PANCE Blueprint Pulmonary (10%)

Patient will present as → a 65-year-old man comes to the office due to 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate chronic obstructive pulmonary disease. His medical history is relevant for a 40-pack-year smoking history, type II diabetes mellitus, hyperlipidemia, and coronary artery stenting 2 years ago. Physical exam shows a barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%.

Cor pulmonale is right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension

• Lung disorders such as PE, vasculitis, ARDS, COPD (most common), asthma, and ILD cause pulmonary artery hypertension
• Pulmonary artery hypertension then leads to right ventricular failure
• Findings include peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift

Pathophysiology of Cor Pulmonale

The diagnosis of cor pulmonale is usually made with an echocardiogram → increased pressure in the pulmonary arteries and right ventricle

• Spirometry can be done to look for chronic lung disease
• The gold standard diagnostic test to directly measure pulmonary pressures and assess for response to vasodilating medications is a right heart catheterization

Treatment of chronic cor pulmonale generally focuses on the underlying pulmonary disease

• Early identification and treatment of the cause are important before cardiac structural changes become irreversible
• Although patients may have significant peripheral edema, diuretics are not helpful and may be harmful; small decreases in preload often worsen cor pulmonale
• Right ventricular ischemia or pulmonary artery stretching can cause anginal chest pain in cor pulmonale that does not respond to nitrates