Pulmonary Approach to Dyspnea, Palpitations, and Fatigue

Question 1

diagnosing a patient with dyspnea has a heavy reliance on what?

Answer 1

the patient description

Question 2

what is tachypnea defined as? what is hypoxemia defined as?

Answer 2

t: RR> 20/minute; hypoxemia: O2 sat <95%

Question 3

what are two examples of pulmonary vascular dsiease?

Answer 3

pulmonary hypertension and pulmonary embolism

Question 4

what is pulmonary hypertension defined as?

Answer 4

the mean pulmonary artery pressure being >20 mmHg

Question 5

how does increased pulmonary pressure manifest?

Answer 5

it puts extra strain on the right ventricle, so you’ll get cor pulmonale (right-sided HF)–> JVD and bilateral LE edema

Question 6

how does pulmonary hypertension present?

Answer 6

dyspnea on exertion, fatigue, chest pain (pleuritic); insidious in onset; signs of right sided heart failure

Question 7

what things would you order when trying to diagnose pulmonary hypertension?

Answer 7

EKG, TTE, cardiac catheterization

Question 8

what is the diagnostic gold standard for diagnosing pulmonary hypertension?

Answer 8

cardiac catheterization

Question 9

what would an EKG show in a patient with pulmonary hypertension?

Answer 9

right ventricular hypertrophy: right axis deviation, RBBB, right atrial enlargement

Question 10

how do you identify right atrial enlargement on EKG?

Answer 10

peaked P waves in lead II

Question 11

how do you identify a RBBB on an EKG?

Answer 11

RsR’

Question 12

when diagnosing pulmonary hypertension, what does a TTE do?

Answer 12

estimates pulmonary artery systolic pressure indirectly by using the tricuspid regurgitation gradient

Question 13

how do you treat pulmonary hypertension if it is not primary?

Answer 13

treatment is fixing the underlying disease

Question 14

what could cause hypercoagulability?

Answer 14

genetic mutations, nephrotic syndrome, hyper-viscosity due to malignancy, contraceptives, smoking

Question 15

what is the role of proteins C and S?

Answer 15

they block sites at VIII and V to inhibit clotting cascade

Question 16

what is the role of antithrombin III?

Answer 16

blocks site at II and X

Question 17

what is involved in the anti-coagulation pathway?

Answer 17

proteins c and s; antithrombin III

Question 18

what happens if there is a protein c and S deficiency?

Answer 18

ineffective regulation of factor VIIIa and Va

Question 19

what happens if there is an antithrombin III deficiency?

Answer 19

ineffective regulation of Xa and IIa (thrombin)

Question 20

what happens if there is a Factor V Leiden mutation?

Answer 20

mutation of factor V prevents binding of protein C

Question 21

what are the symptoms of a PE?

Answer 21

chest pain, palpitations, dyspnea, syncope, LE edema +/-

Question 22

how does a physician determine whether or not they need to work a patient up for a DVT or not?

Answer 22

the wells criteria

Question 23

how does the well’s criteria work?

Answer 23

if you a get a score greater than 6, the index of suspicion is high- you would just automatically go for imaging

Question 24

what is d-dimer?

Answer 24

it has a high negative predictive value

Question 25

what does an EKG show in a patient with a PE?

Answer 25

sinus tach, RV strain, incomplete RBBB, and S1Q3T3

Question 26

how do you identify RV strain on an EKG?

Answer 26

inverted T waves in leads V1-4

Question 27

how do you identify S1Q3T3 on an EKG?

Answer 27

deep S wave in lead 1, Q wave in lead 3, and inverted T wave in lead 3

Question 28

what is the gold standard for imaging for a PE?

Answer 28

CT chest with contrast

Question 29

how do you image screen for a PE in a patient with a contrast allergy or end stage renal disease?

Answer 29

V/Q scan

Question 30

what is an echocardiogram sign of a significantly dilated RV and PHTN and acute PE?

Answer 30

D-shaped LV chamber due to RV enlargement

Question 31

how is an unstable PE defined?

Answer 31

hypotension, RV strain, elevated cardiac enzymes

Question 32

how do you treat an unstable PE?

Answer 32

1) resuscitation 2)thrombolytic therapy

Question 33

how do you resuscitate an unstable PE?

Answer 33

ventilatory support and hemodynamic support

Question 34

what should you do before starting thrombolytic therapy?

Answer 34

ensure no contraindication (currently on anticoagulation, recent falls or concern for intracranial hemorrhage)

Question 35

how do you treat a stable PE?

Answer 35

heparin, low molecular weight heparin, vitamin K antagonist direct oral anticoagulants

Question 36

what are the cons of vitamin K antagonist drugs (warfarin and coumadin)?

Answer 36

cumbersome with diet, drug interactions, requires frequent INR checks, takes time to reach therapeutic level and requires heparin (LMWH) bridge

Question 37

reversal agents for LMWH?

Answer 37

protamine sulfate

Question 38

reversal agents for warfarin?

Answer 38

vitamin K, prothrombin complex concentrate, fresh frozen plasma

Question 39

reversal agents for DOACs?

Answer 39

Xa inhibitors: andexanet alpha

dabigatran: idarucizumab

Question 40

what is the duration of treatment for DVT?

Answer 40

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)