PANCE Blueprint Pulmonary (10%)

• Etiology: COPD (most common), pulmonary embolism, vasculitis, asthma, ILD, acute respiratory distress syndrome
• Physical Exam: Lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2

DX: EKG: S1Q3T3

• Echocardiogram or radionuclide imaging; sometimes right heart catheterization

TX: Diagnose and treat the underlying condition before cardiac structure change becomes irreversible

• • Diuretics not helpful! May be harmful

• More than 90% originate from cots in the deep veins of the lower extremities
• Presents with dyspnea (most common) and pleuritic chest pain
• R/F: Virchow’s triad = hypercoagulable state, trauma, venostasis (surgery, cancer, oral contraceptives, pregnancy, smoking long bone fracture/fat emboli)
• Homan’s sign: (Dorsiflexion of the foot causes pain in calf) indicative of deep vein thrombosis
• EKG: TACHYCARDIA (most common), S1Q3T3 (rare), non-specific ST wave changes

Diagnosis: Well’s Score is used to assess the probability of pulmonary embolism

• Spiral CT = initial method of identifying
• Pulmonary angiography = gold standard definitive
• CXR: Westermark sign or Hampton hump (triangular or rounded pleural base infiltrate adjacent to hilum)
• VQ scans are "old school"= perfusion defects with normal ventilation (normal VQ rules out PE; abnormal – non-specific)
• Venous duplex ultrasound of lower extremities (normal test does not exclude PE)
• ABG = respiratory alkalosis secondary to hyperventilation
• D-dimer

Tx: Heparin is the anticoagulant of choice for the acute phase with factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) and oral direct thrombin inhibitors (dabigatran) thereafter

• Usually caused by an underlying disorder (constrictive pericarditis, mitral stenosis = MC, LV failure, mediastinal disease compression pulmonary veins)
  • Mitral stenosis: mitral valve = tight so blood can’t pass into left ventricle ⇒ pressure backs up to lungs
• When the right heart can’t pump against vascular resistance ⇒ right heart failure = cor pulmonale
• Presentation: Dyspnea on exertion, fatigue, chest pain, edema
• Physical Exam: Loud pulmonic component of second heart sound (P2); Jugular venous distension; Ascites; Hepatojugular reflux; Lower limb edema

Diagnose with a right heart catheterization (gold standard)  → most accurate measure of pressures

• CXR
  • Enlarged pulmonary arteries
  • Lung fields may or may not be clear, dependent on the underlying cause
• Echocardiogram
  • Increased pressure in pulmonary arteries, right ventricles → dilated pulmonary artery
  • Dilatation/hypertrophy of right atrium, right ventricle
  • Large right ventricle → bulging septum
• ECG → Right heart strain pattern: T wave inversion in right precordial (V1–V4), and inferior leads (II, III, aVF)

TX: identify and treat the underlying cause