab
• smoking cessation
• treatment of lipid disorders/other comorbidities that increase risk of atherosclerosis or increase cardiac workload