Term
| what should be in your differential for pts who present w SOB and chest pain? |
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Definition
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Term
| 3 components to thrombus formation |
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Definition
| endothelial injury (to blood vessels), stasis or turbulent blood flow, hypercoagulability of the blood |
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Term
| etiologies of a hypercoagulable state |
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Definition
| malignancies/cancer, pregnancy, estrogen therapy, trauma, sepsis, protein s and protein c deficiency, |
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Term
| vascular wall injury causes |
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Definition
| trauma, surgery, venipuncture, chemical irritation, heart valve disease |
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Term
| circulatory stasis or turbulent blood flow etiologies |
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Definition
| atrial fibrillation, left ventricular dysfunction, venous insufficiency, venous obstruction |
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Term
| hypercoagulable state causes __ which leads to |
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Definition
| predisposed risk then injury initiates clotting cascade then abnormal blood flow causes platelets to adhere to the endothelial cells or damaged tissue |
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Term
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Definition
| is rapidly fatal, this is commonly missed |
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Term
| PE mortality rate depends on |
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Definition
| what happens to your heart, if you start to develop right-sided heart abnormalities mortality goes up or if pt develops hypotension or shock |
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Term
| strong predisposing risk factors |
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Definition
| hip or leg fracture, hip or knee replacement, major general surgery, major trauma, spinal cord injury (manipulating the lower extremity can lead to a DVT->PE) |
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Term
| Moderate predisposing risk factors |
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Definition
| knee surgeries, arthroscopic knee surgery, central venous lines, cancer or chemotherapy, chronic heart or respiratory failure, hormone replacement therapy or birth control pills, and so on, pregnancy/postpartum |
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Term
| low predisposing risk factors |
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Definition
| bed rest for greater than 3 days, immobility for 6-12 hrs, increasing age, , laparoscopic surgery, obesity, pregnancy, varicose veins. |
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Term
| top 3 signs for PE presentation |
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Definition
| dyspnea, pleuritic chest pain or chest pain, and cough |
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Term
| signs of right-sided heart failure due to increased pulmonary resistance |
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Definition
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Term
| other signs/symptoms for PE |
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Definition
| leg swelling/calf tenderness, hemoptysis, wheezing (nonspecific for PE, making it hard to diagnose), fever |
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Term
| two ways to estimate probability of PE |
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Definition
| Well's probability system, Geneva system |
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Term
| what is the D-dimer test? what is it good for |
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Definition
| good for ruling out low-probability pulmonary embolism pts, not used for mod to high probability PE pts bc this test is not good enough if negative to rule out PE. D-dimer is a measure of fibrinolysis. Plasminogen-> Plasmin, Fibrinogen -> Fibrin, get FDP (D-dimer is one), whenever you clot in your bloodstream you automatically start breaking it down (D-dimer is a measure of clot breakdown, not specific for PE) |
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Term
| other times D-dimer will be pos |
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Definition
| clot in coronary artery, clot in brain, clot in peripheral vascular system, DVT, cancer, recent surgery |
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Term
| D-dimer results that indicate PE if presenting w symptoms |
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Definition
| >500 (but can also be this high in other states) |
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Term
| V/Q scan, works how? results? good for who? how is it performed? |
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Definition
| uses radioactive material to compare ventilation to perfusion (if you have a clot in your lung you will have a ventialation-perfusion mismatch). radiologist will score as normal or low, int,high probablity, good for pts who can't do a CT scan, give a radioactive compound that is inhaled which is distributed normally, then inject radioactive compound into the veins--if it can't reach a certain area due to a clot that is a ventilation/profusion (V/Q) mismatch |
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Term
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Definition
| shows the clot, more sensitive |
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Term
| gold standard test for PE |
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Definition
| pulmonary angiography. need interventional radiologist, high mortality and morbidity, not a lot of facilities have |
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Term
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Definition
| S1Q3T3 deep s-wave in lead 1, a Q wave in lead 3 and an inverted T wave in lead 3. indicated right-sided heart strain |
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Term
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Definition
| can be unremarkable or have some abnormalities |
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Term
| Westermark sign on chest x-ray |
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Definition
| decreased pulmonary vascularity in PE, branching abruptly stops |
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Term
| Hampton's hump on chest x-ray |
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Definition
| shadow or density corresponding to a lung segment, always in contacxt with one or more pleural surfaces, PE finding |
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Term
| infiltrate from pneumonia on x-ray |
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Definition
| follows more of a lobe of the lung (vs Hampton's hump that follows more of a segment) |
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Term
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Definition
| to rule in or out MI, elevated in PE, predictor of outcome |
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Term
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Definition
| pt can be hypoxic, hypocapnic or have respiratory alkalosis |
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Term
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Definition
| anticoagulation. thrombolytic therapy- coumadin, haparin, LMWH |
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Term
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Definition
| geneva score predictor, clinical prediction rule ,pulmonary embolism severity index, |
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Term
| Pulmonary embolism severity index classes |
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Definition
| Class I and II have lowest risk of death, possible outpatient treatment, Class III-V 3-month mortality is 19% (helps us determine how aggressively to treat and when to follow-up) |
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Term
| thrombolysis is only used in |
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Definition
| high risk pts (cardiogenic shock or persistent atrial hypotension) |
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Term
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Definition
| vitamin K antagonists (coumadin) (takes 3-4 days to become therapeutic so start on heparin too) |
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Term
| ways to monitor coumadin and heparin |
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Definition
| coumadin- PT or INR. heparin- PTT |
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Term
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Definition
| breaks down antithrombin III allowing for increased levels of activated factors in the blood |
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Term
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Definition
| inhibits vit k dep factors II, VII, IX and X and protein S and C |
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Term
| to treat heparin overdose |
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Definition
| protamine sulfate but typically don't use it bc half life of heparin is so short so you can just stop the drug usually |
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Term
| low molecular weight heparin |
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Definition
| MOA is the same as unfractionated heparin, can give subcutaneously once per day and don't have to measure levels, has much longer half life (you can monitor it w activated factor X test/antifactor Xa but typically just dose based on body weight), fewer side effects |
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Term
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Definition
| LMWH is cheaper, no lab tests, cost savings, used for outpatient therapy |
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Term
| treatment for overanticoagulation |
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Definition
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Term
| while waiting to diagnose PE do what |
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Definition
| start the heparin before the CT if high index of suspicion |
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Term
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Definition
| 5 days until INR is at least 2 for 24 hours (target INR 2-3) |
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Term
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Definition
| reversible cause 3 months, unprovoked 3 months and then reevaluate and look at risk vs benefit ratio, in cancer pts 3-6 months |
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Term
| pulmonary hypertension diagnosis is |
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Definition
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Term
| who can develop pulmonary hypertension |
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Definition
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Term
| definition of pulmonary arterial hypertension |
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Definition
| mean pulmonary arterial pressure >25 mmHg at rest measured by a right heart cath (need to measure the pulmonary artery) or a capillary wedge pressure <15mmHG |
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Term
| ideas of pathology of pulmonary hypertension |
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Definition
| endothelial cell dysfunction->abnormality in lining of blood vessels->endothelial and smooth muscle proliferation->structural changes and remodeling->increases pulmonary vascular resistance (becomes thicker and more fibrotic)->hypertension |
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Term
| risk factors for pulmonary hypertension |
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Definition
| collagen vascular disease, congenital heart disease, portal hypertension, pregnancy |
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Term
| factors that are affected in pulmonary hypertension |
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Definition
| endothelial dysfunction->nitrous oxide dec, dec prostacyclin-> vascular smooth muscle dysfunction |
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Term
| clinical signs are due to |
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Definition
| high resistance to blood flow through the lungs, increased stress on the heart, compromised blood flow through the body due to decreased cardiac output |
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Term
| symptoms of pulmonary hypertension |
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Definition
| SOB particularly during physical activity, fatigue, dizziness, syncope, peripheral edema, chest pains |
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Term
| pulmonary hypertension physical exam findings |
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Definition
| jugular venous distention, ascities (indicates strain on right side of heart) , peripheral edema in legs, pulses diminished |
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Term
| physical exam precordium in pulmonary hypertension |
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Definition
| palpable P2, parasternal heave, loud P2 |
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Term
| auscultate the heart on physical exam |
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Definition
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Term
| primary pulmonary hypertension |
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Definition
| group 1, familial, idiopathic, drug or toxin induced, rare |
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Term
| group 2 pulmonary hypertension |
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Definition
| secondary to left ventricular failure |
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Term
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Definition
| secondary to pulmonary vascular disease or pulmonary disease, COPD |
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Term
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Definition
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Term
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Definition
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Term
| group one pulmonary hypertension has been associated with |
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Definition
| connective tissue disease, HIV, and portal hypertension. |
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Term
| Group 2 pulmonary hypertension has been associated with |
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Definition
| left ventricular systolic or diastolic dysfunction, the alveolar disease, or some of the cardiomyopathies or congenital diseases |
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Term
| Group 3 pulmonary hypertension has been associated with |
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Definition
| COPD, emphysema, chronic bronchitis, interstitial lung disease, sleep disordered breathing |
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Term
| group 4 pulmonary hypertension has been assoicated with |
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Definition
| chronic thromboembolic pulmonary hypertension (only curable form of pulmonary hypertension) |
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Term
| group 5 pulmonary hypertension is associated with |
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Definition
| elevation in artery pressure and associated with systemic disease, could be due to hematological diseases, systemic diseases, like sarcoidosis, metabolic disorders, fibrosing or renal failure on dialysis |
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Term
| diagnostic tests for pulmonary hypertension |
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Definition
| cardiac echo (r/o lung disease), V/Q scan (r/o group 4), right heart cath, can also get chest x-ray (cardiomegaly, distended pulmonary artery) and ekg |
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Term
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Definition
| a screening test that estimates right atrial pressure, |
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Term
| treatment for pulmonary hypertension |
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Definition
| treat the underlying issue, refer to specialist |
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