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.► ABORDAGEM SINDRÔMICA > Symptom To Diagnosis - Dyspnea > Flashcards

Symptom To Diagnosis - Dyspnea Flashcards

1
Q

MCCs of dyspnea:

A
  1. Heart.
  2. Lung.
  3. Anemia.
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2
Q

3 tests that are mandatory in the initial evaluation of dyspnea:

A
  1. Chest radiograph.
  2. ECG.
  3. Ht.
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3
Q

Diagnostic approach of dyspnea - Cardiac etiologies - History:

A

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.

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4
Q

Diagnostic approach of dyspnea - Cardiac etiologies - Physical findings:

A

Valvular heart disease –> Significant murmur.
Arrhythmia –> Irregular pulse.
HF –> S3, JVD, crackles on exam.
Acute coronary syndrome –> S3, JVD, crackles on exam.

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5
Q

Diagnostic approach to dyspnea - Cardiac etiologies - Tests:

A

Valvular heart disease –> Echo.
Arrhythmia –> ECG, holter, event monitor.
HF –> Chest radiography, BNP, echocardiography.
Acute coronary syndrome –> ECG, troponin, stress test, angiography.

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6
Q

Diagnostic approach of dyspnea - Pulmonary etiologies:

A
  1. COPD.
  2. Asthma.
  3. PE.
  4. Pneumonia (CAP, TB, PCP).
  5. ILD.
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7
Q

Pulmonary etiologies - History:

A

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.

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8
Q

Pulmonary etiologies - Physical findings:

A 
COPD --> Decr. breath sounds, wheezing.
Asthma --> Wheezing.
PE --> Unilateral leg swelling.
Pneumonia --> Crackles, fever, thrush, Kaposi sarcoma, skin pop marks.
ILD --> Diffuse lung crackles.
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9
Q

Pulmonary etiologies - Tests:

A

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.

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10
Q

Anemia as a cause of dyspnea - History, physical findings, and tests:

A

History –> Menorrhagia, melena, rectal bleeding.
Physical findings –> Pale conjunctiva.
Echo –> Ht.

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11
Q

Mortality in patients with SHF and DHF?

A

Similar.

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12
Q

Progression of HF:

A
  1. Heart failure often triggers maladaptive neurohormonal changes including increased activation of the SNS and the RAA.
  2. These neurohormonal changes promote Na retention –> Incr. afterload –> Progressive HF.
  3. Therapies that interrupt these responses reduce mortality.
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13
Q

NYHA:

A

I –> Asymptomatic.
II –> Symptoms on ordinary exertion (climbing stairs).
III –> Symptoms with less than ordinary exertion (walking on flat surface).
IV –> Symptoms at rest.

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14
Q

4 STAGES OF HF - ACC/AHA:

A

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.

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15
Q

HF complication - Stroke and thromboembolism:

A

2-4% annual incidence.

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16
Q

Death in HF:

A

Symptomatic mild to moderate HF –> 20-30%/y.

Symptomatic severe HF –> Up to 50%/y.

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17
Q

HF - Mechanism of death:

A

Sudden in 50% - Secondary to V-tach or asystole.

Progressive in 50%.

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18
Q

Evidence-based diagnosis - History in HF:

A

Should assess risk factors:

  1. HTN.
  2. CAD.
  3. Alcohol.
  4. Illicit drug use.
  5. Adiamycin.
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19
Q

EBD - Physical exam - Clinical signs and symptoms may be affected by:

A
  1. Patient’s CURRENT volume status.

2. Chronicity –> CHRONIC HF is frequently asymptomatic.

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20
Q

EBD - S3 gallop:

A

Occurs when large volume of blood rushes from the LA into the LV at the start of diastole (just after S2).

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21
Q

EBD - S3 - Is it an important finding?

A

Virtually PATHOGNOMONIC of volume overload and occurs most commonly in patients with decompensated HF.

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22
Q

EBD - S4 gallop:

A

Occurs when the LA contracts and sends blood into the LV (just before S1).

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23
Q

EBD - S4 importance:

A

An S4 gallop may be heard in some normal patients and in many patients with HTN and LV hypertrophy.
–> NOT SPECIFIC FOR HF.

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24
Q

EBD - JVD:

A

> 3cm of elevation above the sternal angle.

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25
EBD - JVD importance:
Highly specific for HF (>95%) --> May occur in RV or LV failure.
26
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.
27
Most sensitive CXR finding in HF?
Cardiomegaly in CXR --> 74%. Its absence decreases the likelihood of HF (LR- 0.33).
28
Most specific CXR findings for HF:
Pulm. venous congestion and interstitial+alveolar edema --> 96-97%. When present, strongly suggest HF (LR+12).
29
Pleural effusions are seen in ...% of patients with HF.
26%.
30
When is BNP secreted?
FROM LV/RV --> In response to increased volume or pressure or both.
31
BNP
Sens: 87-93%. Spec: 66-72%. LR+ 2.7-3.1. LR- 0.11-0.12.
32
BNP
Sens: 35%. Spec: 90%. LR+2.6. LR-0.05.
33
BNP in COPD patients:
``` May not rule out HF in patients with coexistent COPD: Sens: 35%. Spec: 90%. LR+ 3.5. LR- 0.72. ```
34
BNP>250:
Sens: 89%. Spec: 81%. LR+ 4.6. LR- 0.14.
35
BNP and PE?
BNP is elevated due to RV dilatation: 34% --> BNP=88-487. 33% --> BNP=527-1300.
36
Some authorities use the following criteria to interpret BNP levels:
HF unlikely. 100-500 --> Indeterminate. >500 --> LR+ 6 --> HF most likely diagnosis.
37
Test of choice to diagnose HF:
2D echo.
38
HF is frequently present but UNSUSPECTED in patients in whom COPD is diagnosed:
Studies report unsuspected HF in 25% of patients with COPD. | --> Fewer years of tobacco use than patients without HF (9.6 vs 22.7).
39
MR - Textbook presentation:
Patients with MR may be identified due to an asymptomatic holosystolic murmur at the apex or during an evaluation of: 1. Shortness of breath. 2. Dyspnea on exertion. 3. Orthopnea. 4. Fatigue. Alternatively --> During evaluation of patients with AF.
40
MR diagnosis - Average delay from diagnosis to symptoms is ...?
16y.
41
In patients with severe MR, annual mortality is?
5%.
42
EBD of MR - Physical exam - Grade 3 or louder systolic murmur:
Sens: 85%. Spec: 81%. LR+ 4.5. LR- 0.19.
43
EBD - S3 gallop in MR?
May be heard due to increased flow across the mitral valve.
44
EBD of MR - Role of ECG and chest radiograph:
May demonstrate LA or LV enlargement --> NEITHER is sensitive/specific for the diagnosis.
45
EBD of MR - Test of choice?
Echo --> Diagnosis + Quantification of MR. | Transesophageal echo --> More details.
46
Chronic AR - Textbook presentation:
Typically complain of progressive dyspnea on exertion or the sensation of a pounding heart. Alternatively, may be asymptomatic, and the diagnosis may be suspected when an EARLY DIASTOLIC murmur is detected by a careful examiner.
47
Chronic AR - Progression to symptoms or LV dysfunction in patients with normal LV function develops in ...% of patients per year.
4%.
48
EBD of chronic AR - Why is the pulse pressure wide?
2 processes: 1. Large SV increases the SBP. 2. Regurgitation of blood back into the LV rapidly lowers the DBP.
49
EBD - Are wide pulse pressures specific for chronic AR?
NOT SPECIFIC. 1. Anemia. 2. Fever. 3. Pregnancy. 4. Large AV fistulas. 5. Cirrhosis. 6. Thyrotoxicosis. 7. PDA.
50
EBD of chronic AR - Auscultation:
May demonstrate an EARLY decrescendo DIASTOLIC murmur following S2. Best heard at the left sternal border.
51
EBD in chronic AR - Auscultation sens/spec?
1. More sensitive for moderate to severe AR. 2. 0-64% sens among students and residents. 3. 80-95% sens among experienced cardiologists.
52
EBD in chronic AR - Importance of diastolic murmur finding?
Highly specific --> 98%.
53
EBD in chronic AR - Systolic murmur?
A systolic murmur suggesting AS may be heard. --> Regurgitation results in increasing end diastolic volumes --> Stroke volumes increase to maintain forward flow --> Incr. CO may exceed the capacity of even a normal AV to accommodate flow --> High flow systolic murmur across the aortic valve.
54
EBD in chronic AR - One study reported that ...% of patients with mild to moderate AR had a SYSTOLIC murmur (...% in moderate AR and ...% in mild AR).
51%. | 86%, 50%.
55
Bottom line about murmurs in chronic AR:
Although a diastolic murmur strongly suggests AR, systolic murmurs are often the only murmur heard in patients with AR.
56
EBD in chronic AR - Austin Flint murmur:
1. Aortic regurgitant streams may impact the MV leaflets during diastole resulting in functional mitral stenosis and a late diastolic murmur over the apex. 2. Sensitivity varies from 0-100%.
57
EBD in chronic AR - Test of choice:
Doppler echo.
58
AF - Textbook presentation:
Classically --> Palpitations. Abrupt onset often prompts patients to be seen emergently. Patients may also complain of shortness of breath and dyspnea on exertion. Occasionally, AF is detected during a routine office visit when an irregularly irregular pulse is noted and evaluated.
59
MC clinical arrhythmia:
AF --> Incidence increases with AGE: 3.8% of patients >60yr to 9% in those >80yr.
60
AF - MC etiologies:
1. HTN. 2. CAD. 3. HF.
61
Annual stroke rate in AF patients not receiving anticoagulation is ...%.
4.3%.
62
AF accounts for ... of all strokes at an annual cost of ... billion.
1/6. | 6.6.
63
Stroke is more common in patients with AF who have other clinical risk factors:
1. Valvular heart disease. 2. Prior transient ischemic attack or stroke. 3. Increasing age. 4. HTN 5. DM. 6. HF. 7. Gender (women 1.5-3x more than men).
64
AF - Worsen HF?
AF --> Loss of atrial kick --> Especially important in patients with stiff LV (ie diastolic dysfunction).
65
EBD about AF:
1. Easily recognized on ECG. | 2. Episodic AF can be detected with Holter or event recorders.
66
...% of patients with PE have DVT.
80%.
67
...% of patients with DVT have PE (often asymptomatic).
48%.
68
PE - 3-month mortality is ...%.
17.5%.
69
MC thrombophilia?
Factor V Leiden - 11% of patients with DVT.
70
EBD - Classic presentation of PE:
20-33% --> Chest pain with dyspnea or chest pain, dyspnea, and hemoptysis. 12-25% --> Isolated dyspnea. 80% --> Have risk factors.
71
EBD of PE - Tachypnea has been reported in ...-...% of patients and an accentuated P2 in ...-...%.
54-85%. | 15-57%.
72
EBD of PE - One study reported that ...% of patients with an unexplained exacerbation of COPD actually had a PE.
25%.
73
Bottom line about EBD of PE:
The classic presentation of PE is actually the exception. Patients may have very few symptoms. A high index of suspicion must be maintained for the diagnosis of PE.
74
EBD of PE - CXR:
1. Normal in 50% of patients with PE. | 2. Focal oligemia (45%), wedge-shaped infiltrate (15%), or pleural effusions (45%).
75
EBD of PE - ABG:
May demonstrate hypoxemia and hypocarbia, but findings are neither sensitive nor specific for PE. PaO2
76
EBD of PE - Bottom line about ABG:
Patients with PE may NOT be hypoxic. | Therefore normal arterial O2 does NOT rule out PE.
77
EBD of PE - Troponin?
Elevated in up to 57% of patients with documented PE.
78
Diagnostic approach of dyspnea - Cardiac etiologies - Diagnostic hypothesis:
1. Valvular heart disease. 2. Arrhythmia. 3. HF. 4. Acute coronary syndrome.

.► ABORDAGEM SINDRÔMICA (41 decks)

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