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PCM III > HYHO SPE3-1 > Flashcards

HYHO SPE3-1 Flashcards

1
Q

How is dyspnea different than tachypnea, accessory muscle use, and retractions?

A

Tachypnea, accessory muscle use and intercostal retractions are visible signs of increased work of breathing that can be identified and reported by clinicians.

However, dyspnea is a self-reported symptom.

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2
Q

Cardiac and pulmonary etiologies account for ~__% of cases of shortness of breath.

A

85%

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3
Q

Patients with COPD classically report what sensation in regards to breathing?

A

COPD: strong association with smoking, occupational lung disease or medications; symptoms are progressive over long period of time; reports a sensation of inability to take a deep breath.

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4
Q

Smoking and occupational lung disease is strongly associated with…

A

COPD

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5
Q

What are the positive risk factors for stable angina?

A

Stable Angina:

+risk factors for coronary atherosclerosis (hyperlipidemia, HTN, cigarette smoking, etc.).

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6
Q

How do patients typically describe stable angina?

A

Typically described as heavy, squeezing, pressure, tightness or choking but rarely as pain.

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7
Q

What does “anginal equivalents” mean? What are the key examples of these?

A

“An anginal equivalent is a symptom such as shortness of breath (dyspnea), nausea, diaphoresis (sweating), extreme fatigue, or pain at a site other than the chest, occurring in a patient at high cardiac risk. Anginal equivalents are considered to be symptoms of myocardial ischemia. Anginal equivalents are considered to have the same importance as angina pectoris in patients presenting with elevation of cardiac enzymes or certain EKG changes which are diagnostic of myocardial ischemia.”

-Wiki

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8
Q

In a patient with COPD, what do expect to find while percussing?

A

Percussion may reveal generalized hyperresonance due to hyperinflation.

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9
Q

In a patient with COPD, what do expect to find while auscultating?

A

Decreased breath sounds, wheezing and prolonged expirations are common in COPD.

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10
Q

In a patient with COPD, what do expect to find during tactile fremitus?

A

Transmitted voice sounds and fremitus are decreased due to hyperinflation.

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11
Q

What are some common findings upon inspection and palpation in patients with COPD?

A

COPD: common findings are a barrel shaped chest, limited rib motion and lung expansion with limited exhalation.

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12
Q

What are the special tests associated with COPD?

A

Special tests: Assessment for tactile fremitus, and transmitted voice sounds.
Rib motion is also a ‘special test’ for pulmonary complaints.
Additional assessment of upper airway, such as oropharynx, is recommended.

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13
Q

What are the risk factors associated with COPD?

A

Risk factors: tobacco use, HTN/CV dz, DM, FH, etc.

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14
Q

What are the two important diagnostic tests to do when treating a patient with a potential COPD diagnosis?

A

1.
In the clinic setting, have the patient walk with a pulse-oximeter to assess oxygen desaturation with activity and in an attempt to replicate the symptom of dyspnea. Repeat auscultation at the end of the walk may reveal (expiratory) wheezing that was not present at rest.

2.
Peak flow assessment
Should be reduced in COPD

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15
Q

What is important to remember to do after making a patient walk with a a pulse-oximeter to assess oxygen desaturation?

A

Repeat auscultation at the end of the walk may reveal (expiratory) wheezing that was not present at rest.

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16
Q

What additional testing should be done to assess for COPD if walking test and peak flow assessment was unclear or inconclusive?

A

Additional Testing if diagnosis is unclear or symptoms fail to improve:

  • Pulmonary Function Testing (Spirometry)
  • Chest x-ray
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17
Q

What is the expect PFT diagnosis in those with COPD?

A

COPD diagnosis: FEV1/expected FEV1 ≤ 70%

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18
Q

What would the chest XR show in a COPD patient?

A

Typical finding of COPD include flattening of the diaphragms, increased AP diameter (best appreciated by increased space between sternum and mediastinum on lateral film).

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19
Q

What is a major alternative differential diagnosis of dyspnea to be aware of other than COPD (especially in those with seemingly normal oxygen levels)?

A

Anemia:
Recall that the pulse oximeter measures percent saturated hemoglobin.

If the patient has a hemoglobin of 8mg/dl (normal 11-15mg/dl) the pulse ox can read 95% but the patient is still hypoxic.

Severe anemia can also cause fatigue and dyspnea as well as cardiac symptoms of heart failure and/or angina.

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20
Q

What are the general exam findings in a patient with anemia? What lab test should be ordered?

A

PE findings: generalized pallor, conjunctival pallor, bounding pulses -obtain a CBC to evaluate for anemia

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21
Q

What are the important short-term treatments for those with COPD? There are numerous.

A
  • Patient education: provide written material as well as discussion of diagnosis.
  • Smoking cessation/avoidance
  • Identify other potential triggers: season change, illness, cold air
  • Use of inhalers to manage symptoms
  • Medication side-effects
  • OMT (see above)
  • When to seek medical attention
  • Pulmonology referral for refractory or complicated cases
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22
Q

What are the short-term medication used for rescue in those with COPD? How do taking these medications improve the results of a PFT?

A

Short acting inhaled bronchodilators for rescue:

Beta Agonists (albuterol)

Anticholinergic muscarinic antagonists (ipratropium)

These improve FEV1!

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23
Q

What medications should be used for those with COPD that have persistent symptoms?

A

Long acting bronchodilators for those with persistent symptoms.

Βeta agonists (salmeterol); anticholinergic muscarinic antagonists (tiotropium);

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24
Q

How do long-acting muscarinic antagonists compare to long-acting beta agonists in those with COPD?

A

LAMA improve symptoms and reduce exacerbations > LABA

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25
Q

When should smoking sensation be addressed?

A

-Should be addressed at every visit to encourage cessation and continued abstinence.

  • Cessation significantly improves the rate of decline in pulmonary function, often returning to annual changes similar to that of nonsmoking patients.
  • Cessation improves survival
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26
Q

How does smoking cessation alter the FEV1?

A
  • longitudinal studies show an accelerated decline in FEV1 in a dose-response relationship to the intensity of smoking expressed as pack-years
  • only 15% of variability in FEV1 is explained by pack-years, which suggest other environmental or genetic components
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27
Q

What are the current major treatments for smoking cessation?

A

There are multiple forms of nicotine replacement, bupropion (SNRI) and varenicline (a nicotinic acid receptor agonist/antagonist).

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28
Q

What are the primary preventions associated with COPD?

A

Primary Prevention:

  • Annual flu vaccine
  • Pneumococcal vaccine (PCV13 [Prevnar] followed by PPSV23 [pneumovax] at least one year later)
  • Tdap to protect against Bordetella pertussis
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29
Q

What are the secondary preventions associated with COPD?

A

Secondary Prevention:

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

30
Q

What are the tertiary preventions associated with COPD?

A

Tertiary Prevention:

  • Smoking Cessation/abstinence.
  • Pulmonary rehab
31
Q

What are the major complications of COPD?

A

COMPLICATIONS OF COPD:
Progressive hypoxia: requiring supplemental oxygen

Respiratory failure: During an exacerbation, patients may need support with oxygen, noninvasive positive-pressure ventilation (bipap) or intubation and mechanical ventilation.

32
Q

What is pulmonary rehab?

A

Pulmonary Rehab is a comprehensive treatment program that incorporates exercise, education, psychosocial and nutritional counseling. Proven to improve health-related quality of life, dyspnea and exercise capacity as well as reduce rates of hospitalization.

33
Q

What are COPD exacerbations driven by?

A

Exacerbations of COPD increase in frequency as FEV1<50% of predicted.

Exacerbations are driven by increased airway inflammation.

> 50% of exacerbations are related to bacterial infections, 1/3 to viral infections and the rest unknown.

34
Q

What is end-stage COPD associated with?

A

End-stage COPD is associated with cachexia, weight loss, bitemporal wasting, and diffuse loss of subcutaneous adipose tissue. Patients will qualify for Hospice at this stage.

35
Q

What are the medication side effects of beta agonists?

What about for anticholinergic muscarinic antagonists?

A

Medication side-effects:

  • Beta agonists: tremor, tachycardia
  • Anticholinergic muscarinic antagonists: dry mouth
36
Q

What are the symptoms of stable angina?

A

Patients will indicate the center of symptoms as a fist over the sternum. Descriptions include discomfort as tight, squeezing, heavy, pressure, etc. but NOT pain.

-Radiation to the neck, jaw, back, shoulder, ulnar surface of the arm is painful. Trapezius area is generally spared.

37
Q

What is the simple difference between stable and unstable angina?

A
  • Stable angina occurs with activity and resolves with rest

- Unstable angina occurs at rest or without provocation and is a harbinger for progression to ACS

38
Q

CAD is much more common in men > __ and women >__.

A

CAD is much more common in men > 50 and women >60.

39
Q

What type of pain is reproduced with coughing, laughing and/or taking a deep breath?

A

Pleuritic chest pain is reproduced with maneuvers that cause motion between the pleura and the chest wall, such as coughing, laughing and/or taking a deep breath.

40
Q

What are the supportive findings on PE of stable angina?

A

Stable angina physical examination often is normal early in the disease process.

41
Q

When assessing a patient with stable angina, reproducible chest pain with palpation essentially eliminates ________ cause for the symptoms.

A

Reproducible chest pain with palpation essentially eliminates cardiovascular cause for the symptoms.

42
Q

What should be done during a physical exam when a patient complains of stable angina?

A

Pulmonary evaluation (same as COPD)
Cardiac evaluation: Auscultation over all four listening posts.
Use the bell to listen at the apex and left sternal border with the patient in the left lateral decubitus position to identify S3 or S4 or murmur associated with mitral regurgitation.
-Palpate for PMI
-Auscultate for Carotids bruits
-Evaluate peripheral pulses
-Assess for edema

43
Q

What are the three major diagnostic tests that can potentially be ordered for a patient with stable angina?

A 
DIAGNOSTIC DATA:
1.
ECG
2.
Cardiac Stress test
3.
Stress Echo
44
Q

What would the results of an ECG be in a patient with stable angina?

A

ECG: likley normal in the absence of symptoms. However, findings may include changes consistent with previous MI (Q- waves), repolarization abnormalities (ST-segment and T-wave changes), LVH or rhythm abnormalities.

45
Q

What would the results of a cardiac stress test be in a patient with stable angina?

A

Cardiac Stress test: (AKA exercise or treadmill stress test) ST depressions identified during increased cardiac workload. May also reproduce symptoms of dyspnea.

46
Q

What would the results of a stress echo be in a patient with stable angina?

A

Stress Echo: wall motion abnormalities during increased workload.

47
Q

Other than an ECG, cardiac stress test, and echo, what kind of lab work can/should be ordered on a patient with stable angina?

A

ADDITIONAL DATA is centered around causes of atherosclerosis. Therefore it is reasonable to obtain a fasting glucose (to assess for DM), lipid panel (total cholesterol, LDL, HDL & triglycerides) and electrolytes to evaluate renal function (BUN, Cr, Na, K, CO2, Cl).

48
Q

What is included on a BMP?

A

A Basic Metabolic Panel includes fasting glucose and the electrolyte panel.

49
Q

What is the overall sensitivity of a stress test? What are the contraindications?

A

Overall sensitivity of exercise stress ECG is ~75%, a negative result does not exclude CAD, although it makes the likelihood of three-vessel or left main CAD extremely unlikely.

Contraindication to exercise stress test includes rest angina within 48 hours, unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, severe pulmonary hypertension and active infective endocarditis.

50
Q

What are the short-term treatments for a patient with stable angina?

A
  1. Patient education: discuss diagnosis so the patient understands lifestyle modifications—reduced energy expenditure especially early mornings and after meals.
  2. Lifestyle modification (smoking cessation, weight loss, cholesterol management, etc.)
  3. Engage the patient in decision for Cardiology referral and/or cardiac catheterization.
51
Q

Inability to exercise < 6 minutes is high risk for ______ events.

A

inability to exercise < 6 minutes is high risk for coronary events.

52
Q

Strong consideration for interventional cardiac catheterization and recanalization of vessels ≥__% occlusion.

A

Strong consideration for interventional cardiac catheterization and recanalization of vessels ≥50% occlusion.

53
Q

What is the drug of choice for symptom management in those with stable angina?

A

Nitroglycerine sub-lingual (immediate release) is drug of choice for acute angina symptoms. Onset of action 1-3 minutes. Side effects are related to rapid vasodilation. Long-acting formulations are also available, but not indicated for acute symptoms.

Also indicated:

  • Antiplatelet medication: Aspirin OR clopidogrel if ASA intolerant/allergic
  • medication to decrease demand ischemia: Beta-blockers (i.e. bisoprolol, metoprolol) or Calcium-channel blockers (dihidropyridine such as amlodipine or nondihyropyridine such as diltiazem)
54
Q

What are the possible side effects of ASAs? What about nitrates?

A

ASA: bleeding, bruising; patient should be instructed to avoid other NSAIDs to minimize risk of bleeding, especially GI bleed.

Nitrates: headache, flushing, hypotension, syncope, reflex tachycardia.

55
Q

What are the possible side effects of beta-blockers?

A

Beta blockers: fatigue, depression, bradycardia, heart block, bronchospasm, postural hypotension

56
Q

What are the possible side effects of dihidropyridines?

A

Dihidropyridine: headache, ankle swelling, fatigue, flushing, reflex tachycardia

57
Q

What are the possible side effects of non-dihidropyridines?

A

Nondihydropyridine: bradycardia, heart conduction defect, low ejection fraction, constipation

58
Q

What are the possible complications of unstable angina?

A

Complications -Progression to unstable angina (resting angina symptoms), ACS/MI -CVA -PVD

59
Q

What are the secondary prevention characteristics for a patient with stable angina?

A

Secondary Prevention:
-Assess patient for other CV symptoms i.e. claudication -screening for thyroid dysfunction, anemia, etc. that can increase cardiac workload and cause symptoms to reoccur.

60
Q

What are the tertiary prevention characteristics for a patient with stable angina?

A

-Cardiac Rehab is a comprehensive approach to encourage weight loss, increase exercise tolerance and control risk factors with confidence and the support of multiple healthcare professionals.

  • Smoking cessation/abstinence
  • Treatment of lipid disorders and other comorbidities that increase risk of atherosclerosis OR increase cardiac workload, such as anemia and thyroid dysfunction.
61
Q

What is the sympathetic innervation of heart? What about the lungs?

A

Sympathetic Innervation of Heart: T1 – 6

Sympathetic Innervation of Lungs: T1 - 7

62
Q

What is the parasympathetic innervation of the heart and lungs?

A

Parasympathetic Innervation: Vagus

63
Q

What is the “biomechanical” OMT goal of treating a patient with COPD?

A

Biomechanical: Improve thoracic cage compliance and skeletal motion

64
Q

What is the “neurological” OMT goal of treating a patient with COPD?

A

Neurological: Normalize autonomic tone

65
Q

What is the “respiratory-circulatory” OMT goal of treating a patient with COPD?

A

Resp-Circ: Maximize efficiency of the diaphragm and enhance lymphatic return

66
Q

What is the “metabolic-energetic-immune” OMT goal of treating a patient with COPD?

A

Metabolic-Energetic-Immune: enhance self-regulatory and self-healing mechanisms

67
Q

What is the “behavioral” OMT goal of treating a patient with COPD?

A

Behavioral: Improve psychosocial components of health

68
Q

What are the chapmans points of the heart?

A

Anterior 2nd ICS along sternal border Posterior Intertransverse spaces between T2-3

69
Q

What are the chapmans points of the heart?

A

Anterior 2nd ICS along sternal border Posterior Intertransverse spaces between T2-3

70
Q

What are the chapmans points of the lung?

A

Chapmans’ Points Lungs: Anterior 2nd, 3rd, 4th ICS along sternum Posterior Lateral T2 Spinous process, Intertransverse space betwwen T2-3, T3-4 & T4-5

PCM III (12 decks)

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