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PCM3 > Midterm > Flashcards

Midterm Flashcards

1
Q

Broad causes of dyspnea

A

Pulmonary, CV, Systemic (anemia), psychiatric (anxiety), etc

…effective history taking will delineate system at fault

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2
Q

What os pleuritic chest pain?

A

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

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3
Q

Side effects of COPD medications

A

Beta agonists: tremor, tachycardia

Anticholinergic muscarinic antagonists: dry mouth

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4
Q

Patient education for stable angina

A

Discuss dx with Pt so pt understands lifestyle modifications such as reduced energy expendature, especially early mornings and after meals

Lifestyle modifications: smoking cessation, weight loss, dietary adjust

Engage the patient in decision for Cardiology referral or cath

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5
Q

OSE for Angina

A

Sympathetic innervation: heart = T1-6, Lungs = T1-7

Parasympathetic innervation: Vagus

Chaman Points for Heart: Anterior 2nd ICS at sternal border and posterior transverse spaces btwn T2/3

OMT is not indicated for stable angina

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6
Q

What type of symptom is dyspnea?

A

It is subjective and a self-reporting symptom

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7
Q

SOAP Note: OSE

A

OSE is an objective finding and must include 3out of 4 tart findings to meet guidelines for billing: tenderness (pt comment), asymmetry, restrictions in motion (not the same as orthopedic assessment), and tissue texture changes

List the somatic dysfunction region

Assessment: SD Thorax

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8
Q

CAD in men vs women

A

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

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9
Q

Physical exam for Stable Angina: special considerations

A

Pulmonary evaluation

CV auscultation: use left lateral decubitis posttion to listen for S3, S4, or murmur associated with mitral regurg

PMI for size and shift of apex, listen for bruits, UE/LE pulses and perfusion

Evaluate for edema

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10
Q

Labs for Angina DDX

A

Labs are centered around causes of atherosclerosis:

Fasting glucose and lipid panel

renal functions (BUN, Cr, Na, K, CO2, Cl)

***So…order a BMP with lipid panel

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11
Q

When is a patient with stable angina at greater risk for coronary event?

A

When a patient is unable to exercise for less than 6 minutes, the pt is at high risk for coronary events. Strong consideration for interventional cardiac cath and recannalization of vessels with >50% occlusion

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12
Q

What are the most common etiologies for dyspnea?

A

Cardiac and pulmonary (~85%)

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13
Q

Diagnostic Data for COPD

A

6-minute walk with pulseOx to assess O2 sat with activity and replicate dyspnea; repeat auscultation at the end of the walk, listening for expiratory wheezing not present at rest

Peak Flow Assessment: COPD diagnosis when FEV1/expected FEV1 <70%

PFT (spirometry) and CXR can be used in addendum

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14
Q

American Thoracic Society definition of dyspnea

A

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social and environmental factors and may induce secondary physiological and behavioral responses.

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15
Q

When does Stable Angina progress to Unstable?

A

When angina occurs at rest or without provocation and takes 2-3 nitro doses to abate. Unstable angina is the beginning of ACS

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16
Q

ECG in stable angina

A

Likely normal in the absence of sx. Findings may include changes consistent with previous MI (Q-waves), repolarization abnormalities (ST seg and T wave changes), LVH or rhythm abnormalities

If the baseline ECG is abnormal (eg LBBB) then radionucleotide perfusion images, cardiac megnetic resonance (CMR) stress testing or PET imaging may be necessary to ID regioal ischemia

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17
Q

Angina “equivalents”

A

dyspnea, nausea, fatigue

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18
Q

Dyspnea special considerations

A

Acute vs chronic; made worse or better with…; pleuritic vs nonpleuritic; risk factors (tobacco, HTN, COPD, DM, etc.); ROS: constitutional, edema, palps, recent travel or illness, orthopnea, etc

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19
Q

Sympathetic innervation of Head and Neck

A

T1-5

includes upper esophagus

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20
Q

Sympathetic innervation of the Lungs

A

T1-7

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21
Q

5 model goals of OMT with COPD

A

Biomechanical: improve thoracic cage compliance & skeletal motion

Neurological: Normalize autonomic tone

Resp/Circ: Maximize efficiency of the diaphragm & enhance lymph return

Metabolic/Energetic/Immune: enhance self-regultion/healing mechanisms

Behavioral: Improve psychosocial components of health

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22
Q

Sympathetic innervation of the upper GI

A

T5-10

Includes the lower esophagus

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23
Q

COPD/Dyspnea OSE

A

Sympathetic innervation of the heart: T1-6; Sympathetic innervation of the lungs: T1-7; Parasympathetic innervation: Vagus; Chapman’s points for lungs: Ant 2nd, 3rd, 4th ICS along sternal border, posterior-lateral T2 spinus process, intertransverse spaces between T2/3, T3/4, and T4/5

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24
Q

Parasympatheic innervation by the Vagus nerve (OA, AA)

A

Heart, lungs, esophagus, upper GI, small intestine, kidneys, ascending and transverse colon, upper ureter

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25
Q

Sympathetic innervation of the ureters

A

Upper: T10-11

Lower: T12 - L2

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26
Q

Parasympathetic innervation by Sacral Plexus

A

S2-4

Colon, rectum, repro organs, bladder, pelvis, lower ureter

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27
Q

Sympathetic innervation of the genitourinary tract (including the bladder)

A

T10-L2

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28
Q

Objective signs of dyspnea

A

Tachypnea, accessory muscle use, tripoding…visible signs of increased work of breathing

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29
Q

Long-term mgmt and preventative measures for Stable Angina

A

Secondary prevention: assess for other cv sx (claudication), screen for thyroid dysfunction, anemia, etc. (things that may increase cardiac work load and cause sx to recur

Tertiary prevention: Cardiac rehab (increase exercise tolerance)!, smoking cessation, tx of lipid disorders

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30
Q

Sympathetic innervation of the ascending and transverse colon

A

T10 - L2

31
Q

Alternative Dyspnea DDX with “normal” Pulse-Ox

A

Anemia: Hb will be saturated but Hct will be low therefore a pt may have a 95% pulse Ox but still be hypoxic. Severe anemia can cause fatigue and dyspnea as well as cardiac sx of HF and angina. Physical findings include pallor, especially of the conjunctiva and bounding pulses. Obtain CBC to evaluate for anemia

32
Q

Describe end-stage COPD

A

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

33
Q

COPD Physical Exam

A

Palpation of chest for tenderness and access lung expansion; Percuss to compare sides- in a ladder pattern; auscultate- also in a ladder pattern - 2 anterior and at least 4 posterior while pt takes deep breaths through an open mouth; special tests- tactile fremitus and transmitted voice sounds as well as rib motion. **Additional assessment of the upper airway is also recommended

34
Q

Long-term COPD management (Primary, Secondary, and Tertiary preventative measures)

A

Primary prevention: annual flu vaccine, Pneumococcal Vaccine (PCV13) followed by PPSV23 at least 1 yr later, TDaP (Bordatella pertussis)

Secondary prevention: avoidance of dust, fumes, industrial exposure by using respiratiors or masks

Tertiary prevention- smoking cessation/abstenence, pulm rehab

35
Q

Diagnostic Data flow Chart for Dyspnea

A

Hx and PE plus walking PulseOx, peak flow assess. No DX, move to phase 1:

Phase 1 - CXR, Spirometry, ECG, CBC, BMP. No DX, move to phase 2:

Phase 2 - Chest CT, Lung Vol, DLCO, neuromuscular function testing, echocardiogram, stress testing. No DX, move to phase 3:

Phase 3 - Consider Cardiopulm exercise test and subspecialty referral

36
Q

Effect of cigarettes on COPD

A

Accelerated decline in FEV1 in a dose-dependent response

Only 15% is explained by pack-years, suggesting environmental and genetic components

37
Q

Short-term treatment of COPD

A

Pt education: provide written material as well as discuss diagnosis, smoking cessation/avoidance and idetify other triggers s/a season change, air quality, ect; when to seek medical attention

Medications: inhaled and PO: short-acting inhaled bronchodilators for rescue-Beta agonists (albuterol) and anticholinergic muscarinic antags (ipratropium) to improve FEV1; long-acting bronchodilators if symptoms persist - B agonists (salmeterol), anticholinergic muscarinic antags (tiotropium), LAMA>LABA for sx improvement

OMT (5 models)

Pulmonology referral for refractory or complicated cases

38
Q

Common physical exam findings in COPD

A

Barrel chest, limited rib motion, limited lung expansion with limited exhalation. Percussion may reveal generalized hyperresonance d/t hyperinflation. Decreased breath sounds, wheezing and prolonged expirations are common. Transmitted voice sounds and fremitus are decreased d/t hyperinflation

39
Q

Angina on stress test

A

On a treadmill stress test, ST Depressions identified during increased cardiac workload, may also reproduce sx of dyspnea

40
Q

Medications and side effects for Stable Angina

A

ASA: bleeding, bruising, avoid NSAIDS (GI bleed)

Nitrates: HA, hypotension, syncope, reflex tachycardia

B Blockers: fatigue, depression,, bradycardia, heart block, bronchospasm, postural hypotension

Dihydropiridine: HA, LE edema, fatigue, flushing, reflex tach

Non-dihydropiridine: bradycardia, heart conduction defect, low EF, constipation

41
Q

Describe presenting the patient

A

Brief, generally ~ 5 min

Provide enough info to tell audience how you came to your conclusion

Must be in chronologic order

Must follow SOAP note format

Accurately review events that lead to Pt making the appt

ID risk factors and/or other underlying medical conditions that may affect dx

Generate an assessment and plan (commit!)

42
Q

SOAP note physical exam…what do you document?

A

EVERYTHING you did regardless of outcome!

Use correct grading/scales, clearly specify location/direction, document positive and negative findings

43
Q

Complications of Stable Angina

A

Prgression to unstable angina –> ACS –> MI

CVA

PVD

44
Q

Sympathetic innervation of the small intestines and ascending colon

A

T9-11

45
Q

How would a patient describe angina?

A

Heavy, squeezing, pressure, tightness or choking..rarely described as actual pain.

46
Q

Sympathetic innervation of the descending and sigmoid colon

A

T12 - L2

47
Q

Conclusions drawn from cardiac stress tests

A

Overall sensitivity is ~75%

A negative result does not exclude CAD, although it makes the likelyhood of three-vessel or left main CAD extremely unlikely

Contraindications to cardiac stress testing includes unstable angina w/in 48 hours, unstable ECG rhythm, acute myocarditis, sever aortic stenosis, uncontrolled heart failure, severe pulmonary HTN, and active infective endocarditis

48
Q

Symptoms of stable angina

A

Generally begins on exertion

Levine sign

Discomfort, tight, squeezing, heavy pressure but rarely “pain”

May radiate to neck, jaw, back, shoulder, ulnar surface of arm. Trapezius area is generally spared

Stable angina gets better with rest and 1-2 Nitro

49
Q

Sympathetic innervation of the extermeties

A

Upper: T2-7

Lower: T11- L2

50
Q

Chest X-ray findings with COPD

A

Typically include flattening of the diaphragm, increased AP diameter which is best appreciated by increased space between sternum and mediastinum on a lateral film

51
Q

Sympathetic innervation of the Adrenal glands

A

T5-10

52
Q

Sympathetic innervation of the Heart

A

T1-6

53
Q

Complications of COPD

A

Progressive hypoxia (supplemental O2)

Exacerbations increase as FEV1 decreases, driven by increased airway inflammation (>50% are bacterial, 30% viral)

Respiratory failure during an exacerbation: tx with O2 or bipap, possibly intubation/mechanical vent

54
Q

What is the prupose of admission orders?

A

To outline an initial treatment plan for pts entering a medical facility for specialized care as a means to communicate

55
Q

What is an observation admission?

A

When a patient needs hospital care but expected to stay only on e night to observe progress. Can transition to an inpatient admission if pt meets criteria

56
Q

Admissions orders:

ADC VANDALISMM

A

Admit, Diagnosis, Condition

Vitals, Activity, Nursing, Diet, Allergies, Labs and Diagnostics, IV fluids, Specalists/Consults, Medication, Monitoring

57
Q

What is the three piece framework for admissions orders?

A
  1. Conditions for admission: admit, diagnosis, condition, allergies, meds
  2. Diagnostic procedures: Vitals, activity, Nursing, Diet, Labs, IV fluids, Specalists/consults, Meds
  3. Safety: Medications, Monitoring
58
Q

What does the patient Admit specify?

A
  1. The service
  2. The attending
  3. Particular Unit
  4. Need for telemetry
59
Q

What are criteria for admissions to ICU?

A
  1. Requiring, or likely to require, advanced respiratory support
  2. Patients requiring support of two or more organ systems
  3. Patients with chronic impairment of ONE or more orgen systemswho also require support for an acute, reversable failure of another organ
  4. When the PT needs care that cannot be addressed on another unit d/t medication intensity, need for close monitoring, high risk of declinen in condition
60
Q

How are diagnosies communicated in admissions orders?

A

List the primary DX…it may only be a working diagnosis, but this DX is the biggest concern you have for the Pt (do not list S/SX as a diagnosis)

List in order of priority if you mention multiple and break the into two groups: first the new/acute problem; second the chronic problems

*Listing chronic problems can be helpful in allowing those processing the orders to know the chronic conditions that lead to or are contributing to the admission

61
Q

What is critical condition on admission orders?

A

Patients typically are going to ICU as they are potentially unstable or have been unstable prior to the admission and affectively stablilized enough to be transitioned to a medical unit that is appropriate for their diagnosis and care

62
Q

What info is needed for Vitals in patient admission orders?

A
  1. frequency…usually every 4-8 hours, but can be special instructions such as every 2 hours for 8 hours, then move to every 4 hours
  2. parameters for notifying the physician
63
Q

What are Nursing orders on patient admissions?

A

Orders specific for nursing functions, usually not needed any longer as nurses now develop care plans for pts which include nursing orders.

Examples: deep breathing exercises every 2 hours

Routine oral care

Routine hygiene

64
Q

What could be listed in Specalists/Consultations in admissions orders?

A

Medical Specialists

Nutrition

Phys/Occ Therapy

WOund CAre

Metabolic support

Palliative Care/Hospice

65
Q

What did Dr. Tyler say was the most important aspect of the admissions orders?

A

Medications

  • Medication reconciliation
  • ID all meds and doses
  • Delete/Add
  • Specific to admission

**a patient must have a diagnosis for each medication, cannot state it is something the pt already takes (if the pt takes a PPI every day, even OTC, a diagnosis of GERD needs to be made or the med d/c’d)

66
Q

Body Water compartments and IV fluid distrobution

A

ECW = 20% (plasma and interstitial)

Colloids remain in plasma, NS/LR stay in ECW

ICW = 40%

5DW/Dex Saline spread through ECW and ICW

Minerals, proteins, Fat, glycogen = 40%

67
Q

The “5 R’s” to fuid replacement

A

Resuscitation

Replacement-Redistribute

Routine Maint.

Oral/Enteral Maint.

68
Q

Tonicity of IV fluids

A

Isotonic: NS, LR, D5W (+/-)

Hypotonic: 1/2NS. D5W (+/-)

Hypertonic: 3%NaCl, D10W, D5 1/2NS, D5NS, D5LR

69
Q

When apporaching fluid needs of the pt, how much does the average person need in fluids and electrolytes?

A

25-30 ml/kg water per day and about 1 mmol/kg of Na and K

70
Q

Holliday-Segar Method of pediatric fluid replacement

A

First 10kg = 100ml/kg in 24*

second 10kg = 50ml/kg in 24*

remaining kg = 20ml/kg in 24*

**24kg kid = 1000mL + 500ml + 80ml = 1580 ml/24 hours = 66 ml/hr

-With volume loss, compare normal weight to lost weight: 1 kg = 1 L;

Replace 1/2 the fluid vol in 8 hours and the rest over the next 16 hours with monitoring

71
Q

Resuscition fluid in adults

A

With severe volume depletion, 1-2 L of isotonic saline are given bolus, then replacement is continued at a rapid rate until cinical signs improve

72
Q

When is Lactated Rigner’s used?

A

LR is favored by surgical specalties

  • LR has a tendency to increase the chance of emboli formation in the midst of PRBC transfusion
  • In thoery, the Ca in LR could overwhelm the chelating capacities of the citrate in stored blood, resulting in clot formation

**Avoid use in Rhabdo! , NS is the better choice

73
Q

What must be watched with NS resuscitation?

A

Thsi isotonic solution can induce a metabolic acidosis with aggressive resuscitation

74
Q

Is D5W really isotonic?

A

It is considered isotonic, but may cause significant electrlyte shifts d/t hypotonicity after the initial response phase

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