Final Flashcards
UTI - Risk Factors
Age
Immobility
Instrumentation and urinary catheterization
Atonic bladder (spinal cord)
Increased sexual activity
Spermicide associated in use with diaphragm
Uncircumcised penis
Obstruction (Renal calculi, Prostatic Hyperplasia, Malformations or urinary tract abnormalities)
Constipation
Women is greater than men (Anatomic variations, Surgical or natural menopause without hormone replacement therapy, Pregnancy)
Kidney transplantation
Diabetes Mellitus
Partners of Viagra
STDs
UTI - Pathogenesis
Most common route: Urethra -> Bladder
Upper or Lower Urinary Tract Infection
Blood borne
Fecal associated gram negative (E. coli – 80%, Staphylococcus – 5-15%)
Acquired via lymphatic system
Prevention: Intermittent/condom catheter
Urinary Incontinence - Definition
loss of bladder control or being unable to control urination
Stress Incontinence
Physical exertion-bending, sneezing, coughing ->
Increase intrabdominal pressure ->
Weakness of PFM (external urethral sphincter) and failure of internal urethral sphincter (IUS)
Urge Incontinence (Overactive incontinence)
Sudden desire
Detrusor instability – not fully understood
Triggers: Running water, anxiety, arrival at home
At what age does incontinence typically occur?
> 60 years
Normal characteristics of urine
Color: Yellow-Amber
Urochome – waste product during protein metabolism
Voiding: 3-5 hours and in elderly 2 hours
Abnormal characteristics of urine
Negative: Glucose, Ketones, Blood, Protein, Bilirubin, RBC, WBC
Pyelonephritis
Bacteria ascending from bladder to kidney
Cause: Vesicoureteral reflux (Backflow of urine into the kidneys)
Clinical Manifestations: Abrupt, Murphy’s Sign (punch costal-vertebral angle)
Renal Cell Carinoma
Tumor in kidneys
Palpable abdominal mass
Hematuria – 50%
Wilms Tumor (nephroblastoma)
Most common in children
Malignant
Clinical manifestations: abdominal mass
Renal Calculi - Nephrolithiasis
Acute “Colicky” pain – flank pain radiates to groin or perineal area (scrotum in males and labia in female) with hematuria
Severe pain – no comfortable position
(stones)
Renal Cystic Diseases
Cyst with fluid or tubular elements (semi solid) ->
Degeneration of renal tissue ->
Obstruction of urine flow
Polycystic Kidney Disease (PKD)
Significantly enlarged kidneys (palpable abdominal mass)
What is Chronic Kidney Disease?
Progressive loss -> End Stage Renal Disease (ESRD) -> Require dialysis or transplant
CKD - Pathogenesis
Release of angiotensin leads to VC
Reduce surface area for filtration -> Reduced Glomerular Filtration Rate (GFR)
Afferent, filtration system , bowman space, proximal tubule, into distal convulant tubule leads to excretion.
CKD - Stages w/values
G1: Normal GFR** (> or = 90mL/min) but other signs and symptoms indicating kidney disease **
G2: Kidney damage with midly decreased GFR (60-89 mL/min)
G3a: Mildly to Moderately decreased GFR (45-59 mL.min)
G3b: Moderately to Severely decreased GFR (30-44 mL/min)
G4: Severely decreased (15-29 mL/min) **Systemic damage **
G5: Kidney failure (ESRD, GFR ,15 mL/min) Systemic damage
Stage G1
Blood Urea Nitrogen (BUN) and Creatinine – typically normal
Stage 1 – reversible (DM), remain indefinitely, some progress
BUN and Creatinine
If kidney is damaged -> Urea retention is high in blood (BUN)
Creatine provides energy to muscles and forms Creatinine (byproduct)
Creatinine travels in blood and excreted in urine
Stage G2
Damage capillaries – leak albumin in urine
Can remain here if proper control of HTN and blood glucose
Stage G3a-b:
More noticeable albumin in urine than blood -> Azotemia
Azotemia: increased BUN and Creatinine (Fever, nausea, etc.)
Stage G4
Kidney not able to function
Proteinuria (albuminuria): Excess amounts of urine
Increased BUN and Creatinine
Increased renin -> hypertensive -> progress to stage 5
(Renin being made causes VC leads to HTN)
Stage G5
Failed kidney often needs multiple dialysis and transplant
Uremia – nausea, vomiting, anorexia, lethargy, pruritis (itching), sensory/motor neuropathy, pericarditis, impaired heart function, asterixis, seizures
Kidney cannot excrete toxins
Not able to maintain pH, fluid, electrolyte
Implications of PT - Kidney Disease
Aware of early signs and symptoms
Always ask: Hematuria, unexplained weight loss
Constitutional Symptoms (aka red flags)
Unexplained or insidious onset of back pain, flank or shoulder pain
New onset of mental state changes or increased confusion – delirum or confusion
Appropriate catheter care – obubstructed flow
(Do not hang the urine collection bag above the level of the bladder, never allow kinking, do not rest it on the floor)
Sternal pain or mass – most common due to metastasis to sternum
HTN – due to obstruction (VC increased leads to this)
Risk for UTI
Increased risk for cerebral and aortic aneurysm (weakening of blood vessels)
Risk for mitral valve problems (more fluid in blood leads to more strain)
Intermittent and sometimes not severe colicky pain
Unilateral back pain – thoracolumbar junction to illiac crest
Murphy’s sign (palpation)
- Treat or refer?
–Refer but screen for more information
Implications of PT - Chronic Kidney Disease
Analgesic Nephropathy (toxicity due to chronic NSAIDs)
HTN Meds (Angioedema is swelling of face, mouth, or throat; educate your patients to slowly rise, dangling feet and legs before standing, educate to report unusual swelling)
Short Term Memory Deficits
Osteoporosis Education (Avoid bending and twisting)
Implications of PT - Dialysis
Do not measure BP on the access site
Watch for HTN and Depression
Hand hygiene is most important – contact transmission (WBCs are being urinated our due to condition so infection risk is high)
Loss of lean body mass masked by fluid retention and weight gain (lose all protein in muscles)
Dialysis hypotension is common – drop in SBP >20 mm Hg or a decrease in Mean Arterial Pressure by 10 mm Hg
Ischemia of the limb: due to Thrombus formation in the access site
Itching and HS reactions
Exercise Considerations - CKD
Mild to moderate strength and mobility training – longer duration needed (slowly increase intensity)
3x/week at 40-70% of target HR
Before, during, after dialysis exercise is fine (watch for signs and symptoms)
Dialysis and non-dialysis days are fine
Exercise Considerations - ESRD (End Stage Renal Disease)
Use RPE to monitor Exercise
Exercise 4-6x/week, interval training
No exercise if K (potassium) is >5 mEq/L
BP >200/100 mm Hg – No exercise
Implications of PT - Urinary Incontinence
Bladder Training – Diary and Voiding Schedule
Hypotension precautions – slow rise from the bed
Pelvic Floor Muscle Exercises and Electrical Stimulation
-10 reps, 3-5x a day
-Vaginal Cone
-Biofeedback for relaxation
GI Disorders - Signs & Symptoms
- Nausea and Vomiting
- Diarrhea
- Anorexia
- Constipation
- Dysphagia
- Achalasia (difficulty passing food)
- Heartburn
- Abdominal pain
- GI bleeding (Hematemesis, Melena, Hematochezia)
- Fecal (Incontinence)
Allways look for Constitutional Symptoms (Red Flags)
Causes of intrabdominal pressure
Lifting
Straining
Bending over
Prolonged sitting or standing
Chronic or forceful cough
Pregnancy
Ascites
Obesity
Congestive Heart Failure
Low-Fiber Diet
Constipation
Delayed bowel movement
Vigorous exercise
Hernia - Pathogenesis
Increased abdominal pressure + enlarged cardiac sphincter, pushes stomach through diaphram
Hernia - Clinical Manifestations
Inguinal Hernia
- Intraabdominal pressure can lead to this
Sliding Hernia
- Heartburn in 30-60 minutes after meal
Large Sliding hernia
- Substernal pain
Hernia - PT Implications
Avoid flat supine position and exercise that requires valsalva maneuver
Educate about intraabdominal pressure (Flex: Breath in; Extend: Breath out
GERD (Gastroesophageal Reflux Disease) - Pathogenesis
Reflux (backward flow) of gastric contents into the esophagus due to relaxation of lower esophageal sphincter or alteration in esophageal acid clearance
GERD - Complications
Esophagitis -> Erosions and Ulcer -> Scarring -> Narrowing of esophagus (difficulty swallowing)
GERD - Signs & Symptoms
Heartburn – burning sensation from stomach and rising to chest
30 to 60 minutes after large meal or spice foods, meal with alcohol
Radiate to throat, back and chest
Nighttime is common – lying down
GERD - PT Implications
Promote
-Weight loss (overweight -> excess abdominal fat -> pressure on stomach)
-Swimming and biking than agitative activities (running and aerobics)
Avoid
-Strenuous exercise – inhibits gastric and small intestinal emptying
-High calorie and fatty food immediately before exercise
Positioning
-More upright position
-Esophageal sphincter strengthening
-Left side lying (prevent regurgitation, aspiration, and promote oropharyngeal accumulations)
Gastritis
Disorder to the mucosa (not muscularis mucosa)
Acute: Hemorrhagic or erosive (NSAIDS and Asprin)
Gastritis - Signs & Symptoms
Epigastric pain with abdominal distension, heartburn, Occult GI bleeding
Peptic Ulcer - Patho
Erosion or ulcer of stomach or duodenum due to mucosal insult
Peptic Ulcer - Signs & Symptoms
-Epigastric pain – burning, cramping, aching near xiphoid
-Radiates to back, midthoracic back, upper quadrant, right shoulder
-Perforation of stomach or duodenum
- Coffee-ground emesis (vomiting blood), melena (dark, tarry stools)
- Back pain relieved by antacids –GI and refer
Celiac Disease (Dermatitis) - Patho
Exposure to gluten -> T-cells on intestine (hypersensitive) -> Inflammation and destruction of intestinal cells -> Complications – Cancer, osteoporosis, etc.
Dermatitis - Clinical Manifestations
No symptoms to life threatening (late diagnosis)
GI symptoms
Nutritional deficits – folate, iron, Vit B12, fat-soluble vitamins
Skin: Dermatitis Herpetiformis – rash with intense itch
What is this?
Dermatitis Herpetiformis
Inflammatory Bowel Disease (IBD) - Two types:
- Crohn’s Disease
- Ulcerative Colitis
Crohn’s Disease
Chronic, lifelong, inflammatory diorder- any segment of the intestine can affect all layers of intestines.
Skip lesions – diseased areas of intestine with normal intestines between
Ulcerative Colitis
Chronic inflammatory disorder of the mucosa of the colon – typically rectum -> proximal involvement to entire colon
IBD - Clincial Manifestations
Joint problems – Sacroilitis, monoarthritic, polyarthritic. Migratoey arthralgia (first manifests (sometimes before bowel symptoms)
Ileum – periumbilical pain, lower right quadrant, can refer low back
Psoas abscess – due to extension of intraabdominal infections
- Flexion deformity with pain in extension, fever, lower abdominal pain buttock, hip, thigh, knee; antalgic gait.
- Muscle Tests (Obturator and Iliopsoas (can also do palpation))
Dehydration - Symptoms
Dry lips, hands
Headache
Brittle hair
Incoordination
Disorientation
Irritable Bowel Syndrome
Chronically recurring abdominal pain or discomfort associated with altered bowel habits – no structural, inflammatory, or biochemical abnormalities
**Unknown cause **
IBS - Clincial Manifestations
Pain – steady or intermittent, morning or after eating
Typical: lower left quadrant pain and constipation and/or diarrhea
Often: Relief with evacuation
Tend to disappear during sleep – Nocturnal GI symptoms suggests other GI disorder
Diverticulitis
Fecal matter goes inside and causes inflammation in intestines
Diverticulitis - Clinical Manifestations
Diverticulosis: Asymptomatic: mild, nonspecific, episodic pain
Diverticulitis: 75% uncomplicated. Left quadrant episodic or constant abdominal pain (often left side – sigmoid)
10-15% - urinary symptoms (bladder)
Eating and increased abdominal pressure can increase pain. Bowel movement or passage of flatus – temporary or complete relief.
Diverticulitis - When to refer?
Back pain of non- traumatic or unknown origin – referral if needed
Colorectal Cancer - Signs and Symptoms
Cardinal Sign: Bright Red Stool (rectum)
Diverticulosis, anal fissures, and hemorrhoids
Appendicitis - Clincial Manifestations
Acute appendicitis: Sequential abdominal pain (epigastric, periumbilical or right lowe quadrant)
Constant Right lower quadrant pain/tenderness
Older adults – slight increase in temperature, vague and mild pain, confusion
Women – Acute pelvic pain
Appendicitis - PT Implications
Early recongition is critical
Typical presentation: right thigh pain, groin (testicular), pelvic pain, referred to hip
Pinch an inch test -> Positive if it reproduces right lower quadrant pain
Peritonitis - PT Considerations
Mostly hospitilized
Monitor vitals
Semi-Fowler position (head an torso raised between 15-45 degrees
Raise the side rails
Extreme caution during positional changes – severe pain – report to team
Hepatitis
Inflammation of the liver
Hepatitis A
Virus (acute infectious condition)
Infection route: Fecal-oral, contaminated food or water, person-person contact
Hepatitis B
- Serum Hepatitis
- Blood, body fluids/tissues, oral or sexual contact
- Can lead to cancer
- Second major cause of cirrhosis
Hepatitis C
Same as Hep B Virus!
Blood, body fluids/tissues, oral or sexual contact
Liver Disease - Signs and Symptoms
- Jaundice
- Asterixis
- Dark Urine
- Spider angiomas (branched dialations of supericial capillaries)
- Pain: Right shoulder pain
- Right Upper Quadrant Pain
- GI symptoms
Jaundice
Aka Icterus
Overproduction of bilirubin
Asterixis
Flapping tremor or liver flap and numbness (misinterpreted for carpal tunnel syndrome)
Inability to maintain wrist extension with forward extension of the upper extremity – quick, irregular flexion and extension of the wrist
Cirrhosis - S & S
Ascites
Bleeding gums
Frequent and heavy nose bleeds
Hematemesis
Light stools (almost white) and Tarry stools
Change in dress – shoes unlaced or wear slippers?
- Edema – bilateral feet and ankles
Gall bladder - Clinical Manifestations
RUQ pain with radiation to right scapula (below or between scapula)
Worsen with fatty meal
Murphy’s sign: Pain – subcostal margin palpation as patient inhales
Acute Pancreatitis - Signs & Symptoms
Mild to profound pain with systemic effects
Abdominal pain – RUQ (dull to maximum intensity within 10-20 minutes)
Back pain
Pain after meal. No comfort with positional change
Trigger: High fat meals
Severe: Tachycardia, Tacypnea, hypoxia, pancreatic fluid filled collection
Pancreatitis - Patho
Chronic Pancreatitis
Chronic inflammation -> irreversible changes
Cause: Alcohol (>50% of cases) metabolite acts as a toxin
Pacreatitis - Clinical Manifestations
Epigastric pain – radiates to back
Pain worsens with meal but relieved knee to chest or forward bending
Pancreatitis - PT Implications
Preferred position for both acute and chronit pancreatitis - leaning forward, sitting up, knee to chest position in side lying
Even small ice chips can increase pain - Do not give any food unless nurse/physician allows. Document
Thrombogenesis
Formaiton of blood clots
Types of thrombus
Arterial – Platelet rich (MI, CVA, PAD) -> amputation -> death
Venous – RBCs and Fibrin (Ex: SVT, DVT
Embolus
A solid mass, gas, liquid, fat moves within blood vessel and lodges at a distant site
Prothrombin Time (PT)
Measures how fast blood can clot
Normal: Range 11 to 13.5 seconds
Partial Thromboplastin (PTT)
Monitor patient response to anticoagulants
D-dimer
Dissolution of Clot -> Fibrin threads (D-dimer)
(>500 ng/mL) -> moderate to high risk (DVT)
Wells Clincial Prediction Rule
-2 to 0: Low probability
1-2: Moderate
> or = 3: High
Hemorrhage - Def
Blood escaping from a ruptured blood vessel
What is this?
subdural hematoma
What is this?
Ecchymosis
What are these two called?
Purpura (Right) and Petechiae (Left – small)
Edema - Def
Accumulation of fluid within interstitial tissues or within body cavities
What is this called?
Anasarca
Anasarca - Def
Generalized Swelling
Common causes - Anasarca
Liver failure
Kidney failure
Right sided heart failure
Anasarca - mechanism
- Hydrostatic force – water pushes it out
- oncotic – protein, increases pressure
- No protein, no oncosing pressure to push stuff back
- Ex: Liver
- Produces no protein -> We have water outside, no proteins -> Pitting
Pitting
Often associated with non-lymphatic obstruction
Low protein, high water. Easier to treat.
Non-Pitting
Often with chronic lymphatic obstruction
Harder to treat. High protein.
Types of shock
Hypovolemic: loss of more than a fifth of blood plasma leading to reduced tissue perforation. Insufficient amount of blood for the heart to pump leads to organ failure.
Cardiogenic: Unable to properly pump oxygen rich blood around
Reduced system vascular resistance
Shock - Signs & Symptoms
Tachycardia
Tachypnea (shallow/narrow breaths)
Cool extremities
Decreased pulses
Decreased urine output
Altered mental status
Atherosclerosis
Plaque (a fatty mass protruded in the blood vessel lumen)
Beginning: simple and reversible (Exercise and diet)
Later: Endothelial cells swollen with accumulation of lipids and develop gaps between endothelial cells
Atherosclerosis - Modifiable RF
**Shown to reduce:
Smoking – Nicotine (increases fibrinogen and produces some chemicals that directly affect BV)
Elevated LDL/Total Serum Cholesterol
HTN
Likely reduce
Obesity
Physical Activity is equal to high cholesterol, smoking and high BP
Diabetes (Target A1C <6.5%
Low HDL
60% of adults in the US lead a sedentary life compared to HTN (10%), hypercholesterolemia (10%), smoke one or more packs a day (18%)**
Atherosclerosis - Non-modifiable RF
Age (Women >55; Men >45), Gender (male), Genetics, Ethnicity, Infection (viral, bacterial)
ABI - Normal/Abnormal
Normal: 1.0-1.4
Abnormal: Less than or equal to 0.8. No support stocking! Artery is constricted already, do not want to cause more vasoconstriction.
BP Guidelines
Orthostatic Hypotension - Patho
Autonomic nervous dysfunction (Smooth Muscle – heart and BV – heart-beat, widening BV)
Can cause hypotension: L-dopa, Nitrates, Calcium channel blockers
Hypotension - Signs & Symptoms
Dizziness
Blurring or loss of vision
Syncope or fainting
In older adults: Unexplained or unexpected falls, acute or chronic mental confusion, cardiac symptoms
Lethargy, weakness
HTN - Signs & Symptoms
Asymptomatic: Elevated BP is only sign in early stages
Headache (worse in morning – cortisol, worse on walking)
Vertigo
Flushed face
Spontaneous epistaxis (nosebleed)
Blurred Vision
Nocturnal urinary frequency
Progressive HTN
- CV Symptoms: Dyspnea, orthopnea, chest pain, leg edema
- Cerebral symptoms - confusion
Aneurysm - Patho
- Loss of smooth muscle cells
- Increased matrix metalloproteinase – degradation of elastin
Plague -> Erode -> Stretching of inner/outer layer -> Sac formation
Aneurysm - Def
Abnormal stretching (dilation) of blood vessels (typically > or = 50% of the diameter) - arteries and veins
Abdominal aneurysm
4x more common
Mostly asymptomatic
Intermittent or constant pain
**Mild to severe mid-abdominal
Groin, genitalia, buttock, legs or flank pain
Abdominal heartbeat or dull ache – supine
Back pain may be the only symptom before rupture
> or = 5 cm -> rupture**
Abdominal aneurysm - S & S
Sudden Severe Headache
Nausea and vomiting
Pain above and behind one eye
Sensitivity to light
Drooping eye lid
abdominal Aneurysm - PT Implications
Single or bilateral SLR (single leg raise) - manual muscle testing precautions
Only one leg at a time!
Always palpation for mass before any abdominal procedures – manual therapy or soft tissue/scar mobilization
DVT - RF
Hospitalization/Immobilization
Cardiac Failure
Surgery
Fracture or dislocation
Local trauma
Smoking
Genetics
Neoplasm
Diabetes Mellitus
Obesity
Previous DVT
> 60 years old
DVT - S & S
Dull ache or tight feeling in legs
Pain or tenderness in calf
Leg or calf swelling
- Pitting edema
Warmer skin
Dilation of superficial veins
Cyanotic – severe obstruction
DVT - Precautions
Compression and anticoagulation are standard
Anticoagulant therapy - Monitor for blood in urine, stool, teeth, or any bleeding
DVT - Ambulation
Warfain (Brand name: Coumadin) - Monitored by PT reported as INR
Do not ambulate until you receive results
Un-fractioned Heparin – monitored by PTT
Ambulate if normal
Low molecular weight heparin (LMWH) - almost immediately
What is this?
Varicose Veins
Varicose Veins - S & S
Dialted, tortuous, elongated veins beneath skin upon standing
Varicose Veins - PT Implications
Education
- Avoid – prolonged standing, sitting, corssing legs, sitting too high or deep, constrictive clothing
Compression – Gold standard
Do ABI before compression
- Want to make sure it is venous NOT arterial. We don’t want to compress BVs if it is arterials because we don’t want vasoconstriction.
Chronic Venous Insufficency - S & S
Hemosiderin – stores iron in tissues
Venous stasis ulcer (80% of ulcers)
Can be very painful
Pulmonary Embolism - Clincial Manifestations
**Can lead to silent death
Depends on size and location:
Pleuritic chest pain – inhalation and exhalation
Hemoptysis (cough up blood)**
Angina - Pathogenesis
Myocardial oxygen supply DOES NOT meet an increase in Myocardial Oxygen Demand.
Heart is supplied with blood from the coronary arteries. Without oxygen leads to chest pain.
Causes: Artherosclerosis, Aneurysm, Cocaine use (Sympathomimetic effect, increases HR and contractility), >90% cases caused by Coronary artery occlusion (one or more coronary artery) - Metabolites in the ischemic cell or stretching of myocardium -> irritates myocardial fibers -> myocardial pain
Angina - Types
- Stable Angina
- Unstable Angina
Stable Angina
Classic Exertional Angina
Symptoms relieved with rest or with Nitroglycerin (<15 minutes)
Predictable using Rate Pressure Product (RPP = HR x SBP)
Measures stress on cardiac muscle
Unstable Angina
Unpredictable symptoms and can occur at any time without any precipitating factors
Usually lasts >15 minutes
Resistant to treatment (Nitroglycerin doesn’t have an effect)
Increased risk for MI and Heart arrythmias (lethal)
Angina - Signs and Symptoms
Shortness of breath
Fatigue
Diaphoresis (increased fatigue)
Weakness
Women: Discomfort, crushing and pressing, bad ache
Atypical: Older Adults
Dyspnea
Diaphoresis (Increased fatigue)
Nausea
Vomiting
Syncope
Substernal Pain or retrosternal pain
MI
Fingers clenched, middle of chest, substernal pain
Angina - PT Implications
Differential Diagnosis
- Anterior chest wall syndrome: localized tenderness of intercostal muscles
- Tietze syndrome: costochondral junction inflammation
- Heartburn: Indigestion, Hiatal hernia, gallbladder, esophageal spasm, peptic ulcer, stress
- Pectoralis Major/Minor Tightness
Nitroglycerin
Keep handy
Not relieved by rest or not relieved up to three doses of NG in 10 to 15 mins (5 minutes incremental) – Needs physician evaluation
Promote sitting during Nitroglycerin administration – Syncope & Falls
Check expiration if NG does not produce a burning sensation under the tongue – Need to be replaced in 3 months
Educate patients to follow Nitroglycerin schedule (not less or not more)
Monitor Vitals (BP, HR, and RR)
What is the leading cause of death in the Unites States?
Myocardial Infarction
What is the best predictor of heart attack and CHF?
Best predictor of Heart Attacks (MI)
- Waist to Hip Ratio
Best predictor of CHF
- Pulse Pressure
40 = Healthy
>40 = Abnormal
Zones of infarction - MI
Non-contractile tissue, electrically inert
Dead cells removed and fibrous scar formation
Transmural MI
Necrosis of entire heart tissue
Non-Transmural MI
Necrosis of some layers of heart tissue
Contraindications to exercise after MI
Acute MI (1-2 days w/o physician approval)
Unstable angina
ECG with abnormalities
Signs and symptoms of MI
Poor Oxygen saturation
Hemoglobin less than 8
Acute infection
Right Vs Left CHF – clinical manifestations
Left: Progressive dyspnea, Frothy pink sputum, cerebral hypoxia (irritability, restlessness, confusion, impaired memory, sleep disturbances)
Right: Dependent edema, JVD, Abdominal pain and distention
People can have both.
What is this called?
Jugular venous distention
Dilated Cardiomyopathy - symptoms
Symptoms: Fatigue, weakness, chest pain (not like unstable angina)
BP: Normal or Low
Hypertrophic Cardiomyopathy - Symptoms
Symptoms: Asymptomatic, exacerbated during exercise, increased left ventricular pressure, dyspnea
Presenting symptom: Sudden death
Peripartum cardiomyopathy
Symptoms:
- Orthopnea, cough, palpations, high BP
- Be careful: these may not be present right after the delivery and may take several weeks after delivery
(Weakness of heart)
Mitral Regurgitation – Clinical Manifestations
Asymptomatic to dyspnea symptoms (Orthopnea, Paryoxsmal nocturnal dyspnea)
Fatigue
Right Ventricular Hypertrophy
Asymptomatic until irreversible left ventricular dysfunction
Exertional dyspnea (due to increased left atrial pressure)
Exercise induced fatigue (due to decreased cardiac output)
Aortic Insufficiency – Clinical Manifestations
Wide pulse pressure (>40)
Systolic HT
Exertional dyspnea
Fatigue
Angina, Palpation, Nocturnal dyspnea
Stenosis
Narrowing or constriction of the valve, not able to fully open due to scars or abnormal deposits on the valve leaflets
Obstruction of blood flow
Heart chamber must work against it
Regurgitation (Insufficiency)
Valves DO NOT properly or adequately close in insufficiency
Backward blood flow
Gradual dilation of the heart to increase cardiac output (CO)
Infective endocarditis - clinical manifestations
Arthralgia
Myalgias
Low-back pain
Clubbing
Splinter hemorrhages
Confusion
Rheumatic fever and heart diseases – clinical manifestations
Sore throat (Pharyngitis)
Fever
Carditis
- Pericardial inflammation, chest pain, mitral or aortic valve dysfunction
Acute migratory polyarthritis
- Occurs 2 to 3 weeks after the initial cold or sore throat
Migratory arthralgia – knees, shoulder, feet, ankles, elbows, finger
24 hrs. to several weeks
Chorea (Syndenham) – rapid, purposeless, repetitive movements
- Less common
- Occurs after 1 to 3 months of initial sore throat
- Always preceded by polyarthritis
- Last for weeks to years without permanent CNS impairment
Shortness of Breath (SOB)
Subcutaneous nodules
- Bony prominences and extensor surfaces – knee, heel, arms, back of the head
- Nocturnal cough
- Pericarditis – pathogenesis and clinical manifestations
- Most common vitals and their normal ranges – BP, oxygen saturation, RPE, HR
What is this?
Erythema Marginatum (ring or crescent shaped)
- Evanescent, non-tender, non-puritic rash in trunk and limbs
What is this?
Pericardial Effusion
- Abnormal excess fluid accumulation between the pericardial layers
What is this?
Cardiac Tamponade
- Pericardial effusion with an epigastric bulge
Do beta blockers and calcium channel blockers change HR? In that case, how would you monitor their CV response to exercise?
Beta blockers and Ca+ will lower HR. Monitor patient with RPE.
Exercise Considerations – Pacemakers and AICD
Demand Pacemakers: HR will rise with intensity of exercise
Fixed: HR will not change
- Keep a lower limit for HR
Automatic Implantable Cardioverter Defibrillator (AICD)
- Will deliver shock with ventricular arrythmias
- Find the HR limit for AICD
May need to provide more than typical 5-10 minutes of cool down period
Irregular HB: >6 isolated HB/min - report to physician
Pneumonia - Patho
Endotoxins from infecting organism ->
Damage epithelial cells, goblet cells, and bronchial mucous glands, type II pneumocytes ->
Thickening of bronchial walls with edema ->
Decreased mucociliary clearance
Infection of lung parenchyma
Pneumonia - S & S
**Sudden and sharp pleuritic pain
**Hacking cough
**Productive cough – rust-colored, green purulent
**Decreased chest excursion on the affected side
Slow and mild unnoticeable fever
Complications: Pleural effusion, empyema, lung abscess
Chronic Obstructive Pulmonary Diseases (COPD) - Def and Types (2)
Progressive airflow limitation that is not fully reversible
- Chronic Bronchitis
- Emphysema
Chronic Bronchitis - Patho
Inflammation -> Hypertrophy of goblet cells, mucosal glands, and Smooth muscle -> Impaired ciliary function airway -> obstruction -> poor removal of secretion -> Infection => further mucus production
Distal portions affected -> impairs alveolar ventilation, V/Q mismatch, hypoxia (cyanosis), acidosis
Chronic Bronchitis - S & S
Persistent cough and sputum (morning and evening than midday)
Prolonged expiration & wheezing
SOB, reduced chest expansion
Recurrent infection – fever
Cyanosis
Exercise intolerance
Emphysema - Def
Enlargement of the air spaces beyond terminal bronchiole with decreased elasticity in the distal airways – airway collapse and air trapping.
Emphysema - Patho
Air comes in and gets trapped, old air insides stops new air to come in as air is already in. Air isn’t participating in the gas exchange, aka increases dead space
Emphysema - S & S
Exertional dyspnea to dyspnea at rest
Cough uncommon with little sputum (vs. Chronic bronchitis)
Thin, Tachypnea, prolonged expiration, accessory muscle use
Leaning forward position (diaphragm into a more domed position)
Barrel chest
Nocturnal hypoxemia – decreased sensitivity of chemoreceptors, decreased firing of the intercostal muscles and increased airway resistance – V/Q mismatch – Nocturnal hypoxia
Asthma - Def
Inflammation and increased smooth muscle contraction of the airways to stimuli
Reversible obstructive lung disease
Asthma - Patho
Allergen (IgE mediated) & structural changes ->
Vascular congestion
Vascular permeability - Edema
Mucus (tenacious)
Increased bronchial smooth muscle contraction ->
Impaired muco-ciliary function
Asthma - S & S
Sensation of suffocation or chest tightness – typically the first sign
*Inspiratory and expiratory wheezes
*Non-productive hacking cough to tenacious sputum
Emergency: SBP decreases >10 mm Hg during inspiration, tachycardia, pulsus paradoxus -> Cardiac Arrest if untreated.
Bronchiectasis - Patho
Inflammation – enzymatic degradation of airway connective tissues
Bronchiectasis - S & S
Foul smelling sputum, Persistent coughing and large purulent sputum (morning worse)
Cystic Fibrosis - Patho
Complex and largely unknown
Cl and Na channels effected, elevated
Cystic Fibrosis - S & S
Cough
Sputum
Fever
Weight Loss
Wheezing
TB - Latent and TB disease Patho
Mycobacterium TB, Droplet nuclei, Alveoli ->
- Immune cells and Granuloma - (Latent TB – Not infectious and seen only in tuberculin test)
- TB disease (active infection) – Caseating necrosis, cavity, fibrosis, and calcification of tissues
TB - Latent and TB disease Complications
Tuberculous spondylitis (Pott Disease)
Precautions while treating TB patients
KN95, Gloves, Disinfect Stethoscope, hand washing, yearly TB tests, isolation precautions
Pulmonary Edema - Symptoms
- Engorged neck (Jugular vein distention) and hand veins –- peripheral edema
- Severe -> pink frothy sputum
Physical Therapy
- High fowler position with leg dangling – reduce venous return
- Monitor vitals – life threatening in few minutes
Pulmonary Embolism - Patho
Blood clot in the pulmonary artery
– Obstruction of blood supply to the lung parenchyma
Most common cause: DVT (LE – popliteal or iliofemoral (50%), deep calf veins (5%), 20% UE –subclavian vein)
Most common cause of sudden death in the hospitalized population United States
Pulmonary Embolism - Clinical Manifestations
Dyspnea (84%)
Deterioration of existing dyspnea (74%)
Pleuritic chest pain (74%)
Apprehension (59%)
Cough (53%)
Tachypnea (92%)
What would happen to FEV1/FVC ration in obstructive vs. Restrictive lung conditions?
COPD: FEV1 and FVC decreased
Restrictive: FEV1/FVC remain same or slightly decreased
Cyanosis – Where would you look for central and peripheral cyanosis?
Central – discoloration of the body & mucous membranes (Oral, lips, conjunctivae)
– Arterial saturation is decreased (Inadequate oxygen saturation (deoxyhemoglobin >5.0g/dL) & Decrease in total amount of circulating hemoglobin)
Peripheral - distal extremities
– Arterial saturation may be normal
– Decreased blood supply and perfusion than unsaturated blood
Atelectasis PT management – how deep breathing exercises help?
Deep breathing open the Kohn’s Pores (Connection between one aveola to another)
Which is normal/abnormal?
Left: Normal ; Right: Abnormal
Hemothorax
Blood in pleural space
Pneumothorax
Air enters into pleural cavity
Open pneumothorax
Inspiration shift left (mediastinal and trachial)
Expiration shifts right (mediastinal and trachial)
Tension pneumothorax
Try to seal over open wound over pleural cavity. Air breathed in gets stuck near seal -> building pressure
Pericardial effusion vs pleural effusion
Pericardial effusion
Buildup of fluid around the heart.
Pleural effusion
a collection of fluid in the pleural space between the membrane encasing the lung and the chest cavity
Pleural rub vs. Pericardial rub characteristics
Pleural rub creates pain mostly on the lateral part of the chest wall, whereas pain due to pericardial rub is always central in location. The intensity of pleural rub is increased on pressing the diaphragm of the stethoscope over the affected area, whereas there is no such change in case of a pericardial rub.
Cessation of sounds with holding breath (vs. Pericardial friction rub)
Exercises for restrictive lung disease
Monitor Vitals
Constitutional Symptoms
Bilateral UE D2 Flexion to improve chest wall movement in restrictive lung disease
Pursed Lip breathing/deep breathing
O2 Stat Values
Normal 95-100%
Low 90-94%
Supplemental O2 req’d <90%
Osteoporosis
Postmenopausal (Primary, Type 1)
- Decreased Estrogen ->
- Increased Osteoclast activity and Decreased apoptosis ->
- Increased bone resorption
Senile Osteoporosis (type II/Secondary):
- Decline in Alpha 1- hydroxylase activity in the kidney ->
- decline in serum 1,25-dihydroxyvitamin D (1, 25 (OH) 2D) ->
- malabsorption of calcium and secondary hyperparathyroidism ->
- Bone resorption
T Score of -2.5 and lower
Osteopenia
Low Bone Mass
T: Score: -1.0 and -2.5
Osteomalacia
Impaired bone mineralization
Osteomalacia - Patho
- Vit. D Deficiency
- Renal Osteodystrophy
– (CKD, <60 mL/min GFR)
Osteomalacia is called what in children?
Rickets
Signs and Symptoms: Osteomalcia
Subtle – delayed diagnosis
Diffuse bone pain and tenderness
Paget’s Disease - S & S
- Asymptomatic
- Pain – itself or arthritis in knee or hip
- Skull – Enlargement leads to headache, dizziness, hearing loss
- Spine- tingling and pinched nerves
- Lower Legs – bowlegs and difficulty in walking
Possibility of Heart Failure
Def: New bone gradually regrow onto old bone
Paget’s Disease - Heart Failure
due to increased work for heart to supply blood to the newly formed bones
Osgood Schlatters Disease
Pulling of small bits of immature bone from tibial tuberosity
Osgood Schlatter Disease - S & S
-Increased Q angle – knock knees/flat foot
- Patella Alta (high patella)
– Patella tracking affected; Patella gets pulled up by quadriceps tendon when the ischial tuberosity breaks off.
- Pain
– Flexion moment – increased stress on the tibial tubercle
- Minor stretching is okay, NOT aggressive
What is this called?
Osgood Schlatter Disease
Osteomyelitis - Pathogenesis
- Inflammation of the bone by infection – Bacterial, Fungus, parasites and viral
- Staphylococcus Aureus
Osteomyelitis - How do children get it?
Sharp turn of vasculature leads to blood slowing down. Results in microabscess occuring at this location.
Osteomyelitis - Why do adults not get this as much?
Rare as adults do not have same blood supply
Osteomyelitis - When to refer?
Refer patient if they have pus or if they do not have medication. Easier to treat because of more blood circulation.
Osteomyeltiis Clinical Manifestation - Children
Unexplained cellulitis (painful skin infection with swelling and warmth)
Osteomyelitis - Acute OM
- Low grade fever – systemic
- Pain – intermittment/constant/deep
– Aggravated with activity (increases with weight bearing)
– Periosteum – rapid development of pain, fever, swelling - Spine and Abcess – rigidity, instability
– Psoas abcess – painful hip extension (antalgic gait)
– Myelopathy, Meningitis
Osteomyelitis - Chronic OM
- Local pain, swelling, limping
- Sausage Toe – Good sensitivity and specificity in diabetes
What is this called?
Osteomyelitis
Avascular necrosis - which movements are affected
AROM pain – hip internal rotation and flexion and adduction
Legg-calve-perthes disease - which movements are affected
AROM limitation in hip abduction and rotation (Internal rotation)
OA - Pathogenesis
Wear and Tear – Passive process
Active process
- Matric Metablloproteinases and cyotkines lead to loss of type 2 collagen -> Catabolic degredation of cartilage -> reduced frictionless movements
OA Management
Pharmalogical: NSAIDs
Surgical
Walking
What activities and exercises are strongly recommended for OA management according to 2019 guidelines?
Walking
Gout
Uric acid crystalizes (mono sodium urate crystal – MSU)
Gout - S & S
*Tophi – Subcutaneous nodules of sodium urate crystal (In image)
*Fewer
*Chills
*Malaise
*Pain – Intense “on fire”
*Swelling
Sprain and Stain – degrees
*First degree (mildest) – little tearing, pain or swelling; joint stability is good.
*Second degree – broadest range of damage, with moderate instability and moderate to severe pain and swelling.
*Third degree (most severe) – ligament is completely ruptured; joint is unstable; severe pain and swelling; other tissues are often damaged
Osteochondritis Dissecans
Repetitive stress -> Ischemia and subchondral growth cessation -> Necrosis -> Articular cartilage softening -> Fragment seperation
What is this?
Osteochondritis Dissecans
Muscular dystrophy – Gowers sign and PT exercise modifications
Gowers sign
-Lumbar lordosis
-Toe walking – calf, anterior tibial, peroneal
-Pseudohypertrophy of calf muscles
-Scoliosis
PT Exercise Modifications
-No strenuous exercise
-Low weight, high repitions
-Encourage mobility
Most common muscles weakness associated with muscular dystrophy
Lumbar and gluteal muscles
Rhabdmyolysis - Patho
Muscle damage - Myoglobin -> block kidney-> Kidney failure
Statin Induced Myopathy (cholesterol medication control – statin; Ex: Prozac)
Rhabdomyolysis - S & S
Tea colored or cola colored urine
Rhabdomyolitis - Exercise Modifications
Allow for athletes to properly hydrate when exercising at a high intensity especially when it is hot out to help prevent dehydration. Exercise induced muscle damage can be a sign for rhabdomyolysis be careful.
Myositis Ossificans - PT Implications
Contraindication:
- Aggressive Stretching
Allowed:
- Passive and active movements and strengthening
What is this?
Myositis Ossificans
DOMS and EIMD – Exercise modifications
New exercise during training - Progressive approach of exercise in 1 to 2 weeks
Delayed Onset of Muscle Soreness (DOMS) - 24 to 48 hours
Exercise Induced Msucle Damage (EIMD)
- Inflammatory markers of muscle damage - inflammation
Hypothyroidism - Patho
Iodine Deficiency or Inflammation/Hashimoto’s Thyroiditis ->
Reduced functional thyroid gland ->
Decreased T3 and T4 ->
Hypersecretion of TSH (Due to little T3, T4 because of no iodine) ->
Large production of Thyroglobulin (colloid) -> Glandular enlargement (Colloid Goiter)
Hypothyroidism - S & S
- Weight gain due to decreased lip metabolism
- Fatigue and increased sleep (Due to no energy conversion)
- Prolonged DTR (especially Achilles)
- Bradycardia
- Myxedema
- Constipation
Hyperthyroidism - Patho
Graves Disease (85%), adenoma, thyroid cancer
GD
Increases grandular size ->
Increases synthesize of thyroid hormone ->
- Increased T3 and T4
Results in Goiter
Hyperthyroidism - S & S
Myopathy – difficulty ambulaating, stairs, raising from chair
Heat intolerance
Diarrhea
Weight loss
Tremor
Increased DTR
Atrial fibrillation
Exophthalmos – Protriding eyes
Hair loss
Hyperthyroidism Acute flareup
Can be life threatening
- Fever
- Severe tachycardia
- Delirum
- Dehydration
- extreme irritability
What is goiter, grave’s disease, and exophthalmos?
Goiter
- Glandular enlargement (Colloid Goiter)
Grave’s Disease
- Autoimmune Disease
Exophthalmos
- Protruding Eyes
- Lots of fluid on the backside of the eye
What is this?
Exophthalmos
Would you do exercise when someone has exophthalmos?
No! Document and refer! This can lead to stroke.
Hyperparathyroidism
Excess Calcium in the blood (binded to phospate)
- Osteoclastic activity -> osteoporosis and fractures
- High Ca+ in renal tubules – Nephrocalcinosis (kidney disease) - stone formation
Decreased Vitamin D, leads to less Calcium absorption
Hyperparathyroidism - Clinical Manifestations
Mild to severe proximal muscle weakness of the extremities
Muscle atrophy
Cushing’s Syndrome - PT Implications
Excess Cortisol
- Stength Training – Large Groups (Avoid extreme stress)
- Education on proper body mechanics
- Jogging is not recommended
- Manipulation – Caution (Bones are weak)
What is this?
Cushing’s Syndrome
Fluid imbalance – dehydration signs and symptoms
Fluid Deficit – loss of fluids (hemorrhage, burns, diarrhea, diaphoresism vomiting)
-Poor skin turgor
-Weight loss
-Dryness of mouth, throat, face and absense of sweat - thirst
Actions – Glucose and Insulin
Glucose: Provide energy for cells: muscle, fat, liver and brain.
Insulin: Allows for glucose to be utilized by opening channels
Type 1 DM - Patho
- Auto-immune disease (Type 4 HS)
- Beta Cell destruction in pancreas
- No insulin production (absolute insulin deficiency)
- Ketoacidosis (Excess ketones create metabolic acidosis)
Type II DM - Patho
Normal or excess insulin production
Reduced number and function of insulin receptors – insulin resistance
- Increase blood glucose, cell’s don’t receive glucose
Hypoglycermia - Cardinal Signs
Rapid onset (minutes) - Hypoglycemia
Difficulty concentrating, speaking, focusing
Shaky
Shallow respiration
Hyperglycemia - Cardinal Signs
Gradual (days) - Hyperglycemia
Lethargic
Confused
Thirsty
Dry
Dupuytren contracture
More common in type 1 than type 2
Flexion contracture, nodules (distal palmar crease), thickening cord of palmar fascia – usually third and fourth digits
What is this?
Dupuytren contracture
Diabetic ketoacidosis
- Blood glucose >300 mg/dL (250-300 is caution)
- Thirst (very dry mouth)
- Hyperventilation
- Fruity odor breath
- Confusion
- Dehydration
- Arterial pH <7.30
Insulin shock
- Blood Glucose <70 mg/dL
- Perspiration
- Irritability/nervousness
- Weakness
- Hunger
- Fatigue
- Numbness or lips/tongue
DM - Blood Glucose Levels
Safe Zone: 100-250 mg/dL
Goal:
Type 1: 90 to 130
Type 2: Up to 150
250-300: CAUTION
DM - PT Implications
Encourage fluid intake before exercise
Exercise after 1 hour of a meal
Do not exercise without a meal for 2 hours
Do not inject short acting insulin to the site for 1 hour after exercise – quick absorption
Monitor glucose before and after exercise
- BG decrease when doing strength training
- Cardio – Only for heart, oxidative system
Sickle Cell Disease - S & S
Anemia
Severe infection
Headache
Enlarged organs
Acute episode of SCD
- Hand foot syndrome (painful swelling of hands and feet)
Anemia - PT Implications
Hemoglobin
- <8 g/dL Symptom based approach (monitor vitals especially Spo2)
- <5-7 g/dL (low critical value – HF or death)
Hematocrit
- Male: 42-52%
- Female: 37-47%
- <25% symptoms based approach
Use RPE and gradually increase exercise – poor exercise tolerance
Very careful when using cold
- Cold increases VC and sickling – contraindication for SCD
Anemia - S & S
Fatigue and weakness with minimal exertion
Bleeding – gums, mucous membranes, skin
Thrombocytopenia
Decreased platelets – increases likelihood for bleeding
Thrombocytopenia - S & S
Mucosal bleeding – brushing teeth
Respiratory tract – blowing nose
Uterus – excessive menstrual bleeding
Brain – external hematoma
Thrombocytopenia - PT Implications
Bleeding? Apply ice and pressure
No strenuous exercise allowed
Blood pressure cuff – CAUTION (Give LOTS of time in between each measure)
Mechanical compression and pneumatic pump – contraindicated
Keep eye on aspirin intake – need physician approval
<20 k/uL: Symptom based approach
20,000 - 40,000: Low intensity exercise with no weight or resistance up to 2 lbs
- No resistance during statioonary biking
10,000: Spontaneous CNS, Respiratory tract, and GI bleeding
Ambulation precautions – get clearance from the healthcare team for ambulation
Leukemia S & S - Acute and Chronic
Acute
* Spontaneous bleeding – skin and mucosal surfaces
* Mid-cycle menstrual bleeding or heavy menstrual bleeding
* Leukemia cutis – infiltration of the cancer cells to skin
Chronic
* Nonspecific
* Weight loss
* Splenomegaly (Left upper quadrant pain)
* Chronic to acute leukemia and die within months
What is this?
Leukemia
Lymphoma - S & S
Drenching night sweats
Unexplained weight loss (>10% of BW) over six months
Unexplained fever
Enlarged Lymph nodes
Polycythemia Vera
Neoplasm of bone marrow -> Increased RBC production
Leukemia
Neoplasm of WBC
Infiltration and spread to blood stream and organs
Multiple Myeloma
Primary malignant neoplasm of plasma cells
Second most common hematologic cancer
Lymphoma
Neoplasm of the lymphatic system
Hodgkins Lymphoma
- Upper body
- Reed-Sternberg Cell
Non-Hodgkin’s Lymphoma
- Abdomen, groin
- More common, poor prognosis
Malignant Melanoma
Neoplasm of the skin (Melanocytes – synthesize melanin) cells
Normal and abnormal lymph node identification
Normal: soft, rubbery, mobile, small (<1cm)
Abnormal: Tender, warm, enlarged (but mobile and soft)
Malignant: Enlarged, hard, non-tender or non-mobile
Dermatitis vs. cellulitis
Dematitis: Eczema
- Contact dermatitis
Cellulitis – Infection
- Rashes often with pain and fever
Caution with redness due to orthotics and prothetics
What happens to Calcium absorption, Vit. D, Phosphorus, Parathyroid hormone, Calcitonin levels in Osteoporosis and Hyperparathyroidism?
Parathyroid hormone increase
Activate Osteoclasts break down bone Ca and phosphorus comes out od bone (free calcium)
Ca has high tendensy to attach to phosphorus but in blood stream is low
Leads to more PTH to break things down more because low in blood.
Total calcium level is elevated in this test – calcium level is high
Total phosphorus level is high
PTH is high
Vitamin D deficiency leads to no absorption of Ca from interstine.
Calcitonin is the opposite of PTH don’t have strong evidence what happens with interactions of these other minerals.
What do cancer cells secrete?
PTH like hormone
