Quiz 2 Flashcards
indications for pulmonary function tests/spirometry
- Preop eval of lungs and pulmonary reserve
- response to bronchodilator therapy
- differentiate between restrictive and obstructive
- chronic pulmonary disease
- determine diffusing capacity of lungs
- inhalation allergy tests
forced vital capacity (FVC)
Amount of air that can be forcefully expelled from a maximally inflated lung position. Less than expected values occur in obstructive and restrictive pulmonary diseases.
forced expiratory volume in 1 second (FEV1)
Volume of air expelled during the first second of FVC. In obstructive pulmonary disease, airways are narrowed and resistance to flow is high. Therefore not so much air can be expelled in 1 second, and FEV1 is less than the predicted value.
In restrictive lung disease, FEV1 is decreased because the amount of air originally inhaled is low, not because of airway resistance. Therefore the FEV1/FVC ratio should be measured.
In restrictive lung disease a normal value is 80%, and in obstructive lung disease this ratio is considerably less.
The FEV1 value will reliably improve with bronchodilator therapy if a spastic component to obstructive pulmonary disease exists
what’s a normal spirometry
Greater than 80% of expected value is normal
when is airflow rate considered diminished
Diminished at less than 60% of normal. Increase of 20% with bronchodilator = prescribe
how to dx COPD
Diagnosis of COPD requires demonstration of persistent airflow limitation based on spirometry testing, generally defined as post bronchodilator FEV1/FVC <70%.Classification of COPD severity should be determined by the assessment of spirometry testing at regular intervals. Some risk factors for COPD include smoking, pollution exposure, and genetic predisposition. COPD typically has an onset later in life and a slower progression of symptoms as compared to asthma.Additionally, COPD has a poorer response to inhaled therapy as compared to asthma
Polysomnography (Sleep study) indications
Indicated in any person who snores excessively; experiences narcolepsy, excessive daytime sleeping, or insomnia; or has motor spasms while sleeping; and in patients with documented cardiac rhythm disturbances limited to sleep time. Sleep apnea
Actigraphy
Watch that can be worn a few nights - at home
what’s bronchoscopy used for
Used for performing various diagnostic and therapeutic procedures.oVisualization of the tracheobronchial tree; transbronchial and endobronchialbiopsies; bronchoalveolar lavage; removal of foreign bodies, clots, mucus plugs; and deployment of metallic stents. Aspiration of deep sputum, control of bleeding
Common clinical indications for bronchoscopy include (but are not limited to) hemoptysis, malignancy, interstitial lung disease, pulmonary infections, and pleural effusion
DOES NOT see esophagus
What is Pleural Tap (Thoracentesis and pleural fluid analysis) and why performed
Performed to determine the cause of an unexplained pleural effusion. It is also performed to relieve the intra thoracic pressure that accumulates with a large volume of fluid and inhibits respiration. Transudates are most frequently caused by congestive heart failure, cirrhosis, nephrotic syndrome, and hypoproteinemia
Clear/serous, protein < 3
Exudates are most often found in inflammatory, infectious, or neoplastic conditions.
Cloudy/turbid, + WBC, protein > 3, Low glucose, pleural fluid/serum LCH > 0.6
*CXR is obtained before thoracentesis to ensure that the pleural fluid is mobile and accessible to a needle placed within the pleural space
PE sx and dx findings
sx: Chest pain, SOB, feelings of doom, pleurodynia (pain w/ deep inhale), Tachycardia, hypoxemia, S4 gallop
dx: Increased D-Dimer, decreased fibrinogen, V/P mismatch, low PO2 and high/low PCO2, reduce diffusion capacity, Enlarged PA on CXR, increase alveolar dead space, R ventricular dysfunction, S1Q3T3 on ECG, Pulm artery emboli on CT
***Spiral CT scan dx
what type of test is Ventilation/Perfusion Scan and what’s it used for
Nuclear medicine
Often used to detect PE - Will show mismatch in V/P
CT scan
Diagnosing and evaluating pathologic conditions such as tumors, nodules, hematomas, parenchymal coin lesions, cysts, abscesses, pleural effusion, and enlarged lymph nodes affecting the lungs and mediastinum.
Tumors and cysts of the pleura and fractures of the ribs can also be seen.
When an intravenous (IV)contrast material is given, vascular structures can be identified and a diagnosis of aortic or other vascular abnormality can be made.
With oral contrast material, the esophagus and upper gastrointestinal (GI) structures can be evaluated for tumor and other conditions.
Spiral CT scan is considered the preferred study to identify pulmonary emboli(CT pulmonary arteriography)
Why do CXR
ID and monitoring of:
- Tumors of the lung (primary and metastatic), heart (myxoma), chest wall(soft-tissue sarcomas), and bony thorax (osteogenic sarcoma)
- Inflammation of the lung (pneumonia), pleura (pleuritis), and pericardium(pericarditis)
- Fluid accumulation in the pleura (pleural effusion), pericardium(pericardial effusion), and lung (pulmonary edema)
-Air accumulation in the lung (chronic obstructive pulmonary disease) and pleura (pneumothorax)
- Fractures of the bones of the thorax or vertebrae
- Diaphragmatic hernia
- Heart size, which may vary depending on cardiac function
-Calcification, which may indicate large-vessel deterioration or old lung granulomas (from histoplasmosis or some other former infection)
- Location of centrally placed intravenous access devices
- Infection in the lung, such as pneumonia or tuberculosis
***Fluoroscopy shows motion
Fluoroscopy
uses x-rays to show motion
Tuberculosis Testing and Indications
The tuberculin skin test, also known as the Mantoux test or the protein derivative test (PPD), is the standard method of determining whether a patient is/has been infected with Mycobacterium tuberculosis.
A true positive result indicates that the person’s body was infected with Mycobacterium tuberculosis at some point in life. It does not distinguish between active tuberculosis (TB) infection and latent/dormant TB infection. Rather it confirms exposure to the bacteria.
False positive reactions can occur, especially in patients who have previously received the BCG vaccination.
Patients with latent TB will have TB bacteria in their body but will not feel sick or spread the disease to others.
Patients with active TB will experience symptoms and have the potential to spread the disease to others
Acid-fast bacillus tests are ordered to diagnosis patients with active TB. The acid-fast bacillus test is a microscopic study that looks for acid-fast bacillus bacteria in sputum samples.Mycobacterium tuberculosis is an acid-fast bacillus bacterium
Use of sputum studies (cytology vs culture)
Cytology - Looks for malignant cells. Mostly replaced by biopsy. Used in patients w/ abnormal CXR, productive cough and nothing visible on bronchoscopy
Culture - Indicated in any patient with a persistent productive cough, fever, hemoptysis, or a chest x-ray picture compatible with a pulmonary infection.
Used to diagnose pneumonia, bronchiectasis, bronchitis, or pulmonary abscess.
Bacterium, fungus, or virus can be cultured
Types of BP/HTN
Normal: <120/80 mmHg
Elevated: SBP between 120-129 mmHg and DBP less than 80 mmHg
Stage 1: SBP between 130-139 mmHg or DBP between 80-89 mmHg
Stage 2: SBP at least 140 mmHg or DBP at least 90 mmHg
use of halter monitor
Used to record a patient’s heart rate and rhythm for 1 or more days.
Indicated in patients who experience syncope, palpitations, atypical chest pains, or unexplained dyspnea
Blood Tests Used to Assess Risk for Coronary Vascular Disease
Total Cholesterol
* High-Density Cholesterol
* Low-Density Cholesterol
*Triglycerides
* Apolipoprotein B
* Lipoprotein (a)
* Apolipoprotein E Genotyping
* Fibrinogen
* C-Reactive Protein
* Homocysteine
* Insulin, Fasting
Lipid profile use and meaning
risk of CVD
Lipoproteins are predictors of heart disease. Blood levels should be collected after a 12- to 14-hour fast.
HDL is often called good cholesterol, because it removes cholesterol from the tissues and transports it to the liver for excretion. High levels are associated with a decreased risk for coronary heart disease.
LDL is often called bad cholesterol, because it carries cholesterol and deposits it into the peripheral tissues. High levels are associated with an increased risk for CHD
Cholesterol varies greatly and should be verified by repeat test.
Triglycerides are transported by LDL/VLDL and are deposited in fatty tissue when levels are high
Venous doppler- use and type of test
Ultrasound
Called duplex because it combines the benefits of Doppler with B-mode scanning
Used to detect DVT
Not accurate for detection of venous occlusive disease of the lower calf (venography better)
DVT risks, dx, management
DVT occurs when a blood clot forms in a deep vein, usually in the lower leg, thigh, or pelvis, but sometimes it can occur in the arm
The most serious complication of DVT is when part of the clot breaks off, travels through the bloodstream to the lungs, then causing a blockage known as a pulmonary embolism
Risk factors for DVT include hospitalization, recent surgery, immobility, older age, obesity, positive family history, malignancy, estrogen-based medications (i.e.,birth control and hormone replacement), pregnancy, and injury/trauma
Symptoms of DVT include swelling (usually unilateral), pain, tenderness, and redness over the affected area
The standard diagnostic test for diagnosing a DVT is the venous duplex ultrasound study. It can detect blockages or clots in the deep veins. Other diagnostic tests for DVT include D-dimer blood test, MRI, and CT scan
Treatments for DVT usually include anticoagulants, thrombolytics, and placement of inferior vena cava filters. Providers should also try to eliminate the causative factor. Compression stockings are often encouraged
arterial doppler
Single-mode arterial Doppler studies - peripheral arteriosclerotic occlusive disease of the extremities can be easily located. By slowly deflating blood pressure cuffs placed on the calf and ankle, systolic pressure in the arteries of the extremities can be accurately measured by detecting the first evidence of blood flow with the Doppler transducer. The extremely sensitive Doppler ultrasound detector can recognize the swishing sound of even the most minimal blood flow.
Normally systolic blood pressure is slightly higher in the arteries of the arms than in the legs. If the difference in blood pressure exceeds 20 mm Hg, occlusive disease is believed to exist immediately proximal to the area tested. Lower extremity arterial bypass graft patency can also be assessed with Doppler ultrasound
Ankle/Brachial Index (ABI)
Arterial plethysmography is performed by applying three blood pressure cuffs to the proximal, middle, and distal parts of an extremity. Pressure readings are also taken in the upper arm (brachial) artery. These are then attached to a pulse volume recorder (plethysmograph) that enables each pulse wave to be displayed.
A reduction in amplitude of a pulse wave in any of the three cuffs indicates arterial occlusion immediately proximal to the area where the decreased amplitude is noted. Also, measurements of arterial pressures are performed at each cuff site.
A difference in pressure of greater than 20 mm Hg indicates a degree of arterial occlusion in the extremity.
A positive result is reliable evidence of arteriosclerotic peripheral vascular occlusion. However, a negative result does not definitely exclude this diagnosis, because extensive vascular collateralization can compensate for even a complete arterial occlusion.
An Ankle/Brachial Ratio of <0.9 indicates peripheral vascular disease in the lower extremity. Arterial plethysmography can also be performed immediately after exercise to determine if symptoms of claudication are caused by peripheral vascular occlusive disease.
how to dx MI, what is it, risks, sx
creatinine kinase, troponin, electrocardiography [EKG]
MI is defined as “damage to the cardiac muscle as evidenced by elevated cardiac troponin levels in the setting of acute ischemia”
Risk Factors can include older age, male gender, chronic renal disease, diabetes mellitus, known atherosclerotic disease, family history of coronary artery disease, hyperlipidemia, and hypertension.
Symptoms can include retrosternal chest pain (with or without radiation to arms, neck, jaw), chest pressure, abdominal pain, dyspnea, nausea/vomiting, sweating, and syncope.
EKG and MI
Should be performed within 10 minutes of presentation
Need to assess for ST segment T wave changes, development of pathologic Q waves, or new left bundle branch block
Serum cardiac troponin measurements and MI
An elevated cardiac troponin is required for diagnosis of MI
Watch for a rise or fall of the cardiac troponin
One troponin value should be above the 99 percentile of the normal reference range
Natriuretic Peptides use
Used to identify and stratify patients with congestive heart failure (CHF).
* BNP is best marker
Neuroendocrine peptides that oppose the activity of the renin-angiotensin system.
Released by heart muscle to cause vasorelaxation, inhibition of aldosterone secretion from the adrenal gland and renin from the kidney, thereby increasing natriuresis and reduction in blood volume.
Increased in CHF
Peripheral artery disease
PAD is caused by plaque buildup in the peripheral arteries, most commonly in the arteries of the lower extremities. This plaque buildup results in reduced blood flow to the legs and feet
Risk factors for PAD include smoking, high cholesterol levels, hypertension, diabetes, obesity, positive family history of cardiac disease, and poor eatingpatterns
Symptoms of PAD include pale or discolored extremities, cold extremities, leg weakness or numbness, feeling of pins and needles in legs/feet, sores or wounds on the lower extremities, and lack of growth of toenails and leg hair
A hallmark symptom of PAD is called intermittent claudication, defined as pain, aching, heaviness, or cramping in the legs with walking or climbing the stairs. This discomfort resolves with rest. It usually occurs in the calves. This is the most common symptom of PAD
The first diagnostic test used to diagnose PAD is the ankle-brachial index (ABI) test. This test compares the blood pressure in the ankle with the blood pressure in the arm. As the blood pressure cuff deflates, the blood pressure in the arteries is recorded.
An ultrasound doppler device is utilized to amplify the sound of arterial blood flow in the brachial, dorsalis pedis, and posterior tibial pulses. The test is usually performed with the patient in a supine position. A healthy ABI is 1.00 or greater; if the ABI is less than 0.90 at rest, PAD may be suspected. An ABI less than 0.40 indicates severe PAD
Treatments for PAD often include antiplatelet medications, statins, anti-HTN medications, angioplasty, arterial bypass surgery, and modification of risk factors
Peripheral venous disease sx
swelling of the legs or ankles (edema)
pain that gets worse when you stand and gets better when you raise your legs, leg cramps, aching, throbbing, or a feeling of heaviness in your legs, itchy legs, weak legs, thickening of the skin on your legs or ankles, skin that is changing color, especially around the ankles, leg ulcers, varicose veins, a feeling of tightness in your calves
Echocardiogram
type of ultrasound
Performed to evaluate heart wall motion (a measure of heart wall function) and to detect valvular disease, evaluate the heart during stress testing, and identify and quantify pericardial fluid.
Used in ER for chest pain
Used to diagnose pericardial effusion, valvular heart disease (eg, mitral valve prolapse, stenosis, regurgitation), subaortic stenosis, myocardial wall abnormalities (eg, cardiomyopathy), infarction, aneurysm, and cardiac tumors (eg,myxomas). Atrial and ventricular septal defects and other congenital heart diseases, and post infarction mural thrombi are also recognized with this testing.
Can be done transesophageal (useful in COPD because air gets in way)
cardiac stress test
Eval for CAD in angina, intermittent claudication, evaluate treatment and safe exercise limits
Exercise, chemical or pacer stress
EKG, heart rate and BP usually but echo and nuclear scan can also be used
Arteriography/Venography
Injecting dye and taking x-rays to see vasculature
CT abdomen/pelvis
Used in evaluating the abdominal organs and pelvis. CT can be used to guide needles during biopsy of tumor and aspiration of fluid, in staging known neoplasms, and to monitor abdominal disease when serially and repeatedly performed
diverticulitis
Diverticulosis occurs when small pouches form and push outward through weak spots in the wall of the colon, most commonly the sigmoid colon
Diverticulitis occurs when one or a few of these pouches become inflamed and/or infected
Symptoms of Diverticulitis often include: Severe pain, typically in the lower left side of the abdomen, Nausea and/or vomiting, Constipation or diarrhea, Fever and chills
Diagnostic Tests for Diverticular Disease (in order of importance) include:
1. CT Scan of abdomen and pelvis
2. Blood tests to rule out infection (CBC)
3. Colonoscopy
4. Lower GI series, also known as a barium enema (X-ray)
Treatments often include: High fiber diet and/or fiber supplements, Probiotics, If infection is noted (i.e. diverticulitis)- bowel rest, liquid diet, antibiotics. Severe cases may require colon resection surgery
Acute pancreatitis
Pancreatitis is inflammation of the pancreas. Acute pancreatitis occurs suddenly and is usually short-term. Approximately 275,000 hospital stays occur in theUnited States each year for acute pancreatitis
Risk factors include: male gender, African American race, positive family history of pancreatitis, diabetes mellitus, elevated triglycerides, cystic fibrosis, gallstones, obesity, alcohol abuse, and cigarette smoking
Symptoms include: Severe pain in the epigastric (upper) area of the abdomen, often radiates to the back or can be in the left upper quadrant, Fever, Nausea and/or vomiting, Swollen or tender abdomen on palpation, Tachycardia
Diagnostic Tests often include:
Blood Tests:
Amylase and Lipase (usually elevated)
Lipid Profile (usually elevated)
Blood Glucose (usually elevated due to impaired beta cell function)
CBC (to assess for infectious processes)
Imaging:
Pancreatic and/or gallbladder ultrasound
CT Scan
Treatments often include: Bowel Rest, IV hydration (if hospitalized), Pain medicine, Antibiotics, Low fat diet, Elimination/Treatment of risk factors or predisposing conditions
Stool testing
C. Diff - PCR test. Treat with metronidazole or vancomycin
Culture, O&P (ova & parasites)- diarrhea, fever, and bloating.
Normal stool flora can become pathogenic if bacterial overgrowth occurs as a result of antibiotics, immunosuppression, or excessive catharsis.
Occult blood - colorectal cancer screen. Red meat must be avoided x 3 days
amylase and lipase
Tests for pancreatic disorders
Amylase most sensitive to acute pancreatitis, but not specific
*Lipase usually 5-10 times normal limit in pancreatitis
CMP
Albumin, blood urea nitrogen, calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium, total bilirubin and protein, and liver enzymes(alanine amino transferase, alkaline phosphatase, and aspartate amino transferase).
Liver function test
Alanine transaminase (ALT) test. ALT is an enzyme that helps break down proteins and is found mainly in your liver. High levels in your blood could mean you have liver damage.
Alkaline phosphatase (ALP) test. ALP is an enzyme in your liver, bile ducts, and bone. You might have high levels if you have liver damage or disease, a blocked bile duct, or bone disease.
Aspartate transaminase (AST) test. AST is another enzyme in your liver. High blood levels could be a sign of damage or disease.
Albumin and total protein test. Your liver makes two main proteins: albumin and globulin. Low levels might mean damage or disease. Keep in mind that your immune system also makes globulin.
Bilirubin test. Your body makes bilirubin when it breaks down red blood cells. Usually, your liver cleans bilirubin out of your body. If you have high levels in your blood, a problem called jaundice, you may have liver damage.
Gamma-glutamyl transferase (GGT) test. High levels of the GGT enzyme could point to liver or bile duct damage.
L- lactate dehydrogenase (LD) test. LD is another enzyme that’s high when you have liver damage, but other conditions can also raise its level.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopy that looks inside biliary ducts/gallbladder
Used in the evaluation of the jaundiced patient. It is also used to evaluate patients with unexplained upper abdominal pain or pancreatitis.
