COPD Snapshot

DEFINE: A lung disease that is a combination of chronic bronchitis and emphysema. This disease limits airflow due to inflammation and C02 retention. These individuals often have a chronic cough, wheezing, shortness of air, and increased mucus production. The also generally have destruction of inter-alveolar septa destruction. Alveoli sacs are where 02 and C02 exchange happens.

RISK FACTORS:
1. Smoker
2. Alpha 1 antitrypsin deficiency
3. Chemical irritant exposure

SUBJECTIVE:
1. Shortness of air
2. Wheezing
3. Tight chest
4. Increased mucus production

PHYSICAL EXAM: (HALLMARK SIGNS=**)
1. Barrel chest
2. Clubbing fingernails
3. Wheezes**
4. Rhonchi
5. Decreased lung sounds
6. Thick sputum**
7. Percussion: hyper-resonance
8. Cyanosis

LABS:
1. Spirometry; FEV1/FVC ratio <70%
2. CBC- may see elevated hit
3. Pulse oximetry: Varies from patient to patient but often seen 88-92%
4. ABG: C02 is often elevated
5. D-dimer
6. Continuous pulse oximetry
7. A1-antitrypsin screen (specifically in those <45 yrs old)
8. CXR: Hyperinflation
9. PFT
10. Sleep studies
11. Sputum culture

STAGES: (FEV1=Amount of air that can be forcefully expelled in 1 second)
1. Stage 1- Mild FEV1 80% greater than or equal to this. May have some mild shortness of air and increase mucus. Also an ongoing chronic cough
2. Stage 2- Moderate FEV1 between 50-79%
3. Stage 3-Severe FEV! Between 30-49%
4. Stage 4- END STAGE Very severe. FEV1 <30%
5. Lung transplant. 02 around the clock

MEDICATIONS COMMONLY USED:
1. Short acting B-agonist: Example: Albuterol scheduled and PRN
2. Anticholinergic-example: Ipratropium, Tiotropium. These meds ease the airways
3. Long Acting B-agonist: Salmeterol, Formoterol
4. Expectorants
5. Oxygen (typical 2-3 L in pm)

ACUTE CARE:
1. IV steroids
2. Empiric antibiotic
3. 02 nasal cannula

RISK FOR ACUTE FLARES:
1. Recent URI
2. Influenza
3. Allergies
4. Environmental irritants
5. Weather changes

TEACHING
1. Vaccination- pneumovax & influenza recommended
2. Smoking cessation
3. Your airflow (in & out) is limited due to obstruction, thus you may have ongoing mild shortness of air. If you shortness of air suddenly increases you should be seen ASAP by a medical healthcare
provider (Emergency Room)
4. Pursed lip breathing
5. Avoid triggers: cold air, infections, air pollutants, cigarette smoke
6. Eat smaller more frequent meals

REFERRALS
1. Pulmonologist

COMPLICATIONS:
1. Chronic anemia
2. Respiratory failure
3. Right ventricular hypertrophy
4. Recurrent lung infections
5. Cor pulmonale: right sided heart failure secondary to COPD

DIFFERENTIAL DIAGNOSIS (Dx that can appear similar)
1. Congestive heart failure
2. Bronchitis
3. Pneumonia: Fever, more acute
4. Asthma: may be younger.
5. Lung cancer
6. Chronic pulmonary embolism
7. Bronchiectasis
8. Reactive airway
9. Bronchospasms

WORDS LINKED-ASSOCIATED
1. Emphysema
2. Blue Bloater
3. Pink Puffer
4. Hypoxic drive theory
5. Hypoxia
6. Hypercapnia
7. Spiromerty
8. FEV1

ONLINE RESOURCES:
1. American Lung Association http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/
2. National Heart, Lung, And Blood Institute http://www.nhlbi.nih.gov/health/health-topics/topics/copd
3. Medscape http://emedicine.medscape.com/article/297664-overview
4. COPD Foundation http://journal.copdfoundation.org
REFERENCES:
1. The 5-minute Clinical consult 2015 43rd Edition page 240. Alan J Crop MD, Bryon Veynovich. Editor in Chief Frank J Domino
2. Epocrates COPD May 2016
3. COPD Foundation http://www.copdfoundation.org/What-is-COPD/COPD-Facts/Glossary.aspx
4. Healthline, End-Stage COPD, Written by Rachel Nall, RN, BSN, CCRN Medically Reviewed by Mark R Laflamme, MD on November 19, 2015 http://www.healthline.com/health/copd/end-stage-copd#Overview1
5. UPMC Life Change Medicine http://www.upmc.com/patients-visitors/education/breathing/pages/chronic-obstructive-pulmonary.aspx

Update on May 2nd,2016

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Myocardial Infarction Snapshot

Myocardial Infarction

AKA: MI, Heart attack, Coronary thrombosis, STEMI, NSTEMI, AMI, ACS

SYMPTOMS: Chest pressure, chest tightness, chest pain, shortness of air, nausea, impending doom, anxiety, left arm, left jaw pain, dizziness

RISK FACTORS: Family hx heart disease, smoking, hyperlipidemia, previous MI, hypertension, Diabetes

MEDICATIONS USED FOR IMMEDIATE TX: Aspirin, Morphine, Nitroglycerin, Oxygen

OTHER MEDS THAT MAY BE USED: Clopidogrel, Prasugrel, Ticagrelor

SOME POTENTIAL DRIPS: Heparin drip, Nitro drip, Alteplase, Integrilin

TESTS: EKG, Cardiac enzymes (ex: troponin), lipids, CBC, CMP, BNP, CXR, Echo, stress tests

TREATMENT GOAL: Restore as much perfusion of blood flow to heart to reduce/mitigate amount of heart damage-ischemia

PROCEDURES: Percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery, stent placement

MEDICATIONS RX ONGOING: Statin, aspirin, anticoagulant, ace inhibitor, beta blocker

AFTER CARE: Cardiac rehab, heart healthy-low sodium diet, Weight loss as indicated, smoking cessation

DIFFERENTIAL DX: Pulmonary embolism, CHF exacerbation, COPD exacerbation, Anxiety, Acid reflux

 

REFERENCES:

http://emedicine.medscape.com/article/155919-treatment#d25

NIH

The 5 Minute Clinical Consult Standard 2015, 23rd Edition Wolters Kluwer. Frank J Domino (Editor in Chief) Associated editors R. Balder, J. Golding, J. Grimes.

 

 

Pulmonary Embolism Snapshot

AKA: Lung clot, PE

SYMPTOMS: Shortness of air, dyspnea, chest pain, potential leg pain (if DVT first), chest tightness, anxiety, coughing (sometime with blood), diaphoretic

PHYSICAL EXAM: Tachypnea, tachycardia, hypotension, cyanosis, low 02 saturation

RISK FACTORS: Current DVT, PE or DVT history, Long period best rest, Recent long travel (road trip, plane), family history, clotting disorder (Factor V Leiden), malignancy, birth control, estrogen, smoking, recent surgery, implantable devices, obesity

LABS & TESTS: May consider EKG, Cardiac enzymes, CXR, BNP, ABGs, etc., first depending upon the situation, in order to r/o other causes. More specific tests, if PE specifically suspected, are: D-dimer, CT of chest with contrast (important with contrast), VQ scan if can’t do CT due to renal function (contrast). Will also want to get PT/INR monitoring especially if placed on heparin drip (protocol) and or warfarin.

MEDICATIONS EMERGENT: Lovenox therapeutic dose or the drip below

DRIPS: Heparin (Heparin drip vs SQ Lovenox- usually one or the other)

PROCEEDURES: Inferior vena cava filter (aka: Green filter) (if recurrent and or anticoagulants are contraindicated)

CHRONIC MEDICATIONS: Anticoagulants (Ex: Warfarin)

CONSULTANTS: Pulmonology

TOOLS: Wells Score tool (Score >6 high probability)

WAYS TO PREVENT: Lovenox prophylaxis dose (in hospital, ongoing bed rest, risk to develop), compression stockings, regular physical activity

Note: This is not an all-inclusive list. This is a generalized overview list

Delirium Tremens Snapshot

AKA: DTs, Alcohol withdrawal

WHAT IS IT: Withdrawal symptoms that generally start a couple of days after an alcoholics last drink

SYMPTOMS: Auditory & visual hallucinations, nausea/vomiting, diarrhea, pins & needles, agitation, shaking, confusion, anxiety, palpitations, chest pains (MedlinePlus)

PHYSICAL ASSESSMENT: Fever, tachycardia, high blood pressure, pale skin color, diaphoretic, tremors, tachypnea

RISK FACTORS: Stopping chronic alcohol use abruptly

EMERGENT MEDICATIONS USED FOR TX: Lorazepam, Valium (benzodiazepines help prevent seizures)

OTHER MEDS THAT MAY BE USED: Folic acid, magnesium, multivitamin, thiamine injection, Famotidine (alcoholic gastritis), Zofran

POTENTIAL DRIPS/FLUIDS: Banana bag, IV fluids

ABNORMAL LABS COMMONLY SEEN: Click here to see the post listing commonly seen labs

TESTS: EKG, ETOH level, Mag, phosphorus, CBC, CMP, GABA, Urine drug screen, ABG’s

COMPLICATIONS: Seizures, myocardial infarction, liver complications, gastritis, Wernicke encephalopathy, Wernicke Korsakoff Syndrome, severe electrolyte disturbances, injury from seizures

TREATMENT GOAL: Prevent seizures, control agitation, control nausea & vomiting, and other uncomfortable symptoms, prevent injury

NURSING ORDERS/PROCEDURES: Seizure, fall, elopement precautions. Psyche consult as indicated for depression/SI/HI, CIWA (3)

AFTER CARE: AA meetings, Counseling,

DIFFERENTIAL DX: Opioid overdose, illicit drug use overdose, encephalopathy, stroke, amphetamine toxicity Click here for a more comprehensive list on emedicine.medscape.com)

REFERENCES:

MedlinePlus medical Encyclopedia
Emedicine.medscape.com
AAFP.org