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Maddy - PCM III > HYHO: SPE > Flashcards

HYHO: SPE Flashcards

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1
Q

visible signs of increased work of breathing that can be identified and reported by clinicians

A

tachypnea
accessory muscle use
intercostal retractions

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2
Q

ROS for a pt w/ dyspnea (6 examples)

A 
fever
swelling/edema in le
palpitations
recent travel
coughing at night
awakening short of breath
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3
Q

what patients will report with an “inability to take a deep breath”

A

COPD patients

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4
Q

Dyspnea Physical exam:

- inspection

A

while standing behind pt, observe breathing, shape of chest, and motion of chest wall/ribs

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5
Q

Dyspnea Physical exam:

- palpation

A
  • identify tenderness and assess lung expansion (COPD)

- palpate for point of maximal impulse (angina)

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6
Q

Dyspnea Physical exam:

- percussion

A

comparing side to side in “ladder” pattern

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7
Q

Dyspnea Physical exam:

- auscultation

A 
COPD: 
comparing side to side in "ladder" pattern
- two places anteriorly
- four places posteriorly
- pt breathes through an OPEN mouth

Angina:
- auscultate for carotid bruits

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8
Q

special/other tests in PE for pt w/ dyspnea/COPD

A
  • tactile fremitus
  • assess rib motion
  • assessment of oropharynx/upper airway
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9
Q

supportive PE findings of a pt w/ COPD

A
  • barrel shaped chest
  • limited rib motion
  • lung expansion w/ limited exhalation
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10
Q

percussion sounds on a pt w/ COPD

A

generalized hyper-resonance due to hyperinflation

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11
Q

auscultation findings on a pt w/ COPD

A
  • decreased breath sounds
  • wheezing
  • prolonged expirations
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12
Q

tactile fremitus findings on pt w/ COPD

A

decreased due to hyperinflation

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13
Q

transmitted voice sounds on pt w/ COPD

A

decreased due to hyperinflation

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14
Q

diagnostic test for COPD pt in the office

A

have pt walk w/ pulse oximeter to asses O2 desaturation w/ activity to replicate the symptom of dyspnea, then REPEAT auscultation

  • may reveal expiratory wheezing that was not present at rest
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15
Q

what additional testing should you do in a COPD patient if diagnosis is unclear or symptoms fail to improve

A
  • PFTs (spirometry)

- chest x-ray

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16
Q

expected FEV1 of pt w/ COPD

A

<70% of expected value

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17
Q

peak flow assessment value in a pt w/ COPD should be ____

A

reduced

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18
Q

function of peak flow assessment

A

approximates FEV1

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19
Q

what testing is included in phase 1 of diagnostic testing in a pt w/ dyspnea (4)

A
  • CXR
  • spirometry
  • ECG
  • CBC, CMP
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20
Q

what testing is included in phase 2 of diagnostic testing in a pt w/ dyspnea (6)
(if diagnosis not obtained in phase 1)

A
  • chest CT
  • lung volumes
  • Diffusing capacity of the lungs for carbon monoxide (DLCO)
  • test neuromuscular function
  • echocardiogram
  • cardiac stress test
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21
Q

what testing is included in phase 3 of diagnostic testing in a pt w/ dyspnea (5)
(if diagnosis not obtained in phase 2)

A

consider cardiopulmonary exercise testing and subspecialty referral

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22
Q

alternative ddx for dysnpea other than COPD

A

anemia

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23
Q

CXR of patient w/ COPD

A
  • flattening of diaphragms

- increased AP diameter

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24
Q

sympathetic innervation of the heart is located at what spinal levels

A

T1-T6

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25
sympathetic innervation of the lungs is located at what spinal levels
T1-T7
26
parasympathetic innervation to the heart and lungs is controlled by what nerve
vagus n.
27
anterior chapmans' points for the lungs
anterior 2nd, 3rd, and 4th ICS along sternum
28
posterior chapmans' points for the lungs
- lateral T2 spinous process | - inter-transverse space b/w T2-3, T3-4, T4-5
29
bio-mechanical goals of OMT for COPD pts
improve thoracic cage compliance and skeletal motion
30
neurological goals of OMT for COPD pts
normalize autonomic tone
31
respiratory-circulatory goals of OMT for COPD pts
maximize efficiency of diaphragm and enhance lymphatic return
32
metabolic-energetic-immune goals of OMT for COPD pts
enhance self-regulatory and self-healing mechanisms
33
behavioral goals of OMT for COPD pts
improve psychosocial components of health
34
primary prevention for COPD
- annual flu vaccine - pneumococcal vaccine - Tdap
35
secondary prevention for COPD
avoidance of other dust and fumes (occupational or hobby exposure)
36
tertiary prevention for COPD
- smoking cessation/abstinence | - pulmonary rehab (incorporates exercise, education, psychosocial, and nutritional counseling)
37
end-stage COPD is associated w/ what symptoms
- cachexia - weight loss - bitemporal wasting (temporalis m. wasting) - diffuse loss of subcutaneous adipose tissue
38
clinical presentation of stable angina
pts will indicate the center of the chest pain with a fist over the sternum
39
how do stable angina patients describe their symptoms
- tight, squeezing, heavy, pressure but NOT pain | - radiation to neck, jaw, back, shoulder, ulnar surface of arm (trapezius area is spared)
40
associated sx w/ angina
dyspnea nausea fatigue
41
describe pleuritic chest pain
pain reproduced w/ maneuvers that cause motion b/w pleura and chest wall, such as coughing, laughing, and/or taking a deep breath
42
how to perform cardiac auscultation in PE for angina
auscultate over all four listening posts | - use bell to listen to apex and left sternal boarder
43
how to auscultate for S3 and S4 or murmur associated w/ mitral regurgitation
use bell to listen at apex and left sternal border w/ patient in left lateral decubitus position
44
additional physical exam work ups for a pt with dyspnea w/ suspection of Angina
- evaluate peripheral pulses | - assess for edema
45
what immediately eliminates cardiovascular causes for chest pain
reproducible chest pain w/ palpation
46
what are the possible findings on an ECG of an angina patient w/ symptoms
findings may include: - changes consistent with previous MI (Q waves) - repolarization abnormalities (ST and T wave changes) - LVH - rhythm abnormalities
47
what are the possible findings of a cardiac stress test of an angina pt
- ST depressions identified during increased cardiac workload - may reproduce sx of dysnpea
48
what are the possible findings of a stress echo of an angina pt
wall motion abnormalities during increased workload
49
if a patient with suspecting IHD can exercise adequately and there are no confounding features present on a resting ECG, what is the next diagnostic step?
perform treadmill exercise test
50
if a patient with suspected IHD cannot exercise adequately, what is the next diagnostic step
imaging studies - 2D echo - nuclear perfusion scan - MR scan - PET scan
51
contraindications for stress test (7)
- rest angina within 48 hours - unstable rhythm - severe aortic stenosis - acute myocarditis - uncontrolled heart failure - severe pulmonary HTN - active infective endocarditis
52
what is the sensitivity of an exercise stress ECG
75%
53
anterior and posterior chapman's points for the heart
anterior: 2nd ICS along sternal border posterior: inter-transverse spaces between T2-3
54
goals of OMT for stable angina
NOT INDICATED :)
55
what indicates a patient is at high risk for coronary events and what tx should be considered
inability to exercise for more than six minutes consider interventional cardiac catheterization and recanalization of vessels with more than 50% occlusion
56
medication treatment for acute angina symptoms
- drug of choice: nitroglycerine sublingual (immediate release) - aspirin or clopidogrel if aspirin-intolerant
57
what medications should be given to decrease demand ischemia
- beta blockers (bisoprolol, metoprolol) | - calcium channel blockers (amlodipine, diltiazem)
58
secondary prevention for stable angina
- assess pt for other CV symptoms like claudication | - screen for thyroid dysfunction, anemia
59
tertiary prevention for stable angina
- cardiac rehab (comprehensive approach to encourage weight loss, increase exercise tolerance, control risk factors) - smoking cessation/abstinence - tx of lipid disorders and other co-morbidities that increase cardiac workload or risk of atherosclerosis
60
non cardiovascular or pulmonary differentials for dyspnea
- anemia | - psychiatric issue
61
what are the immunization recommendations for patients w/ COPD
- annual flu vaccine - pneumococcal vaccine (PCV13 - Prevnar) followed by PPSV23 (pneumovax) at least one year later - Tdap to protect against Bordetella pertussis
62
example of a "Plan" for angina patient | this is long, 10 steps, but just be familiar with it I think. not an LO
1. EKG performed - see above 2. start ASA 81 mg/d 3. discussed likely diagnosis of stable angina and scheduled stress test, AHA info provided 4. labs today: lipid profile, CBC, BMP 5. RX: nitro (plus dosage) 6. RX: bisoprolol (plus dosage) 7. contact EMS if sx fail to resolve after 3 nitro 8. follow up next week 9. discuss weight loss and lifestyle modifications 10. OMT deferred pending further evaluation
63
example ddx for patient presenting with dyspnea with suspected angina
1. stable angina 2. COPD 3. paroxysmal a fib
64
example ddx for patient presenting with dyspnea with suspected COPD
1. COPD 2. asthma 3. stable angina
65
example of a "Plan" for COPD patient | this is long, 5 steps, but just be familiar with it I think. not an LO
1. albuterol administered, well tolerated with resolution of sx 2. OMT performed: thoracic inlet opened, rib-raising performed T1-T7, well tolerated 3. smoking cessation discussed 4. albuterol MDI prescribed 5. labs today: CBC, BMP
66
additional data to acquire in a dyspnea case centered around causes of atherosclerosis
- fasting glucose (assess for DM) - lipid panel (total cholesterol, LDL, HDL, triglycerides) - electrolytes (renal function - BUN, Cr, Na, K, CO2, Cl) **BMP includes fasting glucose and electrolyte panel
67
what is the most important fact from this DSA?
somi smells :)

Maddy - PCM III (5 decks)

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