DD exam 2

When is acute bronchitis a red flag? (3 scenarios)

-fever above 100.4 -symtpoms greater than 3 weeks -recurrent episodes

Red flags for lung cancer

-sharp thorax pain (usually unrelenting; chest shoulder, scapular, rib, neck) -worse with inspiration -pulmonary symptoms -hemoptysis -sudden unexplained weight loss

Pulse palpation grading scale

0= no palpable pulse 1+= faint but detectable 2+= normal pulse 3+= increased or full 4+= bounding pulse (*start distal and work proximal)

Elevated BP

120-129 and less than 80

Stage 1 hypertension

130-139 OR 80-89

Stage 2 hypertension

140 or higher OR 90 or higher

Normal HDL

40-60 (double check book)

1/2 pack per day x 10 years = ____ pack year history.

5

____% of adults with low pulmonary function have no idea, undiagnosed, feel out of shape, coughing more than before, ect.

50

Palpitations may be considered physiologic (i.e., "within normal limits") when they occur at a rate of less than ____ per minute.

6

Normal LDL

<100 mg/dL (double check book)

___________ _____________ involves a mild fever from 1-3 days, malaise, back and muscle pain, sore throat, cough with sputum production followed by wheezing, and possibly laryngitis.

Acute bronchitis

Major risk factors for CAD

Age Family history of premature CAD (CAD in male first degree relative <65) Hypertension (140/90 or higher; anti hypertensive medications) Cigarette smoking Diabetes Hypercholesterolemia Low HDL cholesterol (<40 mg/dl) Hypertriglyceridemia (>200 mg/dl) Obesity

Bronchogenic carcinoma (lung cancer) risk factors (7)

Age over 50 First or second hand smoker Prior cancer Environmental exposures Low fiber consumption Family history Lung disease

Pain pattern for pancoasts tumor?

Almost in the ulnar nerve distribution because it is located in the apical lung it can compress the brachial plexus (USUALLY NOT BILATERAL)

____________ is more of a transient, it's a reversible lung disease. They get really hyper responsive to different irritants. So an irritant gets in the lungs, that's going to cause inflammation and restriction. You're going to get that bronchus restriction and swelling, so they're not going to be able to breathe as easy. They're going to have to have a hard time breathing with wheezing and shortness of breath because of that Bronchiospasm.

Asthma

________________ is caused by repeated damage to bronchial walls. The resultant destruction and bronchial dilatation reduce bronchial wall movement so that the secretions cannot be removed effectively rom the lungs and the person is predisposed to frequent respiratory infections.

Bronchiectasis

_________________ is a form of obstructive lung disease that us actually a type of bronchitis. It is a progressive and chronic pulmonary condition that occurs after infections such as childhood pneumonia or CF.

Bronchiectasis

When would you advise a client in physical therapy to take his/her nitroglycerin? A. 45 min before exercise B. When symptoms of chest pain do not subside with 10-15min of rest C. As soon as chest pain begins D. None of the above E. All of the above

C. (Nitroglycerin is used to treat and prevent chest pain, angina, in its oral form)

________ can manifest itself as backup, blood flow backup. We'll see swelling in the limbs and the lower leg. It's going to depend on whether it's the right versus the left side.

CHF (congestive heart failure)

Patient's with ______ actually tend to have more muscular weakness and atrophy, bone density becomes an issue, they may be more osteoporotic because they don't have the good nutrition and because of the lung function, these organs aren't getting the proper nutrition that they need.

COPD

_________ is sort of an umbrella term that describes tissue instability due to inflammation of the lungs. Air cannot move effectively out and trapped air impairs gas exchange. It is characterized by a progressive and consistent deficit in gas exchange.

COPD

Risk factors for hospital acquired pneumonia? (6)

COPD Age over 70 Prolonged hospitalization Malnutrition Serious co-morbidities Impaired consciousness

_______________ emphysema is the most common type of emphysema, it destroys the bronchioles, usually in the upper lung regions. Inflammation develops in the bronchioles but usually the alveolar sac remains intact.

Centrilobular

What are the three types of emphysema?

Centrilobular Panacinar Distal Acinar

Angina types

Check the book!

The clinical definition of _________ ____________ is anyone who coughs for at least 3 months per year for 2 consecutive years without having had a precipitating disease. With this illness there is partial or complete blockage of the airways from mucus secretion that causes insufficient oxygenation in the alveoli.

Chronic bronchitis

_________ _____________ involves a persistent cough with production of sputum (worse in the morning and evening than midday), reduced chest expansion, wheezing, fever, dyspnea, cyanosis, and decreased exercise tolerance.

Chronic bronchitis

Peripheral vascular diseases include: A. Arterial and occlusive diseases B. Arterial and venous disorders C. Acute and chronic arterial diseases D. All of the above E. None of the above

D.

Pain from arterial disease is relieved by _____________ the extremity to help blood flow distally; the feet are cold and demonstrate pallor from the loss of blood flow.

Dangling (NOT ELEVATING)

3+ pitting edema

Deep pitting that indents 6mm; remains indented for >1min; dependent extremity is visibly swollen

__________ is common pulmonary symptom and is defined as shortness of breath.

Dyspnea (could also be from the cardiovascular system)

In _______________ air passages are obstructed (not via mucus) and it is difficult for the person to expire due to the destruction of septa between the alveoli, partial airway collapse, and loss of elastic recoil. As they collapse, pockets of air form between the alveolar spaces called Bullae leading to "dead space".

Emphysema

_______________ involves overdistension of the air space, destruction of pulmonary capillaries, and loss of functional lung tissue.

Emphysema

_______________ may develop in a person after a long history of chronic bronchitis in which the alveolar walls are destroyed, leading to permanent overdistention of the air spaces and loss of normal elastic tension in the lung tissue.

Emphysema

________________ is another disease classified within the COPD umbrella. Now what you have is overdistension of the airspace, so these patients aren't getting air out because of breakdown in the alveolar tissue, and that's going to really destroy their pulmonary capillaries and they're not going to have good functional lung tissue. So the gas exchange again is going to be impaired.

Emphysema

You are seeing an 83-year-old woman for a home health evaluation after a MVA that required a long hospitalization followed by transition care in an intermediate care nursing facility and now home health care. She is ambulating short distances with a wheeled walker, but she becomes SOB quickly and requires lengthy rest periods. At each visit the client is wearing her slippers and housecoat, so you suggest that she start dressing each day as if she intended to go out. She replies that she can no longer fit into her loosest slacks and she cannot tie her shoes. Is there any significance to this client's comments, or is this consistent with her age and obvious deconditioning? Briefly explain your answer.

Examine this client for the presence of cyanosis, orthopnea, and tachycardia; for changes in renal function (decreased urination during the day but frequent urination at night); and for a spasmodic cough triggered by lying down or at night. These may be indicators of CHF and must be reported to the physician. Take note of whether this client is taking NSAIDs and digitalis together, this combination of medications can cause ankle swelling- a symptom that must also be reported to the physician

True or false: Pain coming from the heart can be reproduced with palpation of the chest.

FALSE

True or false: Chronic bronchitis will go away if left untreated,

False

An abdominal aortic aneurysm is very dangerous and if it were to rupture that would be a _________ injury.

Fatal

What are the primary symptoms of CHF?

Fatigue, dyspnea, edema, nocturia

Classic female pain pattern for myocardial infarction?

Feeling irritable, fatigue, nauseous, out of sorts, central upper thoracic pain; also can have epigastric onset of symptoms as well as diffuse chest pain that may radiate in both arms

Why do we look at C-reactive protein and other inflammatory markers in regards to heart disease?

Heart disease often manifests itself from chronic inflammation

Hypertensive crisis

Higher than 180 and/or higher than 120

If a patient has a stent and chest pain what do you do?

Immediate referral; call 911; HUGE RED FLAG

Why does leaning forward ease chest pain stemming from the pericarditis?

It creates a bit of space and therefore takes off pressure from the heart contacting the pericardium

Classic male pain pattern for myocardial infarction?

Left side pain (left shoulder pain, stabbing chest pain that radiates into the shoulder and down the left arm; almost in the ulnar nerve distribution as well as across the left jaw)

Pulmonary backup; dyspnea, cough, consider what supine position will create, fatigue, edema, renal function.

Left sided heart failure

Normal BP

Less than 120 and less than 80

High risk age group for myocardial infarction?

Males: over 55 Females: over 65

2+ pitting edema

Moderate pitting that indents 4mm; disappears within 10-15 seconds

What should you do if a client complains of throbbing pain at the base of the neck that radiates into the interscapular areas and increases with exertion

Monitor vital signs, and palpate pulses. Evaluate past and current medical history for the presence of coronary artery disease. Any suspicion of thoracic aneurysm must be reported to the physician immediately. It is beyond the scope of a physical therapist's practice to suggest the possibility of an aneurysm. Rather, clinical observations should be documented and submitted to the physician. A summary comment can be made such as, "This clinical presentation is not consistent with a musculoskeletal problem. Please evaluate."

Order from mild to severe for types of mucus?

Mucoid Mucopurulent Purulent

Briefly describe the difference between myocardial ischemia, angina pectoris, and MI

Myocardial ischemia is a deficiency of blood supply to the heart muscle that is usually caused by narrowing of the coronary arteries. Angina pectoris is the chest pain that occurs when the heart is not receiving an adequate supply of blood, and therefore, has insufficient quantities of oxygen for the workload. Myocardial infarction is death of the heart tissue when blood supply to that area is interrupted.

1+ pitting edema

No pitting; mild indentation of skin (2mm)

A 48-year-old woman with TMJ syndrome has been referred to you by her dentist. How do you screen for the possibility of medial (specifically cardiac) disease?

PMH/risk factors: personal or family history of CAD, heart disease, angina, MI, or risk factors associated with these (see table 6.3). Assess menstrual history: a menopausal or postmenopausal woman with a high risk for heart disease may develop symptomatic CAD.

"Pack year"

Packs per day x years smoked

_____________ can also occur as an adverse effect of some medications, through the use of drugs such as cocaine, as the result of an overactive thyroid, or because of caffeine sensitivity.

Palpitations

_____________ in any person with a history of unexplained sudden death in the family require medical referral.

Palpitations

When are palpitations clinically significant?

Palpitations may be considered physiologic (i.e., "within normal limits") when they occur at a rate of less than six per minute. Palpitations lasting for hours or occurring in association with pain, shortness of breath, fainting, or severe lightheadedness require medical evaluation. Palpitations in any person with a history of unexplained sudden death in the family require medical referral. Palpitations can also occur as an adverse effect of some medications, through the use of drugs such as cocaine, as the result of an overactive thyroid, or because of caffeine sensitivity. Palpitations as a recurring symptom (even if less than six/minute) should always be reported to the physician.

What are the 3Ps? What is the significance of each one?

Pleuritic pain (exacerbated by respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups; this may be cardiac with pericarditis, or it may be pulmonary); have the client hold his or her breath, and reassess symptoms—any reduction or elimination of symptoms with breath holding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms. Pain on palpation (musculoskeletal origin) Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and that improves when sitting up or leaning forward is often pleuritic in origin).

_______________ is associated with chest/shoulder pain, productive cough (purulent), dyspnea, tachypnea, tachycardia, cyanosis, fever and generalized myalgia.

Pneumonia

Coughing up blood is a ____ _____.

Red flag (immediate referral)

_______-sided failure, is systemic backup. The patient may present with cyanosis. You might see jugular vein distention. Their lower limbs are very swollen.

Right

Systemic backup; right upper quadrant pain, cyanosis, fatigue.

Right sided heart failure

________ _________________ is a spike in pulmonary hypertension, that results in cor pulmonale, and because of that you get back up into the heart. So they're going to get hypoxic and acidotic because they're having that right sided heart failure due to the pulmonary hypertension.

Status asthmaticus

A 55-year-old male grocery store manager reports that he becomes extremely weak and breathless when he is stocking groceries on overhead shelves. What is the possible significance of this complaint?

The onset of MI can be precipitated by working with the arms extended over the head. Ischemia or infarction may be the cause of this client's symptoms. Assess for history of heart disease and the presence of known hypertension, angina, past episodes of heart attack, or CHF. Assess vital signs with increased workload and assess the effect of increasing the workload of the lower extremities only. Evaluate for TOS, especially with cardiovascular component. Evaluate for and trigger points of the chest, upper abdomen, and upper extremity. This client should be evaluated by his physician; the therapists information gathered from the assessment will be helpful in the medical differential diagnosis

True or false: A menopausal or postmenopausal woman with a high risk for heart disease may develop symptomatic CAD.

True

True or false: Advanced bronchiectasis can cause pneumonia, cor pulmonale, or right-sided ventricular failure.

True

True or false: Arterial and occlusive disease are synonymous.

True

True or false: COPD affects the whole system, so certainly we can see a spike in pulmonary hypertension that has downstream effects on the lung, the liver and the pancreas and function of the gastrointestinal track will all be impaired because of COPD.

True

True or false: Clear (mucoid) mucus is not concerning.

True

True or false: Clinical signs and symptoms of bronchiectasis very widely, depending on the extent of the disease and on the presence of complicating infection.

True

True or false: Lung cancer is usually not obvious until the later stages.

True

True or false: Most patients have a combination of left and right sided heart failure.

True

True or false: Obstructive bronchitis, emphysema and asthma are considered Chronic Obstructive Pulmonary Diseases.

True

True or false: Palpitations as a recurring symptom (even if less than six/minute) should always be reported to the physician.

True

True or false: Palpitations lasting for hours or occurring in association with pain, shortness of breath, fainting, or severe lightheadedness require medical evaluation.

True

True or false: Sometimes woman do not present with pain at all leading up to a myocardial infarction but rather feel irritable and fatigued.

True

True or false: The drive to breathe in a healthy person is from the increase in arterial carbon dioxide levels. So when using oxygen therapy it is important to not add too much oxygen when treating a person with COPD as they will lose their drive to breathe.

True

True or false: The profile of patients who are at risk for cardiovascular disease is the same profile of patients who have osteoarthritis, tendinopathy and a lot of different musculoskeletal condition.

True

True or false: Pancoasts tumors are a type of lung cancer.

True (in the apical of the lung)

Pain radiating down the arm can be from compression on the brachial plexus stemming from pathology within the _______ ______.

Upper lungs

4+ pitting edema

Very deep pitting that indents 8mm; remains 2-5mins; dependent leg is grossly distorted

An ____________ is distension of the artery.

aneurysm

Coronary artery disease

atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle

Cyanosis

bluish discoloration of the skin

_____________________ involves a chronic "wet" cough with copious foul-smelling secretions; generally worse in the morning after the individual has been recumbent for a length of time, hemoptysis, occasional wheezing sounds, dyspnea, sinusitis, weight loss, anemia, malaise, recurrent fever and chills, and fatigue.

bronchiectasis

By definition if they've been sick or having this cough for three months out of the year over the course of two years, then that will be defined as ________ ___________. They don't necessarily have to have any other type of precipitating disease. Just simply knowing that they have the cough, shortness of breath, wheezing, and they really aren't going to be able to tolerate the exercises that we're providing, their cardiovascular system's going to be impaired.

chronic bronchitis

What is hemoptysis?

coughing up blood

Pursed lip breathing in the sitting position while leaning forward on the arms relieves symptoms of dyspnea for the client with ____________.

emphysema

If the pain is worse with exercise, that's _____________ angina.

exertional

Chronic bronchitis is a little different from acute bronchitis. So now we're talking about a prolonged and systemic mucus hypersecretion, so because of that you're going to see this ______________ lung tissue because the condition's been around for so long that lung tissue gets thicker. That's going to create a more productive cough and it's going to be persistent.

hypertrophy

______-sided heart failure, we're going to see pulmonary backup. Obviously, that patient is going to have backup to the lungs and so you're going to see shortness of breath, cough. They aren't going to want to lay in supine, right? When they lay supine, it makes it worse. They get more of a backup so they don't want to assume that position.

left

__________________ is inflammation of the sac around the heart.

pericarditis

Pain that is worse when lying down and that improves when sitting up or leaning forward is often ____________ in origin.

pleuritic

___________ pericarditis usually occurs with an insidious onset .

primary

_______________ pericarditis occurs for some reason; for example the patient was sick and they had an infection.

secondary

Pulmonary embolism symptoms

sudden chest pain, dyspnea, increased respiratory rate, also may have cough, tachycardia, fever, diaphoresis, anxiety, & possible syncope