D118 Unit 5 Study Guide

D118 Unit 5 Study Guide

Student Name

Western Governors University 

D118 Adult Primary Care for the Advanced Practice Nurse

Prof. Name

Date

Managing Chronic Pulmonary Disorders and Diseases

What is Asthma and How Does It Present Clinically?

Asthma is a chronic inflammatory disease of the airways characterized by heightened sensitivity to various environmental or internal triggers. This sensitivity leads to episodic and reversible narrowing and inflammation of the bronchial passages. Patients typically experience symptoms such as recurrent coughing, wheezing, chest tightness, and shortness of breath. These symptoms can vary significantly, from mild irritation to severe attacks that can be life-threatening. Early diagnosis and appropriate management are vital to reduce the risk of severe exacerbations and to improve patient quality of life (Global Initiative for Asthma [GINA], 2024).

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

The physical exam in asthma aims to confirm the diagnosis while excluding other conditions, assess the severity of airway obstruction, identify medication-related side effects, and detect comorbid illnesses influencing disease control. Auscultation often reveals wheezing, and prolonged expiratory phases can indicate airway obstruction. Careful examination helps differentiate asthma from other respiratory disorders (GINA, 2024).

How is Asthma Managed Immediately?

In the acute setting, asthma exacerbations are treated with short-acting beta-agonists (SABAs) administered via inhalers or nebulizers. Typically, two doses are given about 20 minutes apart, with 2 to 6 puffs per dose. This approach promptly relieves bronchospasm, decreases airway resistance, and improves airflow, providing symptom relief (GINA, 2024).

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

Spirometry is the cornerstone for diagnosing asthma by demonstrating reversible airway obstruction. A significant improvement in forced expiratory volume in one second (FEV1) of at least 12% and 200 mL after bronchodilator administration confirms the diagnosis. This reversibility helps distinguish asthma from other chronic obstructive lung diseases (American Thoracic Society, 2023).

What Are the Risk Factors for Poor Asthma Outcomes?

Identifying risk factors for poor asthma control at diagnosis and periodically thereafter is essential to guide treatment and prevent complications. Key factors include uncontrolled symptoms, frequent exacerbations, poor adherence or incorrect use of inhaled corticosteroids (ICS), excessive reliance on SABAs, low lung function (FEV1 below 60%), psychosocial challenges, allergen or smoke exposure, previous ICU admissions, comorbidities such as obesity, and biomarkers of allergic inflammation like elevated eosinophils and fractional exhaled nitric oxide (FENO). Pregnancy also increases the risk of poor asthma control.

Table 1: Risk Factors for Poor Asthma Outcomes

Risk Factor	Description/Impact
Uncontrolled symptoms	Heightens the risk of exacerbations
≥1 exacerbation/year	Indicates likelihood of severe future attacks
Poor ICS adherence	Results in suboptimal asthma control
Incorrect inhaler technique	Reduces medication effectiveness
High SABA use (>1 canister/month)	Associated with increased mortality risk
Low baseline FEV1 (<60%)	Reflects severe airway obstruction
Psychological/socioeconomic issues	Increases exacerbation risk
Smoking/allergen exposure	Promotes airway inflammation and hyperresponsiveness
ICU admission history	Marker of severe disease
Comorbidities (e.g., obesity)	Worsen asthma control
Elevated eosinophils and FENO	Indicates allergic airway inflammation
Pregnancy	Raises risk for poor asthma control

What Are the Five Steps for Pharmacologic Management of Asthma?

Asthma management follows a stepwise pharmacologic strategy that adjusts treatment intensity based on symptom control and exacerbation risk. Early initiation of low-dose ICS is critical for preventing lung damage and severe attacks.

Table 2: Stepwise Pharmacologic Treatment of Asthma

Step	Reliever Medication	Preferred Controller Medication	Other Controller Options
1	As-needed SABA	Consider early low-dose ICS	None
2	As-needed SABA	Low-dose ICS	Leukotriene receptor antagonists (LTRA)
3	As-needed SABA or ICS/formoterol	Low-dose ICS + LABA	Medium/high-dose ICS + LTRA or theophylline
4	As-needed SABA or ICS/formoterol	Medium/high-dose ICS + LABA	Tiotropium (≥12 years), high-dose ICS/LABA, slow-release theophylline
5	Specialist consultation	Tailored therapy per specialist	Additional immunomodulators

When Should Patients with Asthma Be Referred or Hospitalized?

Referral to a pulmonology or asthma specialist is warranted for severe cases characterized by frequent hospitalizations, poor symptom control affecting daily activities, multiple emergency visits, resistance to standard therapies, or when advanced diagnostics for allergy assessment and therapeutic adjustments are needed (GINA, 2024).

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Chronic Cough

What Are the Clinical Features and Management of Chronic Cough?

Chronic cough, defined as lasting over eight weeks, often presents with throat clearing and production of thick mucus, especially in the mornings. Physical examination may reveal pharyngeal redness, which suggests sinusitis or allergic causes. Lung auscultation might identify crackles or wheezing, correlating with underlying pulmonary conditions such as edema, fibrosis, asthma, or COPD. Ear canal irritation can also stimulate cough reflexes. Treatment targets the underlying cause and focuses on trigger avoidance. If pulmonary function tests are normal but asthma is suspected, a methacholine challenge test may aid diagnosis (Irwin et al., 2023).

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

When chest imaging is normal, chronic cough commonly results from eosinophilic airway diseases responsive to corticosteroids (e.g., asthma, eosinophilic bronchitis), upper airway cough syndrome due to postnasal drip, and gastroesophageal reflux disease (GERD).

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Chronic Obstructive Pulmonary Disease (COPD)

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

COPD typically manifests with progressive breathlessness, chronic cough, and sputum production. Physical examination in advanced disease may reveal lung hyperinflation, clubbing of nails, finger staining from tobacco, increased chest diameter (barrel chest), use of accessory muscles, a forward-leaning posture, and pursed-lip breathing to improve ventilation efficiency (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2024).

What Are the Management Strategies for COPD?

Management centers on smoking cessation, pulmonary rehabilitation, encouraging regular physical activity, and pharmacotherapy with bronchodilators (beta-agonists, anticholinergics), inhaled corticosteroids, and in select cases, surgical interventions such as lung volume reduction surgery (GOLD, 2024).

What Are the Four Severity Classifications of COPD?

COPD severity is classified by airflow limitation measured by FEV1 percentage predicted:

Table 3: COPD Severity Classification

Stage	Description
GOLD 1	Mild airflow limitation (FEV1 ≥ 80%)
GOLD 2	Moderate airflow limitation (FEV1 50–79%)
GOLD 3	Severe airflow limitation (FEV1 30–49%)
GOLD 4	Very severe airflow limitation (FEV1 <30%)

When Should Patients with COPD Be Referred to the Hospital?

Hospitalization is necessary for patients with severe symptom interference, recurrent exacerbations, oxygen therapy needs, preoperative assessment, refractory exacerbations, persistent infiltrates, sleep disturbances, respiratory failure, or complications such as cor pulmonale (GOLD, 2024).

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Diagnostic Studies for Pulmonary Diseases

Table 4: Common Diagnostic Tests in Pulmonary Medicine

Diagnostic Test	Purpose/Use
Pulmonary Function Tests (PFTs)	Assess airflow limitation and lung volumes
Chest Radiography (X-ray, CT, MRI)	Detect structural abnormalities or masses
Positron Emission Tomography (PET)	Evaluate metabolic activity of lesions
Bronchoscopy	Visualize and biopsy airways
Electrocardiogram (EKG)	Assess cardiac involvement or pulmonary hypertension
Blood Tests (D-dimer, ABG, Alpha-1 antitrypsin)	Diagnose clots, gas exchange, enzyme deficiencies

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Lung Cancer

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 hemoptysis. Physical examination may reveal lymphadenopathy, bone tenderness, hepatomegaly, neurological deficits, or signs of superior vena cava syndrome such as facial swelling and distended neck veins. Malignancy may also increase thrombotic risk causing deep vein thrombosis (Molina et al., 2023).

What Diagnostic Studies Are Used for Lung Cancer?

Diagnosis involves blood tests including tumor markers, imaging such as chest X-ray, CT (the gold standard), PET, MRI, and invasive techniques like bronchoscopy with biopsy. Molecular profiling aids personalized treatment planning (Molina et al., 2023).

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Pneumothorax

What Are the Clinical Features and Management of Pneumothorax?

Pneumothorax presents with sudden breathlessness and unilateral chest pain. Tension pneumothorax can cause respiratory distress, tachycardia, tracheal deviation, and cyanosis, requiring emergency treatment. Management depends on severity, ranging from observation in small pneumothoraces to needle aspiration, chest tube placement, or surgery for larger or recurrent cases (Light, 2024).

Table 5: Types of Pneumothorax and Management

Type	Characteristics	Management
Primary Spontaneous Pneumothorax (PSP)	Occurs without trauma in healthy individuals	Needle aspiration or chest tube
Secondary Spontaneous Pneumothorax	Associated with underlying lung disease	Chest tube, possible surgery
Traumatic Pneumothorax	Due to blunt or penetrating trauma	Tube thoracostomy
Iatrogenic Pneumothorax	Result of medical procedures	Tube placement as needed

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Pulmonary Embolism

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

Pulmonary embolism (PE) often presents acutely with sudden dyspnea, rapid breathing, pleuritic chest pain, leg swelling or pain, hemoptysis, tachycardia, and jugular venous distension. Symptoms may be nonspecific, including syncope or malaise. Physical exam findings vary with embolus size and include respiratory distress and hypoxemia. Management involves stabilization, oxygen therapy to maintain saturation above 92%, and anticoagulation with heparin or direct oral anticoagulants. Severe cases may require thrombolysis or mechanical interventions (Kearon et al., 2023).

What Are the Risk Factors for Pulmonary Embolism?

Risk factors include recent surgery or trauma, immobilization, malignancy, stroke, heart failure, smoking, pregnancy, estrogen therapy, and prior PE history.

How Is Pulmonary Embolism Diagnosed?

Diagnosis involves electrocardiography to exclude cardiac causes, chest X-ray to rule out alternate lung pathology, ventilation-perfusion scanning, and computed tomography angiography (CTA), the diagnostic gold standard (Kearon et al., 2023).

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Sarcoidosis

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

Sarcoidosis is a granulomatous disorder often involving the lungs but can affect multiple organs. Symptoms include fatigue, cough, chest pain, arthritis, skin lesions, and eye inflammation. Auscultation is usually normal but may reveal wheezing in advanced disease. Neurological involvement is rare. Treatment focuses on symptom control, often with corticosteroids for progressive disease. Asymptomatic patients may only need observation and supportive care, including pulmonary rehabilitation (Iannuzzi et al., 2023).

How Is Sarcoidosis Diagnosed and Monitored?

Diagnosis uses high-resolution CT to differentiate inflammation from fibrosis. Lab markers include elevated serum angiotensin-converting enzyme (ACE), hypergammaglobulinemia, and hypercalcemia. Skin testing may show anergy. Ongoing monitoring involves clinical assessments and periodic imaging (Iannuzzi et al., 2023).

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Sleep Disorders

Table 6: Sleep Disorders – Symptoms and Management

Disorder	Symptoms & Signs	Management Options
Insomnia and Non-Restorative Sleep	Difficulty falling/staying asleep	Pharmacotherapy (zolpidem, eszopiclone), sleep hygiene
Sleep-Related Breathing Disorders	Loud snoring, apneas, excessive daytime sleepiness	CPAP, oral appliances, surgery
Central Nervous System Hypersomnias	Excessive daytime sleepiness unrelated to other causes	Stimulants (dextroamphetamine, methylphenidate)
Sleep-Related Movement Disorders	Urge to move legs, worse at rest/night	Lifestyle changes, gabapentin enacarbil, dopamine agonists
Parasomnias	Sleepwalking, night terrors, REM behavior disorder	Environmental changes, benzodiazepines, antidepressants

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Abdominal Aortic Aneurysm (AAA)

Clinical Presentation and Management of AAA

An abdominal aortic aneurysm is a permanent enlargement of the abdominal aorta, typically exceeding 3.0 cm or 50% above normal vessel diameter. Patients may exhibit hypotension, a pulsatile abdominal mass, and abdominal or back pain. Diagnosis relies on physical examination and imaging. Treatment ranges from medical surveillance for small aneurysms to open surgical or endovascular repair (EVAR) for larger or symptomatic aneurysms (Johnston et al., 2024).

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Carotid Artery Disease

Presentation, Examination, and Treatment

Carotid artery disease often presents with transient ischemic attacks or strokes, manifesting as contralateral weakness, sensory loss, or transient vision loss (amaurosis fugax). Auscultation may detect carotid bruits. Treatment includes statins, antihypertensives, antiplatelet therapy, and surgical options such as carotid endarterectomy in severe cases (Goldstein et al., 2024).

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Coronary Artery Disease and Angina

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

Coronary artery disease typically causes chest pain described as pressure or squeezing, sometimes with associated nausea, diaphoresis, or dyspnea. Stable angina management includes aspirin, beta blockers, lipid-lowering agents, and nitrates. Unstable angina requires urgent ECG evaluation and risk stratification to rule out acute coronary syndrome (Amsterdam et al., 2024).

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Heart Failure

Clinical Features and Physical Examination of Heart Failure

Heart failure manifests with dyspnea, fatigue, peripheral edema, pulmonary congestion, and abdominal discomfort. Physical signs include jugular venous distention and leg swelling. Diagnosis involves clinical evaluation combined with imaging and laboratory tests to guide management (Yancy et al., 2023).

Abdominal Fullness, Bloating, and Appetite Loss

These symptoms are common in heart failure and require lifestyle interventions including smoking cessation, salt restriction, alcohol avoidance, and regular exercise. Screening with B-type natriuretic peptide (BNP) and echocardiography is standard for diagnosis. Pharmacologic treatment includes ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists (Yancy et al., 2017).

New York Heart Association Classifications of Heart Failure

Table 7: NYHA Functional Classification

Class	Description
I	No limitation of physical activity; ordinary activity causes no symptoms
II	Slight limitation; comfortable at rest but symptoms with ordinary activity
III	Marked limitation; comfortable at rest but symptoms with less than ordinary activity
IV	Unable to perform any physical activity without discomfort; symptoms at rest

Diagnosis of Congestive Heart Failure (CHF)

CHF diagnosis combines clinical evaluation, imaging such as echocardiography for ventricular function and valve status, and invasive procedures like left heart catheterization if coronary artery disease is suspected. BNP is a sensitive biomarker indicating cardiac stress and heart failure (McMurray et al., 2014).

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Infective Endocarditis and Myocarditis

Infective Endocarditis

Infective endocarditis presents with low-grade fever, chills, weight loss, and new heart murmurs. Other signs include joint pains, petechiae, kidney infections, and Roth spots on the retina. Treatment involves prolonged intravenous antibiotics and sometimes valve surgery (Baddour et al., 2015).

Myocarditis

Symptoms range from fever and atypical chest pain to severe cardiogenic shock. Management includes rest, avoiding stimulants, and heart failure treatment with ACE inhibitors, diuretics, and beta blockers. BNP levels assist in diagnosis (Cooper, 2009).

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Hypertension: Clinical Presentation and Management

Hypertension is often asymptomatic but may cause tinnitus, headaches, or dizziness. Accurate blood pressure measurement involves multiple readings in various positions. Management focuses on lifestyle modification and pharmacologic therapy including 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 defined by severe blood pressure elevation (usually above 180/120 mmHg) accompanied by acute target organ damage such as encephalopathy or pulmonary edema (Whelton et al., 2018).

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Peripheral Arterial Disease (PAD) and Venous Insufficiency

What Are the Clinical Features, Examination Findings, and Treatment Approaches for PAD and Venous Insufficiency?

Patients with PAD frequently report intermittent claudication, ischemic rest pain, leg fatigue, and poor wound healing. Physical examination assesses peripheral pulses, capillary refill, and presence of ulcers or swelling.

Treatment prioritizes lifestyle modifications such as smoking cessation and management of hypertension, diabetes, and hyperlipidemia. Compression stockings help venous insufficiency when ankle-brachial index (ABI) is above 0.8. Pharmacologic therapy includes antiplatelets (aspirin or clopidogrel), statins, and cilostazol to improve walking distance. Surgical interventions like angioplasty or bypass grafting are considered in advanced disease (Gerhard-Herman et al., 2017).