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Maddy - PCM III > HYHO: SPE > Flashcards

HYHO: SPE Flashcards

1
Q

visible signs of increased work of breathing that can be identified and reported by clinicians

A

tachypnea
accessory muscle use
intercostal retractions

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2
Q

ROS for a pt w/ dyspnea (6 examples)

A 
fever
swelling/edema in le
palpitations
recent travel
coughing at night
awakening short of breath
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3
Q

what patients will report with an “inability to take a deep breath”

A

COPD patients

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4
Q

Dyspnea Physical exam:

- inspection

A

while standing behind pt, observe breathing, shape of chest, and motion of chest wall/ribs

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5
Q

Dyspnea Physical exam:

- palpation

A
  • identify tenderness and assess lung expansion (COPD)

- palpate for point of maximal impulse (angina)

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6
Q

Dyspnea Physical exam:

- percussion

A

comparing side to side in “ladder” pattern

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7
Q

Dyspnea Physical exam:

- auscultation

A 
COPD: 
comparing side to side in "ladder" pattern
- two places anteriorly
- four places posteriorly
- pt breathes through an OPEN mouth

Angina:
- auscultate for carotid bruits

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8
Q

special/other tests in PE for pt w/ dyspnea/COPD

A
  • tactile fremitus
  • assess rib motion
  • assessment of oropharynx/upper airway
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9
Q

supportive PE findings of a pt w/ COPD

A
  • barrel shaped chest
  • limited rib motion
  • lung expansion w/ limited exhalation
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10
Q

percussion sounds on a pt w/ COPD

A

generalized hyper-resonance due to hyperinflation

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11
Q

auscultation findings on a pt w/ COPD

A
  • decreased breath sounds
  • wheezing
  • prolonged expirations
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12
Q

tactile fremitus findings on pt w/ COPD

A

decreased due to hyperinflation

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13
Q

transmitted voice sounds on pt w/ COPD

A

decreased due to hyperinflation

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14
Q

diagnostic test for COPD pt in the office

A

have pt walk w/ pulse oximeter to asses O2 desaturation w/ activity to replicate the symptom of dyspnea, then REPEAT auscultation

  • may reveal expiratory wheezing that was not present at rest
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15
Q

what additional testing should you do in a COPD patient if diagnosis is unclear or symptoms fail to improve

A
  • PFTs (spirometry)

- chest x-ray

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16
Q

expected FEV1 of pt w/ COPD

A

<70% of expected value

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17
Q

peak flow assessment value in a pt w/ COPD should be ____

A

reduced

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18
Q

function of peak flow assessment

A

approximates FEV1

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19
Q

what testing is included in phase 1 of diagnostic testing in a pt w/ dyspnea (4)

A
  • CXR
  • spirometry
  • ECG
  • CBC, CMP
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20
Q

what testing is included in phase 2 of diagnostic testing in a pt w/ dyspnea (6)
(if diagnosis not obtained in phase 1)

A
  • chest CT
  • lung volumes
  • Diffusing capacity of the lungs for carbon monoxide (DLCO)
  • test neuromuscular function
  • echocardiogram
  • cardiac stress test
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21
Q

what testing is included in phase 3 of diagnostic testing in a pt w/ dyspnea (5)
(if diagnosis not obtained in phase 2)

A

consider cardiopulmonary exercise testing and subspecialty referral

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22
Q

alternative ddx for dysnpea other than COPD

A

anemia

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23
Q

CXR of patient w/ COPD

A
  • flattening of diaphragms

- increased AP diameter

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24
Q

sympathetic innervation of the heart is located at what spinal levels

A

T1-T6

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25
Q

sympathetic innervation of the lungs is located at what spinal levels

A

T1-T7

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26
Q

parasympathetic innervation to the heart and lungs is controlled by what nerve

A

vagus n.

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27
Q

anterior chapmans’ points for the lungs

A

anterior 2nd, 3rd, and 4th ICS along sternum

28
Q

posterior chapmans’ points for the lungs

A
  • lateral T2 spinous process

- inter-transverse space b/w T2-3, T3-4, T4-5

29
Q

bio-mechanical goals of OMT for COPD pts

A

improve thoracic cage compliance and skeletal motion

30
Q

neurological goals of OMT for COPD pts

A

normalize autonomic tone

31
Q

respiratory-circulatory goals of OMT for COPD pts

A

maximize efficiency of diaphragm and enhance lymphatic return

32
Q

metabolic-energetic-immune goals of OMT for COPD pts

A

enhance self-regulatory and self-healing mechanisms

33
Q

behavioral goals of OMT for COPD pts

A

improve psychosocial components of health

34
Q

primary prevention for COPD

A
  • annual flu vaccine
  • pneumococcal vaccine
  • Tdap
35
Q

secondary prevention for COPD

A

avoidance of other dust and fumes (occupational or hobby exposure)

36
Q

tertiary prevention for COPD

A
  • smoking cessation/abstinence

- pulmonary rehab (incorporates exercise, education, psychosocial, and nutritional counseling)

37
Q

end-stage COPD is associated w/ what symptoms

A
  • cachexia
  • weight loss
  • bitemporal wasting (temporalis m. wasting)
  • diffuse loss of subcutaneous adipose tissue
38
Q

clinical presentation of stable angina

A

pts will indicate the center of the chest pain with a fist over the sternum

39
Q

how do stable angina patients describe their symptoms

A
  • tight, squeezing, heavy, pressure but NOT pain

- radiation to neck, jaw, back, shoulder, ulnar surface of arm (trapezius area is spared)

40
Q

associated sx w/ angina

A

dyspnea
nausea
fatigue

41
Q

describe pleuritic chest pain

A

pain reproduced w/ maneuvers that cause motion b/w pleura and chest wall, such as coughing, laughing, and/or taking a deep breath

42
Q

how to perform cardiac auscultation in PE for angina

A

auscultate over all four listening posts

- use bell to listen to apex and left sternal boarder

43
Q

how to auscultate for S3 and S4 or murmur associated w/ mitral regurgitation

A

use bell to listen at apex and left sternal border w/ patient in left lateral decubitus position

44
Q

additional physical exam work ups for a pt with dyspnea w/ suspection of Angina

A
  • evaluate peripheral pulses

- assess for edema

45
Q

what immediately eliminates cardiovascular causes for chest pain

A

reproducible chest pain w/ palpation

46
Q

what are the possible findings on an ECG of an angina patient w/ symptoms

A

findings may include:

  • changes consistent with previous MI (Q waves)
  • repolarization abnormalities (ST and T wave changes)
  • LVH
  • rhythm abnormalities
47
Q

what are the possible findings of a cardiac stress test of an angina pt

A
  • ST depressions identified during increased cardiac workload
  • may reproduce sx of dysnpea
48
Q

what are the possible findings of a stress echo of an angina pt

A

wall motion abnormalities during increased workload

49
Q

if a patient with suspecting IHD can exercise adequately and there are no confounding features present on a resting ECG, what is the next diagnostic step?

A

perform treadmill exercise test

50
Q

if a patient with suspected IHD cannot exercise adequately, what is the next diagnostic step

A

imaging studies

  • 2D echo
  • nuclear perfusion scan
  • MR scan
  • PET scan
51
Q

contraindications for stress test (7)

A
  • rest angina within 48 hours
  • unstable rhythm
  • severe aortic stenosis
  • acute myocarditis
  • uncontrolled heart failure
  • severe pulmonary HTN
  • active infective endocarditis
52
Q

what is the sensitivity of an exercise stress ECG

A

75%

53
Q

anterior and posterior chapman’s points for the heart

A

anterior: 2nd ICS along sternal border
posterior: inter-transverse spaces between T2-3

54
Q

goals of OMT for stable angina

A

NOT INDICATED :)

55
Q

what indicates a patient is at high risk for coronary events and what tx should be considered

A

inability to exercise for more than six minutes

consider interventional cardiac catheterization and recanalization of vessels with more than 50% occlusion

56
Q

medication treatment for acute angina symptoms

A
  • drug of choice: nitroglycerine sublingual (immediate release)
  • aspirin or clopidogrel if aspirin-intolerant
57
Q

what medications should be given to decrease demand ischemia

A
  • beta blockers (bisoprolol, metoprolol)

- calcium channel blockers (amlodipine, diltiazem)

58
Q

secondary prevention for stable angina

A
  • assess pt for other CV symptoms like claudication

- screen for thyroid dysfunction, anemia

59
Q

tertiary prevention for stable angina

A
  • cardiac rehab (comprehensive approach to encourage weight loss, increase exercise tolerance, control risk factors)
  • smoking cessation/abstinence
  • tx of lipid disorders and other co-morbidities that increase cardiac workload or risk of atherosclerosis
60
Q

non cardiovascular or pulmonary differentials for dyspnea

A
  • anemia

- psychiatric issue

61
Q

what are the immunization recommendations for patients w/ COPD

A
  • annual flu vaccine
  • pneumococcal vaccine (PCV13 - Prevnar) followed by PPSV23 (pneumovax) at least one year later
  • Tdap to protect against Bordetella pertussis
62
Q

example of a “Plan” for angina patient

this is long, 10 steps, but just be familiar with it I think. not an LO

A
  1. EKG performed - see above
  2. start ASA 81 mg/d
  3. discussed likely diagnosis of stable angina and scheduled stress test, AHA info provided
  4. labs today: lipid profile, CBC, BMP
  5. RX: nitro (plus dosage)
  6. RX: bisoprolol (plus dosage)
  7. contact EMS if sx fail to resolve after 3 nitro
  8. follow up next week
  9. discuss weight loss and lifestyle modifications
  10. OMT deferred pending further evaluation
63
Q

example ddx for patient presenting with dyspnea with suspected angina

A
  1. stable angina
  2. COPD
  3. paroxysmal a fib
64
Q

example ddx for patient presenting with dyspnea with suspected COPD

A
  1. COPD
  2. asthma
  3. stable angina
65
Q

example of a “Plan” for COPD patient

this is long, 5 steps, but just be familiar with it I think. not an LO

A
  1. albuterol administered, well tolerated with resolution of sx
  2. OMT performed: thoracic inlet opened, rib-raising performed T1-T7, well tolerated
  3. smoking cessation discussed
  4. albuterol MDI prescribed
  5. labs today: CBC, BMP
66
Q

additional data to acquire in a dyspnea case centered around causes of atherosclerosis

A
  • fasting glucose (assess for DM)
  • lipid panel (total cholesterol, LDL, HDL, triglycerides)
  • electrolytes (renal function - BUN, Cr, Na, K, CO2, Cl)

**BMP includes fasting glucose and electrolyte panel

67
Q

what is the most important fact from this DSA?

A

somi smells :)

Maddy - PCM III (5 decks)

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