CR Clinical Patterns

Question 1

Describe valvular heart disease.

Answer 1

Insufficient closing causing regurgitation of blood OR insufficient opening impeding forward flow of blood (stenosis).

Question 2

Describe dilated cardiomyopathy. Name three risks for this condition.

Answer 2

Increased diameter in the LV, so it can fill but cannot contract. Stagnant blood increases the risk of clotting and can back up into pulmonary circulation.
RF: late pregnancy, chemo, alcohol

Question 3

Describe hypertrophic cardiomyopathy.

Answer 3

Pathologic hypertrophy or LV causing reduced diameter (thickened walls) and abnormal filling. Often occurs in young athletes, may be genetic or acquired. Causes sudden cardiac death as it can be asymptomatic or just ^WOB.

Question 4

Describe cardiac tamponade. List 3 symptoms.

Answer 4

Fluid buildup in the pericardial sac surrounding the heart. Eventually this will compress the heart and reduce CO (limit filling). Often post-up from puncture.

i) jugular distension
ii) hypotension (esp SBP w/ inspiration)
iii) muffled heart sounds

Question 5

Describe arteriosclerosis.

Answer 5

Stiffening of arteries over time due to reduced elastin, calcification, thickening or atheromas.

Question 6

Describe atherosclerosis .

Answer 6

Stiffening of arteries due to atheroma deposits (TGs/WBCs/cholesterol) in the lumen of vessels. This will weaken the arteries and increase risk of MI, aneurysm, stroke etc.

Question 7

Describe aortic stenosis and list the consequences.

Answer 7

Stenosis of the ascending aorta secondary to age-related arteriosclerosis or atherosclerosis.

i) heart murmur (aortic regurgitation)
ii) hypertrophy
iii) angina
iv) syncope (2’ vasoD on exertion w/ no ^SBP, vBP).

Question 8

Describe what aneurysms. What is one common location and the outcomes?

Answer 8

Weakening in a blood vessel wall often causing dilation and rupture or a dissection (layers slowly dissociateand tear apart and blood seeps through out of the artery). Commonly the abdominal aorta (AAA) which is usually a dissection - these are often fatal.

Question 9

What is a flail chest? How does it affect respiration?

Answer 9

i) A fracture in >/= 2 consecutive ribs in >/= 2 places along the bone following blunt trauma (often w/ pulmonary contusion).
ii) flail segment sucks in on inspiration and mediastinum is pushed away resulting in reduced filling of affected lung. Flail pushes out on expiration and mediastinum pushed towards. Overall reduced ventilation to that lung.

Question 10

What is a pneumothorax? List the different types.

Answer 10

A pneumothorax is the presence of air in the pleural space which often causes a lung collapse. Rx w/ chest tube.

i) open: puncture wound air moves freely between
ii) closed: air does not move in or out of space
ii) tension: wound opens on inspiration and closes on expiration causing air trapping.
iii) spontaneous: air filled cyst-type structure spontaneously bursts (tall, young men).
iv) hemothorax: blood, not air, in pleural space.

Question 11

What is congestive heart failure? List and describe the two types.

Answer 11

Inability of heart to pump blood at the required rate to meet the needs of tissues.

i) systolic: deterioration of contractile function.
ii) diastolic: cannot accomodate ventricular blood volume.

Question 12

List the S/S of CHF and the describe the medical management.

Answer 12

i) SOB
ii) peripheral edema (abnormal Na+ and water retention)
iii) clubbing/cyanosis
iv) cachexia/fatigue
Rx: pacemaker, heart transplant, LVAD, or other surgery to Tx underlying cause.

Question 13

List the S/S of L sided CHF. Name primary causes.

Answer 13

i) blood damming in pulmonary circulation.
ii) SOB when lying - nocturnal gasps for air
iii) dyspnea on exertion
iv) pulmonary congestion (crackles/wheezes)
v) REDUCED KIDNEY AND BRAIN PERFUSION.
Causes: ischemic heart diease, HTN, valvular disease or myocardial disease.

Question 14

List the S/S of R sided HF (cor pulmonale). Name primary causes.

Answer 14

i) reduced peripheral blood flow
ii) pitting edema (^ peripheral venous pressure)
iii) congested portal and systemic circulation (liver damage, enlarged spleen)
Causes: LV failure, chronic pulmonary HTN, COPD, CF.

Question 15

Describe angina pectoris. List some common medical managements.

Answer 15

Transient ischemia of the heart causing recurrent episodes of chest pain and SOB. Resultant of obstruction or spasm of coronary arteries.
Rx: aspirin, nitroglycerin, surgery if needed.

Question 16

List the types of angina.

Answer 16

i) stable: triggered by exertion or stress, relieved accordinly.
ii) unstable: occurs at any time (more dangerous)
iii) prinzmetal/variant: occurs at rest and is the most severe. Occurs more often in younger people.

Question 17

What blood test are conducted to confirm the presence of an MI?

Answer 17

i) Troponin

ii) Creatine kinase.

Question 18

List the types of lung cancer.

Answer 18

1. Small cell (20-25%): develops in bronchial mucosa. Spreads rapidly and metastasizes early.
2. Non-small cell:
   a. squamous cell: near hilum, slow spread, late metastases.
   b. adenocarcinoma: slow/mod spread, early metastases
   c. large cell: rapid spread, wide spread mets, poor prognosis.

Question 19

List the types of brain cancer.

Answer 19

i) intracerebral: tumour neurons don’t proliferate but surrounding cells do. Intra-tentorial common in paeds.
ii) intracerebral metastatic: often from lung, prostate, breast cause reduced brain tissue & CSF volume.
iii) medulloblastomas
iv) neuronoma (schwannoma)

Question 20

Describe pneumonia and list common causes.

Answer 20

Inflammation and infection of lung parenchyma. Can be bacterial or viral or fungal.

i) aspiration
ii) contamination (viral, fungal etc.)
iii) ventilator associated

Question 21

Name and describe the types of pneumonia.

Answer 21

i) typical: sudden onset, usually bacterial.

ii) atypical “walking pneumonia”: bacteria that doesn’t respond to normal antibiotics, no symptoms and minimal sputum.

Question 22

List and describe the stages of pneumonia.

Answer 22

i) consolidation: w/n first 24hrs, ++ congestion and secretions
ii) red hepatization (resembles liver): 2-3 days after consolidation, alveolar capillaries become engorged with blood, resembles liver in consistency.
iii) grey hepatization: 2-3 days later, avascular as exudates compress alveolar capillaries
iv) resolution: resorption and restoration of pulmonary architecture.

Question 23

Describe atelectasis and list potential causes.

Answer 23

Collapse of normally expanded lung parenchyma. This may be in patches, segments, or entire lobes.
Causes:
i) blocked bronchus/bronchiole
ii) compression (Ex. pneumothorax)
iii) post-anaesthetic

Question 24

Describe ARDS and list potential causes. List medical Rx.

Answer 24

A secondary condition of acute respiratory failure w/ severe hypoxemia. Characterized by inflammation at the alveolar-capillary interface causing protein and fluid to infiltrate the interstitium and alveoli. White out on CXR.
Causes:
i) aspiration
ii) emboli
iii) trauma
iv) indirect following infection.
Rx: PEEP to splint airways open. Proning if severe.

Question 25

Describe SARS and it’s S/S.

Answer 25

Viral respiratory illness caused by SARS coronavirus.
S/S are flu-like (may lead to pneumonia):
i) myalgia
ii) fever
iii) cough
iv) sore throat
v) lethargy

Question 26

Describe a lung abcess and one pre-disposing feature.

Answer 26

Following infection or injury, an area of lung tissue necrotizes and the body attempts to localize this by building up a wall around it consisting of a cavity with necrotic debris and fluid (mostly pus). Most commonly aspiration infection. Predisposition if alcoholic.
Rx: Chest PT, antibiotics.

Question 27

Describe IRDS and explain how it is medically managed.

Answer 27

Infant Respiratory Distress Syndrome occurs in infants whose lungs have not fully developed - they lack surfactant (prevents collapses). This often occurs with premature birth, multiple pregnancies, C-section, blue baby. Rx: artificial surfactant.

Question 28

Describe hypoxemic respiratory failure and common causes.

Answer 28

Gas exchange failure resulting in low blood O2 w/ no increase in CO2 production. Often resultant of:

i) pneumonia
ii) ARDS
iii) obstructive lung disease
iv) pulmonary embolism

Question 29

Describe hypercapnic respiratory failure and common causes.

Answer 29

++ CO2 in the blood causing reduced O2. Due to:

i) reduced ventilation from drugs or respiratory control
ii) acute upper/lower airway obstruction
iii) weak/impaired repiratory muscles

Question 30

Describe asthma and name the two types.

Answer 30

Chronic condition of upper airway, sometimes lung, inflammation causing obstructive bronchospasm (gas trapping) due to hyper-responsiveness to various stimuli.
i) instrinsic: adult > kids
hypersensitivity to stress, exercise, cold air, drugs, virus etc.
ii) extrinsic: kids > adults
due to allergen exposure

S/S: wheezing, chest tightness, coughing, SOB, secretions and bronchial edema.

Question 31

What is the PT and medical management for asthma?

Answer 31

PT: education to avoid triggers, management of SOB (ex. PLB)
Med: Inhaled corticosteroids

Question 32

Describe COPD and list the risk factors.

Answer 32

Chronic, progressive respiratory condition associated with hypercompliant lungs and hyperinflation. COPD will eventually result in RV CHF due to HPV.

i) SMOKING
ii) air pollution
iii) infection
iv) hereditary (emphysema type, lysis tissue)
v) aging

Question 33

Describe bronchiectasis (COPD) and the S/S.

Answer 33

Irreversible necrosis and DILATION of airways secondary to chronic bacterial infection. Common after CF, bronchial tumours, TB. Alveoli eventually turn to scar tissue due to chronic inflammation. S/S:

i) secretions (damage reduces clearance)
ii) inflammation and infection (reduced clearance)
iii) dyspnea w/ exertion or stress.

Question 34

Describe chronic bronchitis (COPD) and the S/S:

Answer 34

Defined as chronic or recurrent productive cough at least 3months of the year, for at least 2 years. Commonly related to smoking.
i) excessive mucous secretions
ii) bronchioles dilate and alveoli are enlarged and deformed
“blue bloaters”

Question 35

Describe emphysema (COPD) and the S/S.

Answer 35

Dyspnea and irreversible damage to air/blood interface (walls break down, alveoli enlarge causing reduced surface area for gas exchange) as well as lung elasticity - ++ compliance. Commonly related to aging.
i) flat diaphragm 2’ hyperinflation (mechanical disadvantage)
ii) dyspnea etc.
iii) malnourishment (difficulty plus increased caloric demand)
“pink puffers”

Question 36

Describe the pathology of interstitial lung disease and describe the S/S as well as medical Rx.

Answer 36

Restrictive lung disease caused by progressive tissue scarring following inflammation from an environmental or systemic insult (ex. asbestos or rheumatoid arthritis).
S/S:
i) dyspnea, cyanosis, clubbing etc.
ii) scarring on CT
Rx: 
i) O2 therapy
ii) lung transplant
iii) pulmonary rehab

Question 37

Describe the pathology of pulmonary fibrosis and describe the Rx.

Answer 37

Restrictive lung disease and scarring (type of ILD) caused by inhaling harmful substances. Often idiopathic, but 1/3 of the time follows TB.
Rx: radiation, pharma, pulm rehab, lung transplant

Question 38

Name 3 types of ILD and their pathophysiology.

Answer 38

i) pulmonary fibrosis: inhaling harmful chemicals
ii) idiopathic pulmonary fibrosis: scarring w/o known cause
iv) pneumoconiosis: occupational lung disease (ex. coal workers lung esp. asbestosis)

Question 39

Describe tuberculosis as well as the associated S/S.

Answer 39

Myobacterium tuberculosis is an infectious inflammatory systemic disease that has particular effects on the lungs (may disseminate to kidneys, meninges bones etc.). Healthy immune systems prevent infection and keep it dormant. It deposits granulomas into the lungs. S/S include:
i) persistent productive cough
ii)weight loss
iii) fever
iv) night sweats
v) fatigue
Rx: chest PT if needed.

Question 40

Describe the pathology of pleural effusion and describe the two types.

Answer 40

Accumulation of fluid within the pleural space compressing the lung and reducing expansion.
i) transudative: commonly due to heart/renal/liver failure, clear, low protein, endogenous fluid.
ii) exudative: commonly due to infection or cancer, exogenous fluid content (ex. blood, pus etc.), opaque.
Rx: thoracentesis, PT positioning to prevent pressure on one area of the lung.

Question 41

Describe pulmonary edema as well as the presentation and identify possible causes.

Answer 41

Fluid accumulation in extravascular areas of the lung, often in LV CHF, due to back flow of blood into pulmonary circulation and eventually through the interstitium into the lung. May also be caused by increased alveolar permeability (ARDS, drugs etc.)
S/S:
i) pink, frothy sputum.
ii) coarse crackles

Question 42

Describe the pathology of pulmonary emboli as well as the respective types.

Answer 42

Presence of emboli (clot) in pulmonary circulation, usually traveled from elsewhere and blocks blood flow in pulmonary circulation. Rapidly fatal.

i) air emboli: from trauma or surgery, small can be resorbed
ii) thromboembolism: usually dislodged DVT
iii) fat emboli: following # of long bone.

Question 43

Describe the pathophysiology of cystic fibrosis. Explain how it is diagnosed.

Answer 43

An inherited autosomal recessive disorder affecting all EXOCRINE glands (sweat and mucous). Organs most affected include the lungs, pancreas, intestine and liver. An mutated protein produces a thick, sticky mucous that the lungs cannot clear causing persistent infection, inflammation and permanent lung damage. The protein also block Cl- channels causing Na+ and H2O to go along with it. The result is dehydrated sticky mucous. Note: it starts obstructive as unable to push O2 out (hyperinflation), after damage and scarring turns into restrictive disease.
Dx: sweat test (Cl- concentration), gene testing

Question 44

Describe the S/S of cystic fibrosis.

Answer 44

i) dyspnea, clubbing, etc.
ii) delayed puberty
iii) abnormal pale stool
iv) salty skin
v) OSTEOPEROSIS (w/ kyphosis, scoliosis.. eventual myalgia)
vi) dehydration
v) infertility
vi) diabetes?!
vii) thickening of bronchial walls.

Question 45

List some medical and PT management for cystic fibrosis.

Answer 45

Airway clearance techniques (active cycle breathing, autogenic drainage etc.), aggressive antibiotics, bronchodilators.

Question 46

Describe the pathophysiology of peripheral arterial/vascular disease as well as the common presentation.

Answer 46

Occlusion of peripheral arteries, most commonly in the legs, as a result of underlying ATHEROSCLEROSIS. This is a common cause for amputation of the lower limb.
RF: T2DM, CVD, HTN, hyperlipidemia, smoking, sedentary, obesity, age.
S/S:
i) INTERMITTENT CLAUDICATION (pain w/ walking)
ii) reduces puls
iii) ulcers
iv) shiny skin and/or gangrene
v) limited function
vi) Pain, Pallor, Pulseless, Parasthesia, Paralysis, ‘Perishingly cold, Sudden onset of claudication

Question 47

Describe the pathophysiology of thrombophlebitis. List some RFs.

Answer 47

A clot that develops in a vein and occludes blood flow. with secondary inflammation. Can be superficial or deep.
RFs: prolonged immobility, oral contraceptives, smoking, surgery, pregnancy, varicose veins, dehydration.

Question 48

Describe the pathophysiology of chronic venous insufficiency. List some S/S.

Answer 48

Inadequate venous return over a prolonged period. Often caused by DVT, cancer or trauma causing valvular dysfunction and stasis. Most commonly occurs in the legs.

i) thickening and pigmentation (brown) of the skin
ii) progessive edema at the ankles and feet
iii) ulcers
iv) leathery looking skin

Question 49

Describe the pathophysiology of varicose veins and the eventual outcome of concern.

Answer 49

Enlarged, twisted veins in the lower extremity resultant from valvular dysfunction and abnormal dilation. Will develop into thrombophlebitis eventually. Often overlaps with chronic venous insufficiency and can be treated surgically.