Final Exam Flashcards
What is the main cause of right sided heart failure?
Left sided heart failure
What is the main cause of left sided heart failure?
Coronary artery disease (CAD)
What is paroxysmal nocturnal dyspnea?
Acute episodes of severe shortness of breath and coughing that wake patient up at night (secondary to heart failure)
How is paroxysmal nocturnal dyspnea different from orthopnea?
Orthopnea is shortness of breath upon lying down — before they even fall asleep.
Of the two, paroxysmal nocturnal dyspnea and orthopnea, which is more specific to heart failure?
Paroxysmal nocturnal dyspnea
Because the left ventricle fails to pump blood. Blood backs up into the lungs. Excess blood in the lung vasculature leaks into lung tissue/alveoli and 1-3 hours after lying down that starts to affect the patients ability to breath.
What are the classic physical exam findings associated with left sided heart failure (HF)? (Lung auscultation? Heart auscultation?)
Tachypnea (fast breathing)
Tachycardia (fast heartrate)
Decreased oxygen saturation
Lung auscultation: crackles in the base which could progress to diffuse crackles and wheezing
Heart auscultation: S3 may be heard over apex
What are the classic physical exam findings associated with right sided heart failure (HF)? (Lung auscultation? Heart auscultation?)
Increased jugular venous pressure
Peripheral pitting edema, symmetrical
Hepatomegaly may cause RUQ discomfort due to congestion of the liver
What is dilated cardiomyopathy?
Failure due to reduced contractile force causing decreased forward flow and backup into lungs
What is hypertrophic cardiomyopathy?
Failure due to disorientation of cells and non-compliant ventricle
What are the causes of dilated cardiomyopathy versus hypertrophic cardiomyopathy?
Dilated—toxic, familial, infectious, idiopathic
Hypertrophic—inherited, HTN
(Both can be caused by ischemic, valvular)
Describe the 4 stages (A-D) of heart failure (HF)?
Stage A: high risk but no structural heart damage
Stage B: asymptomatic but structural damage
Stage C: structural and symptoms
Stage D: refractor, end stage HF
Note: A-D Staging is used to determine treatment
What are the treatments for the 4 stages A-D?
Stage A: risk factor modification and ACD-inhibitor for heart remodeling
Stage B: same plus beta blocker to slow the heart
Stage C: same plus diuretics and aldosterone and sodium restricted diet
Stage D: same plus end of life care or cardiac transplant
Can heart failure ever improve with treatment?
Cardiac function in some patients can improve through myocardial remodeling with medication
Untreated HF has poor prognosis. It is progressive and eventually fatal.
What are the 4 classes of HF used for?
Functional status is important predictor of patient prognosis
What are the 4 classes of heart failure?
Class 1: No symptoms of HF with or limitation of ordinary activities (such as shopping, climbing stairs, carrying groceries or walking)
Class 2: ordinary activities somewhat limited as they produce symptoms: fatigue, dyspnea, palpitations, angina
Class 3: Ordinary activities are moderately impaired because minimal activity produces symptoms but still comfortable at rest
Class 4: Ordinary activities are severely limited and has symptoms at rest
What does a normal vs trapped air vs solid abnormalities sound like with percussion of the lung?
Normal: resonant
Trapped air: hyperresonant (e.g. pneumothorax, emphysema)
Solid abnormalities: dull (e.g. pleural effusion, pneumonia)
What is the most common cause of pleurisy? And what is the management plan for pleurisy?
Viral infection
Tx: NSAIDs and controlling underlying pathology
Which type of fluid is found in each of the 4 types of pleuritic effusions?
Hydrothorax — serous fluid from viral or organ failure
Chylothorax — lymph from lung or breast cancer
Pylothorax — pus from pneumonia infection
Hemothorax — blood from trauma
What are the signs and symptoms of pneumothorax?
History: dyspnea, tachycardia, pleuritic chest pain radiate to back or shoulder
Physical: chest NOT tender to palpation, decreased lung sounds, hyperresonance, decreased tactile fremitis
What are the signs and symptoms suggestive of pulmonary embolism?
History: dyspnea, pleuritic pain, tachypnea (fast, shallow), cough, hemolysis, tachycardia, low grade fever
Physical: crackles, S4 sounds
What blood test result would help you rule out pulmonary embolism (PE)?
D dimmer blood test would be positive
If it is negative, R/O PE
What are 2 key symptoms of a patient with typical bacterial pneumonia?
Fever and sputum
Physical exam:
- Dullness to percussion
- Increased tactile fremitus
- Crackles over area of consolidation heard on auscultation
Compare and contrast typical vs atypical pneumonia
Typical ”sick as stink”
- acute onset
- productive cough
- fever, chills, malaise
Atypical “walking pneumonia”
- gradual onset
- non-productive cough
- low fever
What is the classic lung sound associated with bronchitis (blue bloater)?
Scattered rhonchi, crackles, wheezes possible
What are the USPSTF recommendations for lung cancer screening?
Annual CT in high risk patients 55-74 yo with 30-pack year history who still smoke or have quit within 15 years
E.g. 1 pack / day for 30 years
E.g. 1/2 pack / day for 60 years
Compare and contrast the clinical presentations of pancoast tumor and superior vena cava syndrome
Pancoast: men 40-60 yo with smoking history, shoulder pain that may radiate C8 radiculopathy, extremity edema if tumor is anterior and invades subclavian vein, Horner’s syndrome if tumor invades sympathetic nerves.
SCV: compression decreases return blood flow from head, neck, arms to heart. Often due to cancers. Edema?
Compare and contrast the abnormalities in a patient with lung cancer who presents with Syndrome of Inappropriate ADH (SIADH) vs. Cushing’s
General lung cancer: fatigue, anorexia, unintentional weight loss.
SIADH: hyponatrimia <135
Sx: falls, gait disturbances, headache, nausea, fatigue, anorexia, lethargy, coma
Cushing’s: >serum cortisol
Sx: central weight gain, striae, proximal mm weakness, HTN, peripheral edema, moon fancies, buffalo hump
What are the main 3 pathophysiologic components of asthma?
- Smooth muscle contraction (bronchoconstriction)
- Airway edema
- Increased mucous production
What labs and tests can be used to help make the diagnosis of asthma? For each one, what is the outcome that suggests asthma?
- Methacholine challenge — decreased air flow supports Dx
- Check for response to brochodilator — improved airflow supports Dx
- Peak expiratory flow meter
— reduced flow - Blood test for eosinophils
— elevated levels - Skin test for allergies
— allergic asthma
What is the management plan for a patient with asthma exacerbation?
(2) inhaler meds: rescue inhaler and maintenance meds
Avoid triggers
Chiropractic manipulation improves symptoms
What is the pathophysiology of emphysema?
Alveoli have been destroyed (enlarged).
Air gets trapped.
Poor O2 exchange.
On pulmonary function testing, is the ratio of FEV1/FVC increased, decreased or unchanged in obstructive lung disease?
COPD: decreased ratio
<70% of predicted valve
What causes the decreased total lung capacity (TLC) in extrinsic restrictive lung conditions?
Skeleton inhibits full expansion of chest wall
NMS
Obesity
What are examples of extrinsic restrictive lung conditions?
Chest wall abnormalities
Neuromuscular conditions
What are examples of intrinsic restrictive lung conditions?
Interstitial lung disease: asbestosis, sarcoidosis, idiopathic pulmonary fibrosis
Pneumonitis: inhaled inorganic dust, inhaled organic dust
What is obstructive vs restrictive lung disease?
Obstructive is where normal air flow is limited at any level
Restrictive is reduced lung volume due to lung parenchyma disease, problems with chest cage or neuromuscular dysfunction but flow of air through airway is NOT blocked
What is the diagnostic threshold for making the diagnosis of restrictive lung disease by TLC? Is the ratio of FEV1/FVC increased, decreased or unchanged?
Unchanged
The ratio is unchanged since FEV1 and FVC are both reduced due to decreased TLC
Recognize symptoms and signs suggestive of obstructive sleep apnea
NOT restrictive lung condition
Episodes of apnea because upper airway collapses—causes O2 desaturation and sleep arousals
Sx: snoring, pauses in breathing during sleep, excessive daytime sleepiness
Recognize symptoms and signs suggestive of pneumoconiosis
Due to inhaling mineral dust e.g. crystalline silica, coal, asbestos
Sx: progressive dyspnea, dry cough, insidious “sneaky” onset
Recognize symptoms and signs suggestive of costochondritis
Intermittent pain
Sx: Inflammation at 1+ costosternal or costochondral junctions, NO swelling
DDX: Tietze’s syndrome is inflammation WITH swelling of costal cartilage and sharp, unilateral pain
Recognize symptoms and signs suggestive of shingles
Unilateral, dermatomal pain then vesicular rash
Refer to PCP for acyclovir. Very contagious!
What is cervical pseudoangina?
Cervical spine issues can potentially be referred to the chest: osteophytes, discopathy, spondylosis
What are some clues from patient’s history that are suggestive of chest pain caused by panic disorder?
Sympathetic Sx: feeling of unreality or being detached from oneself. Dizziness, paresthesia, shaking.
In taking a patient’s history, what features could help you differentiate between chest pain caused by GERD vs esophageal spasm?
GERD will have heartburn, liquid or partially regurgitated food in the back of the throat. Aggravated by lying down and after a meal.
Esophageal spasm will have chest pain and intermittent dysphagia. Pain triggered by hot/cold foods/beverages
What is Murphy’s sign and what does it suggest?
1) Ask patient to exhale. 2) examiner places hand below costal margin on the right side at the mid-clavicular line. 3) patient is instructed to inspire.
(+) is when patient stops breathing in and winces in a “catch” in breath
Suggests gallbladder
What is carnett’s sign and what test results makes an abdominal wall trigger point more likely?
1) doc palpates area of tenderness 2) ask patient to lift head and shoulders to contract abdominal wall muscles while keeping pressure on tenderness
(+) pain increases suggests abdominal wall as source of pain
(+) pain decreases suggests intra-abdominal organ as source of pain
In a patient with peritonitis, is guarding likely to be voluntary or involuntary?
Involuntary guarding
Rigidity
Cough test
Rebound tenderness — withdrawal of pressure hurts more than the pressure
In a patient with peritonitis, are bowel sounds likely to be increased or decreased?
Decreased/absent bowel sounds
Adynamic ileus and late mechanical bowel obstruction
What other physical exam signs are alarming for possible “acute” abdomen?
Jar sign
Rebound tenderness
How can you tell if a hernia is incarcerated or not?
“If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Strangulation. An incarcerated hernia can cut off blood flow to part of your intestine.” Mayo Clinic
What is courvoiser’s sign? What does it suggest?
Painless enlargement of gallbladder in jaundiced patient. Suggests cancer obstructing biliary tree.
Name the physical exam signs associated with chronic liver disease
?
Recognize the symptoms and signs suggestive of acute appendicitis
History: acute onset abdominal pain-starts periumbilical region and localizes to RLQ, anorexia, nausea/vomiting and fever
Physical: McBurney’s point, Rovsing’s sign when pressure to LLQ causes RLQ pain, Psoas sign, Obturator sign
Recognize the symptoms and signs suggestive of nephrolithiasis
History: Tenderness to palpation at costovertebral angle suggests kidney infection or inflammation such as pyelonephritis, kidney stones, nephrolithiasis
Physical: Jar sign, rebound tenderness
Recognize the symptoms and signs suggestive of mechanical bowel obstruction/paralytic ileus
Vomiting, colicky pain. Bowel movement stops. Visible peristalsis in a patient with colicky abdominal pain and vomiting is a strong indicator of bowel obstruction.
Compare and contrast nephrolithiasis and pyelonephritis
Pyelonephritis ONLY causes fever (NOT nephrolithiasis).
Kidney stones can lead to pyelonephritis (infection) or inflammation (kidney stones aka nephrolithiasis). Dysuria, hematuria, N/V.
What is the most severe class of HF and what is the yearly mortality rate for patients in that class?
Class 4: ordinary activities are severely limited and patient has symptoms at rest
30-70% mortality rate annually
