D118 Unit 5 Study Guide

D118 Unit 5 Study Guide

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Western Governors University

D118 Adult Primary Care for the Advanced Practice Nurse

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D118 Unit 5 Study Guide

Module Vocabulary Key Questions

Managing Chronic Pulmonary Disorders and Diseases

What is Asthma and How Does It Present Clinically?

Asthma is a chronic inflammatory disorder of the airways marked by increased sensitivity of the tracheobronchial tree to various stimuli. This leads to episodic and reversible narrowing and inflammation of the airways. Patients typically experience symptoms such as episodic coughing, wheezing, shortness of breath, chest tightness, and soreness. The severity of symptoms can range from mild to severe (Global Initiative for Asthma, 2024).

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

The physical exam aims to achieve four objectives:

1. Confirm diagnosis and exclude other conditions.

2. Assess the severity of asthma.

3. Identify any adverse effects of asthma medications.

4. Detect coexisting medical issues that might influence asthma management.

Common physical findings might include wheezing and signs of airway obstruction (GINA, 2024).

How is Asthma Managed Immediately?

Initial treatment involves inhaled short-acting beta-agonists (SABA), with up to two treatments spaced 20 minutes apart, using 2–6 puffs via metered-dose inhaler or nebulizer (GINA, 2024).

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

Asthma diagnosis via spirometry involves demonstrating reversible airflow obstruction. A significant improvement in forced expiratory volume in 1 second (FEV1) post-bronchodilator administration—typically an increase of ≥12% and ≥200 mL—supports asthma diagnosis (American Thoracic Society, 2023).

What Are the Risk Factors for Poor Asthma Outcomes?

Risk factors should be assessed at diagnosis and reassessed every 1–2 years, especially in patients with exacerbations. Key risk factors include:

What Are the Five Steps for Pharmacologic Management of Asthma?

Early treatment with low-dose ICS is crucial for better lung function and prevention of severe exacerbations (GINA, 2024).

When Should Patients with Asthma Be Referred or Hospitalized?

Referral to an asthma specialist is recommended for:

• Patients with asthma-related hospitalization, indicating severe chronic asthma.

• Poorly controlled asthma with frequent missed work/school, ED visits, or hospitalizations.

• Asthma unresponsive to appropriate therapy.

• Requests for second opinions or complex cases such as occupational asthma.

• Need for allergy skin testing, detailed pharmacotherapy advice, or classification of asthma severity.

Chronic Cough

What Are the Clinical Features and Management of Chronic Cough?

Chronic cough is defined as lasting longer than eight weeks. Patients often report constant throat clearing and thick mucus production, especially upon waking. Physical examination helps identify causes such as pharyngeal erythema (sinusitis or allergic disease), inspiratory crackles (pulmonary edema or fibrosis), expiratory wheezes (asthma or COPD), or ear canal irritation triggering cough reflexes.

Management includes treating underlying causes such as asthma, COPD, or sinusitis, and reducing exposure to triggers. If pulmonary function tests (PFTs) are normal but suspicion remains, a methacholine challenge test may be performed to diagnose asthma (Irwin et al., 2023).

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

• Corticosteroid-responsive eosinophilic airway diseases (e.g., asthma, eosinophilic bronchitis).

• Upper airway cough syndrome (postnasal drip).

• Gastroesophageal reflux disease (GERD).

Chronic Obstructive Pulmonary Disease (COPD)

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

COPD manifests mainly as dyspnea, chronic cough, and sputum production. Advanced disease features include hyperinflation of the lungs, tobacco staining on fingers, clubbing of nails, increased chest anteroposterior diameter, and use of accessory muscles during breathing (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2024).

Patients often adopt a forward-leaning posture with pursed-lip breathing to improve ventilation.

What Are the Management Strategies for COPD?

Management includes:

• Smoking cessation as a cornerstone intervention.

• Pulmonary rehabilitation and exercise programs.

• Pharmacologic therapy with bronchodilators (beta-agonists and anticholinergics), inhaled corticosteroids, and, when appropriate, surgical interventions such as lung volume reduction surgery.

What Are the Four Severity Classifications of COPD?

The GOLD criteria classify COPD severity based on symptoms, airflow limitation, and exacerbation risk into four stages:

When Should Patients with COPD Be Referred to the Hospital?

Hospital referral is indicated for patients with:

• Severe symptoms limiting daily activities and recurrent exacerbations despite treatment.

• Need for oxygen therapy evaluation, including nocturnal oxygen.

• Preoperative assessment for high-risk surgeries.

• Acute exacerbations not responding to outpatient treatment.

• Persistent pulmonary infiltrates unresponsive to antibiotics.

• Sleep disturbances or respiratory failure needing advanced care.

• Cor pulmonale with refractory right heart failure.

• Consideration of α1-antitrypsin augmentation therapy (GOLD, 2024).

Diagnostic Studies for Pulmonary Diseases

Lung Cancer

How Does Lung Cancer Present, and What Are Its Physical Exam Findings?

Lung cancer symptoms vary widely but often include cough, weight loss, chest pain, and hemoptysis. Physical exam may reveal signs of metastasis such as palpable lymphadenopathy, bone tenderness, hepatomegaly, or focal neurological deficits. Superior vena cava syndrome is also a classic sign, manifesting as facial edema and dilated neck veins. Deep vein thrombosis may be present due to the hypercoagulable state associated with malignancy (Molina et al., 2023).

What Diagnostic Studies Are Used for Lung Cancer?

Evaluation includes:

• Laboratory tests: CBC, CMP, liver function tests, tumor markers, alpha-1 antitrypsin levels.

• Imaging: Chest X-ray, CT (gold standard), PET, MRI.

• Procedures: Lung biopsy, bronchoscopy, bone scan, thoracentesis.

• Molecular testing for targeted therapies (Molina et al., 2023).

Pneumothorax

What Are the Clinical Features and Management of Pneumothorax?

Patients typically present with sudden breathlessness and unilateral pleuritic chest pain. Physical findings depend on pneumothorax size and type. Large or tension pneumothorax is a medical emergency characterized by respiratory distress, tachycardia, tracheal deviation, and cyanosis. Management ranges from observation (small pneumothorax) to needle aspiration, chest tube placement, and surgery for large or tension pneumothorax (Light, 2024).

How to Differentiate Types of Pneumothorax?

Pulmonary Embolism

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

Pulmonary embolism (PE) commonly presents with sudden dyspnea, tachypnea, pleuritic chest pain, leg swelling or pain, hemoptysis, tachycardia, and jugular venous distention. Some patients exhibit nonspecific symptoms like malaise or syncope. Physical exam findings vary based on embolus size and location and may include respiratory distress and hypoxemia (Kearon et al., 2023).

Management priorities include stabilization, oxygen supplementation (goal saturation ≥92%), and anticoagulation with agents such as heparin, low-molecular-weight heparin, or direct oral anticoagulants. Severe cases may require thrombolysis or mechanical support (Kearon et al., 2023).

What Are the Risk Factors for Pulmonary Embolism?

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

How Is Pulmonary Embolism Diagnosed?

Diagnostic studies include:

• Electrocardiogram (EKG) to rule out cardiac causes.

• Chest X-ray to exclude other lung pathology.

• Ventilation/perfusion (V/Q) scan.

• Computed tomography angiography (CTA), considered the gold standard (Kearon et al., 2023).

Sarcoidosis

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

Sarcoidosis is a multisystem granulomatous disease often involving the lungs. Symptoms may include fatigue, cough, chest pain, arthritis, skin lesions, and ocular involvement. Auscultation is often normal but wheezing may occur in advanced disease. Neurological symptoms are uncommon but can occur (Iannuzzi et al., 2023).

Management focuses on symptom control and may include corticosteroids for advanced or symptomatic disease. Asymptomatic patients with early-stage disease may be monitored without therapy. Supportive care may involve pulmonary rehabilitation, oxygen therapy, and psychosocial support.

How Is Sarcoidosis Diagnosed and Monitored?

Diagnosis involves high-resolution computed tomography (HRCT) to differentiate inflammatory versus fibrotic lung changes. Laboratory findings include elevated serum angiotensin-converting enzyme (ACE), hypergammaglobulinemia, and occasionally hypercalcemia. Skin testing may reveal anergy. Ongoing monitoring includes clinical evaluation and imaging studies (Iannuzzi et al., 2023).

Sleep Disorders

Abdominal Aortic Aneurysm (AAA)

Clinical Presentation and Management of AAA

AAA involves permanent dilation of the abdominal aorta (≥3.0 cm diameter or 50% larger than normal). Classic signs include hypotension, pulsatile abdominal mass, and abdominal or back pain. Palpation techniques and auscultation for bruits assist diagnosis. Management ranges from medical monitoring to open surgical repair or endovascular aneurysm repair (EVAR) depending on size and rupture risk (Johnston et al., 2024).

Carotid Artery Disease

Presentation, Examination, and Treatment

Carotid artery disease often causes transient ischemic attacks or strokes, presenting as contralateral weakness, sensory changes, or transient vision loss (amaurosis fugax). Neck auscultation may reveal a carotid bruit. Management includes medical therapy with statins, antihypertensives, and antiplatelet agents, with carotid endarterectomy reserved for severe stenosis (Goldstein et al., 2024).

Coronary Artery Disease and Angina

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

Symptoms include chest pain described as pressure, heaviness, or squeezing, often with nausea, diaphoresis, or dyspnea. Management of stable angina focuses on acetylsalicylic acid, beta blockers, lipid-lowering agents, and nitrates. Unstable angina requires urgent evaluation with ECG and risk stratification to rule out acute coronary syndromes (Amsterdam et al., 2024).

Heart Failure

Clinical Features and Physical Examination of Heart Failure

Heart failure presents with symptoms such as shortness of breath, fatigue, peripheral edema, pulmonary edema, and abdominal discomfort. Examination may reveal jugular venous distention and lower extremity edema. Diagnosis requires clinical assessment corroborated by imaging and laboratory tests to guide management (Yancy et al., 2023).

Abdominal Fullness, Bloating, and Appetite Loss

Some patients report symptoms such as abdominal fullness or bloating accompanied by a reduced appetite. Management strategies include lifestyle modifications like smoking cessation, reducing dietary salt intake, avoiding illicit drugs, limiting alcohol consumption, and maintaining regular physical exercise. Emerging evidence recommends screening with B-type natriuretic peptide (BNP) and echocardiography in patients with risk factors to enable early heart failure (HF) intervention by a cardiology team, which may help prevent HF progression. Pharmacologic management often includes angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), beta-blockers (BB), and spironolactone (spiro) (Yancy et al., 2017).

New York Heart Association Classifications of Heart Failure

Question: What are the New York Heart Association (NYHA) Classifications of heart failure?

Answer:
The NYHA functional classification categorizes heart failure based on the severity of symptoms and physical activity limitations:

Diagnosis of Congestive Heart Failure (CHF)

Question: How is congestive heart failure diagnosed?

Answer:
Diagnosis of CHF involves clinical evaluation, imaging, and invasive procedures. Left-sided heart catheterization with coronary artery angiography is useful to assess coronary artery disease extent and ischemia contributing to heart failure. Echocardiography is essential to evaluate ventricular function, valve abnormalities, and to measure ejection fraction (EF). BNP measurement is a sensitive marker indicating cardiac stress and heart failure presence (McMurray et al., 2014).

Infective Endocarditis and Myocarditis

Infective Endocarditis

Question: What are the clinical features, examination findings, and management of infective endocarditis?

Answer:
Patients often present with low-grade fever, chills, weight loss, and heart murmurs. Additional manifestations include arthralgias, myalgias, petechiae, kidney infection, and Roth spots (retinal hemorrhagic lesions). Management requires prolonged intravenous antibiotic therapy and, in some cases, valve replacement surgery (Baddour et al., 2015).

Myocarditis

Question: Describe the presentation, physical exam, and management of myocarditis.

Answer:
Symptoms range from fever, atypical chest pain, fatigue, palpitations, to severe cardiogenic shock or arrhythmias. Management emphasizes bed rest, avoidance of stimulants (alcohol, caffeine, nicotine), and refraining from strenuous exercise for six months. Medical therapy aligns with heart failure treatment using ACE inhibitors or ARBs, loop diuretics, and beta-blockers. BNP levels aid diagnosis (Cooper, 2009).

Hypertension: Clinical Presentation and Management

Question: What are the clinical features, examination methods, and treatment of hypertension?

Answer:
Symptoms may include tinnitus, headache, and dizziness, but many patients remain asymptomatic. Proper blood pressure measurement requires the patient to be seated with feet on the floor for five minutes, using a cuff size appropriate to arm circumference, with the arm supported at heart level. Multiple readings in both arms, including standing measurements in older adults, are recommended.

Management focuses on lifestyle changes: regular exercise, cessation of alcohol and tobacco, weight control, and stress reduction. Pharmacological therapy includes ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers (CCBs). Nondihydropyridine CCBs like verapamil and diltiazem are contraindicated in patients with reduced ejection fraction heart failure (Whelton et al., 2018).

Hypertensive Emergency Criteria

Question: What defines a hypertensive emergency?

Answer:
A hypertensive emergency is characterized by severely elevated blood pressure (typically >180/120 mmHg) with evidence of acute target organ damage such as encephalopathy, myocardial infarction, pulmonary edema, or acute renal failure (Whelton et al., 2018).

Peripheral Arterial and Venous Insufficiency

Question: What are the clinical features, examination findings, and treatment approaches for peripheral arterial disease (PAD) and venous insufficiency?

Answer:
Patients may complain of claudication, ischemic rest pain, leg fatigue, or poor wound healing. Examination involves checking pulses, capillary refill, and assessing for swelling or ulcers. Treatment prioritizes tobacco cessation, aggressive management of hypertension, diabetes, and hyperlipidemia, and use of compression stockings (ABI >0.8). Antiplatelet therapy with aspirin or clopidogrel and statins are recommended. Cilostazol can improve walking distance in claudication. Surgical interventions include angioplasty and bypass grafting when indicated (Gerhard-Herman et al., 2017).

Valvular Heart Disease and Murmurs

Question: How do valvular heart diseases present, and what are their examination and management strategies?

Answer:
Symptoms include chest pain, palpitations, dizziness, syncope, fatigue, and dyspnea. Physical exam begins with inspection and palpation of the chest to assess the point of maximum impulse (PMI), followed by auscultation for heart sounds and murmurs.

Non-pharmacologic management includes activity restrictions for severe aortic stenosis. Medical therapy targets risk factor modification and symptom control. Surgical options, such as transcatheter aortic valve replacement (TAVR), are reserved for patients with high surgical risk (Nishimura et al., 2017).

Valvular Heart Murmurs: Characteristics and Management

Diverticular Disease: Presentation and Management

Question: What differentiates diverticulitis from diverticulosis, and how are these conditions managed?

Answer:
Diverticulosis refers to the presence of multiple colonic diverticula, often asymptomatic, with intermittent abdominal symptoms like bloating or irregular bowel habits. Diverticulitis is inflammation of one or more diverticula, presenting with left lower quadrant pain, fever, leukocytosis, nausea, and vomiting.

Physical examination may reveal localized tenderness, guarding, or a palpable mass in diverticulitis, while diverticulosis usually has a normal exam. Management includes stool testing, colonoscopy, antibiotics for diverticulitis, and dietary fiber for diverticulosis (Strate & Morris, 2019).

Gastroesophageal Reflux Disease (GERD)

Question: How does GERD present, and what are the key examination and treatment principles?

Answer:
Symptoms include heartburn and chest pain that can mimic angina. Oral examination may reveal dental erosions, halitosis, and signs of scleroderma. Respiratory symptoms such as cough and wheezing may be present.

Management involves histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and promotility agents like metoclopramide for delayed gastric emptying (Katz et al., 2022).

Gastrointestinal Hemorrhage

Question: What are the clinical features, examination findings, and management strategies for gastrointestinal bleeding?

Answer:
Patients may present with hematemesis, melena, or hematochezia. Early assessment includes vital signs, mental status, and skin examination for signs like telangiectasia or cirrhosis. Management may involve balloon tamponade, surgical shunting, or transjugular intrahepatic portosystemic shunt (TIPS) to control bleeding (Strate & Gralnek, 2016).

Hepatitis and Liver Disease

Question: What are the typical symptoms, examination features, and treatments of hepatitis?

Answer:
Symptoms include anorexia, fatigue, myalgias, nausea, fever, and abdominal pain. Physical examination assesses vital signs and systemic complications. Management depends on etiology and may include antiviral therapies such as nucleoside analogues. Biopsy is sometimes necessary for staging (European Association for the Study of the Liver, 2017).

Inflammatory Bowel Disease (IBD)

Question: What are the clinical presentation and management of ulcerative colitis (UC) and Crohn’s disease (CD)?

Answer:
Patients often have abdominal pain, diarrhea, fatigue, weight loss, fever, and joint pain. Physical exam may reveal oral ulcers, hyperactive bowel sounds, abdominal tenderness, and perianal lesions suggestive of CD. Management includes 5-aminosalicylates, immunomodulators like azathioprine, corticosteroids, and biologics such as infliximab (Torres et al., 2020).

Irritable Bowel Syndrome (IBS)

Question: How is IBS diagnosed and managed?

Answer:
IBS presents with abdominal pain and altered bowel habits, but lacks alarm symptoms such as weight loss or GI bleeding. Physical exam is usually unremarkable, but tenderness may be present. Management focuses on symptom relief using fiber supplements, antispasmodics, antidiarrheals, and psychotropic agents for associated anxiety or depression (Ford et al., 2018).

Chronic Pancreatitis

Question: What is the clinical presentation and treatment approach for chronic pancreatitis?

Answer:
Patients experience recurrent epigastric pain radiating to the back, nausea, steatorrhea, and weight loss. Physical exam may show tenderness or signs of malnutrition. Management includes alcohol and smoking cessation, pain control with analgesics, pancreatic enzyme replacement, vitamin supplementation, and potentially surgical interventions (Yadav & Lowenfels, 2013).

Gastrointestinal Tumors

References

• Baddour, L. M., et al. (2015). Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation, 132(15), 1435-1486.

• Cooper, L. T. Jr. (2009). Myocarditis. New England Journal of Medicine, 360(15), 1526-1538.

• European Association for the Study of the Liver. (2017). EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection. Journal of Hepatology, 67(2), 370-398.

• Ford, A. C., et al. (2018). Irritable bowel syndrome. Lancet, 391(10114), 1814-1825.

• Gerhard-Herman, M. D., et al. (2017). 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease. Circulation, 135(12), e726–e779.

• Katz, P. O., et al. (2022). Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 117(1), 27-56.

• McMurray, J. J., et al. (2014). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 35(27), 1787-1847.

• Nishimura, R. A., et al. (2017). 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Circulation, 135(25), e1159-e1195.

• Strate, L. L., & Gralnek, I. M. (2016). Management of acute lower gastrointestinal bleeding. Gastroenterology, 150(7), 1683-1691.

• Strate, L. L., & Morris, A. M. (2019). Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology, 156(5), 1282-1298.

• Torres, J., et al. (2020). Crohn’s disease. Lancet, 395(10221), 1246-1260.

• Whelton, P. K., et al. (2018). 2017 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. Journal of the American College of Cardiology, 71(19), e127-e248.

• Yadav, D., & Lowenfels, A. B. (2013). The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology, 144(6), 1252-1261.

• Yancy, C. W., et al. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 70(6), 776-803.