Other Systems Flashcards
DM - Clinical Definitions
What is diabetes mellitus (DM)?
What is the difference between type 1 DM and type 2 DM?
Diabetes mellitus (DM) is a chronic, systemic disorder that is characterized by hyperglycemia (excess glucose in the blood) and disruption of the metabolism of carbohydrates, fats, and proteins due to an insufficient amount of insulin (type 1 DM) or an ineffectiveness of the action of insulin (type 2 DM).
- Note: Insulin is a hormone that is secreted by the beta cells of the pancreas to facilitate transport of glucose from the blood and into the cells for use as energy and storage as glycogen.
In type 1 diabetes mellitus (aka, insulin-dependent DM [IDDM], or juvenile-onset DM), the cause of hyperglycemia is an absolute deficiency of insulin production and secretion (i.e., “not enough insulin”) due to cell-mediated autoimmune destruction of the beta cells of the pancreas.
- Patients with type 1 DM require exogenous insulin to remain alive.
In type 2 diabetes mellitus (aka, non-insulin-dependent DM [NIDDM], adult-onset DM), the causes of hyperglycemia is two-fold. The first is that cellular resistance to insulin action causes insulin to be ineffective at the cellular level. The second is that the beta cells are unable to secrete increased amounts of insulin when needed.
- Type 2 DM is associated with obesity.
Reference:
- Goodman and Fuller (4th ed.), p.506 (“Definition and Overview”), 509 (“Type 1 Diabetes Mellitus,” “Type 2 Diabetes Mellitus”)
DM - Clinical Presentation
What are the hallmark signs and symptoms of diabetes mellitus (DM)?
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Polyuria (excessive urination)
- Rationale: In an attempt to restore balance and normal levels of glucose, the kidney excretes the excess glucose, resulting in glucose in the urine (glucosuria). Glucose excreted in the urine acts as an osmotic diuretic and causes excretion of increased amounts of water.
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Polydipsia (excessive thirst)
- Rationale: Due to dehydration secondary to polyuria
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Neuropathies
- Eye involvement: Diabetic retinopathy
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Nerve involvement: Diabetic peripheral neuropathy
- Loss of sensation typically presents bilaterally in a stocking or glove-like pattern (*see Goodman and Fuller [4th ed.], p.1668 [Figure 39-5]).
- Loss of sensation associated with diabetic peripheral neuropathy increases the risk of developing diabetic ulcers and Charcot disease.
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Autonomic nervous system involvement: Autonomic neuropathy
- Loss of sweat production, resulting in skin that is dry, inelastic, and cracked with a buildup of calluses
- Loss of blood pressure control as a result of dysregulation of the baroreceptor reflex
- Musculoskeletal issues (e.g., adhesive capsulitis)
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Cardiovascular issues
- The acceleration of atherosclerosis associated with diabetes mellitus increases the risk of developing coronary artery disease and peripheral arterial disease.
*Note: Other signs associated with hyperglycemia include (1) fruity-smelling (acetone) breath due to ketoacidosis secondary to increased fat utilization for energy, (2) nausea and vomiting, and (3) dry and crusty mucous membranes.
References:
- Goodman and Fuller (4th ed.), p.510 (“Increased fat mobilization occurs…), 511 (Table 11-13), 512-516
- See “Specific NPTE Study Topics” Word doc.
Charcot Disease
What is Charcot disease?
Charcot disease (aka, Charcot arthropathy, neuroarthropathy, or neuropathic arthropathy) refers to chronic progressive degeneration of the stress-bearing portion of a joint and subsequent destruction of the bones.
- Charot disease occurs most commonly at the foot and ankle and is therefore also called Charcot foot deformity.
- Diabetes mellitus is the most common cause of Charcot disease.
- One hypothesis for how Charcot disease occurs is that the loss of sensation secondary to peripheral neuropathy allows for repeated microtrauma and progressive, noninfectious joint and bone destruction.
*Note: Initially, acute Charcot disease may present with swelling (edema), redness (erythema), and increased warmth of the foot and ankle. Pain may be minimal because of the underlying peripheral neuropathy. Later, when bone deformities and dislocations occur, there may be severe deformities of the foot and ankle (e.g., rocker-bottom foot deformity–see image below).
References:
- Goodman and Fuller (4th ed.), p.515 (“Sensory Neuropathy”)
- See DMGMC lecture, “DM, Foot Ulcers, and Amputations” (slide 33).
DM - PT Implications
What are the major indications, contraindications, guidelines, or protocols for treating diabetes mellitus?
- Insulin therapy can result in hypoglycemia (deficiency of glucose in the blood).
- Hypoglycemia can occur when the blood glucose level drops to 70 mg/dL or less and can be the result of an overdose of insulin, late or skipped meals, or overexertion in exercise.
- Examples of signs and symptoms of hypoglycemia include:
- Nervousness
- Weakness
- Difficulty speaking and concentrating
- Pallor and sweating
- Intervention: Immediately provide carbohydrates in some form (e.g., fruit juice, honey, hard candy, or commercially available glucose tablets or gel) to help raise the blood glucose levels and reduce the severity of hypoglycemia.
- To prevent diabetic ketoacidosis during exercise, preexercise blood glucose levels should be between 100 and 250 mg/dL. Blood glucose levels greater than or equal to 250 mg/dL is considered hyperglycemic and, in conjunction with evidence of ketosis, is not safe for exercise.
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Examples of foot care guidelines:
- Daily inspection of feet to check for possible skin breakdown
- Wear shoes with socks.
- Ensure comfortable and proper shoe fit, and break into the new shoes slowly.
- For a patient with type 2 DM, exercise helps to increase insulin sensitivity, thus lowering blood glucose levels and the amount of exogenous insulin required.
- Note that exercise has NOT yet been shown to improve glycemic control among patients with type 1 DM (*see p.518, “Type 1 Diabetes Mellitus”).
Reference:
- Goodman and Fuller (4th ed.), p.521 (“Special Implications for the Therapist”), 523 (Box 11-6), 643 (Box 12-14)
Liver Disease - Clinical Definition
What is liver disease?
Liver disease (aka, hepatic disease) refers to pathological damage to the liver (e.g., as a result of alcohol abuse) that impairs the functions of the liver. The liver is a large organ that is located in the right upper-quadrant of the abdomen.
Some of the functions of the liver include:
- Production of a yellow or greenish fluid called bile, which helps to carry away waste and break down fats in the small intestine during digestion
- Clearing the blood of drugs and other poisonous substances
- Clearance of bilirubin, a yellow bile pigment that is formed from the metabolic breakdown of hemoglobin in red blood cells (erythrocytes)
References:
- Vander’s (15th ed.), p.548 (liver, bile), 552 (bilirubin)
- John Hopkins Medicine: Liver–Anatomy and Function (https://www.hopkinsmedicine.org/health/conditions-and-diseases/liver-anatomy-and-functions)
Liver Disease - Clinical Presentation
What are the hallmark signs and symptoms of liver disease?
The hallmark signs and symptoms of liver disease include:
- Jaundice (aka, icterus), or yellow discoloration of the skin, sclerae of the eyes, and mucous membranes
- Flapping tremor (aka, asterixis, liver flap), or quick, irregular extensions and flexions of the wrist and fingers during active wrist extension (*see image below)
- Muscle tremors
- Hyperreflexia (aka, hyperreactive reflexes, hyperactive reflexes)
- Ascites, or abnormal accumulation of fluid in the cavity of the abdomen (i.e., peritoneal cavity) (*see image below)
- Right upper-quadrant abdominal pain
Reference:
- Goodman and Fuller (4th ed.), p.909 (Box 17-1), 911 (“Jaundice”)
Hyperhidrosis
What is hyperhidrosis?
Hyperhidrosis refers to generalized or local excessive sweating.
Hyperhidrosis can be part of the clinical presentation of endocrine and other disorders.
Reference:
- Merriam-Webster Dictionary: Hyperhidrosis (https://www.merriam-webster.com/dictionary/hyperhidrosis)
Acute Leukemia
What is acute leukemia?
Acute leukemia refers to a malignant, progressive cancerous disease that results in the accumulation of functionless cells called blast cells in the bone marrow and blood that block the development of normal cell development (e.g., white blood cells, red blood cells, platelets).
Patients with acute leukemia often experience spontaneous bleeding or bleeding with minor trauma due to platelet deficiency (aka, thrombocytopenia). Patients also often have infections due to a lack of white blood cells and anemia (deficiency in red blood cells or hemoglobin) due to a lack of red blood cells.
Treatment of acute leukemia involves chemotherapy and potentially bone marrow transplant.
References:
- Google Dictionary: Leukemia
- Goodman and Fuller (4th ed.), p.723 (“Acute Leukemia”)
GERD - Clinical Definition
What is gastroesophageal reflux disease (GERD)?
What are the hallmark symptoms of GERD?
Gastroesophageal reflux disease (GERD) refers to the backward flow (reflux) of gastric contents into the esophagus accompanied by a failure of anatomic mechanisms (i.e., barrier between the stomach and esophagus) and failure of physiologic mechanisms (e.g., clearance of stomach acid from the esophagus) to protect the esophagus.
The hallmark symptoms of GERD include:
- Heartburn, which refers to a burning sensation that begins at the stomach and rises up the chest
- Swallowing during meals can also exacerbate the pain associated with GERD due to involvement of the esophagus.
References:
- Goodman and Fuller (4th ed.), pp.868-869 (“Definition,” “Clinical Manifestations”)
- Goodman et al. (6th ed.), p.124 (“…chest pain, neck pain, or upper back pain from a problem with the esophagus will likely get worse when the client is swallowing or eating.”)
GERD - PT Implications
What are the major indications, contraindications, guidelines, or protocols for treating gastroesophageal reflux disease (GERD)?
- When exercising, patients with GERD should be in upright positions to reduce the likelihood of GERD occuring–the effect of gravity in the upright position makes it more difficult for the reflux of gastric contents to occur. The left-sidelying position will also help to alleviate GERD by increasing the natural bend of the lower esophagus to the left.
- Patients should avoid the following positions that can exacerbate the effects of GERD:
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Supine, especially after eating
- Increased risk of aspiration in supine
- Right-sidelying because of straightening of the esophagus
- Prone because of the increase in intraabdominal pressure
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Supine, especially after eating
Reference:
- Goodman and Fuller (4th ed.), p.871 (“Special Implications for the Therapist–Positioning”)
NSAIDs
What are nonsteroidal anti-inflammatory drugs (NSAIDs)?
What is the primary side effect of NSAIDs?
Nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin) are a group of drugs that are used for the following purposes:
- Decrease inflammation
- Decrease pain
- Decrease high body temperatures associated with fever
- Decrease blood clotting (anticoagulation)
The primary side effect of NSAIDs is gastrointestinal (GI) damage (e.g., stomach discomfort, upper GI hemorrhage, ulceration) due to inhibition of the formation of protective prostaglandins, rendering the stomach more susceptible to damage from acidic gastric juices.
- The difference between the clinical presentations of stomach (gastric) ulcers and duodenal ulcers is that eating will aggravate pain for stomach ulcers whereas eating (peristalsis) will alleviate pain for duodenal ulcers.
Reference:
- Ciccone (5th ed.), p.219, 224-225 (“Gastrointestinal Problems”)
Hiatal Hernia - Clinical Definition
What is a hiatal hernia?
A hiatal hernia (aka, diaphragmatic hernia) refers to the protrusion of the stomach into the thoracic cavity through the esophageal opening in the diaphragm.
Reference:
- Goodman and Fuller (4th ed.), p.867 (“Definition and Incidence”)
Hiatal Hernia - PT Implications
What are the major indications, contraindications, guidelines, or protocols for treating hiatal hernia?
For any client with a known hiatal hernia, the flat supine position and any exercises requiring the Valsalva maneuver (which increases intraabdominal pressure) should be avoided during therapy intervention. Before discharge, the client must be warned against activities that cause increased intraabdominal pressure and given safe lifting instructions.
- Valsalva maneuver refers to a technique involving forced expiration against a closed glottis as the abdominal and thoracic muscles are contracted. (The glottis is the natural space between the vocal cords inside the neck.) The Valsalva maneuver causes an increase in both intraabdominal and intrathoracic pressure. Supine exercises such as bilateral leg lifts can encourage the Valsalva maneuver.
References:
- Goodman and Fuller (4th ed.), p.868 (“Special Implications for the Therapist”)
- See “Specific NPTE Study Topics” Word doc.
AAA
What is an abdominal aortic aneurysm (AAA)?
Abdominal aortic aneurysm (AAA) refers to the abnormal stretching (dilation) of the abdominal aorta. The dilated abdominal aorta can place excessive pressure on surrounding structures, resulting in lower abdominal pain and dull low back pain. This along with an abdominal heartbeat when lying down are early warning signs of impending rupture of the aneurysm.
Reference:
- Goodman and Fuller (4th ed.), p.630 (“Definition and Overview”), 631 (Figure 12-27), 632 (“Clinical Manifestations”)
Psoas Abscess
What is a psoas abscess?
Describe the clinical presentation of a psoas abscess.
How do you assess for a psoas abscess?
A psoas abscess refers to a collection of pus in the iliopsoas muscle group.
The clinical presentation of a psoas abscess includes:
- Pain in the right or left lower quadrant
- Referred pain to the lower back
The presence of a psoas abscess can be determined by faciliating a contraction of the iliopsoas muscle group. This can be accomplished by having the patient complete resisted active hip flexion in supine (*see image below). A positive iliopsoas sign that indicates a psoas abscess is characterized by pain in the right or left lower quadrant.
References:
- UpToDate: Psoas Abscess (https://www.uptodate.com/contents/psoas-abscess#:~:text=Psoas%20%28or%20iliopsoas%29%20abscess%20is%20a%20collection%20of,by%20the%20hematogenous%20route%20from%20a%20distant%20site)
- YouTube: Psoas Sign (https://www.youtube.com/watch?v=n0a0PCwsVQ4&feature=emb_title)
- Goodman and Fuller (4th ed.), p.889 (Figure 16-13A)
Testicular Cancer
What is testicular cancer?
What are the hallmark signs and symptoms of testicular cancer?
Testicular cancer refers to a malignant tumor in one or both testicles.
The hallmark signs and symptoms include:
- Enlargement of the testis with diffuse testicular pain, swelling, or hardness
- Lower back pain that radiates around the iliac crest and to the groin
- Neck or supraclavicular adenopathy
- Adenopathy refers to any disease or enlargement involving glandular tissue, especially tissue involving lymph nodes.
- Positive iliopsoas sign
- Invasion of the testicular tumor into the psoas muscle can be determined by faciliating contraction of the iliopsoas muscle group (*see image below). This can be accomplished by having the patient complete resisted active hip flexion in supine. A positive iliopsoas sign is characterized by pain in the right or left lower quadrant.
References:
- Goodman and Fuller (4th ed.), p.889 (Figure 16-13A), 1013 (“Overview”), 1014 (“Clinical Manifestations”)
- YouTube: Psoas Sign (https://www.youtube.com/watch?v=n0a0PCwsVQ4&feature=emb_title)
- Merriam-Webster Dictionary: Adenopathy (https://www.merriam-webster.com/medical/adenopathy#:~:text=Medical%20Definition%20of%20adenopathy%20%3A%20any%20disease%20or,especially%20%3A%20one%20involving%20lymph%20nodes%20cervical%20adenopathy)
Over-Hydration vs. Dehydration
Differentiate between the clinical presentations of over-hydration and dehydration.
Overhydration (i.e., “volume excess”)
- Hypertension
- Dependent edema (aka, peripheral edema) with pitting edema
Dehydration (i.e., “volume depletion”)
- Orthostatic hypotension
- Poor skin turgor (i.e., lack of skin elasticity) (*see image below)
References:
- Physiopedia: Dehydration (https://www.physio-pedia.com/Dehydration)
- Physiopedia: Fluid Excess/Intoxication (https://www.physio-pedia.com/Fluid_Excess/Intoxication)
Hyperthyroidism and Hypothyroidism
Differentiate between hyperthyroidism and hypothyroidism.
Hyperthyroidism (i.e., hyperfunction of the thyroid gland) refers to excessive secretion of thyroid hormone that results in a generalized elevation of body metabolism and all other body processes. The hallmark signs and symptoms include:
- Goiter, or mild symmetric enlargement of the thyroid (*see left image below)
- Exophthalmos, or abnormal protrusion of the eyes (*see right image below)
- Heat intolerance, or increased sensitivity to heat
- Weight loss despite having an increased appetite
- Signs of increased sympathetic nervous system activity (e.g., anxiety, tremors, jumpiness, increased heart rate)
- Increased deep tendon reflexes (e.g., grades of 3+ or 4+)
Hypothyroidism (i.e., hypofunction of the thyroid gland) refers to a deficiency of thyroid hormone that results in a generalized slowed body metabolism and all other body processes (e.g., bradycardia, slowed neurologic functioning). The hallmark signs and symptoms include:
- Cold intolerance, or increased sensitivity to cold
- Weight gain
- Decreased deep tendon reflexes (e.g., grade of 1+), especially in the Achilles (calcaneal) tendon
*Note: Both hyperthyroidism and hypothyroidsim are commonly caused by underlying autoimmune disruptions or diseases that affect the thyroid gland.
References:
- Vander’s (15th ed.), pp.342-343 (“Hypothyroidism and Hyperthyroidism”)
- Goodman and Fuller (4th ed.), p.489 (“Hypothyroidism–Clinical Manifestations”)
Abdominal Diastasis Recti - Clinical Definition
What is abdominal diastasis recti?
What exercises are specifically designed to treat abdominal diastasis recti?
Abdominal diastasis recti (aka, diastasis rectus abdominus [DRA]) refers to separation of the rectus abdominis muscles in the midline at the linea alba. This condition is frequently seen in the women who are pregnant. Any separation that is larger than two finger widths (i.e., 2 cm) is considered significant.
It is recommended that patients with abdominal diastasis recti initially complete the head lift or head lift with pelvic tilt exercises (*see image below) to help correct or reduce the separation of the rectus abdominus muscles while minimizing intra-abdominal pressure. Progress abdominal strengthening exercises only after the separation is two finger widths (i.e., 2 cm) or less.
- *Note: If the patient is more than 13 weeks (i.e., ~3 months) pregnant (i.e., post-first trimester), the patient should NOT remain in the supine position for more than 5 minutes. Prolonged supine positioning will result in supine hypotensive syndrome due to the weight of the heavy uterus impinging on the inferior vena cava, resulting in a decrease in venous return to the heart.
- *Note #2: Trunk curls are contraindicated for patients with abdominal diastasis recti due to the excessive increase in intra-abdominal pressure associated with the exercise.
References:
- Kisner and Colby (7th ed.), pp.994 (“Diastasis Recti”)
- For more about supine hypotensive sydnrome, see “Specific NPTE Study Topics.”
