[HYHO] SPE 1 Dyspnea Flashcards
How is dyspnea often reported?
Self-reported by the pt
What etiologies account for 85% of cases of SOA?
Cardiac and pulmonary
What is the order of physical exam for a thoracic examination?
IPPA
Inspect
Palpate
Percuss (ladder pattern)
Auscultate (ladder pattern)
What common special tests can be done when evaluating for COPD? What are the findings for each test?
Tactile fremitus (typically decreased)
Transmitted voice sounds (typically decreased)
Rib motion (limited expansion)
Assessment of oropharynx
After history, physical examination, and obtaining a differential diagnosis for dyspnea, what is the next step in making a diagnosis?
Walking pulse oximetry
Peak flow assessment
To make a COPD diagnosis, the FEV1/expected FEV1 ratio must be ___
Less than or equal to 70%
What is a walking oximetry test?
Pt walks with a pulse-oximeter to assess O2 desaturation with activity and to replicate dyspnea
May administer pre and post-bronchodilator to assess effectiveness of treatment
If no dx made with history and PE, what diagnostic data is gathered in phase 1 testing of dyspnea?
CXR
spirometry
ECG
CBC, BMP
If no dx is made in phase 1, what diagnostic data is gathered in phase 2 testing of dyspnea?
Chest CT (consider angio for thromboembolic dz) Lung volume, DLCO, tests of neuromuscular fxn
Echocardiogram, cardiac stress testing
If no information is gathered in phase 2, what diagnostic data is gathered in phase 3 of dyspnea testing?
Consider cardiopulmonary exercise testing
Consider subspecialty referral
Why would anemia be considered as an alternative ddx for dyspnea? What test would you obtain to evaluate for anemia?
Pulse ox only reads saturated hemoglobin, but pt may have a low hemoglobin level (hypoxic)
Order a CBC
Typical CXR findings for COPD
Flattened diaphragm
Increased AP diameter
What are the levels for sympathetic innervation to the heart? Lungs?
Heart: T1-6
Lungs: T1-7
What is the parasympathetic innervation to the heart and lungs?
Vagus
Anterior Chapman’s points for lungs?
2, 3, 4 ICS along sternum
Posterior Chapman’s points for lungs?
Lateral T2 SP
intertransverse space b/w:
T2-3
T3-4
T4-5
Goals of OMT COPD (5 models)
Biomechanical: Improve thoracic cage compliance, skeletal motion
Neurological: Normalize autonomic tone
Resp-Circ: Maximize efficiency of diaphragm and enhance lymphatic return
Metabolic-Energetic-Immune: enhance self-regulatory and self-healing mechanisms
Behavioral: Improve psychosocial components of health
What rescue/short-acting medications are prescribed for COPD?
Short acting inhaled bronchodilators:
B-agonists (albuterol)
Anticholinergic muscarinic antagonists (ipratropium); improve FEV1
What long acting medications are prescribed to COPD pts with persistent sx?
B agonists (salmeterol)
Anticholinergic musclarinic antagonists (tiotropium) - better for improving sx and reducing exacerbations
When should smoking cessation be addressed in pts with COPD?
Every visit
What pharmacologic therapies are provided for pts interested in smoking cessation?
Nicotine replacement
Bupropion (SNRI)
Varenicline (nicotinic acid receptor agonist/antagonist)
Long term management of COPD: Primary prevention
Annual flu vaccine - PCV13/Prevnar followed by PPSV23 the next year
Tdap to protect against Bordatella pertussis
Long term management of COPD: Secondary prevention
Avoidance of dust and fumes (occupational or hobby exposure)
Long term prevention of COPD: Tertiary prevention
Smoking cessation/abstinence
Pulmonary rehabilitation (tx program w/ exercise, education, psychosocial and nutritional counseling to improve quality of life and reduce hospitalization)
Exacerbation of COPD increase in frequency as FEV1 ___
<50% of predicted (massive decrease)
50% of COPD exacerbations are due to what? 1/3 to what?
50% due to bacterial infection
1/3 to viral
2 main complications of COPD
Progressive hypoxia
Respiratory failure
In order to prevent respiratory failure during a COPD exacerbation, what measures must be taken?
Support w/ O2
Noninvasive positive-pressure ventilation (bipap) OR intubation and mechanical ventilation
What kind of COPD is associated with cachexia, weight loss, bitemporal wasting, and diffuse loss of subcutaneous tissue?
End-Stage COPD
Where would you admit a patient with end-stage COPD?
Hospice
What symptom will patients with stable angina NOT describe?
Chest pain
(But they will have tight, squeezing, heavy, pressure sensations)
Where will pts will stable angina usually indicate as the center of their symptoms? Where does it radiate?
Sternum
Radiates to neck, jaw, back, ulnar surface of arm (NOT TRAPEZIUS)
What sx are anginal “equivalents”?
Dyspnea
Nausea
Fatigue
Unstable angina is a harbinger for progression to what?
ACS
Who is CAD more common in?
Men >50
Women >60
What motions can reproduce chest pain?
Coughing
laughing
taking a deep breath
(anything that causes motion b/w the pleura and the chest)
In cardiac examination, where would you auscultate to identify mitral regurgitation? What are you listening for?
Apex and L sternal border
Listen for S3, S4 murmurs (use the Bell)
What supportive finding in physical examination essentially eliminates cardiovascular disease for sx cause?
Reproducible chest pain w/ palpation
What do you want to make sure you evaluate in PE for possible stable angina?
Cardiac/Pulmonary evaluation
Palpate for PMI
Auscultate for carotid bruits
Evaluate peripheral pulses
Assess for edema
Possible indications for stress testing of patient (4)
- Dx of ischemic heart disease uncertain
- Assess functional capacity of pt
- Assess adequacy of tx program for IHD
- Markedly abnormal calcium score on EBCT
What is the next step for a patient with suspected IHD who is able to exercise adequately but has confounding features on EKG?
Imaging study to identify regional ischemia:
Echo, nuclear perfusion scan (MIBI), cardiac MRI, Cardiac PET
A cardiac stress test may expose what findings?
ST depressions
(and reproduced sx of dyspnea)
A stress echocardiogram may expose what findings?
Wall motion abnormalities
Overall sensitivity of an exercise stress EKG is what percent? Negative result makes what unlikely?
75%
Negative result makes 3 vessel or left main CAD unlikely
What are some contraindications to exercise stress test?
Basically any recent, unstable heart condition
Rest angina w/in 48 hrs
Unstable rhythm
Severe aortic stenosis
Acute myocarditis
Uncontrolled heart failure
Severe pulmonary HTN
Active infective endocarditis
What are the anterior/posterior chapman’s points for the heart?
Anterior - 2nd ICS along sternal border
Posterior: Intertransverse spaces b/w T2-3
What drugs are used for short term sx management of stable angina? (3)
Nitroglycerin subl-lingual
Antiplatelet medication - ASA OR clopidogrel
Medication to dec demand ischemia: BBs (bisoprolol, metoprolol) or CCBs (amlodipine or diltiazem)
What sx in stable angina is high risk for coronary events?
Inability to exercise <6 minutes
Long term management of Stable Angina: Secondary prevention
Assess pt for other CV sx
Screen for thyroid dysfxn, anemia that increases cardiac workload and recurrence
Long term management of Stable Angina: Tertiary prevention
Cardiac Rehab - encourages weight loss, exercise tolerance, control of risk factors
Smoking cessation
Tx of lipid disorders/other comorbidities
3 main complications of Stable Angina
Progression to unstable angina/ACS/MI
CVA
PVD
Why do pts with a cardiac hx who smoke e-cigarettes need cessation counseling?
E-cigarettes can increase frequency of angina episodes
