Pulmonary Embolism Discussion Question
Imagine a patient with Pulmonary Embolism comes into your office with your selected condition or disorder. What elements in the patient history and physical exam would indicate the patient has the selected condition or disorder? Select two differential diagnoses that could be applied to this patient. How did you arrive at the two differential diagnoses? Include history and physical examination findings that would support each of the two alternative diagnoses.
Discussion Question Replies
DQ-1
Takotsubo Cardiomyopathy initially appears an an acute life threatening disease process involving the cardiovascular system (Renko, Doyle & Sokoloski, 2019).
Takotsubo cardiomyopathy (TC) is an uncommon condition that mimics a heart attack and occurs after extreme and immense physical or emotional stress (Kalra et al., 2019). It also occurs in women far greater than men, as 89% of Takotsubo diagnoses are female (Kalra et al., 2019). TC also has a consistent finding of occurring mostly in post menopausal women (Renko, Doyle & Sokoloski, 2019). Takotsubo presents on an echocardiogram as left ventricular cardiomyopathy and is reversible (Kalra et al., 2019).
The origination is believed to be cardiotoxic in nature from a sudden surge in catecholamies, excess adrenergic stimulation like pheochromocytoma, intense coronary vasospasm, and some neurological emergencies (Kalra et al., 2019). Recognizable properties of TC is that the left ventricle shows hypokinesis of the mid and apical left ventricle, while the base remains unchanged or shows compensatory hypokinesis (Kalra et al., 2019). Even though TC is reversible, mortality for an acute onset of TC is actually the same as an Acute Coronary Syndrome patient (Renko, Doyle & Sokoloski, 2019).
Due to TC’s unique presentation mimicing an MI or ACS, this is a case of the risk of not doing tests being far greater to the patient and their life, than doing lab work and tests (Renko, Doyle & Sokoloski, 2019). So for this reason, a full cardiovascular workup is necessary (Renko, Doyle & Sokoloski, 2019).
The unique presentation of Takotsubo is the same as an acute myocardial infarction (MI), or Acute Coronary Sydrome (ACS) which would necessitate a MI and ACS workup (Renko, Doyle & Sokoloski, 2019). Labs and tests include EKG, troponins, cardiac enzyme, and echocardiogram (Kalra et al., 2019). TC will show positive changes for ischemia on an EKG, elevated troponins, and left ventricular wall abnormalities (Kalra et al., 2019). At this point it would be appropriate to continue to coronary catheterization, and in TC it shows no epicardial coronary disease (Kalra et al., 2019).
A major complication of TC is a thrombus in the left ventricle due to hypokinesis, but this is rare, and able to be managed appropriately with anti-coagulation (Kalra et al., 2019).
Left ventricular recovery depends on the source of emotional or physical stress (Kalra et al., 2019). There is an average recovery time of 12 weeks, while when associated with generalized anxiety, recovery can be as little as 7 days although rare (Kalra et al., 2019). ACE inhibitors have been associated with a reduction of recurrence when prescribed at discharge (Kalra et al., 2019). References:
Kalra, D. K., Bai, C., Sanghani, R., Tracy, M., Feinstein, S., Lichtenstein, S. J., & Parekh, K. (2019). Takotsubo cardiomyopathy in a man with no trigger and multiple cardioembolic complications—A rare constellation. Echocardiography, 36(5), 975–979. https://doi-org.lopes.idm.oclc.org/10.1111/echo.14333 Renko, A. E., Doyle, W. C., & Sokoloski, P. W. (2019). Traumatic Takotsubo Cardiomyopathy in a Patient with Extensive Coronary Artery Disease. Case Reports in Emergency Medicine, 1–6. https://doi-org.lopes.idm.oclc.org/10.1155/2019/7270426
DQ-2
Hypertension is the most prevalent treatable risk factor for stroke and other vascular events. Hypertension is defined as the systolic and/or diastolic blood pressure that is higher than expected for age or pregnancy status and is classified as primary or secondary (Dolan & James, 2017). Though most patients are symptomatic, clinical characteristics can include occipital headaches, headache on awakening in the morning, blurry vision, left ventricular hypertrophy (after long standing hypertension) (Dolan & James, 2017). Those that are pregnant with hypertension may have proteinuria, edema, and excessive weight gain (Dolan & James, 2017). Utilizing treatment guidelines and available evidence, when determining the appropriate therapeutic options for a patient with hypertension, it is important to first determine which category they are in (Whelton, Carey, Aronow, 2018). Blood pressure (BP) is categorized as normal, elevated, or stages 1 or 2 hypertension. Developed by multiple health organizations, including the American College of Preventive Medicine, the 2017 High Blood Pressure Guidelines define normal BP as <120/<80 mmHg, elevated BP as 120-129/<80 mmHg, hypertension stage 1 as 130-139 or 80-89 mmHg, and hypertension stage 2 as >140 or >90 mmHg (Whelton, Carey, Aronow, 2018).
It is important to obtain a thorough history and physical assessment, as well as screen and manage the patient for nonmodifiable (age, ethnicity, gender) and modifiable (smoking, diet, activity) risk factors for hypertension and cardiovascular disease (CVD). The goal of diagnostic studies is to identify target organ damage, any underlying cause, and/or additional risk factors of hypertension (Whelton, Carey, Aronow, 2018). I would obtain an electrocardiogram, obtain a urinalysis (may reveal proteinuria) and obtain labs that would include fasting lipid profile, fasting blood glucose, electrolytes, creatinine, and calcium levels. Furthermore, current guidelines focus attention on practical and systems issues that are frequent barriers in clinical practice (Stafford, 2018). As an example, the guidelines emphasize proper techniques for accurately measuring blood pressure, including making multiple readings only after patients have rested in a seated position for more than five minutes. (Stafford, 2018).
References
Dolan, E., & James, K. (2017). Current approach to masked hypertension: From diagnosis to clinical management. Clinical & Experimental Pharmacology & Physiology, 44(12), 1272–1278.
Stafford, R. S. (2018). New High Blood Pressure Guidelines: Back on Track with Lower Treatment Goals, but Implementation Challenges Abound. American Journal of Preventive Medicine, 55(4), 575–578. https://doi-org.lopes.idm.oclc.org/10.1016/j.amepre.2018.04.023
Whelton, P.K., Carey, R.M., & Aronow, W.S. (2018). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association. Task Force on Clinical Practi. Počki, (1), 68. https://doi-org.lopes.idm.oclc.org/10.22141/2307-1257.7.1.2018.122220
DQ-3
Heart failure is a clinical syndrome that is from a result in impaired the ability of the heart ventricles to fill and eject blood. This is a result of structural and functioning impairment. The heart may have difficulty in ejecting blood effectively. One of the test used to evaluate this is diagnosed using an echocardiogram and the ejection fraction is measured. Normal left ventricle ejection fraction ranges from 55% to 70%. Heart failure severity is diagnosed when a patient is less than 50% ejection fraction. There are other tools available in order to help assess the degree of cardiac injury. The New York heart association uses stages of functionality in order to measure the degree of heart failure. They are 5 stages of heart failure according to the New York heart association. Common causes of heart failure are uncontrolled hypertension or cardiac injury. Hypertension causes extra stress to the heart causing it to grow. This creates structural changes that inhibits cardiac contractility. The first assessment starts with the history and physical and patient interview. A simple questions such as asking the patient about how many pillows do they utilize to sleep may help point on the severity. This will help suspect any heart failure. One day to assess for heart failure is by listening to the heart with a stethoscope. We will be listening for either a classic S3 gallop on the point of maximum impulse. One will find a sound that resembles the word ken-tuk-ky. The patient may present with some form of JVD, dyspnea, tachycardia peripheral edema and crackles in lung sounds. The other assessment that we can assume to help diagnose heart failure is over the same landmark PMI. In this area we will assess for a S4 murmur. This murmur is right before S1 and it represents atrial contraction in the attempt to compensate for low cardiac output. AS symptoms worsen many other problems may arise such as hepatomegaly, generalized edema, cyanosis, hypotension, frothy sputum and or pink sputum from the lungs. These patients are prone to pneumonia, and pulmonary embolism, dependent edema. Such differential diagnosis may be made. There is a laboratory test that is routine for suspected heart failure. This laboratory test is called BNP. This may be used as an indication of heart failure but may not indicate the true severity (Omar,Guglin, 2016).
Management of heart failure involves lowering blood pressure and lowering preload in order to lessen the stress of the heart. Some of the medications used are ACE inhibitors, ARBs,ARNI,MRA, beta blockers , loop diuretics, nitrates, and a few other inotropes. Nitrates are frequently used in acute episodes of heart failure (Wang,Samai, 2020).
Omar, H. R., & Guglin, M. (2016). A single BNP measurement in acute heart failure does not reflect the degree of congestion. Journal of Critical Care, 33, 262–265. https://doi.org/10.1016/j.jcrc.2016.02.023
Wang, K., & Samai, K. (2020). Role of high-dose intravenous nitrates in hypertensive acute heart failure. American Journal of Emergency Medicine, 38(1), 132–137. https://doi.org/10.1016/j.ajem.2019.06.046