NURS 8026 1st Edition Lecture 1Current LectureDifferential diagnosis of Shortness of Breath (SOB)Important questions to ask if anybody comes with SOB1. Have you had any sick contact?2. When does it start?3. What makes it better/worst? 4. Are you contact anybody who are sick5. Any recent respiratory infection?6. Any recent weight change?7. Do you smoke?8. Any recent trauma?9. How the problem effects on ADL?10. Any PND-? (Attacks of breathlessness occurring at night11. What is the quality of breathing? 12. Are you coughing with sputum (frothy sputum-sigh of infection)Definiton:1. SOB, breathlessness and dyspnea all refer all refer to an abnormal awareness of breathing2. Sensation of difficult, uncomfortable breathing includes both perception of labored breathing and the patient’s reaction to that sensation.3. Common presenting complain can be insidious or abrupt-acute or chronic 4. Orthopnea refers to dyspnea in recumbency 5. PND are attacks of breathlessness occurring at night awakening the patient Pathophysiology of SOB:– Many “dyspnea ’mechanisms not entirely clear– Increased stimulate on of brain-stem respcenter; area of Medulla contains coordina3ngcenters• Pneumotaxic center: controls rate & paMern• Dorsal resp group: controls inspiration• Ventral group: controls modulates inspiration& expirationDifferental Diagnosis of SOB• Usually a system related problem• Can stem from pulmonary, cardiac, anemia, hypothyroidism, N/M diseases• Difficult to differentiate cardiac from pulmonary may be a cardiopulmonary diseaseCategories of possible dysfunction (SOB): -Pulmonary system• Airway• Parenchyma• Pleura• Chest wall• Blood vessels– Cardiac dysfunction– Neuromuscular– Anxiety disorderDyspnea (also SOB, air hunger)Subjective symptom of breathlessness.Normal in heavy exertionPathological if it occurs in unexpected situations.Differential diagnosis of Shortness of BreadthStress/anxiety/deconditioningHeart DiseaseEmboli Pulmonary diseaseAnemiaNeuromuscular diseaseTrachea/upper airway obstructionSleep disorderAcute Condition SOB1. Aspiration of Foreign Body2. Anaphylaxis3. Pulmonary embolism (PE)4. Spontaneous Pneumothorax5. Status asthmatic6. Acute bronchial asthma7. Pneumonia8. Noncardiogenic pulmonary edema- ARDS- Noxious gas inhalation- High altitude pulmonary edema, 8. Cardiogenic pulmonary edema 9. HyperventilationChronic conditions– COPD: Emphysema, Chronic bronchitis, Chronic bronchial asthma– Restrictve lung disease:- Intestinal (e.g. Sarcoidosis, scleroderma)- Chest wall deformities- Pleural fibrosis- Neuromusculardisease (ALS,myasthenia gravis)– Nonpulmonary causes:• CHF (low output states)• Anemia• Hyperthyroidism• Upper airway disease• Obesity• NeurosisChronic Condition Of SOBAnemiaAnemia:1. 65% of the FE(Iron is in circulating HgB.2. 1 ml of blood=0.5mg FE9Iron)3. Each healthy pregnancy depletes body 500mg of Fe4. Male must consume 1 mg of Fe to maintain iron level. Always investigate if male is anemic. Male shouldn’t be anemic. If they are anemic it could be cancer5. Mensuration Female consume 2mg/daily FEMean Corpuscular Volume (MCV)=82-98Mean Corpuscular Hemoglobin Concentration=32-34 Classification of anemia according to cell size.Microcy+c/ Hypochromic MCV<82, MCHC<32 in the presence of Hgb <12 F & <13.5 M1. Iron deficiency anemia2. Thalassemia3. Anemia of chronic diseaseMacrocy+c/Normochromic MCV>98 MCHC norm in the presence of anemia1. Vitamin B 12 deficiency “pernicious2. Folate deficiency3. Drugs or bone marrow failure (Medication induced anemia)Normocytic/Normochromic(in the presence of anemia)1. Blood loss2. Hemolytic anemia3. Chronic disease4. Bone marrow infiltrationAnemia History: Watch out for following1. Progressive dyspnea2. H/o blood loss (GI, menses…)3. C/o weakness, fatigue4. Poor nutrition debilitated state5. Race6. Age7. Gender8. Family history9. H/O of anti-convulsing chemotherapySign and symptoms of anemias: SOB and fatigue are the firse sign of anemia*****1. Easy fatigability2. Irritability3. Headache4. Tachycardia5. Palpitations6. Tachypnea on exertion7. Glossitis8. Peripheral neuropathy(vit B12 deficiency anemis-on older people who has GI problem)Pagophagid= in Greek “pagos” means frost and “phagis” means. (Frost eating or pica eating). Early graying of hair, burning sensation of tongue, loss of proprioception (stumbling in dark) mayindicate vit B12 deficiency Paresthesia, Change in color, bulk, and frequency of stoolsPhysical Findings on anemic patient• In mild-moderate anemia (hgb 6-12g/dl) there may be few physical findings: tachycardia& tachypnea• Severe anemia<6g/dl:– Sensitvity to cold, wt loss, lethargy– Skin: jaundice, bleeding, pallor– CV:tachy,”hemic”murmur, gallop, angina– HEENT: glossitis, angular stomatitis – Eyes: eyelid edema, rental hemorrhage– Neuro: H/A, vertigo, depression, impaired thought processDiagnostic tests for Anemia:1. H/H2. MCV (82-98) average size of RBC to calculate hct/rbc3. MCHC (32-34)weightof hgb/volume of rbc to calculate Hgb/Hct4. RDW-indication in the variation of size of RBC (RDW-relative distribution wt.)5. Retcular Count (33-137x103) –indicates bone marrows ability to respond to anemia & make more RBC( if we give Iron to the anemic patient then we can see increase reticular count after some time which indicate bone marrow is respond to iron therapy)6. Ferriten (M: 16-300, F:4-161)– indicates available stores of iron in the body, major iron-storing protein, low count indicates low stores. Ferritin decrease in iron deficiency anemias.7. TIBC(250-460)- measures protein available to bind w/FE, it is Increased w/FE deficiencyIron deficiency anemia (IDA) sign and symptoms: Pallor (conjunctiva, chilosis, Koilonchyia)• Lab results1. HGB<14 M,<12 F2. Low MCV,MCHC3. Low RBC4. Increased RDW5. Low serum Fe (<50 mg/ml)6. TIBC elevatedPernicious anemia (vit B12 deficiency anemia) d/t malabsorption: S/s1. Insidious onset, median age 602. Paresthesia, numbness, ataxia (*** these symptoms do not present in folate deficiency anemia)3. Dementa, psychosis4. Smooth beefy red tongue d/tatrophic glossitis Lab for pernicious anemia1. – H/H decreased2. – RBCs decreased3. – Retc normal or low4. – MCV>1005. – Serum B12 decreased<250Folic acid deficiency anemia deficiency (Diet deficiency): S/S (Folic acid deficiency