D118 Unit 5 Study Guide

D118 Unit 5 Study Guide

Managing Chronic Pulmonary Disorders and Diseases

What is Asthma and How Does It Present Clinically?

Asthma is a chronic inflammatory disorder of the airways that leads to increased sensitivity to various internal and external triggers. This heightened airway responsiveness causes periodic narrowing and inflammation of the bronchial tubes, which is reversible. Patients with asthma typically experience recurring episodes of coughing, wheezing, chest tightness, and shortness of breath. The severity of these symptoms can range from mild inconvenience to severe, potentially life-threatening episodes. Prompt identification and treatment are essential to minimize exacerbations and enhance the patient’s quality of life (Global Initiative for Asthma [GINA], 2024).

What Does the Physical Examination of a Patient with Asthma Include?

The physical exam for asthma aims to confirm the diagnosis, rule out other conditions, assess disease severity, monitor adverse effects of treatment, and detect any comorbidities. Common findings include wheezing heard during lung auscultation and signs of airway obstruction such as prolonged expiration phases. This assessment is critical for guiding treatment plans (GINA, 2024).

How is Asthma Managed Immediately?

In acute asthma episodes, treatment begins with short-acting beta-agonists (SABAs) delivered by inhalers or nebulizers. Usually, two doses are given 20 minutes apart, each consisting of 2 to 6 puffs. This therapy rapidly alleviates bronchospasm, reducing airway resistance and improving airflow (GINA, 2024).

What Are the Diagnostic Criteria for Asthma Using Spirometry or Pulmonary Function Tests?

Spirometry plays a crucial role in confirming asthma by demonstrating reversible airflow obstruction. A positive test shows an increase in forced expiratory volume in one second (FEV1) of at least 12% and 200 mL after administering a bronchodilator. This reversibility is characteristic of asthma and helps differentiate it from other obstructive lung diseases (American Thoracic Society, 2023).

What Are the Risk Factors for Poor Asthma Outcomes?

Identifying risk factors for poor asthma control is vital during diagnosis and follow-up. These include uncontrolled symptoms, frequent exacerbations, poor inhaled corticosteroid (ICS) adherence, incorrect inhaler use, excessive use of SABAs, low baseline lung function (FEV1 <60%), psychological or socioeconomic issues, allergen exposure, smoking, ICU admissions, comorbidities such as obesity, elevated allergic markers (eosinophils and FENO), and pregnancy.

What Are the Five Steps for Pharmacologic Management of Asthma?

Asthma treatment follows a stepwise approach, where medication intensity is adjusted according to symptom control and exacerbation risk. Early use of low-dose ICS is important to prevent lung damage and severe attacks.

When Should Patients with Asthma Be Referred or Hospitalized?

Referral to a specialist is recommended for patients with severe asthma characterized by frequent hospitalizations, persistent uncontrolled symptoms, frequent emergency visits, inadequate response to treatment, or when advanced allergy testing or therapy modifications are necessary (GINA, 2024).

What Are the Clinical Features and Management of Chronic Cough?

Chronic cough, lasting over eight weeks, is often accompanied by throat clearing and thick mucus, particularly in the morning. Physical findings may include throat redness (sinusitis/allergies), lung crackles (pulmonary edema/fibrosis), wheezes (asthma/COPD), or ear canal irritation triggering cough reflex. Treatment focuses on addressing the underlying cause such as asthma, COPD, or sinus disease, alongside avoiding triggers. Methacholine challenge tests may aid diagnosis if asthma is suspected despite normal pulmonary function tests (Irwin et al., 2023).

What Are the Most Common Causes of Chronic Cough with Normal Chest Radiography?

Common causes include eosinophilic airway diseases responsive to corticosteroids (e.g., asthma, eosinophilic bronchitis), upper airway cough syndrome (postnasal drip), and gastroesophageal reflux disease (GERD).

How Does COPD Present Clinically, and What Are Key Physical Findings?

COPD is marked by progressive shortness of breath, chronic cough, and sputum production. Advanced signs include hyperinflated lungs, nail clubbing, finger discoloration from smoking, barrel-shaped chest, use of accessory muscles, forward-leaning posture, and pursed-lip breathing (GOLD, 2024).

What Are the Management Strategies for COPD?

Management includes smoking cessation, pulmonary rehabilitation, regular exercise, bronchodilators (beta-agonists and anticholinergics), inhaled corticosteroids, and in select patients, surgical options like lung volume reduction (GOLD, 2024).

What Are the Four Severity Classifications of COPD?

When Should Patients with COPD Be Referred to the Hospital?

Hospitalization is necessary for patients with severe symptoms that disrupt daily life, recurrent exacerbations, oxygen therapy needs, preoperative assessments, non-responsive acute exacerbations, persistent infiltrates, sleep disturbances, respiratory failure, or cor pulmonale (GOLD, 2024).

Diagnostic Studies for Pulmonary Diseases

How Does Lung Cancer Present, and What Are Its Physical Exam Findings?

Lung cancer often presents with persistent cough, unexplained weight loss, chest pain, and coughing up blood. Physical examination may reveal lymph node enlargement, bone tenderness, enlarged liver, neurological deficits, and signs of superior vena cava syndrome such as facial swelling and distended neck veins. Patients may also develop deep vein thrombosis due to a cancer-associated hypercoagulable state (Molina et al., 2023).

What Diagnostic Studies Are Used for Lung Cancer?

Workup includes blood tests (complete blood count and tumor markers), imaging such as chest X-rays, CT scans (gold standard), PET, and MRI, plus invasive procedures like bronchoscopy and biopsy. Molecular profiling assists in selecting targeted therapies (Molina et al., 2023).

What Are the Clinical Features and Management of Pneumothorax?

Pneumothorax typically causes sudden shortness of breath and unilateral chest pain. Large or tension pneumothoraces can lead to respiratory distress, rapid heartbeat, tracheal deviation, and cyanosis, requiring emergency intervention. Treatment ranges from observation for small cases to needle aspiration, chest tube insertion, or surgery for severe cases (Light, 2024).

How to Differentiate Types of Pneumothorax?

What Are the Clinical Presentation, Examination, and Management of Pulmonary Embolism?

Pulmonary embolism (PE) commonly presents suddenly with shortness of breath, rapid breathing, chest pain that worsens with breathing, leg pain or swelling, coughing blood, rapid heart rate, and jugular venous distension. Symptoms may also be vague like syncope or fatigue. Physical signs depend on embolus size and include respiratory distress and low oxygen levels. Treatment includes stabilization, oxygen to keep saturation above 92%, anticoagulation with heparin or direct oral anticoagulants, and for severe cases, thrombolytics or mechanical support (Kearon et al., 2023).

What Are the Risk Factors for Pulmonary Embolism?

Risk factors include recent surgery or trauma, prolonged immobility, malignancy, stroke, heart failure, smoking, pregnancy, estrogen therapy, and previous PE episodes.

How Is Pulmonary Embolism Diagnosed?

Diagnosis uses EKG to rule out heart causes, chest X-ray to exclude other lung diseases, ventilation-perfusion scans, and computed tomography angiography (CTA), which is the gold standard (Kearon et al., 2023).

What Are the Clinical Features, Physical Examination Findings, and Management of Sarcoidosis?

Sarcoidosis is a granulomatous disease affecting lungs and other organs. Patients may experience fatigue, cough, chest pain, arthritis, skin lesions, and eye inflammation. Auscultation is often normal but wheezing may occur in advanced disease. Neurological symptoms are rare. Treatment focuses on symptom control, often with corticosteroids for significant disease, while asymptomatic cases may need only observation and pulmonary rehabilitation (Iannuzzi et al., 2023).

How Is Sarcoidosis Diagnosed and Monitored?

Diagnosis relies on high-resolution CT scans differentiating inflammatory versus fibrotic lung changes. Laboratory markers include raised serum angiotensin-converting enzyme (ACE), hypergammaglobulinemia, and occasional hypercalcemia. Skin tests often show anergy. Monitoring includes clinical evaluation and periodic imaging (Iannuzzi et al., 2023).

Sleep Disorders – Symptoms and Management

Clinical Presentation and Management of Abdominal Aortic Aneurysm (AAA)

An AAA is defined as a permanent dilation of the abdominal aorta of 3.0 cm or more or at least 50% larger than normal. Symptoms may include hypotension, pulsatile abdominal mass, and abdominal or back pain. Diagnosis involves palpation and auscultation for bruits. Management ranges from monitoring to surgical repair or endovascular aneurysm repair (EVAR) based on size and rupture risk (Johnston et al., 2024).

Presentation, Examination, and Treatment of Carotid Artery Disease

Carotid artery disease often manifests as transient ischemic attacks or strokes, with symptoms like contralateral weakness, sensory loss, or transient vision loss (amaurosis fugax). Auscultation may reveal carotid bruits. Treatment includes statins, blood pressure control, antiplatelets, and carotid endarterectomy for severe disease (Goldstein et al., 2024).

How Does Coronary Artery Disease Present and How Is It Managed?

Coronary artery disease (CAD) typically causes chest pain described as pressure or squeezing, often accompanied by nausea, sweating, or shortness of breath. Stable angina is managed with aspirin, beta blockers, lipid-lowering drugs, and nitrates. Unstable angina requires urgent ECG evaluation to exclude acute coronary syndromes (Amsterdam et al., 2024).

Clinical Features and Physical Examination of Heart Failure

Heart failure symptoms include dyspnea, fatigue, swelling of extremities, pulmonary congestion, and abdominal discomfort. Physical signs include jugular venous distention and peripheral edema. Diagnosis uses clinical evaluation combined with imaging and labs to guide treatment (Yancy et al., 2023).

Abdominal Fullness, Bloating, and Appetite Loss in Heart Failure

Symptoms such as abdominal bloating and poor appetite often accompany heart failure. Management involves lifestyle modifications like smoking cessation, salt restriction, and exercise. Screening with B-type natriuretic peptide (BNP) and echocardiography is recommended. Pharmacologic treatment includes ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists (Yancy et al., 2017).

New York Heart Association (NYHA) Classifications of Heart Failure

Diagnosis of Congestive Heart Failure (CHF)

CHF diagnosis is based on clinical examination, imaging such as echocardiography for ventricular function and valve assessment, and invasive procedures like left-sided heart catheterization. BNP is a sensitive marker for cardiac stress and heart failure (McMurray et al., 2014).

Infective Endocarditis and Myocarditis

Infective Endocarditis: Patients often have low-grade fever, chills, weight loss, and heart murmurs. Other signs may include joint pain, petechiae, kidney infection, and retinal hemorrhages (Roth spots). Treatment involves prolonged intravenous antibiotics and sometimes valve surgery (Baddour et al., 2015).

Myocarditis: Symptoms range from fever and chest pain to severe heart failure. Management includes rest, avoidance of stimulants, and heart failure treatment (ACE inhibitors, diuretics, beta blockers). BNP helps in diagnosis (Cooper, 2009).

Hypertension: Clinical Presentation and Management

Hypertension is frequently asymptomatic but may present with tinnitus, headache, or dizziness. Proper blood pressure measurement technique is critical. Treatment includes lifestyle changes and medications such as ACE inhibitors, ARBs, thiazides, and calcium channel blockers. Nondihydropyridine calcium channel blockers are contraindicated in heart failure with reduced ejection fraction (Whelton et al., 2018).

Hypertensive Emergency Criteria

A hypertensive emergency is characterized by severely elevated blood pressure (typically >180/120 mmHg) accompanied by acute target organ damage such as encephalopathy or pulmonary edema (Whelton et al., 2018).

What are the clinical features, examination findings, and treatment approaches for peripheral arterial disease (PAD) and venous insufficiency?

Patients with PAD often present with intermittent claudication, ischemic rest pain, leg fatigue, and poor wound healing. Physical exam includes assessment of peripheral pulses, capillary refill, and evaluation for swelling or ulcers. Treatment emphasizes lifestyle changes such as smoking cessation and control of comorbidities like diabetes and hypertension. Compression stockings may be used if the ankle-brachial index (ABI) exceeds 0.8 to manage venous insufficiency. Pharmacological options include antiplatelets (aspirin, clopidogrel), statins, and cilostazol to improve walking distance. Advanced cases may require surgical interventions like angioplasty or bypass grafting (Gerhard-Herman et al., 2017).

Valvular Heart Murmurs: Characteristics and Treatment

Valvular heart murmurs exhibit distinctive clinical characteristics depending on the affected valve, each presenting with specific auscultatory features and associated symptoms. Understanding these murmurs aids in diagnosis and guides appropriate management.

Aortic Stenosis is characterized by a loud, harsh crescendo-decrescendo murmur best heard at the second right intercostal space, often radiating to the neck. A palpable thrill may accompany the murmur. Patients commonly experience fatigue, dizziness, syncope, angina, and a reduced pulse pressure. Diagnostic confirmation is achieved with echocardiography, and patients often require referral to cardiology. For those at high surgical risk, transcatheter aortic valve replacement (TAVR) is a preferred treatment option (Nishimura et al., 2017).

Mitral Regurgitation presents as a holosystolic, blowing murmur heard at the cardiac apex and radiating towards the left axilla. Clinical features include fatigue, exertional dyspnea, palpitations, and left atrial enlargement. Echocardiography is essential for diagnosis, with management ranging from medical therapy to surgical repair in severe cases.

Mitral Valve Prolapse is identified by a midsystolic click, often accompanied by a late systolic murmur, accentuated in the sitting position or during the Valsalva maneuver. While usually benign, symptoms such as dysrhythmias, chest pain, and anxiety may be present. Echocardiography is the diagnostic tool of choice.

Aortic Regurgitation manifests as a high-pitched, decrescendo diastolic murmur audible at the left third intercostal space and radiating downward. Patients may demonstrate a wide pulse pressure, head bobbing, and dyspnea on exertion. Early cardiology consultation for surgical repair is recommended.

Mitral Stenosis produces a diastolic rumbling murmur with an opening snap and a loud first heart sound at the apex. Symptoms often include dyspnea on exertion and poor tolerance of pregnancy. Echocardiographic evaluation guides the need for surgical intervention.

Diverticular Disease: Presentation and Management

What distinguishes diverticulitis from diverticulosis, and how are these conditions treated?

Diverticulosis refers to the presence of multiple diverticula in the colon, usually asymptomatic or presenting with mild, intermittent symptoms such as bloating or irregular bowel habits. In contrast, diverticulitis occurs when these diverticula become inflamed, resulting in acute clinical signs including left lower quadrant abdominal pain, fever, leukocytosis, nausea, and vomiting.

Physical examination in diverticulitis may show localized tenderness, abdominal guarding, or even a palpable mass, whereas diverticulosis typically lacks physical findings. Diagnosis often involves stool analysis and colonoscopy to assess overall colonic health. Management differs: diverticulitis requires antibiotic therapy to treat the infection, while diverticulosis is managed primarily through increased dietary fiber intake to prevent progression or complications (Strate & Morris, 2019).

Gastroesophageal Reflux Disease (GERD)

How does GERD present clinically, and what are the principles of examination and treatment?

GERD commonly presents with heartburn and chest discomfort, which can mimic angina pectoris. On oral examination, dental erosions and halitosis may be observed, alongside signs that could suggest systemic conditions like scleroderma. Respiratory symptoms such as chronic cough or wheezing may occur secondary to acid reflux irritating the airways.

Treatment focuses on reducing gastric acid production, primarily through histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). Prokinetic agents like metoclopramide may be used in patients who have delayed gastric emptying to improve symptoms (Katz et al., 2022).

Gastrointestinal Hemorrhage

What are the signs, examination findings, and treatment options for gastrointestinal bleeding?

Patients with gastrointestinal bleeding may exhibit hematemesis (vomiting blood), melena (black, tarry stools), or hematochezia (bright red blood per rectum). Early assessment includes monitoring vital signs and mental status, along with skin examination for telangiectasia or signs of chronic liver disease, such as cirrhosis.

Treatment depends on the bleeding source and severity. For esophageal varices, balloon tamponade can be employed for acute control. Surgical shunts or transjugular intrahepatic portosystemic shunts (TIPS) are options to reduce portal hypertension and manage recurrent variceal bleeding (Strate & Gralnek, 2016).

Hepatitis and Liver Disease

What symptoms and physical findings are common in hepatitis, and what treatments are recommended?

Hepatitis typically presents with systemic symptoms such as anorexia, fatigue, myalgia, nausea, fever, and abdominal discomfort. Physical examination focuses on detecting jaundice and signs indicating liver failure.

Treatment strategies depend on the underlying cause. For viral hepatitis, antiviral agents such as nucleoside analogues may be required. In certain cases, liver biopsy is performed for disease staging to inform management (European Association for the Study of the Liver, 2017).

Inflammatory Bowel Disease (IBD)

What are the clinical features and management strategies for ulcerative colitis and Crohn’s disease?

IBD commonly presents with abdominal pain, diarrhea, fatigue, weight loss, fever, and extraintestinal manifestations like arthritis. Physical examination may reveal oral ulcers, abdominal tenderness, hyperactive bowel sounds, and perianal lesions—especially indicative of Crohn’s disease.

Treatment involves 5-aminosalicylates, immunomodulators such as azathioprine, corticosteroids for acute exacerbations, and biologic agents like infliximab to reduce inflammation and maintain remission (Torres et al., 2020).

Irritable Bowel Syndrome (IBS)

How is IBS diagnosed and treated?

IBS is characterized by abdominal pain and altered bowel habits without alarming symptoms like weight loss or gastrointestinal bleeding. Physical exam is generally unremarkable, though mild tenderness may be present.

Management centers on symptom relief through dietary fiber supplementation, antispasmodics, antidiarrheal medications, and psychotropic drugs when associated with psychological symptoms such as anxiety or depression (Ford et al., 2018).

Chronic Pancreatitis

What clinical features characterize chronic pancreatitis, and how is it managed?

Patients with chronic pancreatitis typically experience recurrent epigastric pain radiating to the back, nausea, steatorrhea, and unintended weight loss. Physical exam may reveal abdominal tenderness and signs of malnutrition.

Treatment priorities include cessation of alcohol and tobacco use, pain control with analgesics, pancreatic enzyme replacement therapy, vitamin supplementation, and surgical intervention if complications arise (Yadav & Lowenfels, 2013).

Gastrointestinal Tumors: Symptoms, Physical Findings, and Management

References

Baddour, L. M., et al. (2015). Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications. Circulation, 132(15), 1435–1486.

Cooper, L. T. Jr. (2009). Myocarditis. New England Journal of Medicine, 360(15), 1526–1538.

European Association for the Study of the Liver. (2017). EASL clinical practice guidelines: Management of chronic hepatitis B virus infection. Journal of Hepatology, 67(2), 370–398.

Ford, A. C., et al. (2018). Irritable bowel syndrome. Lancet, 391(10114), 1814–1825.

Gerhard-Herman, M. D., et al. (2017). 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease. Circulation, 135(12), e726–e779.

Katz, P. O., et al. (2022). Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 117(1), 27–56.

McMurray, J. J., et al. (2014). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 35(27), 1787–1847.

Nishimura, R. A., et al. (2017). 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Circulation, 135(25), e1159–e1195.

Strate, L. L., & Gralnek, I. M. (2016). Management of acute lower gastrointestinal bleeding. Gastroenterology, 150(7), 1683–1691.

Strate, L. L., & Morris, A. M. (2019). Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology, 156(5), 1282–1298.

Torres, J., et al. (2020). Crohn’s disease. Lancet, 395(10221), 1246–1260.

Whelton, P. K., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248.

Yadav, D., & Lowenfels, A. B. (2013). The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology, 144(6), 1252–1261.

Yancy, C. W., et al. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure. Journal of the American College of Cardiology, 70(6), 776–803.