RVF: right ventricular failure

HTN: hypertension

Non-dyspneic pulmonary
edema (so you need to listen
for it)

Atypical

May not subjectively

experience the classic
symptoms such as
paroxysmal nocturnal
dyspnea or coughing

Typical onset is insidious

with change in function,
food or fluid intake, or
confusion

Presentations

Confusion
Self-neglect
Falling
Incontinence

Apathy
Anorexia
Dyspnea
Fatigue

Interventions for COPD

Bronchodilators

Anticholinergics

Duoneb, ipatropium

Corticosteroids

Pulmonary toilet

Getting plenty of fluids (to make the mucous thinner and easier to
expel)

Irritant avoidance

No smoking, etc.

Oxygen therapy

PaO2 </= 55 mmHg or POX </= 88% on RA at rest

59/89% + cor pulmonale, CHF, erythrocytosis

Some limited situations (eg, sleep) if proven

20 years (left). If a person quits smoking and adheres to therapy for COPD, his
future decline can be expected to parallel that of a person wo/ lung disease (right).
You wont gain anything back after quitting smoking but youll push the lung decline
back from where they were when you quit smoking

Exercise
Pursed-lip

breathing

Diaphragmatic breathing

Belly breathing can drop the diaphragm and allow extra area for lungs
to expand

Gradual increases

Rest as needed

Aerobic exercise

Aerobic exercises get legs moving may not be a lot, but there needs to be some

Nutrition

Recommendations & Reality clash

Financial issues

Supplements

Vitamin D prevents osteoporosis, also in those that have an existing vit d

deficiency, it also can help slow progression of COPD

Other restrictions (cardiac, diabetic)

Many small meals

Functional limitations in meal preparation

Overview of the pathogenesis of T2DM

Insulin resistance (muscle, fat, liver)

Insulin secretory dysfunction

Increased endogenous glucose production

Deranged adipocyte biology

Decreased incretin effect

Test

Prediabetes

Diabetes

FPG

100-125 mg/dL

126 mg/dL

OGTT

140-199 mg/dL

200 mg/dL

A1C

5.7-6.4%

6.5%

Interventions can reduce the rate of progression from prediabetes

to diabetes
o

Healthy diet

Physical activity

Weight loss

Semmes-Weinstein monofilament exam

o

10 points of exam

Randomize approach

Vibration testing

On-off testing

Timed testing

10 sec difference: sensate

20 sec difference: insensate

Diabetic testing

Sensate or insenate, X out of 10 trials/foot

0-1 insensate: No nerve damage (ND)

2-4 insensate: ND possible, refer

5+ insensate: ND very likely, treat

Individualized Glycemic
Control

Consider more
stringent A1C
goals (<6%) in
recently dx
patients with
long life
expectancy

Less stringent
goals for
patients with
frequent or
severe
hypoglycemia,
advanced
complications
and those who
respond poorly to therapy

ANTI-HYPERGLYCEMIC THERAPY

Glycemic targets

HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])

Pre-prandial PG <130 mg/dl (7.2 mmol/l)

Post-prandial PG <180 mg/dl (10.0 mmol/l)

Individualization is key:

Tighter targets (6.0 - 6.5%) - younger, healthier

Looser targets (7.5 - 8.0%+) - older, comorbidities,

hypoglycemia prone, etc.

Avoidance of hypoglycemia

Educating in self care

Dietary teaching

Exercise as tolerated

Foot care

Careful review/return demonstrations of medication and especially insulin

use

Teaching recognition of early symptoms of hypoglycemia & its first-aid

treatment

Review of sick day routine

Patient education materials

1) Free, reproducible patient handouts in English and Spanish
diabetes.org/toolkit
2) Diabetes Risk Test
diabetes.org/risktest
3) My Health Advisor 8 and 10 year CMR calculator
diabetes.org/MHA

Adults with prediabetes

Exercise program should include:

150 minutes/week of moderate-intensity aerobic activity

(50%-70% maximum heart rate)
o

Spread over 3 or more days every week

No more than 2 consecutive days without exercise

Resistance training 2 times/week (in absence of

contraindications)*

Evaluate patients for contraindications prohibiting certain types of

exercise before recommending exercise program
Consider age and previous level of physical activity

Grains and starchy foods

Non-starchy
vegetables

Spinach
Carrots
Lettuce
Greens
Cabbage
Green beans
Broccoli
Cauliflower

Tomatoes

Whole grain breads

whole wheat or rye
Whole grain
High-fiber

Protein

Chicken or turkey
without the skin
Fish such as tuna,
salmon, cod or
catfish
Tofu, eggs, low-

Study Guide for Skin

LaBlanc & Baranoski article

These slides w/ discussion

Focus on concepts of large, complex issues (example: ulcer types and

management)

Relevant sections of Bates text

Focus on details of do not miss problems (example: melanoma)

Cardiovascular

The discussion of "codes" and DNR orders earlier this semester.

The readings for and lecture on the respiratory system last week.
The readings in Lewis assigned for this week.