Symptom To Diagnosis - Dyspnea Flashcards
MCCs of dyspnea:
- Heart.
- Lung.
- Anemia.
3 tests that are mandatory in the initial evaluation of dyspnea:
- Chest radiograph.
- ECG.
- Ht.
Diagnostic approach of dyspnea - Cardiac etiologies - History:
Valvular heart disease –> Rheumatic heart disease.
Arrhythmia –> Palpitations.
HF –> CAD or risk factors, HTN, alcohol abuse, PND.
Acute coronary syndrome –> Chest pain, CAD risk factors.
Diagnostic approach of dyspnea - Cardiac etiologies - Physical findings:
Valvular heart disease –> Significant murmur.
Arrhythmia –> Irregular pulse.
HF –> S3, JVD, crackles on exam.
Acute coronary syndrome –> S3, JVD, crackles on exam.
Diagnostic approach to dyspnea - Cardiac etiologies - Tests:
Valvular heart disease –> Echo.
Arrhythmia –> ECG, holter, event monitor.
HF –> Chest radiography, BNP, echocardiography.
Acute coronary syndrome –> ECG, troponin, stress test, angiography.
Diagnostic approach of dyspnea - Pulmonary etiologies:
- COPD.
- Asthma.
- PE.
- Pneumonia (CAP, TB, PCP).
- ILD.
Pulmonary etiologies - History:
COPD –> >20pack years tobacco.
Asthma –> Cold +/- exercise –> Symptoms; + family history.
PE –> Sudden onset, pleuritic pain, cancer, surgery, immobilization, estrogen.
Pneumonia –> Fever, productive cough, high-risk sexual exposures, injection drug use.
ILD –> Known connective tissue disease, Raynaud, vocational, occupational exposure.
Pulmonary etiologies - Physical findings:
COPD --> Decr. breath sounds, wheezing. Asthma --> Wheezing. PE --> Unilateral leg swelling. Pneumonia --> Crackles, fever, thrush, Kaposi sarcoma, skin pop marks. ILD --> Diffuse lung crackles.
Pulmonary etiologies - Tests:
COPD –> CXR, PFTs.
Asthma –> PFTs, bronchodilator response, methacholine induced.
PE –> D-dimer, CTA, V/Q scan, Leg duplex.
Pneumonia –> CXR, HIV, CD4 (when appropriate).
ILD –> PFTs, High res chest CT.
Anemia as a cause of dyspnea - History, physical findings, and tests:
History –> Menorrhagia, melena, rectal bleeding.
Physical findings –> Pale conjunctiva.
Echo –> Ht.
Mortality in patients with SHF and DHF?
Similar.
Progression of HF:
- Heart failure often triggers maladaptive neurohormonal changes including increased activation of the SNS and the RAA.
- These neurohormonal changes promote Na retention –> Incr. afterload –> Progressive HF.
- Therapies that interrupt these responses reduce mortality.
NYHA:
I –> Asymptomatic.
II –> Symptoms on ordinary exertion (climbing stairs).
III –> Symptoms with less than ordinary exertion (walking on flat surface).
IV –> Symptoms at rest.
4 STAGES OF HF - ACC/AHA:
A –> At risk for HF.
B –> Structural changes (LV hypertrophy or decr. EF) but no symptoms.
C –> Structural changes and symptoms.
D –> Structural changes and refractory symptoms despite therapy.
HF complication - Stroke and thromboembolism:
2-4% annual incidence.
Death in HF:
Symptomatic mild to moderate HF –> 20-30%/y.
Symptomatic severe HF –> Up to 50%/y.
HF - Mechanism of death:
Sudden in 50% - Secondary to V-tach or asystole.
Progressive in 50%.
Evidence-based diagnosis - History in HF:
Should assess risk factors:
- HTN.
- CAD.
- Alcohol.
- Illicit drug use.
- Adiamycin.
EBD - Physical exam - Clinical signs and symptoms may be affected by:
- Patient’s CURRENT volume status.
2. Chronicity –> CHRONIC HF is frequently asymptomatic.
EBD - S3 gallop:
Occurs when large volume of blood rushes from the LA into the LV at the start of diastole (just after S2).
EBD - S3 - Is it an important finding?
Virtually PATHOGNOMONIC of volume overload and occurs most commonly in patients with decompensated HF.
EBD - S4 gallop:
Occurs when the LA contracts and sends blood into the LV (just before S1).
EBD - S4 importance:
An S4 gallop may be heard in some normal patients and in many patients with HTN and LV hypertrophy.
–> NOT SPECIFIC FOR HF.
EBD - JVD:
> 3cm of elevation above the sternal angle.
EBD - JVD importance:
Highly specific for HF (>95%) –> May occur in RV or LV failure.
Importance of classic signs/symptoms (orthopnea, PND, crackles, gallops, and edema) in the diagnosis of HF:
NOT SENSITIVE - Their absence does NOT RULE OUT HF.
Even in severe CHRONIC HF –> 42% of patients did NOT have crackles, increased JVP, or edema.
Most sensitive CXR finding in HF?
Cardiomegaly in CXR –> 74%. Its absence decreases the likelihood of HF (LR- 0.33).
Most specific CXR findings for HF:
Pulm. venous congestion and interstitial+alveolar edema –> 96-97%. When present, strongly suggest HF (LR+12).
Pleural effusions are seen in …% of patients with HF.
26%.
When is BNP secreted?
FROM LV/RV –> In response to increased volume or pressure or both.
BNP
Sens: 87-93%.
Spec: 66-72%.
LR+ 2.7-3.1.
LR- 0.11-0.12.