Pulmonary Approach to Dyspnea, Palpitations, and Fatigue Flashcards
diagnosing a patient with dyspnea has a heavy reliance on what?
the patient description
what is tachypnea defined as? what is hypoxemia defined as?
t: RR> 20/minute; hypoxemia: O2 sat <95%
what are two examples of pulmonary vascular dsiease?
pulmonary hypertension and pulmonary embolism
what is pulmonary hypertension defined as?
the mean pulmonary artery pressure being >20 mmHg
how does increased pulmonary pressure manifest?
it puts extra strain on the right ventricle, so you’ll get cor pulmonale (right-sided HF)–> JVD and bilateral LE edema
how does pulmonary hypertension present?
dyspnea on exertion, fatigue, chest pain (pleuritic); insidious in onset; signs of right sided heart failure
what things would you order when trying to diagnose pulmonary hypertension?
EKG, TTE, cardiac catheterization
what is the diagnostic gold standard for diagnosing pulmonary hypertension?
cardiac catheterization
what would an EKG show in a patient with pulmonary hypertension?
right ventricular hypertrophy: right axis deviation, RBBB, right atrial enlargement
how do you identify right atrial enlargement on EKG?
peaked P waves in lead II
how do you identify a RBBB on an EKG?
RsR’
when diagnosing pulmonary hypertension, what does a TTE do?
estimates pulmonary artery systolic pressure indirectly by using the tricuspid regurgitation gradient
how do you treat pulmonary hypertension if it is not primary?
treatment is fixing the underlying disease
what could cause hypercoagulability?
genetic mutations, nephrotic syndrome, hyper-viscosity due to malignancy, contraceptives, smoking
what is the role of proteins C and S?
they block sites at VIII and V to inhibit clotting cascade
what is the role of antithrombin III?
blocks site at II and X
what is involved in the anti-coagulation pathway?
proteins c and s; antithrombin III
what happens if there is a protein c and S deficiency?
ineffective regulation of factor VIIIa and Va
what happens if there is an antithrombin III deficiency?
ineffective regulation of Xa and IIa (thrombin)
what happens if there is a Factor V Leiden mutation?
mutation of factor V prevents binding of protein C
what are the symptoms of a PE?
chest pain, palpitations, dyspnea, syncope, LE edema +/-
how does a physician determine whether or not they need to work a patient up for a DVT or not?
the wells criteria
how does the well’s criteria work?
if you a get a score greater than 6, the index of suspicion is high- you would just automatically go for imaging
what is d-dimer?
it has a high negative predictive value
what does an EKG show in a patient with a PE?
sinus tach, RV strain, incomplete RBBB, and S1Q3T3
how do you identify RV strain on an EKG?
inverted T waves in leads V1-4
how do you identify S1Q3T3 on an EKG?
deep S wave in lead 1, Q wave in lead 3, and inverted T wave in lead 3
what is the gold standard for imaging for a PE?
CT chest with contrast
how do you image screen for a PE in a patient with a contrast allergy or end stage renal disease?
V/Q scan
what is an echocardiogram sign of a significantly dilated RV and PHTN and acute PE?
D-shaped LV chamber due to RV enlargement
how is an unstable PE defined?
hypotension, RV strain, elevated cardiac enzymes
how do you treat an unstable PE?
1) resuscitation 2)thrombolytic therapy
how do you resuscitate an unstable PE?
ventilatory support and hemodynamic support
what should you do before starting thrombolytic therapy?
ensure no contraindication (currently on anticoagulation, recent falls or concern for intracranial hemorrhage)
how do you treat a stable PE?
heparin, low molecular weight heparin, vitamin K antagonist direct oral anticoagulants
what are the cons of vitamin K antagonist drugs (warfarin and coumadin)?
cumbersome with diet, drug interactions, requires frequent INR checks, takes time to reach therapeutic level and requires heparin (LMWH) bridge
reversal agents for LMWH?
protamine sulfate
reversal agents for warfarin?
vitamin K, prothrombin complex concentrate, fresh frozen plasma
reversal agents for DOACs?
Xa inhibitors: andexanet alpha
dabigatran: idarucizumab
what is the duration of treatment for DVT?
minimum of 3 months for all patients; indefinite anticoagulation is intended for those with underlying disease with high risk of VTE recurrence (malignancy or genetic mutations)
