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---

I
...
They collectively refer to the processes

by which oxygen and carbon dioxide are transported between atmosphere and tissue via concentration gradients,
perfusion, and affinity of hemoglobin for oxygen
1
...
It is
determined by the partial pressure of oxygen present in the alveoli, condition of the alveolar capillary membrane,
and the amount of hemoglobin present and the cardiac output of the patient
...
Hypoxemia - Insufficient oxygen content in the blood
...

b
...
Diffusion pressures – diffusion is the net movement of anything (atoms, ions, molecules, energy etc
...
The bigger the difference, the steeper the concentration gradient and the faster the
molecules of a substance will diffuse
...
Hemoglobin’s affinity for oxygen - allows for blood transport of far more oxygen than could be
dissolved in plasma alone
e
...
Ventilation - refers to the exchange of extra-pulmonary and intra-alveolar gas mixtures and the exchange of
oxygen and carbon dioxide at the alveolar capillary membrane level
...
Resupply of oxygen diffused from the alveoli into blood and removal of CO2 diffused from blood into
the alveoli maintains the alveolar capillary pressure gradients

1

b
...
Noninvasive Oxygen Therapy
a
...
Each additional liter of flow increases the FIO2 by
approximately 4%
...

b
...

Up to 50L/min and 100% FIO2
...

c
...
The usual FIO2 amounts ordered are
24%, 28%, 31%, 35%, 40% and 50%
...
Non rebreathing masks can achieve oxygen concentrations of 80-90%, A one way valve prevents
exhaled gases from entering the reservoir bag thus maintaining the FIO2
...
Noninvasive positive pressure ventilation (NPPV)
...
These decrease the need for endotracheal
intubation and mechanical ventilation in patients with neuromuscular disease, COPD, CHF and
postoperative respiratory compromise or insufficiency
...
May be poorly tolerated by patients with
claustrophobia or aerophagia
...
Initially 5 cm H2O of pressure
should be applied
...


o

BiPAP – works by supporting both inspiration and expiration
...
An inspiratory pressure of 5-10 cmH2O and an expiratory pressure of 5 cm are usual
starting points
...
e
...

Inspiratory pressures can be slowly increased to achieve adequate tidal volumes and minute
ventilation
...


Discuss Clinical Measurements

■

Exercise tolerance is the ability to perform a normal exercise load
...
Example: Climbing a flight of stairs without stopping
2

Asses: Is there dyspnea, air hunger?
■

Does the patient report distress? Does the patient appear distressed?

Cyanosis

Dusky bluish tint from excessive amounts of unsaturated hemoglobin
The more central the cyanosis the greater it’s severity
...
Some blood gas analyzers also measure the methemoglobin, carboxyhemoglobin, and hemoglobin
levels
...
The results of an ABG will assess the following:
a
...
Oxygen saturation of arterial hemoglobin
c
...
Presence or absence of metabolic imbalance
e
...


o

pH: 7
...
45

o

Partial pressure of oxygen in ABG (PaO2): 75 - 100 mmHg

o

Partial pressure of carbon dioxide: 35-45 mmHg

o

Bicarbonate (HCO3): 22-26 mEq/L

o

Base excess: -3 to + 3 mEq/L

o

Saturation of arterial oxygen (SaO2): 95 – 100%

Partial pressures of arterial oxygen and carbon dioxide and arterial oxygen saturation decline as
altitude above sea level increases

g
...
As a rule, PaO2 should be 4-5
times the percentage of O2
...
Normal
ratios are 300-500 mmHg
...


3

h
...
A rising PaCO2 means a decrease in ventilation has
occurred

o

In Acute Respiratory Acidosis, for every 10 mmHg increase in PaCO2 above 40 mmHg, the pH
should decrease by 0
...


EX: PaCO2 of 50mmHg
...
40 as the default pH ➔ 7
...
08 = pH of 7
...

*In Chronic Respiratory Acidosis – for each 10 mmHg increase in PaCO2, the pH should only
decrease by 0
...
08 for every 10-mmHg decrease in PaCO2 below
40 mmHg
...
08 X 2 = 0
...

Use 7
...
40 + 0
...
56
*In Chronic Respiratory Alkalosis – the pH should only increase by 0
...


ABG are frequently used for the following

i
...
Measurements as described above
iii
...
Detection and quantification of the levels of abnormal hemoglobin (carboxyhemoglobin and
methemoglobin)

III
...
Often painful and involves risk of injury with compromise to perfusion to distal site
b
...
An indwelling catheter left in
place is a source of infection and vascular complications
c
...
An abnormal
modified Allen’s test is an absolute contraindication to the procedure as well as severe PVD and active
Raynaud’s syndrome (particularly sampling at the radial site)
4

d
...
The radial arteries are then
manually occluded by applying pressure to them simultaneously
...
This is a
negative test indicating it is safe to use the radial artery
...
Modified Allen’s Test – The patient’s hand is initially held high with the fist clenched
...
This allows the blood to
drain from the hand
...
The palm will appear white
...
A pink color should
return to the palm, usually within 6 seconds indicating that the ulnar artery is patent, and the superficial
palmar arch is intact
...

■

ABGs are not a continuous measurement; accuracy reflects only one point in time
...
Needs to be heparinized without excessive amounts
b
...
Sample must be run within a few minutes after drawing
d
...


Discuss Uses of Pulse Oximetry
A
...
It is a noninvasive, continuous, and inexpensive method for
transcutaneous measurement of the degree to which hemoglobin in arterial blood is saturated with
oxygen (SaO2)
B
...


Normal values are variable and must be interpreted considering altitude the patient’s age and
cardiopulmonary function
o

SpO2 of 90% represents a PaO2 of 60 mmHg

o

SpO2 of 75% represents a PaO2 of 40 mmHg

o

SpO2 of 50% represents a PaO2 of 27 mmHg

D
...


o

Darker skin pigments

o

Certain nail polishes

o

With alkalosis or hypothermia, PaO2 may be lower than predicted by SpO2

o

With acidosis or hyperthermia, the PaO2 may be higher than predicted by the SpO2

Limitations of pulse oximetry include
o

It is only a presumptive reflection of SaO2 and does not provide information regarding pH, PaCO2
or respiratory rate

o

It will misinterpret carboxyhemoglobin as oxyhemoglobin and give a false reading

o

When carbon monoxide poisoning is suspected, an ABG analysis is a more reliable measurement
of oxygenation

o

In some circumstances (shock, hypothermia, severe PVD, use of high dose vasopressors) a
peripherally placed oximeter will not accurately reflect central oxygenation

o

Remember that pulse oximetry measures oxygen saturation not arterial blood oxygen conten

6

1
...
It is a
specific form of chronic, progressive and fibrosing interstitial pneumonia
...
It
occurs in adults and the disease is limited to the lungs
...
In the past, treatment was aimed at
minimizing the inflammation and slowing the worsening of symptoms which happen when the
disease progresses
...

This helps to explain why only a few patients respond to anti-inflammatory therapies and why the
prognosis remains poor
...
Etiology/General Concepts
A
...
Also, exposure to stone, metal,
wood, and organic dust has been suggested as a risk factor
...

Although pathophysiology is not completely understood, pulmonary epithelial cell injury and
aberrant wound healing are thought to play a significant role
...
Prior to treatment, the following must be ruled out
a
...
Autoimmune disorders
c
...
In patients with prior malignancy the lymphangitic spread of tumors should also be
excluded

1

C
...
Exact numbers are unknown
...
22 to 8
...
IPF is the most common cause of interstitial lung
disease among elderly patients
...

b
...
Most of the men are > 55 years of age which
makes it difficult to distinguish worsening functional capacity of the disease to normal
changes with age

3
...
Subjective Findings or Symptoms
Patients commonly report a gradual onset usually over several months, of their symptoms
...

a
...
Nonproductive or hacking cough
...
Many patients report a loss of appetite and weight loss
d
...
Inorganic dusts like silica or asbestos
ii
...
Fumes from chlorine and sulfur dioxide
iv
...
Radiation to lung parenchyma
vi
...
Family history should be explored for:
i
...
Lung diseases
iii
...
Physical findings

a
...
Look for widened and rounded tips of the finger and toes (clubbing)

4
...
Chest X-RAY – usually ordered for adults with cough and progressive shortness of
breath
...

Other changes include interstitial infiltrates, nodules and cystic changes called
“honeycombing”

d
...
Characteristics which confirm IPF include peripheral, bibasilar reticular
opacities, opacities with architectural distortion, traction bronchiectasis and
honeycombing
...

e
...
In patients with
IPF, studies typically show a restrictive ventilatory defect
...
The diffusing capacity of lung
for carbon dioxide is commonly reduced
...

f
...
When the
disease is severe, there is retention of carbon dioxide
...
Routine lab findings are not helpful
i
...

ii
...
PPD test should be done
iv
...
Lung tissue biopsy - diagnosis by fiber optic bronchoscopy with transbronchial biopsy
of the lunch parenchyma is safe and should be done first
...
Bronchoalveolar lavage (BAL) should be done to assess for inflammation and

to obtain secretions for culture such as acid-fast bacillus, fungi and Nocardia
(Nocardiosis is a disease caused by bacteria found in soil and water
...
It is most common in people with weakened immune systems
who have difficulty fighting off infections (for example, people with cancer or those
taking certain medications such as steroids)
...
Biopsies obtained during a BAL may be inadequate for diagnosis and are
subject to sampling error; patients who are clinically stable should undergo
open lung biopsy by thorascopic technique
...
Preoperative PFTs must be done

C
...
Treatment

a
...
Used for acute exacerbations although scientific evidence/support for
benefit is lacking
ii
...
Far fewer demonstrate objective improvement on x-ray or on PFTs
iv
...
Alternative treatments that may be considered in select patients include
cyclophosphamide (Cytoxan) 1 mg/kg/day or azathioprine (Imuran) 3 mg/kg/day
although data to support immunosuppressive therapy in this setting is limited
...


c
...
This drug was originally developed as an anti-tumor
agent before it was noted to be effective against fibroblasts
d
...
This drug has anti-inflammatory and antifibrotic
effects
e
...


Lung transplantation remains the ultimate therapy in those with advanced IPF
...
Prognosis for IPF patients is often poor due to the continued progression of the disease
...
Pulmonary rehabilitation has been associated with improvement in six-minute walk
and quality of life
b
...
6, 38
...
4 months respectively

5

1
...
PH has
several etiologies and can be a progressive and fatal disease if not diagnosed and treated
...
2 to 5
...

A
...
Vasoconstriction due to hypoxemia and acidosis
b
...
Occlusion of the pulmonary vasculature (due to pulmonary embolism)
d
...
Increased Pulmonary Venous Pressure
a
...
Valvular heart disease (mitral valve stenosis and aortic valve stenosis
c
...
Increased Pulmonary Blood Flow (left to right shunt)
D
...
Idiopathic Pulmonary Arterial Hypertension - Seen most often in young women

2
...

PH is most often due to left heart disease (Group II) or parenchymal lung disease (Group III)
...

A
...
Group I: Pulmonary Arterial Hypertension

i
...
Drugs and toxins: Amphetamines and methamphetamines, cocaine, phentermine
iii
...
Associated pulmonary arterial hypertension: collagen vascular disease
(scleroderma), congenital shunts between systemic and pulmonary circulation,
portal hypertension, HIV infection, or other disease or disorders
v
...
Schistosomiasis – PH can develop in patients infected with schistosomiasis
species, particularly if they have hepatosplenic involvement

2
...

This group has elevated pulmonary pressures due to a high left atrial pressure (mean >14
mmHg) resulting in pulmonary venous hypertension (post capillary PH)
...
Left ventricular systolic or diastolic dysfunction
ii
...
Constrictive pericarditis
iv
...
Group III: Pulmonary Hypertension Associated With Lung Diseases Or Hypoxemia
i
...
Sleep disordered breathing, alveolar hypoventilation
iii
...
Developmental lung abnormalities
4
...
PE in the proximal or distal pulmonary arteries
ii
...
Group V: Miscellaneous, Hematologic, and Systemic Disorders
i
...
Sarcoidosis
iii
...
OTHER: PH can also be classified as Pre- or Post- capillary PH

i
...

Patients with a mean pulmonary artery wedge or occlusive pressure (mPAWP or
mPAOP) less than or equal to 15 mm Hg fall into this category
...


Post capillary PH is due to elevations of pressure in the venous and pulmonary
capillary systems (pulmonary venous hypertension)
...
You will see patients with mixed pre- and post- capillary features
...
Describe the signs and symptoms related to pulmonary hypertension - Clinical presentation
1
...
Exercise intolerance
3
...
Those related to the underlying cause of pulmonary hypertension
5
...
LE edema
7
...
Hoarseness due to impingement on the laryngeal nerve by the enlarging pulmonary
artery
9
...
Syncope
11
...
Describe the subjective/physical examination findings
...
Obtain a full PMH for associated conditions to include CHF, OSA, connective
tissue diseases, and venous thromboembolism
...
Look for skin
changes from scleroderma, stigmata of liver disease, clubbing (congenital heart disease) and
abnormal breath sounds (parenchymal lung disease)
...
Labored respirations and DOE
2
...
Peripheral edema related to right ventricular (RV) failure
...
Right sided failure is called cor pulmonale
...
Ascites, distended neck veins
5
...
Loud pulmonic valve
5
...

The purpose of diagnostic testing is to confirm your clinical suspicion of PH, to determine the
etiology, to gauge the severity of your patient’s condition to guide your treatment
...
Lab: CBC will show an increase in hemoglobin and hematocrit if hypoxemia is present,
ABG: elevated arterial partial pressure of carbon dioxide (PaCO2) is an important clue for
a hypoventilation syndrome
2
...
Other possible findings from comorbid diseases include interstitial
infiltrates (interstitial lung disease), hyper inflated lungs (COPD, emphysema)
3
...
Two-dimensional echocardiogram is usually used to diagnose pulmonary
hypertension
...
It will be done with a saline injection to
assess for a shunt
...

ii
...
Elevated mean pulmonary
artery pressure with normal pulmonary capillary wedge pressure, elevated
pulmonary artery systolic pressure and tricuspid regurgitation velocity
4
...
Six-minute walk test - a test of functional capacity
...
It is
rare for a patient to be diagnosed while still a class I
...
More often this
classification is used to describe patients that have demonstrated a substantial response to

therapy that were once a Class II or III but have improved to a Class I
...

■

WHO Class III: May not have symptoms at rest but activities greatly limited by shortness of

breath, fatigue, or near fainting
...


■

WHO Class IV: Symptoms at rest and severe symptoms with any activity
...
Most patients in this class
are also volume overloaded with edema in their feet and ankles from right heart failure
6
...
Cardiac MRI – investigate for cardiac anomalies that have be the cause of PH especially if a
transesophageal echocardiogram is contraindicated
8
...

Measurements of pulmonary pressures are obtained to determine elevations and help in
diagnosis
...
Other tests may be considered to rule out thromboembolic disorders
■

Lower extremity Doppler

■

Ventilation/perfusion scan- critical for excluding thromboembolic disease but could also
be abnormal in pulmonary veno-occlusive disease and fibrosing mediastinitis

■

Computed tomography (CT): confirms suspicious of thromboembolic disease, estimates
lung parenchyma and mediastinum
...
Discuss pharmacological and non-pharmacological patient management of pulmonary
hypertension
...
Management depends on the specific category
A
...
COPD

b
...
Obstructive Sleep apnea
B
...
Consider anticoagulation due to increased risk for intrapulmonary thrombosis and
thromboembolism
...
Warfarin is dosed to achieve an INR of 1
...
5
...
If polycythemia is severe, (hematocrit > 60%) therapeutic phlebotomy should be considered
to yield a hematocrit of approximately 55%
...
Pharmacological therapy
...

a
...

i
...
Should not be used
empirically in the absence of demonstrated acute vasoreactivity
...
Nifedipine 90-240 mg PO daily
iii
...
Prostacyclins
i
...
Initiated in controlled setting, usually in the hospital
2
...
Treprostinil (Remodulin, Tyvasc)
1
...
Injection: 1
...
If the dose cannot be tolerated, decrease the dose to
...
Oral: 3 breaths (18 mcg) via oral inhalation per treatment session
QID during waking hours approximately 4 hours apart
...
Iloprost (Ventavis)
a
...
5 mcg inhaled
...


c
...
Block the binding of endothelin-1 to its receptors on
pulmonary artery smooth muscle cells which would typically cause vasoconstriction
and cellular hypertrophy/growth
...
Ambrisentan (Letairis)
1
...
Dose is 5 mg daily, may increase to 10 mg daily
ii
...
Must enroll in Tracleer access program
2
...
5 mg PO BID for 4 weeks
3
...
Consider referral for transplantation
G
...
Discuss implications of pulmonary hypertension for the geriatric population

A
...
It is very unlikely it is pulmonary artery hypertension; more likely to be pulmonary venous
hypertension due to left ventricular systolic or diastolic failure, aortic or mitral valve disease
or left atrial non-compliance

a
...


a
...
It may be caused by blunt trauma, mechanical ventilation, central venous access devices, rib
fracture and bleb rupture
b
...
If the amount that collects is more
than 1500 cc it is considered massive
...
Open pneumothorax is also known as a “sucking chest wound”
■

Air flows from atmosphere to the pleural space and back again

■

It can lead to a tension pneumothorax if covered with an occlusive dressing or if the skin flap does not
allow air to escape
...
Tension pneumothorax
■

Collapse of the lung caused by a one-way entrance of air flow into the pleural space
...
Spontaneous pneumothorax
■

A primary spontaneous pneumothorax occurs without a precipitating event in a person who does not
have known lung disease
...
A
secondary spontaneous pneumothorax results from underlying parenchymal lung disease including
COPD (Chronic Obstructive Pulmonary Disease) and emphysema, interstitial lung disease, necrotizing
lung infections and cystic fibrosis
...
The difference between the rates in men and women is
unknown
...


Iatrogenic pneumothorax occurs after thoracentesis, central line placement, trans bronchial biopsy,
thoracic needle biopsy and barotrauma from mechanical ventilation

b
...
Describe the subjective and physical exam findings of a patient with a pneumothorax
...
If
the patient reports a history of recent chest trauma or medical procedure, this can assist you in your diagnosis
and the presence of pneumothorax should be explored
...
Symptoms
do not always predict the size of the pneumothorax
a
...
Respiratory distress, hypoxia and tachypnea are likely to be seen in patients with a large
pneumothorax in a patient with underlying lung diseases
ii
...
Decreased level of consciousness (LOC) if hypoxemia is extreme
iv
...
Cyanosis
vi
...
Shallow respirations
viii
...
Decreased or absent breath sounds on the affected side
x
...
A tension pneumothorax may cause severe respiratory distress leading to circulatory collapse due
to decreased cardiac output and decreased blood pressure
xii
...
Subcutaneous emphysema may be felt if the pneumothorax is the result of a penetrating trauma
or pneumomediastinum

d
...
ABG (Arterial blood gas) may reveal respiratory acidosis
b
...
You will see a separation of the pleural shadow from the chest wall
...
As patients exhale
and lung volume decreases, lungs recoil and the pleural space fills with air from the pneumothorax
...


Remember, a tension pneumothorax may show a mediastinal and tracheal shift toward the contralateral
side and depression of the ipsilateral diaphragm
...
An EKG may show heart strain
...
There may be
diminished QRS amplitude and an anterior axis shift
...


d
...
Thoracic ultrasound has
more sensitivity than a supine chest radiograph
...
This will be helpful in critical ICU patients
...

Normal findings would include the presence of the “sliding sign” which demonstrates movement of the
visceral and parietal pleural moving against each other during inspiration
...
The absence of lung sliding indicates the
possibility of pneumothorax, as there are other causes for its absence
...
Another normal finding is “comet tails,” or a ray-like opacity produced by the air-filled parenchyma below
the pleura
...
In pneumothorax, this sliding is absent and so are the

comet tail artifacts from the pleura
...


f
...
It may also be useful in differentiating a pneumothorax
from bullous lung disease
...
Discuss patient management of a pneumothorax
...
A small primary spontaneous pneumothorax smaller than 15% to 20% requires only observation and
serial chest x-rays to confirm that it is not getting larger
...

b
...
The
needle should be inserted over the TOP of the 3rd rib as there are blood vessels and nerves running under
each rib that will cause excessive pain to the patient if inserted in that region

An obese person or a patient with a large amount of breast tissue may not have complete resolution with
a standard catheter due to inability to reach the area
...
Chest tube insertion to low wall suction (- 20 cm) for a pneumothorax or hemothorax is appropriate
d
...
These
individuals have underlying pulmonary pathology that alters normal lung structure
...

If a patient develops a secondary pneumothorax with a large defect while a chest tube is in place, consult
a pulmonologist as a procedure called ‘Pleurodesis’ (“pleural sclerosis”) may be indicated
...

e
...


Treatment for open pneumothorax includes application of a three-sided dressing leaving one side
unsecured to allow air to escape

g
...
Consider auto transfusion
...
Definition of Pulmonary Embolism (PE)

The clinical presentation of PE is variable and often nonspecific making the diagnosis challenging
...

■

The term PE refers to on obstruction of the pulmonary artery or one of its branches by material (e
...
, thrombus,
tumor, air, or fat) that originated elsewhere in the body
...
g
...
It becomes lodged in the
pulmonary arterial circulation causing a cessation or obstruction of blood flow
...
Classification of PE

PEs can be classified by the time-based pattern (Acute, Subacute, or Chronic), by the presence or absence of
hemodynamic stability (hemodynamically unstable or stable PE), the anatomic location (Saddle, Lobar, Segmental,

Subsegmental), and the presence or absence of symptoms
...
TIME-BASED CLASSIFICATION:



Acute PE = this is a form of venous thromboembolism (VTE) that is common and sometimes fatal
...



Subacute PE = Some patients with PE may also present subacutely within days or weeks following the

initial event
...
e
...


2
...
Hemodynamically Unstable PE = also called "massive" or "high-risk" PE



A hemodynamically unstable PE is one that results in hypotension defined as SBP < 90 mmHg or a
drop in SBP of > 40 mmHg from baseline for a period > 15 minutes OR hypotension that requires

vasopressors or inotropic support and the change in BP cannot be explained by sepsis, arrhythmia,
left ventricular dysfunction from MI, infarction, or hypovolemia
...


Rev 11/21

“Massive” PE - is defined as obstruction of the pulmonary arterial tree that exceeds 50% of the crosssectional area, causing acute and severe cardiopulmonary failure from right ventricular overload
...
Thus, the term "massive" PE does not
necessarily describe the size of the PE as much as its hemodynamic effect
...
Hemodynamically Stable PE = defined as PE that does not meet the definition of hemodynamically
unstable PE
...
The key difference
with low-risk and submassive/intermediate-risk PEs is they are hemodynamically stable (yes, they may be
hypotensive but it resolves with IVF [aka fluid responsive] or RV dysfunction yet vitals are still stable
...
ANATOMIC LOCATION



Saddle PE = lodges at the bifurcation of the main pulmonary artery, often extending into the right and left

main pulmonary arteries
...



Most PE move beyond the bifurcation of the main pulmonary artery to lodge distally in the main lobar,
segmental, or subsegmental branches of a pulmonary artery
...


o

PE can be bilateral or unilateral, depending on whether they obstruct arteries in the right, left, or
both lungs
...
PRESENCE OR ABSENCE OF SYMPTOMS



Symptomatic - refers to the presence of symptoms that usually leads to the radiologic confirmation of
PE



Asymptomatic - refers to the incidental finding of PE on imaging (e
...
, contrast-enhanced computed
tomography performed for another reason) in a patient without symptoms
Rev 11/21

Accurate diagnosis is the key to reducing overall mortality - The distinction between stable and unstable PE is
important to determine risk of death
...

Death typically occurs due to right ventricular failure

C
...
The Wells Score is the
preferred system per UpToDate (2021)
...
The Wells Criteria be applied, and the score calculated to determine the probability of PE into a three-tiered
system of:

■

o

Low (score <2) *See PERC Rule below

o

Intermediate (score 2 to 6)

o

High (score >6)

Subsequent testing is dependent upon the likelihood of PE (Labs, CT Angiography, alternative imaging)

Despite validation of the Wells criteria, for unclear reasons, clinicians do not use them or use them incorrectly in
up to 80 percent of patients

In addition, they may not be as accurate in older or critically ill patients
Wells criteria have been best validated in outpatients presenting with suspected PE
...

Rev 11/21

Wells Criteria includes the following:

■

Clinical symptoms of deep vein thrombosis (DVT) (3 points)

■

Other diagnoses are less likely than PE (3 points)

■

Heart rate >100 (1
...
5 points)

■

Previous DVT/PE (1
...
PERC RULE: The PERC rule was designed to identify patients with a low clinical probability of PE in whom the
risk of unnecessary testing outweighs the risk of PE and can be used to determine whether diagnostic
evaluation with D-dimer is indicated
...
libux
...
edu/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acutepulmonary-embolism?search=pulmonary%20embolism&topicRef=8253&source=see_link#H11827084

Some clinicians and hospitals measure D-dimer in ALL low-risk patients
...


Rev 11/21

3
...
Describe the Etiology/Incidence/Predisposing Factors of Pulmonary Embolism
Estimates of the incidence of PE in the general population have increased following the introduction of D-dimer
testing and the use of CT scans with pulmonary angiography
...

a
...
Fat embolism, orthopedic trauma especially through marrow containing bone
ii
...
Tumor fragments
iv
...
Septic debris from indwelling venous devices

E
...

The most common presenting symptom is dyspnea followed by chest pain (classically pleuritic but often dull) and

cough
...
Thus, it is critical that a high level of suspicion be maintained such that clinically relevant cases are
not missed
...
Dyspnea at rest or with exertion (73%); can be insidious or acute onset
...
More likely present when PE is in the main or lobar vessels
...

May be LESS frequent in the elderly who have no prior history of cardiopulmonary disease
...
Tachypnea (54%)
c
...
Pleuritic pain (66%) – often a result of inflammation of the pleura due to pulmonary infarction
e
...


Orthopnea (28%)

g
...
Wheezing (21%)
i
...


Arrhythmias (i
...
, Afib)

k
...


Hemodynamic collapse
Rev 11/21

m
...
Apprehension, anxiety, and perception of “impending doom”

F
...

Both subjective and objective findings depend on the degree of clot burden
...
Tachycardia
B
...
Initially elevated BP
D
...
Chest pain, dull, central, and pleuritic with pulmonary infarction
F
...
Cardiovascular compromise with hypotension and shock
...
Pulmonary vascular resistance is increased thus impeding right ventricular
outflow and diminishing flow from the right side of the heart
...
Signs of right ventricular overload
a
...
Increased intensity of the second heart sound
I
...


Signs of fat embolization
a
...
Altered consciousness
c
...
Petechiae over the thorax, shoulder, and axillae

G
...
Arterial Blood Gas Analysis – impaired gas exchange from PE is due to mechanical and functional obstruction
of the vascular bed altering the ventilation to perfusion ratio and also due to inflammation resulting in
surfactant dysfunction and atelectasis resulting in intrapulmonary shunting
a
...
Variable degrees of hypoxemia
B
...

Rev 11/21

D-dimer testing is best used in conjunction with clinical probability assessment
A positive D dimer indicates the need for further testing to determine the presence of other causes or the
location of the clot
...


C
...
Nonspecific changes
b
...
Chest X-ray would likely be normal or with small infiltrates and/or effusion
E
...
PE protocol chest CT requires IV administration of iodinated contrast
b
...
Used according to standardized protocols in conjunction with expert interpretation, this test has good
accuracy for detection of large (proximal) PEs, but it has a lower sensitivity for detecting small (distal)
emboli

Rev 11/21

d
...
Ventilation perfusion scan
a
...
VQ scans are most useful in a patient with a normal chest x-ray
c
...
If read as high probability for PE, treat with anticoagulation
e
...
If CXR is abnormal or if COPD is present, lung scanning may lead to an erroneous interpretation
...
Pulmonary angiography remains the Gold Standard for diagnosis of PE
...


Rev 11/21

This Photo by Unknown Author is licensed under CC BY-SA

a
...
Lobar - Most PEs move beyond this bifurcation and lodge distally in the main lobar, segmental and
sub segmental branches of the PA
...
PE can be bilateral or unilateral
...
Smaller thrombi that end up in the peripheral segmental or sub segmental branches are more likely
to cause pulmonary infarction and pleuritic

I
...


Some authorities believe that spiral cut, high resolution CT scan of the chest will reliably show central PE

H
...

When a patient presents with suspected acute pulmonary embolism, initial resuscitative therapy should focus
upon oxygenating and stabilizing the patient
...
Then begin the mainstay of therapy which is anticoagulation
...
Patients should be routinely reevaluated for anticoagulation needs and adverse reactions if receiving anticoagulation
...
These agents have FBA labeling for treatment of PE
a
...
5 mg SQ once daily for patients < 50 kg
ii
...
5 mg SQ once daily for patients 50-100 kg
iii
...
Argatroban
Rev 11/21

i
...
5 – 3 times baseline
c
...
Anticoagulation For Venous Thromboembolism

a
...
Weight based dosing includes an initial bolus of 80 units/kg followed by a continuous infusion
of 18 units/kg
ii
...
5 times control
iii
...
Low molecular weight heparin (enoxaparin/Lovenox) 1 mg/kg SQ every 12 hours
...

i
...
No extensive monitoring is needed
c
...
Begin at the time of diagnosis of PE, the first dose is 5-10 mg PO

ii
...
Monitor the international normalized ratio (INR) after initial daily doses of Coumadin
...
5 for at least 2-3 days
iv
...
For recurrent episodes, treat
longer for 6-12 months
...
Rivaroxaban (Xarelto) 15 mg PO BID with food for 21 days followed by 20 mg once daily with food
i
...
Approved in patients with DVT/PE
iii
...
Must be renally dosed
v
...
Fibrinolytic treatment: note contraindications before using this therapy
i
...
Recombinant tissue plasminogen activator (Alteplase) 100 mg as a continuous infusion over
2 hours

Rev 11/21

iii
...
Once fibrinolytic therapy is completed, begin heparin or enoxaparin when the PTT is less than
2 times control
f
...
Surgical embolectomy is reserved for those patients with massive emboli in the central pulmonary
arteries and the clot is causing hypotension and shock
h
...


Supplemental oxygen is indicated to keep oxygen saturation above 90%

j
...
If left untreated the mortality rate is
approximately 30%
...


Discuss Pulmonary Vasculitis Types and Treatments

A
...
Necrotizing granulomas of the respiratory tract, both upper and lower, pulmonary micro angiitis and
glomerulonephritis
b
...
Hemoptysis
ii
...
Cough
iv
...
Antineutrophilic cytoplasmic antibodies (ANCA) are often positive (ANCA is used to detect and diagnose
certain forms of autoimmune vasculitis)
d
...
Treatment has two components
i
...
Maintenance immunosuppressive therapy for a period of time to prevent remission
f
...
Treatment can include glucocorticoids in combination with methotrexate,
cyclophosphamide,
2
...
or rituximab
4
...
Induction therapy – Experts vary in opinions whether to begin with pulse methylprednisolone (7-15
mg/kg to a maximum dose of 500-1000 mg/day for 3 days) in all patients or only in those with necrotizing
or crescentic glomerulonephritis or more severe respiratory disease
i
...
Oral cyclophosphamide 1
...
IV Cyclophosphamide 0
...
Rituximab 375 mg/m2 per week for 4 weeks
v
...
Maintenance therapy

i
...
3 mg/kg per week
...
If tolerated the doses can increase
by 2
...

ii
...
Lymphomatoid granulomatosis - rare disorder characterized by overproduction (proliferation) of white blood
cells (lymphocytes)
...

a
...
Lung
ii
...
Skin (especially)
iv
...
Kidneys (rarely)
b
...
In general, treatment follows those for diffuse large B cell lymphomas
d
...




Gallstones may stay in the gallbladder of be excreted into the cystic duct along with the bile
...




Inflammation of the gallbladder or cystic duct is called cholecystitis

CHOLELITHIASIS (GALLSTONES)

I
...
Pathophysiology


pg
...


■

Crystals then aggregate on the microstones, which grow to form ‘macrostones’

■

Process usually occurs in gallbladder, which may have decreased motility and biliary stasis
...


■

The stones can accumulate and fill the entire gallbladder
...

■

Associated with biliary stasis, bacterial infections and biliary parasites

■

More common in East Asia

3) Pigmented black stones: Rare; usually form in gallbladder



■

Associated with chronic liver disease and hemolytic disease

■

Composed of calcium bilirubinate with mucin glycoproteins

It is NOT known why the hepatocytes (liver cells) secrete bile that is supersaturated with cholesterol
...
Clinical Manifestations


Differential diagnosis would also include acute gastritis



Diagnosis is made through a combination of history, physical examination and laboratory and radiologic studies



Often asymptomatic



Cardinal Manifestations of cholelithiasis

pg
...

o


Provider cannot depend solely on Murphy’s sign

Biliary colic – pain that occurs 30 minutes to several hours after eating a fatty meal; and is caused by the lodging

of one or more gallstones in the cystic or common bile duct with obstruction and distention



o

Pain can be intermittent or steady; reaches a peak then completely abates over time

o

Usually located in the RUQ and radiates to mid upper back

o

Jaundice indicates that the stone is lodged in common bile duct

o

Abdominal tenderness and fever indicate cholecystitis

Complications include:
o

Pancreatitis from obstruction of pancreatic duct

IV
...
3

Oral bile salts may dissolve cholesterol stones, but they can recur when medication is discontinued

o

Morphine: The administration of Morphine during acute cholecystitis can lead to spasm of the sphincter

of Oddi and exacerbate pain symptoms
...

o

Surgery:
o

Laparoscopic cholecystectomy is PREFERRED treated for gallstones that cause obstruction and
inflammation

o

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy with stone retrieval- used
for treatment of bile duct stones
...


CHOLECYSTITIS



Can be acute or chronic



Both forms are exclusively caused by lodging of gallstones within the cystic duct



Obstruction causes the gallbladder to become distended and inflamed



Pain is like that caused by gallstones



Pressure against the distended wall of the gallbladder decreases blood flow and can result in ischemia, necrosis,
and perforation of the gallbladder



Obstruction may lead to reflux into the pancreatic duct, causing pancreatitis

Essentials of Diagnosis for ACUTE cholecystitis: Fever, leukocytosis, rebound tenderness, and right upper quadrant or

epigastrium; abdominal muscle guarding are common findings


Labs: WBC elevation (12,000-15,000/mcl) Serum bilirubin (1-4 mg/dL), aminotransferase (up to 300 units/mL) and
alkaline phosphatase levels may be elevated



U/S Right upper quadrant:


U/S findings suggestive of acute cholecystitis include:




Gallbladder wall thickening, pericholecystic fluid and a sonographic Murphy sign
...
4

CT abdomen: may show complications of acute cholecystitis, such as perforation or gangrene
...
Surgical
treatment for chronic cholecystitis is the same as for acute
...
2% with surgery except for older patients in which it is higher
...
5



Abdominal trauma



Hyperlipidemia



Smoking



Certain medications



Genetic factors (hereditary pancreatitis and cystic fibrosis)



Cause unknown in 15-25% of cases



May be acute or chronic

ACUTE PANCREATITIS

Read: Friedman, L
...
(20210
...
In Papadakis & McPhee CURRENT: Medical
diagnosis & treatment
...
New York, NY: McGraw-Hill (Supplemental Materials > Online Textbooks)


Usually, a mild disease and resolves spontaneously



Approx
...
e
...
e
...
6

o

Chronic alcohol use may also cause formation of protein plugs in pancreatic ducts and spasm of the
sphincter of Oddi, resulting in obstruction

o

The obstruction leads to intrapancreatic release of activated enzymes, auto digestion, inflammation, and
pancreatitis
...


Clinical Manifestations:



Epigastric or mid-abdominal constant pain ranging from mild abdominal discomfort to severe, incapacitating pain
– MAIN MANIFESTATION



Pain may radiate to the back due to the retroperitoneal location of the pancreas



Pain is caused by:

pg
...
e
...




Both Grey-Turner’s and Cullen’s signs are not specific but are associated with severe acute pancreatitis and a high
mortality
...




Nausea, vomiting, sweating and weakness



Abdominal tenderness and distention



Fever



Leukocytosis, elevated serum amylase and elevated serum lipase
...
8

THE UNIVERSITY OF TEXAS MEDICAL BRANCH
SCHOOL OF NURSING MASTERS PROGRAM
GNRS 5624 ACNP CONCEPTS AND PRACTICUM II: ADULT
o

Xray's of abdomen- may show gallstones or a ‘sentinel loop’ -a segment of air-filled small intestine most
commonly in the LUQ; also, may show the ‘colon cut-off sign’- a gas filled segment of transverse colon
abruptly ending in the area of the pancreatic inflammation

o

Ultrasound: good screening test and for detection of gallstones, but not usually helpful in pancreatitis due
to overlying bowel gas

o

Endoscopic ultrasound: provides more detailed imaging of pancreas

o

Contrast enhanced CT/MRI- only if diagnosis is uncertain

o

Endoscopic Retrograde Cholangiopancreatography (ERCP)- used in patients with severe pancreatitis with
suspected gallstones or worsening clinical examination
■

Not routinely used in acute pancreatitis

o

Elevated serum amylase – characteristic but NOT diagnostic of severity or specificity of disease

o

Elevated serum lipase – PRIMARY DIAGNOSTIC MARKER – more specific than amylase to the pancreas
...
9NS or LR at 1/3 of the total 72-hour fluid volume administration within the first
24 hours of presentation (I
...
, 250-500cc/hr
...


o

Supportive medical care: NSAIDs, acetaminophen

o

May resume oral intake of fluid and food when patient is free of pain and has active bowel sounds
...
Low fat diet preferred
...
9

SEVERE DISEASE: includes necrotizing pancreatitis; risk factors include younger age, alcohol etiology, higher hematocrit,

higher serum glucose and Systemic Inflammatory Response syndrome in the first 48 hours of admission
...


o

Nasogastric suction –bowel rest for several days until pain is reduced and BS return
o

If tolerated: Enteral nutrition with use of jejunal tube feeding may be tolerated and may decrease pancreatic
enzyme secretion, prevent bacterial gut overgrowth, and maintain gut barrier function OR

o
o

o

Parenteral hyper alimentation with lipids – use ONLY if enteral feeding is not tolerated

Surgical therapy:
o

ERCP within 24 hours IF concurrent acute cholangitis present

o

Gallstones may require surgical intervention

o

Resection of necrotic tissue for abscess or necrotizing pancreatitis (can be sterile or infected)

o

Sphincteroplasty with stone extraction -if sphincter dysfunction found or stone in common bile duct

In severe acute pancreatitis- H2 receptor antagonists: decrease gastric acid (hydrochloric acid) production and
can decrease stimulation of pancreas by secretin

o

Antibiotics – in infections only! Imipenem 500mg q 8 hours IV is used due to its achieving bactericidal levels in
pancreatic tissue for most causative organisms
...


Consultation:


GI should evaluate all cases of pancreatitis



Surgical consultation for severe acute pancreatitis related to gallstones or necrotizing pancreatitis



Social Work if alcoholism is suspected
...


pg
...
S
...
Liver, Biliary Tract & Pancreas Disorders
...
Pp 754-757
...
25% of cases



Toxic metabolites and chronic release of inflammatory cytokines contribute to the destruction of acinar cells and
islets of Langerhans, fibrosis, strictures, calcification, ductal obstruction, ischemia, and pancreatic cysts



Pancreatic pseudocysts development - walled-off areas or pockets of pancreatic juice, necrotic debris, or blood
within or adjacent to the pancreas
o



May appear up to 1 month post pancreatitis

Mnemonic for predisposing factors: TIGAR-O



Toxic - metabolic



Idiopathic



Genetic



Autoimmune



Recurrent and severe acute pancreatitis



Obstructive

Symptoms:


Pain (chronic/intermittent epigastric pain) is CLASSIC symptom of all forms of chronic pancreatitis and is due
to intraductal pressure, increased tissue pressure, ischemia, neuritis, ongoing injury and changes in central
pain perception

pg
...


Labs/Diagnostics:


Amylase and lipase may be elevated; however normal values do not exclude diagnosis



Alkaline phosphatase and bilirubin may be elevated- due to compression of bile duct



Glycosuria- may be present



Excess fecal fat – need stool analysis



Abdominal Xray's: may show calcifications due to pancreaticolithiasis in 30% of patients



CT pancreas: may show ductal dilatation, heterogeneity, or atrophy of pancreatic gland



ERCP: MOST SENSITIVE imaging study for chronic pancreatitis; shows dilated ducts, intraductal stones, strictures,

and pseudocysts


MRCP and EUS: less invasive alternatives to ERCP

Complications:


Opioid addiction- common



Diabetes mellitus – brittle control



Pancreatic pseudocyst or abscess



Cholestatic liver enzymes with or without jaundice



Malnutrition



Bile duct stricture



Exocrine pancreatic insufficiency



Osteoporosis



Peptic ulcer



Pancreatic cancer – may relate to tobacco and alcohol abuse

pg
...




Endoscopic therapy or surgery – indicated to treat underlying biliary tract disease, drain pseudocysts, eliminate
obstruction of pancreatic duct, etc
...
13

Intrahepatic Biliary Tract Diseases
Disorders include Secondary Biliary Cirrhosis, Primary Biliary Cholangitis (PBC), and Primary Sclerosing
Cholangitis
...


•

Partial obstruction can promote secondary bacterial infection (i
...
, ascendingcholangitis) that can
aggravate inflammatory injury
...

Labs/Diagnostics:

•

The diagnosis of PBC is based on the detection of cholestatic liver chemistries (often an isolated elevation
of alkaline phosphatase) and antimitochondrial antibodies in a titer > 1:40 in serum
...


•

Liver biopsy not necessary unless antimitochondrial antibodies are absent

•

In patients WITHOUT cirrhosis, the degree of elevation of alkaline phosphatase is strongly related to the
severity of ductopenia (a reduction in the number of bileducts in the liver) and inflammation
...


DIFFERENTIAL DIAGNOSIS:

•

Chronic biliary tract obstruction (from stones or stricture)

•

Primary sclerosing cholangitis

•

Cholestatic drug toxicity

•

Sarcoidosis

•

Chronic hepatitis (in some cases)Management:

•

Ursodiol (ursodeoxycholic acid) 13-15 mg/kg/day split into 1 – 2 doses ispreferred medical
treatment
...
When to Refer:

•

For Liver Biopsy, is needed

•

For Liver Transplant evaluation

When to Admit:

•

GI bleeding

•

Stage 3-4 hepatic encephalopathy

•

Worsening kidney function

•

Severe hyponatremia

•

Profound hypoxia

Primary Sclerosing Cholangitis (PSC)
Definition/Etiology:

•

Uncommon disease: most common in men aged 20-50 years

•

Often associated with ulcerative colitis (present in approx
...


•

Likely autoimmune-mediated and progressive disorder usually leading tocirrhosis

Labs/Diagnostics:

•

Elevated cholestatic profile: elevated alkaline phosphatase and AST/ALT

•

Cholangiography: either performed by MRI cholangiopancreatography (MRCP)or endoscopic retrograde
cholangiopancreatography (ERCP); PSC changes include multifocal bile duct strictures and segmental
dilations

•

ERCP is Gold Standard for diagnosis PSC
...


•

The only long-term effective treatment for PSC is liver transplantation

•

Episodes of acute bacterial cholangitis may be treated with Ciprofloxacin 750mg bid po or IV
...


•

Fulminant is defined by development of hepatic encephalopathy within 8 weeksafter the onset of liver
failure

•

Sub fulminant hepatic failure occurs when these findings appear between 8weeks and 6 months after
onset of acute liver injury

•

Both carry poor prognosis

•

Acetaminophen (maximum dosage 4 gms/day) and idiosyncratic drug reactions = MOST common causes
...
5)
...


Subjective Complaints:

•

Weakness/fatigue/mental status changes

•

Jaundice/Pruritus- may be absent early in course

•

Anorexia/Weight loss

•

Abdominal discomfort – RUQ or generalized distention from ascites

•

Nausea and vomiting

Patient History:

•

Timing of symptom onset

•

History of alcohol use

•

History of prior episodes of jaundice

•

Medication use

•

Risk factors for intentional drug overdose- history of depression or prior suicideattempts

•

Toxin exposure, including occupational toxin exposures or wild mushroomingestion

•

Risk factors for acute viral hepatitis, including travel to endemic areas, IV druguse, occupational exposure,
sexual exposure, chronic HBV (Hepatitis B virus)infection, immunosuppression

•

Risk factors for hepatic ischemia, including hypotension, cardiac failure,hypercoagulable disorder,
oral contraceptive use, or malignancy

•

Family history of liver disease, such as Wilson disease
...
5), aminotransferase levels (often markedly
elevated), bilirubin level (elevated), CBC/platelet count (low- thrombocytopenic),ammonia level (elevated)
...
Due to coagulopathy, the biopsy is performed via a Trans jugular approach

Prominent bile stasis in bile ducts, bile ductular proliferation with surrounding neutrophils, portal tract
edema of a percutaneous approach
...


•

Liver transplantation has the BEST OUTCOME in fulminant liver disease

A
...
Viral Hepatitis Management:

•

Supportive care for viral hepatitis A and E; no virus specific treatment is available

•

Acute hepatitis B should be treated with one of the hepatitis B antiviral agents

C
...
0 is a reliable indicator for Wilson disease
...
Acute fatty liver of pregnancy/HELLP syndrome

•

Triad of jaundice, coagulopathy, and low platelets along with features of pre-eclampsia (HTN and
proteinuria) are indicators of HELLP
...


•

Can have intrahepatic hemorrhage or hepatic rupture requiring emergentintervention

•

Prompt delivery of baby critical in good outcome
...
ICU Management:

•
•

Cerebral edema and intracranial hypertension (ICP) are critical to monitor

If increased ICP develops, measures to decrease ICU include:

o Hyperventilation
o Hypertonic sodium chloride
o Mannitol
o Barbiturates if other measures fail

•

In cases of grade III or IV encephalopathy, consider:

o Intubation for airway protection
o CT scan of head to evaluate for cerebral edema
o ICP monitoring recommended
...
Model for End-stage Liver Disease (MELD) – prognostic model (disease severity scoring system) that uses a
patient’s labs (serum total bilirubin, INR, and Creatinine) topredict 3-month survival
...
S
...


Chronic Liver Disease

•

Cirrhosis represents a late stage of progressive hepatic fibrosis characterized bydistortion of the hepatocytes
and formation of regenerative nodules

•

Irreversible in late stages

•

In earlier stages, specific treatments are aimed at the underlying cause so as to improve or reverse cirrhosis
...
5 g/dL

2
...
5 g/dL

< 2
...
7

1
...
3

> 2
...
Scoring is interpreted as the following:

•

Score 5-6 = Child-Pugh class A (well compensated disease), 1-to-2-year survivalrate, 100% and 85%
respectively

•

Score 7-9 = Child-Pugh class B (significant functional compromise)
...
Cardiac:
a
...


Arrhythmias

c
...


Activity intolerance

B
...


Jaundice

b
...


Pruritus

C
...


Ascites

b
...


Decreased vascular volume

d
...


Hyponatremia (hemodilution)

f
...


Hypoglycemia

h
...
Gastrointestinal:
a
...


Decreased appetite

c
...


Varices

e
...
Hematologic
a
...


Impaired coagulation

c
...
Immune System:
a
...
Neurologic:
a
...
Respiratory:

I
...


Dyspnea

b
...


Hypoxemia

Renal: (Hepatorenal syndrome); individuals with End stage liver disease (ESLD)may develop:
a
...


Oliguria

c
...


Low urinary sodium levels

e
...
5-5
...


•

Ammonia- elevated (normal, 10-80microg/dL)

MANAGEMENT:
A
...


Administer Lactulose 15-30 mL every 3-4 hours (po or NGT)
...


b
...


Limit protein to lean proteins

d
...
Monitor for hypoglycemia
a
...


Titrate rate dependent on serum glucose levels

c
...
Coagulopathy
a
...


Fresh frozen plasma (FFP) as warranted

D
...


Free water restriction - < 1500mL per day if serum sodium level <125mEq/L

b
...
Hypokalemia: KCL replacement as warranted
F
...
Ascites
a
...


Fluid restriction- < 1500mL/day if serum sodium < 125mEq/L

c
...
Spironolactone 100mg/day divided doses (max 400mg/day)
ii
...
Goal: Reduce weight 1 lb
...

d
...
Administer albumin 6-8 grams IV per liter ascites removed- protectsintravascular volume
ii
...
For paracentesis > 5L – replace albumin to prevent hypovolemiaafter large volume
paracentesis

iv
...


Monitor BUN/serum Cr for elevation- dialysis if warranted
...


Avoid hepatotoxic substances

g
...
Patient History – your admission history should be thorough but concise
...
You should review previous histories of the patient
if available prior to interviewing the patient, not only to be able to proceed in an organized fashion but to make
note of previous medical problems that may impact your differential diagnoses and treatment plan
...
e
...
“I have a pain in my stomach that won’t go away
...
Use “OLD CARTS” or “PQRST + the 3 As
...
If the patient’s symptom/complaint is of long duration, it is important to
inquire why they decided to seek medical attention at this time
...


o

Inquire about related history
...
If
their family member has been treated for the patient’s current CC, this could be pertinent
information for you to obtain
...

Even if the patient denies having any medical problems it is important to still ask about major diseases
individually: HTN, MI, PUD, DM, Cancer, CVA, COPD
...
Also ask
about past hospitalizations and ER visits and the reason for each
...
It is important to also verify how often meds are taken, especially if
it varies from how it is prescribed
...

 Allergies – Main focus is medication allergies, but it is important to note food, tape, seasonal
...

 Immunizations – Influenza, pneumococcal, tetanus are pertinent but be cognizant of age specific
guidelines
...

 Family History (FH) – explore medical problems of blood relatives primarily first-degree relatives
...
Inquire
about smoking, dipping, and vaping
...
All ages should be asked
...
If you feel it is appropriate
and can be safely done without losing the patient’s trust on your first encounter, ask about finances
regarding obtaining food and necessities
...
It will be part of a
social worker or case manager assessment in most hospital settings
 Review of symptoms (ROS) – Obtaining a thorough ROS can be done quickly if you use a “cheat sheet”
until you are comfortable that you will not forget to inquire about an important symptom
...

Intentional loss or unexplained?) Fatigue, weakness, fever, chills, night sweats

o

Skin – rashes, cuts, bruises, moles, warts, including hair and nails in this section

o

HEENT – there are multiple symptoms you can ask about
...
“Eye problems” can include cataracts, glaucoma, and vision impairment
...
Ringing in ears, nosebleeds, sinus problems, cough, hoarseness, throat pain, neck
tenderness
...
Will need to ask these in words the patient
can understand
...


o

Hematology – Anemias, easy bruising?

o

Gastrointestinal – this is a broad category, and you will get many “yes” answers so you will need
to investigate thoroughly
...
What
do their stools look like? If blood is noted, explore …in the toilet, on the tissue? Have you been
told you have hemorrhoids?

o

Genitourinary – Includes urine patterns
...
Any blood? Loss of
urine involuntarily? In what situations? Any kidney failure or abnormal kidney function? Many
patients correlate kidney function with being able to urinate only
...
If appropriate, investigate sexual
history, partners, and history of STDs
...
Limit their ROM or
safe ambulation? History of gout? Muscle aches and pains, which ones?

2
...
Loss of memory, confusion?

o

Psychiatric – Depression, anxiety, mood changes or sudden swings, insomnia, suicidal tendencies

Physical Exam
Performing a complete physical exam smoothly, completely and in a brief period of time takes practice
...
A focused exam is acceptable for a
follow up visit unless the patients have an array of symptoms
...

For example, if you are treating a patient for LE cellulitis, it is not necessary to perform a cranial nerve exam
...
The following systems are
components of a PE (Physical Exam):
o

General appearance – age, gender, race, height, weight
...
If there are multiple tattoos, briefly state
where they are
3

o

HEENT – Examine the head for abnormalities, areas of tenderness, bruising
...
Take your time listening to the rate and rhythm and
extra heart sounds
...


o

Breast- Masses, discharges, tenderness?

o

Abdomen – Note the contour, observe for scars
...
Perform pelvic exam in women if appropriate to CC

o

Rectal – Quick rectal exam can determine presence of hemorrhoids and assess sphincter tone
...


o

MSK – Note and document presence of amputations and prostheses, deformities, swelling,
tenderness, warmth

o

Peripheral Vascular – Note hair pattern or absence of hair, color changes, pulses

o

Neurological – Assess mental status, crania nerves, DTRs

3
...
List them in priority order in your head and think about information you have gathered that will either
support or exclude them
...
Be specific; outline radiologic tests or other studies, medications, and consults
...
Admission orders including specifics as indicated by patient condition
...
Admitting
orders are patterned on the mnemonic: “A
...
C
...
If the patient is postoperative, list the procedure



Condition – Is the patient stable, guarded, critical



Vital signs – Should include frequency and parameters for notification



Activity – i
...
, bedrest, up with assistance, bathroom privileges only
...
Can also include drug intolerances if appropriate



Nursing procedures – tests including preparations needed (enemas, etc
...
Wound care, patient education and specialty requests (“Please document spousal visits
in the EMR”)



Diet ordered



I & O - If required more often than Q shift, be specific and include parameters you wish to be notified
...

Do not short cut on medication reconciliation
...
There may be medications that have been added to the patient’s treatment
that are not well documented in their record
...
Progress Notes Including Presentation During Hospital Rounds
Progress notes should summarize events and occurrences that have occurred, problems that remain active, results
of tests or tests that are outstanding, and discharge plans
...


Components of the Progress Note:


Date/time/service



Subjective data - How does the patient feel today? Document in their words, preferably in quotes



Objective data – General appearance, VS, I & O, PE (it is important to emphasize if there has been a
change in any physical findings); Lab/diagnostic results (if there is a pertinent change it should be noted:
i
...
, WBC ^12,000



Current meds - Indicate days on antibiotic therapy, if applicable (i
...
, Day 6 of Levaquin 500 mg IV Q24H)



Assessment/Diagnosis – evaluation of the data, have any conclusions been drawn?



Plan – write a plan for each problem you are addressing this admission



Discharge plan – May indicate if placement is pending if care manager is involved

Presentations should include


Patient’s name, age, gender, diagnosis, surgeries/procedures that have been done and when



Pertinent data only – what is their current status, what lab results are back, which are abnormal, same with
tests and procedures
...
Procedure Notes
Any invasive procedure should be documented in a procedure note
...
These notes are short with pertinent
information documented under each category
...



Date/time – specific to the procedure performed



Procedure performed – state it as described for billing, with CPT codes



Indications for procedure
...
e
...




Lab tests – did you obtain any tests prior to procedure? Document all labs pertinent to the procedure itself
(i
...
, INR (International Normalized Ratio), BUN (Blood Urea Nitrogen), Creatine)



Description of procedure – Use detail outlining the preparation (clean, sterile), how you positioned the
patient, how you anesthetized or sedated them, devices used (catheters, lines) location of procedure (left
lateral chest), drains, outcome



Complications and estimated blood loss (EBL) – it is ok to say minimal or 10mls or less
...




Disposition – How did the patient tolerate the procedure? What position did you leave them in, supine, HOB
elevated, asleep, awake? Did you speak with family? Be brief unless there is a problem
...
e
...
Describe specimens if they were
obtained
...


7
...

The components of a discharge summary should include all the following:


Date of admission



Date of discharge



Attending MD/ACNP
...
This is the specific reason that the patient was initially admitted to the hospital
...
Or Dizziness
...
Include secondary diagnosis, sometimes they occur after
admission
...
NSTEMI 2
...
Include surgical procedures with dates, procedures the team performed with dates or state
"None"



Brief history – Summarize the patient’s history and what led to the admission
...




Hospital course – Do this in an orderly and organized fashion
...
Include treatments, medicines given including doses and
length especially if antibiotics and patient’s response
...
(“Potassium increased to 5
...
5 when spironolactone was decreased to
25 mg daily
...
If date and time of appt is known, include it
...
This section should also include any dietary restrictions and activity limitations
...
It should include both current and past medical problems
...
That should include primary care
providers and consultants
...
General Guidelines for Patient Admission to an Intensive Care Unit (ICU)
...
However, good
clinical assessment, good medical decision making, and common sense should always guide your decisions
...
This can include patients on experimental protocols utilizing new
therapies with potential or unknown complications
...


9
...
Examples of reasonable situations/conditions that warrant ICU discharge include:
 The patient’s physiological status has improved or stabilized, and ICU monitoring is no longer indicated
 The patient’s physiological status has worsened or deteriorated but active interventions are no longer planned
or aggressive measures will be withdrawn
...
If the patient is at end of
life, this may also be best for family and friends to be around the patient
...
Guidelines for Management of The Electronic Medical Record (EMR)
Customized order sets, progress notes and ordering may exist in the work environment
...
They enable you to keep a current working list that you are responsible for as a primary provider
or consultant
...
Pre-operative Assessments
When you are asked to do a preoperative assessment of a patient, the primary concern or emphasis is placed on
cardiovascular disease
...
Then perform a complete head to toe physical exam regardless of the perceived risk of the procedure
...


Consider the following areas when you evaluate the patient:
a
...
Pay particular attention to the results of the following tests:
o

Urinalysis – an untreated UTI may progress to urosepsis if not noticed

9

o

CBC (Complete Blood Count) – look for signs of infection
...
Is the patient anemic? Is it new or chronic, is it explained in the
history?

o

CXR (Chest x ray) – PA & Lateral
...


o

PFTs - not routinely obtained for surgery but if the patient has a history of COPD, heavy smoking history,
or undergoing lung surgery or cardiac bypass, PFTs will help assess the risk for prolonged mechanical
ventilation post operatively and need for pulmonary consult
...
Assessment of surgical risk
...

o Nutritional status- review the patient’s diet history and intake in the hospital and prior to admission
...
If the surgery is extensive and a long
recovery is a possibility, these will be key factors
...
If
the patient is undergoing surgery and has a chronic illness that has caused an unintentional weight loss of
20%, a prolonged recovery and increased mortality is also a possibility
...
Patients with DM and/or renal failure are also at
risk of complications, especially if their chronic disease is not well controlled
o Risk for bleeding – Examine the patients PSH, have they had problems with bleeding in other surgeries?
Has anyone in their family had this problem? Are they on blood thinners or antiplatelet therapy that need
to be addressed prior to surgery? Aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) can also
predispose patients to bleeding/bruising post procedure
...

o Thromboembolic events – Even if the patient does not have a PMH of a thromboembolic event they are at
a higher risk if they have cancer, are obese, are older than 45, use oral contraceptives or have a history of
PVD
...
In all
patients, BP should be < 140/90
...
If the patient is at considerable risk for surgery, it should be postponed unless it is an
10

emergency, and a cardiology consult requested
...
Patients that
continue to smoke and obese patients also pose a higher pulmonary risk
...
If there
is any doubt and the surgery Is elective, err on the side of safety and cancel the procedure
...
Control of Chronic Illnesses
▪

Diabetes Mellitus - tight control of blood sugars during the perioperative period will decrease complications
and mortality
...
It is anticipated that the stress of the procedure and recovery will tip this
group over into higher insulin needs
...
You will need to watch serum glucoses
closely and maintain them below 200 mg/dl



Insulin 0
...
5 units/hr
...
Infuse glucose separately and maintain glucose
below 200 mg/dl



Portland Protocol – ongoing prospective research study that shows surgical patients have less
complications and improved mortality when glucose control is even tighter with levels < 150
mg/dl


o

With any management plan chosen, glucoses should be monitored every 2-4 hours

For patients not requiring insulin, the following is recommended


If the patient is diet controlled only, avoid glucose solutions on the day of surgery
...
, monitor glucose every 4-6 hours and maintain < 200 mg/dl with sub
q insulin

▪

Coronary Artery Disease: continue aspirin unless risk of uncontrolled bleeding is a concern, continue patient’s
beta blockers, calcium channel blockers and nitrates

11

▪

Anemia: Patients have fewer complications if Hgb is at least 8mg/dl
...
Dialysis
patients should be dialyzed the morning of surgery if possible
...
If
not, discuss the need for transfusion
...


▪

Pulmonary Disease: All smoking should cease
...

Bronchodilators should be administered pre anesthesia and intra operatively by IV if the patient has severe
disease

d
...
Medium acting
benzodiazepine may be needed to reduce anxiety and allow sleep the day before surgery
...
Morning of Surgery - the following are points to review as the patient goes to surgery
...


▪

Have pre-operative medications been administered (antibiotics, analgesics, sedatives, or other meds ordered
per anesthesia?

▪

Patient/family education completed on what to expect post operatively? (Tubes, incisions, dressing pain,
nursing care)

f
...
Safe sedation, control of patient anxiety, pain control, minimize the
memory of the operative and peri-operative experience

12
...
Maintenance requirements:
1500-2000 ml/24 hours
...
Potassium should not be added to fluids for the first 24 hours due to intracellular shifts occurring
during this time
...


12

General rule: replace 20 mEq for every liter of fluid lost

o

Pulmonary Care: Deep breathing, cough, Incentive Spirometry every 1-2 hours
...
No dressing needed on dry wounds
...
Most staples can come out
on day 5 or 6 (done in the outpatient setting) if the patient is still in the hospital
...
If more than 50 ml of drainage is anticipated in an 8hour period, a bag is placed
...
All invasive lines should be removed as soon as possible, including Foley, central line, art line, chest
tube

o

DVT (Deep Vein Thrombosis) Prophylaxis: Anticoagulation is indicated by procedure
...
Add anti thromboembolic stockings unless contraindicated, or
sequential boots
...
Increase pulmonary toilet and
assure adequate hydration
...
If they begin to feel “sick” and are not meeting their
expected milestones post operatively (ambulation, pain improvement, appetite) suspect infection
...
Consider empiric antibiotic therapy
...
Is there a persistent
increase in heart rate and decrease in blood pressure? Is there specific and localized pain (e
...
, abdomen), a
change in mental status? Is there a decrease in hemoglobin not explained by the procedure or possible over
hydration with IVF? Some instances of internal bleeding require transfusion or reoperation
...


o

Infection: Locate source, organisms (if possible) and treat according to guidelines

o

Pain: Post-operative pain should be managed aggressively to avoid limitation of movement by the patient
...
Patients with poorly controlled pain
13

release stress hormones that can lead to vasospasm or hypertension
...
The goal of pain
management should also include transitioning the patient successfully from IV forms to PO forms of
medications as soon as safely possible

---