HYHO: SPE Flashcards
visible signs of increased work of breathing that can be identified and reported by clinicians
tachypnea
accessory muscle use
intercostal retractions
ROS for a pt w/ dyspnea (6 examples)
fever swelling/edema in le palpitations recent travel coughing at night awakening short of breath
what patients will report with an “inability to take a deep breath”
COPD patients
Dyspnea Physical exam:
- inspection
while standing behind pt, observe breathing, shape of chest, and motion of chest wall/ribs
Dyspnea Physical exam:
- palpation
- identify tenderness and assess lung expansion (COPD)
- palpate for point of maximal impulse (angina)
Dyspnea Physical exam:
- percussion
comparing side to side in “ladder” pattern
Dyspnea Physical exam:
- auscultation
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
special/other tests in PE for pt w/ dyspnea/COPD
- tactile fremitus
- assess rib motion
- assessment of oropharynx/upper airway
supportive PE findings of a pt w/ COPD
- barrel shaped chest
- limited rib motion
- lung expansion w/ limited exhalation
percussion sounds on a pt w/ COPD
generalized hyper-resonance due to hyperinflation
auscultation findings on a pt w/ COPD
- decreased breath sounds
- wheezing
- prolonged expirations
tactile fremitus findings on pt w/ COPD
decreased due to hyperinflation
transmitted voice sounds on pt w/ COPD
decreased due to hyperinflation
diagnostic test for COPD pt in the office
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
what additional testing should you do in a COPD patient if diagnosis is unclear or symptoms fail to improve
- PFTs (spirometry)
- chest x-ray
expected FEV1 of pt w/ COPD
<70% of expected value
peak flow assessment value in a pt w/ COPD should be ____
reduced
function of peak flow assessment
approximates FEV1
what testing is included in phase 1 of diagnostic testing in a pt w/ dyspnea (4)
- CXR
- spirometry
- ECG
- CBC, CMP
what testing is included in phase 2 of diagnostic testing in a pt w/ dyspnea (6)
(if diagnosis not obtained in phase 1)
- chest CT
- lung volumes
- Diffusing capacity of the lungs for carbon monoxide (DLCO)
- test neuromuscular function
- echocardiogram
- cardiac stress test
what testing is included in phase 3 of diagnostic testing in a pt w/ dyspnea (5)
(if diagnosis not obtained in phase 2)
consider cardiopulmonary exercise testing and subspecialty referral
alternative ddx for dysnpea other than COPD
anemia
CXR of patient w/ COPD
- flattening of diaphragms
- increased AP diameter
sympathetic innervation of the heart is located at what spinal levels
T1-T6
sympathetic innervation of the lungs is located at what spinal levels
T1-T7
parasympathetic innervation to the heart and lungs is controlled by what nerve
vagus n.
anterior chapmans’ points for the lungs
anterior 2nd, 3rd, and 4th ICS along sternum
posterior chapmans’ points for the lungs
- lateral T2 spinous process
- inter-transverse space b/w T2-3, T3-4, T4-5
bio-mechanical goals of OMT for COPD pts
improve thoracic cage compliance and skeletal motion
neurological goals of OMT for COPD pts
normalize autonomic tone
respiratory-circulatory goals of OMT for COPD pts
maximize efficiency of diaphragm and enhance lymphatic return
metabolic-energetic-immune goals of OMT for COPD pts
enhance self-regulatory and self-healing mechanisms
behavioral goals of OMT for COPD pts
improve psychosocial components of health
primary prevention for COPD
- annual flu vaccine
- pneumococcal vaccine
- Tdap
secondary prevention for COPD
avoidance of other dust and fumes (occupational or hobby exposure)
tertiary prevention for COPD
- smoking cessation/abstinence
- pulmonary rehab (incorporates exercise, education, psychosocial, and nutritional counseling)
end-stage COPD is associated w/ what symptoms
- cachexia
- weight loss
- bitemporal wasting (temporalis m. wasting)
- diffuse loss of subcutaneous adipose tissue
clinical presentation of stable angina
pts will indicate the center of the chest pain with a fist over the sternum
how do stable angina patients describe their symptoms
- tight, squeezing, heavy, pressure but NOT pain
- radiation to neck, jaw, back, shoulder, ulnar surface of arm (trapezius area is spared)
associated sx w/ angina
dyspnea
nausea
fatigue
describe pleuritic chest pain
pain reproduced w/ maneuvers that cause motion b/w pleura and chest wall, such as coughing, laughing, and/or taking a deep breath
how to perform cardiac auscultation in PE for angina
auscultate over all four listening posts
- use bell to listen to apex and left sternal boarder
how to auscultate for S3 and S4 or murmur associated w/ mitral regurgitation
use bell to listen at apex and left sternal border w/ patient in left lateral decubitus position
additional physical exam work ups for a pt with dyspnea w/ suspection of Angina
- evaluate peripheral pulses
- assess for edema
what immediately eliminates cardiovascular causes for chest pain
reproducible chest pain w/ palpation
what are the possible findings on an ECG of an angina patient w/ symptoms
findings may include:
- changes consistent with previous MI (Q waves)
- repolarization abnormalities (ST and T wave changes)
- LVH
- rhythm abnormalities
what are the possible findings of a cardiac stress test of an angina pt
- ST depressions identified during increased cardiac workload
- may reproduce sx of dysnpea
what are the possible findings of a stress echo of an angina pt
wall motion abnormalities during increased workload
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?
perform treadmill exercise test
if a patient with suspected IHD cannot exercise adequately, what is the next diagnostic step
imaging studies
- 2D echo
- nuclear perfusion scan
- MR scan
- PET scan
contraindications for stress test (7)
- rest angina within 48 hours
- unstable rhythm
- severe aortic stenosis
- acute myocarditis
- uncontrolled heart failure
- severe pulmonary HTN
- active infective endocarditis
what is the sensitivity of an exercise stress ECG
75%
anterior and posterior chapman’s points for the heart
anterior: 2nd ICS along sternal border
posterior: inter-transverse spaces between T2-3
goals of OMT for stable angina
NOT INDICATED :)
what indicates a patient is at high risk for coronary events and what tx should be considered
inability to exercise for more than six minutes
consider interventional cardiac catheterization and recanalization of vessels with more than 50% occlusion
medication treatment for acute angina symptoms
- drug of choice: nitroglycerine sublingual (immediate release)
- aspirin or clopidogrel if aspirin-intolerant
what medications should be given to decrease demand ischemia
- beta blockers (bisoprolol, metoprolol)
- calcium channel blockers (amlodipine, diltiazem)
secondary prevention for stable angina
- assess pt for other CV symptoms like claudication
- screen for thyroid dysfunction, anemia
tertiary prevention for stable angina
- 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
non cardiovascular or pulmonary differentials for dyspnea
- anemia
- psychiatric issue
what are the immunization recommendations for patients w/ COPD
- annual flu vaccine
- pneumococcal vaccine (PCV13 - Prevnar) followed by PPSV23 (pneumovax) at least one year later
- Tdap to protect against Bordetella pertussis
example of a “Plan” for angina patient
this is long, 10 steps, but just be familiar with it I think. not an LO
- EKG performed - see above
- start ASA 81 mg/d
- discussed likely diagnosis of stable angina and scheduled stress test, AHA info provided
- labs today: lipid profile, CBC, BMP
- RX: nitro (plus dosage)
- RX: bisoprolol (plus dosage)
- contact EMS if sx fail to resolve after 3 nitro
- follow up next week
- discuss weight loss and lifestyle modifications
- OMT deferred pending further evaluation
example ddx for patient presenting with dyspnea with suspected angina
- stable angina
- COPD
- paroxysmal a fib
example ddx for patient presenting with dyspnea with suspected COPD
- COPD
- asthma
- stable angina
example of a “Plan” for COPD patient
this is long, 5 steps, but just be familiar with it I think. not an LO
- albuterol administered, well tolerated with resolution of sx
- OMT performed: thoracic inlet opened, rib-raising performed T1-T7, well tolerated
- smoking cessation discussed
- albuterol MDI prescribed
- labs today: CBC, BMP
additional data to acquire in a dyspnea case centered around causes of atherosclerosis
- 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
what is the most important fact from this DSA?
somi smells :)
