Other Systems 2 Flashcards
System interactions in pregnancy
- Postural changes
- HR and BP changes
Side lying in pregnancy
LEFT S/L
AVOID Supine hypOtensive Syndrome
Pregnancy complications
Pre-eclampsia vs Eclampsia
Gestational DM
Pregnancy exercises
Posture
Precautions
Changes w/ Pregnancy
Weight GAIN
How much and why?
20-30lbs
ESSENTIAL for baby’s nourishment
Changes w/ pregnancy
MSK System
Talk about posture
Posture changes!
Forward head-> kyphosis-> incd lordosis-> APT—think COM moves forward
Postural stress continues post-partum d/t lifting and carrying of baby
Changes w/ pregnancy
MSK Changes
Posture
How do we TREAT this?
- Posture edu., stretch tight mm’s/strengthen weak mm’s, pelvic stab. ex’s, POST. pelvic tilts
CVS Changes: Pregnancy
ALL first…summarized
- BP LOW in first and second trimesters then INCs last trimester
- Supine lying compresses IVC (after 4th mo.)–> NO supine lying after 1st trimester
- RHR INCs 10-20bpm
- L. S/L== BEST
CVS Changes: Pregnancy
BP
LOW in first/second trimesters
INCs last trimester
CVS Changes: Pregnancy
Supine lying
- compresses IVC
- DEC in CO==> supine hypotensive syndrome
- NO supine after 1st trimester!!!
In gen, CO INCs, but Decs in supine!!
CVS Changes: Pregnancy
RHR
INCs 10-20 bpm
CVS Changes: Pregnancy
LEFT S/L
- BEST!!!
- DECs compression IVC, maximizes CO, DECs GERD bc int. organs relaxed, improves maternal and fetal circ.
System Interactions in Pregnancy
See chart
Practice!
34yo pregnant female doing pelvic floor ex’s in supine. Dizzy, sweating, nausea. Which cond?
Supine HypOtensive syndrome bc supine compresses IVC
A: Incd pressure on IVC causing hypOtensive syndrome
Pre-Eclampsia think….
Acute HTN!!!
*usually BP inc’s 3rd trimester, but this is acute/sudden HTN
Pre-Eclampsia
How is this dx confirmed??
think pregnancy induced HTN
BP reading in excess of 140/90.. THEN
2nd abnorm BP reading 4hrs AFTER first CONFIRMS dx
EMERGENCY!
Pre-Eclampsia
what is it and s/s?
Pregnancy induced HTN after the 20th wk of gestation
- S/S: Inc in PRO in urine, hypERreflexia, edema, HA, sudden wt gain
This pregnancy complication is ALWAYS ACCOMPANIED W/ SEIZURE
Eclampsia
Practice!
Pt seen AFTER UNcomp’d vaginal delivery of 3rd child. During tx, pt begins to complain of HA, vis. disturbs, suddenly develops SZ. MOST likely cond?
A: Eclampsia– AFTER pregnancy, or DURING delivery– ALWAYS assocd w/ SZ
Other answers:
- PREeclampsia== DURING pregnancy– preg induced HTN
- Gestational DM== INC BG during pregnancy, usually returns to NORM (remember FBG >126, Total BG >200)
- Ectopic preg== fert egg implants OUTSIDE uterine cavity
Practice!
PT educating one of their pts regarding effects of pregnancy and implications for positioning and posture. Which is LEAST approp?
INAPPROP== small wedge under L. hip during 2nd trimester– WRONG! you want L. S/L!!! (so put it under R hip)
Other answers (all approp):
- Pt w/ preg induced HTN must NOT do high int ex’s
- breath-holding, valsalve’s should be AVOIDED
- Borgs 12-14 during ex is acceptable for UNcomp’d preg
Pregnancy and Contraindications to Ex.
DO NOT EX when…
- Hemodynamically sig. heart dis/comps
- Restrictive Lung Disease
- INcompetent cervix- EARLY dilation of cervix BEFORE full term
- Vaginal bleeding- esp 2nd/3rd trimesters
- Placenta previa after 26wks gestation- placenta in descended pos and may detach before delivery
- Preeclampsia or preg induced HTN
- Rupture of membranes–lose amniotic fluid
- Premature labor- labor before 37th week of preg
- Maternal T1DM- Diabetic ketoacidosis
- Severe anemia- HbG lvls low
Practice!
20yo female after UNcomp’d delivery has 3cm diastasis recti w/ weak abs. what ex is MOST approp?
Diastasis Recti Guidelines
A: Head lifts w/ arms bracing abdomen
Guidelines:
- >2cm –> abd bracing + exercise
- 3cm–> Abd bracing + Head lift (just lift head); Progression= Abd bracing + Head lift + PPT
- 4cm–> Abd bracing + NO exercises!
- Split < 2cm–> Bracing not important, do head lifts + PPT
More on Tx for Diastasis Recti
Head lifts and Pelvic tilts
- Head lift: Hook-lying and cross arms around stomach for support–> Exhale and lift only head off floor while simultaneously using hands to gently approximate rectus mms towards midline–> lower head and relax
- Head lift w/ Pelvic tilt (progression): Hooklying pos–> arms over diastasis for support as in “head lift”–> slowly lift head while approx. rectus mm’s and perform PPT– lower head and relax
NOTE: ALL abd contractions w/ exhale to minimize intra-abd pressure
GU recap
- tx for functional incont?– prompted voiding, strengthen LE, cueing
- Incont seen w/ DM– Overflow (dribbles, distended bladder)
- BP changes in preg?– LOWER 1st/2nd trimesters, HIGHER 3rd
- Ex to AVOID w/ diastasis? double leg lifts, crunches, scissors, curl-ups
GastroEsophageal Reflux Dis (GERD)
Sx’s, Complications
Reflux of gastric content of the gastroduodenal contents INTO esophagus
Sx’s:
- Heart burn– 30mins AFTER eating & @ night lying down
- Dysphagia, sour taste, hoarse voice, Atyp pain head/neck
Comps:
- Aspiration PNA, asthma
- Esophagitis
Practice!
All of following are guidelines in Tx pts w/ GERD except….
WRONG: encourage R S/L to sleep for noturnal reflex— NO, we want LEFT S/L
Other answers:
- Anything in supine should be scheduled BEFORE meals and avoided after just eating
- Encourge LEFT S/L for nocturnal reflex (bc GI organs relaxed when LEFT– think anatom pos of stomach) Nocturnal reflex== regurg. @ night
- Mod of pos twrds more UPRIGHT pos is req’d
Tx of GERD:
- maintain UPRIGHT
- Eat 3-4hrs before sleep
- AVOID supine- tends to straighten esophagus
- Sleep on L. side– prevents nocturnal reflex (regurg @ night)
- Exercise comp’d 2-3hrs after eating or BEFORE meals
- AVOID spicy, chocolate, fatty, peppermint
- Drugs: Antacids, H2 receptor blockers, Proton pump inhibitors
Practice!
44yo male excessive amts of alcohol referred for knee pain. During Tx pt reports R. sided shoulder pain. Which structure MOST likely source of referred pain?
LIVER! – refers to RUQ/R. shoulder
Others:
- Prostate: refers to low back
- Appendix: refers to RLQ
- Kideny: refers to Mid back, I/L shoulder
Remember: R= Liver/gallbladder, appendix; L= stomach
Pain referral patterns:
ALL FIRST
Mid-back/Scapula: esophagus, gallbladder, stomach, pancreas
Shoulder
- L: heart, diaphragm, spleen, tail of pancreas
- R: gallbladder/liver, head of pancreas (head is always RIGHT)
Pelvis/Low back/Sacrum: colon, appendix, pelvic viscera
Pancoast Tumor (upper lung tumor): pain referred in C8-T2 nerve distribution; Mimics TOS
Pain Referral Patterns:
Midback/Scapula
esophagus, gallbladder, stomach, pancreas
Pain Referral Patterns:
Shoulder:
LEFT shoulder
Heart, diaphragm, spleen, tail of pancreas
Pain Referral Patterns:
Shoulder:
RIGHT shoulder
Liver/gallbladder, head of pancreas (head is always RIGHT)
Pain Referral Patterns:
Pelvis/Low Back/Sacrum
Colon, appendix, pelvic viscera
Typical Pain Patterns: Quadrants
ALL first
RUQ: peptic ulcers, gallbladder patho, head of pancreas
RLQ: appendix, Chron’s
LLQ: diverticulitis, ulcerative colitis, IBS
LUQ: tail of pancreas, spleen patho
Typical Pain Patterns: Quadrants
RUQ “Good Luck Hot Pack”
RLQ “Air Conditioning”
RUQ: “Good Luck Hot Pack”
- Gallbladder, Liver, Head of pancreas, Peptic ulcers
RLQ: “AC (Air Conditioning)”
- Appendix, Chron’s
Typical pain patterns: Quadrants
LUQ “Dont Banana Split”
LLQ “DUI”
LUQ: “Dont Banana Split
- Diaphragm, Body/tail pancreas, Spleen
LLQ: “DUI”
- Diverticulitis, Ulcerative colitis, IBS
Practice!
44yo male evald by PT. Referred pain in the L. shoulder (spleen, heart, diaphragm, tail of pancreas). Dx of +Kehrs sign (SPLEEN) All causes of this?
Recent laproscopy, intra-abd bleed, rupture of spleen
NOT a cause–> trauma to Head of pancreas (remember Head is always RIGHT (RUQ and R shoulder)
Kehrs Sign==> pain in LEFT shoulder caused by air or blood in abd cavity; +Test= perform SLR & causes L shoulder pain
Hernia and Refer pain
Hiatal hernia (the one to know!!!) causes _ pain. What else to know?
Shoulder!
Hiatal hernia think weak diaphragm, L shoulder pain
Sx’s similar to GERD
Hernia referral pain
Femoral vs Inguinal vs Umbilical
Femoral–> Lateral pelvic wall + groin pain
Inguinal–> Groin pain
Umbilical–> Pain around umbilical ring in mid-lower abdomen
Practice!
44yo male eval’d. Underwent hernia repair 3wks ago. AVOID which activity?
A: Stretching ANTERIOR spinal and hip mm’s BEFORE incision healed
DO NOT DO THIS!— stretching posterior is ok!
Remember: Hiatal hernia think WEAK diaphragm, L. shoulder pain
Cholecystitis
think gallbladder
Blockage or impaction of gallstones in cystic duct resulting in inflamm of gallbladder
- Pain in RUQ (Good Luck Hot Pack), radiates to R shoulder
- nausea, vom, low grade fever
- PAIN INCS WITH INGEST OF FATTY FOOD!
-
Cholecystitis:
Special Test?
Murphy Sign
- palp near R subcostal margin, deep breath, if pain/tender during insp==> (+) Test
Peptic Ulcers
(2):
Think…
RUQ
“Good Luck Hot Pack”
1. Gastric (stomach) ulcers
2. Duodenal
Peptic Ulcers:
Gastric (stomach) ulcers
- In stomach–> chronic use NSAIDs, stress, anxiety, H pylori bacteria
- Pain INCs w/ presence of food–> acid secretion–> pain after eating (acid burns ulcer)
- Pain relieved w/ antacids, med tx of H pylori
Peptic Ulcers
Duodenal ulcers
- Ulcerative lesions in duodenum–> MAIN cause H pylori
- Pain incs w/ absence of food (bc duodenum, not stomach), early mornings, in bw meals
- Pain relieved by med tx of H pylori
Peptic Ulcers
More characteristics
- Pain=> burning, cramping in epigastric area, refers to R shoulder, RUQ
- Coffee ground emesis (both types) and melena (dark) tarry stools (more duodenal)==> peptic ulcer dis.
Inflammatory Bowel Disease
2 components
- ULcerative Colitis– LLQ (DUI)
- CRohn’s Disease– RLQ (AC)
Inflammatory Bowel Disease
1. Ulcerative colitis
- ONLY Lg intestine & rectum
- CONTINUOUS lesions
- S/S: rectal pain, bleeding, bloody diarrhea w/ mucus/pus, fecal urgency, wt loss, LBP
- LLQ– ULcerative
Inflammatory Bowel Disease
2. Crohn’s Disease
- Autoimmune, think pass gas, aggravated w/ stress
- Occurs ANYWHERE in GI tract
- Skip lesions=> lesions “skip” around
- S/S: pain relieved by passing gas, abdom pain, Wt loss (same as UC), jt reactive arthritis
- RLQ– CRohn’s
Practice!
Pt c/o L lower abdom pain (LLQ= DUI). Pt reports LBP accompanied w/ wt loss, nausea, vom, bloody stool lately. MOST LIKELY dx?
A: Ulcerative colitis
Others:
- CRohns== RLQ (AC)
- Appendicitis== RLQ (AC)
- Acute pancreatitis== R (Good Luck Hot Pack) or LUQ (Dont Banana Split)
IBS
Irritable Bowel Syndrome
LLQ= “DUI” bc where do you get DUI? in the LLQ!
IBS think “Your colon is nervous/spastic
Spastic, nervous or irritable colon
- Causes: Emo. stress, anxiety, high fat, lactose foods
- Pain relieved by defecation (rememer Crohns relieved by passing gas)
- Sx’s disappear while sleeping
- Ribbon like stools– bc spastic colon
- LLQ
- Tx: Stress reduce, diet mods, Exercise**
Appendicitis:
Inflamm of appendix–progress leads to swollen/gangrenous appendix
- Perforated==> peritonitis (fluid in abdomen)
- RLQ (AC)
- Tender @ McBurneys pt, Rovsing’s sign (opp palp of McBurneys) for pain migration, Blumber’s sign for Rebound tenderness
IMMEIDATE MEDICAL ATTENTION!
Speaking of Appendicitis and RLQ
More tests on this?
Psoas sign= pain w/ passive hip EXT
Obturator sign= pain w/ passive hip IR
Hop sign= hop
Markel sign= heel raise & lower= heel raise pain
McBurneys Pt vs Rovsing’s for Appendicitis
see pics
Note that Rovsings is just palpating OPP of Mcburneys but getting pain @ McBurney’s
Practice!
30yo w/ R lower abom pain (RLQ= AC). PT performs “pinch-an-inch” test which is +. Which cond?
Appendicitis–> +Pinch-an-inch in RLQ
Others:
Diverticulitis (LLQ)– Pinch-an-inch + in LLQ== divertic
Crohn’s== RLQ
IBS== LLQ (DUI)
GI Recap
- stools seen w/ duodenal ulcer? Black (melena), tarry
- Cond’s w/ pain in RLQ (AC)– appendicitis, crohns
- Referred pain for diaphragm– LUQ, L shoulder (Dont Banana Split)
- Pain incs after ingest fatty food? Cholecystitis (Gallbladder–> R shoulder/R scapula, RUQ: “Good Luck Hot Pack)
