Patho Exam 3 Flashcards
Normal values for HR
Increase/decrease with activity?
60-100
INCREASES with activity (b/c increasing work load)
Normal values for BP
Increase/decrease with activity?
<90/60 for low BP)
BP should go UP with increased work load
Normal values for RR
Increase/decrease with activity?
12-20 (some say 12-18)
Should INCREASE with activity (generally, you take deeper breaths first, then increase RR)
Normal values for SpO2
Increase/decrease with activity?
98-100
*O2 drops as you age. By 90+ you might see a “normal” value <90
INCREASES with activity (if it has room to do so; otherwise if normal, will stay normal unless you have a respiratory disorder)
Cardiac output = __ x ___. Normal cardiac output = ___
CO = SV x HR Normal = 4-8 L/min
___ is the amount of blood coming out to the [right/left] ventricle every time it contracts.
This is the difference between the end [diastolic/systolic] minus the end [systolic/diastolic] volume. This is about what percentage of the blood in that ventricle? What percentage remains after each contraction?
STROKE VOLUME = amt of blood coming from LEFT ventricle each contraction.
Difference between the end DIASTOLIC (bigger) and end SYSTOLIC volume (smaller). 55-70% of blood is pumped out each time, so 30-40% sticks around in LV!
What factors contribute to Stroke Volume?
Contractility
Preload
Afterload
Describe contractility. When might it be weird?
Contractility = how well/the amount the LV can contract
- Abnormal arrhythmia can cause the ventricle to depolarize at a different rate and contract abnormally
- Frank Sterling relationship comes into play here
Describe preload. Why might it be low?
Preload = how much blood volume RETURNS to the LV before it contracts. Think of it as venous return (how much blood is getting back from the periphery during diastole right before systole). End diastolic volume
Might be low:
- Dysfunctional valves in peripheral veins –> blood pooling
- Low blood volume (b/c dehydrated, excess blood loss, etc)
Describe afterload.
Afterload = pressure in the aorta that the LV has to overcome to get blood out of the LV, into the aorta, and to the periphery.
Harder to get blood out if you have aortic stenosis (stiff and narrowed), or if aortic valve is a little broken/small
RESISTANCE TO FLOW
What factors regulate heart rate?
Intrinsic rate (from different nodes in heart, generally SA node)
Autonomic Regulation
__ is the inability for heart rate to increase in response to increased activity and/or inability to achieve 85% of HR max.
CHRONOTROPIC INCOMPETENCE
Chronotropic incompetence is associated with [right/left] [ventricle/atrium] dysfunction, ___, and increased ___. Other potential associations include… (8)
Chronotropic incompetence is associated with LEFT VENTRICLE dysfunction, myocardial ischemia, and increased mortality
OTHERS:
- Older age
- Presence of CAD
- Smoking
- Exercise intolerance
- LV dilation
- Ischemia
- SA or AV node dysfunction
- Issue with modulating autonomic tone
___ describes a sustained HR increase of greater than or equal to 30 bmp within 10 minutes of standing or head-up tilt without orthostatic hypotension. Who do we see this in? Symptoms include __ and ___. Etiology is unknown, but it’s associated with ___, __, __, and/or limited/restricted ___.
POTS: POSTURAL TACHYCARDIA SYNDROME describes a sustained HR increase of greater than or equal to 30 bmp within 10 minutes of standing or head-up tilt without orthostatic hypotension.
COMMON IN TEENAGERS (in adolescents 12-19yo, >40bpm required). MORE COMMON IN WOMEN
Symptoms include LIGHTHEADEDNESS and VISUAL BLURRING. Etiology is unknown, but it’s associated with DECONDITIONING, RECENT VIRAL ILLNESS, CHRONIC FATIGUE, LIMITED/RESTRICTED AUTONOMIC NEUROPATHY
*A general aerobic conditioning program helps!
HR Recovery describes a [rapid/delayed] decrease in HR (</= __bpm) during the first minute post activity.
HR recovery = DELAYED decrease in HR ( increased mortality. </=12bpm
Abnormal HR responses may be associated with…(5)
- Medications
Eg. beta blockers (HR increase with workload is MUCH Smaller % than without beta blocker)
Eg. Ca2+ channel blocker (reduces resting HR, but HR increases at normal proportion with activity) - Heart transplant
Vagus n is severed so you lack parasympathetic inhibition of HR, so resting HR is higher. These pts need longer to respond to exercise b/c they rely on hormonal response to increase HR and let body respond, rather than normal sympathetic response
-Autonomic dysfunction
Eg diabetics
- Ischemia
E.g blockage to R coronary artery that supplies AV or SA node –> abnormal HR - Mechanical support
Devices takeover heart workload –>abnormal HR response)
A [ventricular/atrial] arrhythmia is predictive of mortality or diagnostic for CAD
VENTRICULAR
Ventricular arrhythmias:
- Increased ventricular ectopy [implies/does not necessarily mean] ischemic dz.
- Increased ventricular ectopy during [activity/ recovery] predicts mortality.
- Runs of ventricular [bradycardia/ tachycardia] are associated with CAD/ischemia
- Increased ventricular ectopy DOES NOT NECESSARILY MEAN ischemic dz.
- Increased ventricular ectopy during RECOVERY predicts mortality.
- Runs of ventricular TACHYCARDIA are associated with CAD/ischemia
What is the Frank-Starling Relationship?
Describes the relationship and “sweet spot” between ventricular end diastolic volume (think optimal sarcomere length) and stroke volume (y axis)
- With a way stretched or way contracted ventricle, it’s very hard to get a contraction. Sweet spot gives an optimum length-tension relationship and ventricle can contract.
- Stroke volume can change based on extra volume (eg heart failure) or not enough volume (e.g dehydration, bleeding post trauma) and can affect length-tension relationship in heart contractions
In a normal BP response to activity, systolic should [go up/go down/ stay same/ depends]. If changes, how much?
Diastolic should [go up/go down/ stay same/ depends]
Systolic should GO UP ~10 mmHg per MET (metabolic equivalent) of exercise.
(Walking 2mph = ~2 METS)
Diastolic can stay same, go up or go down - all normal!
If you increase workload, what would be an ABNORMAL BP response to activity? Why is this bad?
Abnormal = increase workload and see a DROP in systolic
Bad because you’re not maintaining cardiac output. The workload is too great for that pt for somer reason.
Drop in systolic BP is associated with ___ and __. It identifies those at risk for __
Drop in systolic BP associated with severe CAD and ischemic LV dysfunction. It identifies those at risk for VENTRICULAR FIBRILLATION
Describe the normal response to standing
1) 500-1000 mL blood pooling in legs
2) DECREASED venous return to <3
3) Decreased CO and BP
4) Decreased arterial baroreceptor response and INCREASED sympathetic activity
5) Increased venous return, PVR, CO
6) Limits fall in BP (~5-10 mmHG SBP, 5-10 mmHG SBP), and INCREASEs in HR (10-25 bpm)
Orthostasis defines a change in BP from __ to ___. Systolic BP drops __ mmHg, and Diasotlic BP drops __ mmHg.
Orthostasis: change in BP with postion change from SUPINE to STANDING
Systolic drops >= 20mmHg
Diastolic drops >= 10mmHg
Within 3 mins of standing or at last 60 on tilt table
Confounded by:
- food inestion
- time of day
- state of hydration
- ambient temperature
- recent recumbency
- postural deconditioning
- hypertension
- medications
- gender
- age
What might cause orthosasis?
- [incr/decr] intravascular volume
- _____
- Alcohol consumption (impairs ___)
- [incr/decr] age
- Medications, including…(6)
DECREASED intravascular volume Autonomic Insufficiency Alcohol consumption (impairs VASOCONSTRICTION) AGING Medications: - Antidepressants -Beta and alpha blockers - ACE inhibitors - Vasodilators/nitrates - Ca2+ channel blockers - Opiates
How do you treat orthostasis?
- Meds (midodrine, florinef)
- Increased salt in diet
- Compression:
- –LE compression therapy: 40-60 mmHg
- — Abdominal binder
Renal problems may mimic…
LOW BACK PAIN
If it’s there all of the time and isn’t reproducable or aggravated by movement/test, then it’s likely not something we can treat
The kidneys deal with fluid and chemical balance. Metabolic waste is excreted through the urine and includes…
- Urea nitrogen (from protein metabolism)
- Creatinine (from muscle)
- Normal cellular environment ion regulation (Na+, k+, Ca2+, Mg2+, PO4)
What labs do we look at for renal function?
BUN, Creatinine, Na+, K+, GFR (Glomerular Filtration Rate)
___ increases with dehydration, high protein diet, blood in GI tract, catabolic states, injury, infection, fever and steroids.
BUN
___ is a more accurate determination of renal fxn because it is liberated from muscle tissue at a constant rate and excreted at the same rate. Women have less because of lower muscle mass.
CREATININE
Changes in __ levels can result in changes in mental status because of its involvement in the CNS and PNS.
Na+
With changes in K+ levels, what is most susceptible? What might we see clinically?
K+ = heart most susceptible. May see arrhythmias, cardiac arrest, weakness, irritability, difficulty with muscle contraction, pain or spasm.
High OR low K+ can cause sudden cardiac death
We want to see glomerular filtration rates (GFRs) >___. Under that, we suspect some kidney damage.
GFR <90 = kidney damage
What renal test would we use to look at pH levels, protein levels, specific gravity, glucose detection, ketones, blood cells, and infection?
Urinalysis. Also looks at color (dark = blood)
If you get an abnormal urinalysis and suspect infection, what might you test next?
Culture and sensitivity. Determines what exactly is causing the infection (microorganism)
What can we see with a plain film KUB (means: ___)
KUB = Kidney-ureters-bladder
XR of abdominal area, lets you see huge obstructions, large stones, etc. Not a ton of detail
___ uses a fiberoptic scope to look at bladder and urethra. It [can/cannot] visualize kidneys
Cystocopy looks at bladder and urethra. CANNOT visualize kidneys
What might indicate a renal issue? (11)
a. Aneuria or oliguria
b. Dysuria
c. Nocturia
d. Hematuria or pyuria
e. Increased frequency
f. Increased urgency
g. Intermittency/post-void dribbling
h. Chronic retention or voiding issues
i. Pain: shoulder back, flank, pelvis, lower abdomen (generally at costovertebral angle)
j. Costovertebral tenderness
k. Fever and/or chills
Urinary tract infections are called __ or ___ in the lower tract, and ___ in the upper tract.
Lower = cystitis, urethritis Upper = pyelonephritis (kidney inflammation)
Risk factors for UTIs include…
- Women
- Pregnancy
- Older adults
- Catheterization
- Instrumentation
- Sexual intercourse
- Obstruction
Kidney stones occur more in [men/women]. Onset is generally in __-__s (age range), but [increases/decreases] with age. Accompanied with [gradual/sudden] pain onset
Kidney stones occur in MEN > women
- Onset in 30-40s but INCREASES with age
- SUDDEN pain
Acute kidney failure has a [sudden/gradual] onset. Labs show [increased/decreased] Cr and BUN. It may be due to… (5)
Acute kidney failure = SUDDEN onset. INCREASED BUN & Cr. Due to:
- Shock
- Trauma
- Obstruction
- Toxicity
- Infection
Chronic kidney failure is due to prolonged injury to ___ (potentially due to what diseases?) We see changes in multiple body systems. Discuss what systems and what we might see.
Chronic kidney failure = prolonged injury to nephron (incl glomerulus, renal tubules, or collecting duct), potentially secondary to DM or HTN.
- Hematologic: anemia, toxins interfere with platelet aggregation
- Cardiovascular: CAD, HTN, heart failure, pulm edema, DOE, pericarditis - heart failure stresses kidneys, but so do the meds you’re on!
- GI (n/v, anorexia)
- Musculoskeletal (Decrased Ca2+ absorption, joint calcifications)
- Integumentary (itching, hyperpigmentation, bruising)
- Eyes (blurring, dry/red eyes)
- CNS: seizure, coma, lethargy, sleep problems, inability to concentrate
- PNS: uremic toxins –> loss of vibratory sensation, decreased DTRs, paresthesia, muscle cramps/twitching, foot drop
How does hemodialysis work?
- Blood travels to dialyzer in plastic tube with semi-permiable membrane
- Dialyzing fluid contains electrolytes to facilitate osmosis (waste goes into dialysate)
Why would a patient use CVVH (____) or CRRT (___)?
CVVH = Continuous Venovenous hemofiltration CRRT = Continuous Renal Replacement Therapy
- These are for pretty severe patients that can’t handle the large fluid shifts (1-2 lbs!) that come with normal dialysis (esp if they have a <3 problem). Distributes the same fluid loss over a 24h period
How often do patients do dialysis? How long each time?
3-4 days/week, 3-4 hours a session
What is used to access blood for a dialysis?
Arteriovenous fistula - anastamose arterial and venous systems
Describe the different types of peritoneal dialysis.
CAPD = continuous ambulatory peritoneal dialysis. Osmosis faciltates waste removal -drains into a bag by gravity via a small catheter in abdomen.
CCPD = continuous cycling peritoneal dialysis. Uses machine to fill and empthy diasylate. Usually overnight
IPD = intermittent periotneal dialysis. Extended CCPD with multiple exchanges a day. Lets you spread dialysis out through the day and easier to do at home (easier than going to center for dialysis)
*Usually for 36-42 hours/week
PT concerns with dialysis patient
- Treatment timing
- Access location (no BP over a fistula!)
- Complications: graft infection, peritonitis
- Dialysis dementia (aluminum accumulation –> acute mental status changes)
- Diet restrictions (low protein, Na, K, fluid restriction)
- Dialysis disequilibrium (antibiotics –> vestibular problem b/c odotoxicity, osmotic pressure can increase in brain)
Differentiate between the following types of incontinence:
- Functional
- Overflow
- Stress
- Urge
- Functional: can’t make it to restroom in time, but know need to urinate
- Overflow: leakage from overfull bladder b/c not properly/adequately emptying bladder. Too much volume!
- Stress: cough, laugh, sneeze, valsalva
- Urge: strong, sudden need to urinate (more of a neurogenic cause b/c bladder spasms/contractions)
A [primary/secondary] tumor arises from cells that are normally local to the given structure. A [primary/secondary] tumor arises from cells that have metastasized from another part of the body.
A PRIMARY tumor arises from cells that are normally local to the given structure. A SECONDARY tumor arises from cells that have metastasized from another part of the body.
Differentiate between benign and malignant neoplams
Benign = usually harmless, doesn’t spread
Malignant = usually harmful, tends to spread
What is the name of the theory that says that neoplasm (tumor) originates from a single cell with a genetic change? This goes on to say that a ____ aberration creates tumor cell proliferation due to addition, delation, translocation, or inversions of part or entire chromosome.
SOMATIC MUTATION THEORY
chromosomal aberration
Why do we bother staging tumors?
- Helps with prognosis
- Gives info about potential for metastasis
What are early warning signs of CA? Think CAUTIONS
C: Changes in bowel or bladder habits (often neuro-related)
A: A sore that doesn’t heal in 6 wks
U: Unusual bleeding or discharge
T: Thickening or lump in breast, elsewhere
I: Indigestion or difficulty in swallowing
O: Obvious change in wart or mole
N: Nagging cough or hoarseness
S: Supplemental signs and symptoms (rapid unintentional weight loss, changes in vital signs, frequent infections, night pain, pathologic fracture, proximal muscle weakness, change in DTRs)
What are early warning signs of cancer that we might see as PTs?
- NIGHT PAIN that can’t be reproduced with testing
- PROX. MUSCLE WEAKNESS (also might be b/c steroids or immunosuppressant meds)
- Changes in VITAL SIGNS
- Changes in DTRs
- Pathologic FRACTURE (fx without trauma b/c tumor weakening bone)
- Rapid, unintentional WEIGHT LOSS
Early signs of melanoma - ABCDE!
- Asymmetry: uneven edges, unlike halves
- Border: irregular, poorly defined
- Color: black, shades of brown, red, white
- Diameter: larger than a pencil eraser
- Elevation/Evolving: raised, uneven
Systemic effects of CA (5)
“VAN For Days!”
Nausea Vomiting Anorexia Fever without infection Depression and/or anxiety
Pain occurs in __-__% of early stage and __-__% of late stage CA patients.
Pain occurs in 50-70% of early stage and 60-90% of late stage CA patients.
What causes pain in cancer? (5)
- Nerve infiltration/compression (sharp stabbing)
- Ischemic pain (throbbing, may have compression from tumor)
- From diagnostic or therapeutic procedures
- Bone destruction
- Visceral compression
___% of patients with new CA have clinically detectable metastases, and __-__% have hidden metastases. Mets are usually seen within __-__ years of initial diagnosis. How does a tumor metastasize?
30% have clinically detectable mets
30-40% have hidden mets
Usually seen within 3-5 yrs of initial dx
- Tumors shed tumor cells into the blood stream. 99% of those cells are killed within 24h.
- This is more likely to occur via veins because arterial walls are stronger
SO tumor development depends heavily on blood supply from adjacent tissue (usually found in areas with HIGH blood flow)
Common locations of bone metastases?
Vertebrae (60% thoracic, 30% lumbar) Pelvis Ribs (posterior) Skull Femur (proximal) Humerus (proximal)
What are common sites of mets in the body?
- Pulmonary (venous drainage from body comes in SVC and IVC)
- Hepatic systems (filters blood from stomach, colorectum, and pancreas)
- Bone (poor prognosis)
- CNS
- Lymphatic system
With surgical resection, the primary PT concern is __. The three types of tumor resection are __, __, and __. Describe each.
PAIN.
PRIMARY TUMOR RESECTION
- takes out tumor. May therapeutically or prophylactically remove lymph nodes too
CYTOREDUCTIVE RESECTION (Debulking) - Common for highly vascularized tumors and in brain
PALLIATIVE RESECTION
- MDs know they can’t treat it, but this reduces pain, corrects obstructions, and can alleviate pressure
What are side effects of surgical resection?
Fatigue Disfigurement/deformity Loss of function Infection Increased pain Bleeding Scar Tissue Fibrosis
____ change or modify the relationship between the tumor and the host by strengthening the host’s biological response to the tumor. This is a type of ___
BIOLOGIC RESPONSE MODIFIER
Type of BIOTHERAPY
A bone marrow or stem cell transplantation from YOUR OWN body is called ___ and from a donor is called __. Patients are generally first treated with ___ chemo with the goal being to ___. Then, the patient undergoes the ___. The lowest point post-transplant is called the __ and occurs _-__ days post transplant. Finally, the body undergoes ___ __-__ days post transplant.
AUTOGENIC - your own marrow/stem cell
ALLOGENIC - donor marrow/stem cell
Patients are generally first treated with CONDITIONING chemo with the goal being to WIPE OUT THE PT’S IMMUNE SYS. Then, the patient undergoes the TRANSPLANT. The lowest point post-transplant is called the NADIR and occurs 5-7 DAYS post transplant. Finally, the body undergoes ENGRAFTMENT 10-21 days post transplant.
The mortality rate in graft vs host disease (GVHD) is [high/low].
HIGH mortality rate
Radiation therapy is ideal for [diffuse/localized] lesions. Maximum radiation is delivered usually [daily/weekly/monthly] for at least ____ (how long?). Goal is to ____.
Radiation therapy (XRT) is good for LOCALIZED lesions. Radiation is delivered DAILY for at least a MONTH. Goal: shrink tumor, then surgically excise it.
Describe external vs internal delivery of radiation therapy.
EXTERNAL DELIVERY (Traditional method)
- Goal: deliver max dosage for max tumor control, minimize sequelae in normal tissue
- Set the patient up Stereotactically.
- DO NOT wash off XRT markings
- Uses an IONIZING BEAM via a linear accelerator
- Frequency: 5 equal fractions weekly x 3-6 weeks
INTERNAL DELIVERY
- Intracavity and interstitial implants
A major side effect of XRT is ___. Describe the pathology of this as it gets more severe (3 phases)
FIBROSIS
1) LOSS of tissue ELASTICITY with induration
2) Significant INDURATION with rigidity of surface layers and retraction of surface contours in dermis, subcutaneous tissue
3) ULCERATION AND NECROSIS from extravasation of fibrinous exudate and/or vascular compromise –> nerve entrapment and stenosis, obliteration, obstruction of parenchymal or hollow structures
The goal of chemotherapy is to deliver maximal dosage to maximize ___. Most chemotherapeutic agents affect what kind of cells?
Chemotherapy goal: deliver max dosage to maximize CELL DEATH (limited by toxicity)
- Most chemotherapeutic agents affect DIVIDING cells
What are methods of chemo delivery?
IV Arterial infusion Intrathecal Intramuscularly Orally Interstitially
Side effects of chemo:
- [incr/decr] blood counts (AKA ___)
- [Hyper/hypo] coagubility
- [High energy/fatigue]
REDUCED blood counts (leukopenia, NADIR, Absolute Neutrophil Count)
HYPERcoagubility
FATIGUE
Describe WBC ranges for minimal, moderate, and severe risk of infection.
Low WBCs (Leukopenia) –> infection risk:
Minimal: 1,000-5,000
Moderate: 500-1,000
Severe: <500
Patients with cancer tend to clot [more/less] because of the cancer itself. Why? Patients with impaired __ function are more at risk for this.
CA pts clot MORE because of the cancer. The tumor disrupts clotting sequence and its natural inhibitors by mechanical and/or by cellular products. Pts with impaired BONE MARROW function are at increased risk. DVT is associated
What factors could contribute to fatigue in cancer patients?
Treatment-related myelosuppression
Sleep deprivation
Pain emotional distress
Advanced dz
Two chemo-drug-related side effects PTs should monitor
Cardiac Toxicity
Peripheral neuropathy
A “cure” means that ___. Complete remission = __ years
Complete remission means ___.
Partial remission means ___
Cure = disease is GONE. Remission = 5 years
Complete remission = all signs of dz are gone. Not “cured” until 5 year mark
Partial remission = primary tumor 1/2 of original size
Survival rate is expressed as the chances of ___
Chances of being alive at 1, 5, and 10-yr mark
Greatest PT considerations for CA patients involve __, __, and ___
Orthopaedic (pathologic fx, bone tumors)
Neuro (Sp cord, brain tumors/mets)
Immobility syndromes/other
What 3 questions are essential to ask about a lump or nodule?
1) Is this new/how long has it been there?
2) Has the size changed
3) Does your MD know?
What two areas tend to be the focus of interventions with pts with CA?
- Energy conservation
- Functional retraining
Factors affecting aging include (4)
Genetics
Diet
Social conditions
Occurrence of age-related dzs
Cellular aging is/can be a combination of ___ shortening leading to ___, ___ insults that crete free radicals, DNA repair defects that lead to the accumulation of ___, and abnormal ___ signaling
Cellular aging is/can be a combination of TELOMERE shortening (leading to REPLICATIVE SENESCENCE), ENVIRONMENTAL insults that crete free radicals, DNA repair defects that lead to the accumulation of MUTATIONS, and abnormal GROWTH FACTOR signaling
With aging, we see:
- [incr/decr] thickness of distal vessel walls
- [incr/decr] size of proximal vessels
- [incr/decr] connective tissue & lipids
- Atrophy of ___ fibers
- [incr/decr] elastic fiber content
- [Epithelial/endothelial] thickening
- Smooth muscle ___
- [Incr/decr] collagen content
- Loss of ____ integrity
- INCREASED thickness of distal vessel walls
- INCREASED size of proximal vessels
- INCREASED connective tissue & lipids (subendothelial layer)
- Atrophy of ELASTIC fibers (medial layer)
- DECREASED elastic fiber content
- ENDOTHELIAL thickening
- Smooth muscle CALCIFICATION
- INCREASED collagen content
- Loss of VENOUS VALVE integrity
Vascular tissue changes with aging lead to increased ___ within vessel walls, increased ___, and subsequently increased ___
Increased STIFFNESS in vessel walls –>
Increased VASCULAR RESISTANCE –>
Increased BP
The potential for venous pooling with vascular changes in aging leads to what clinically?
LE edema
Why might less O2 be available for delivery to tissues in an older adult?
There’s potential for impaired diffusion of O2 across vessel walls because they’re no longer elastic/compliant like before
Clotting risk goes [up/down] in older adults. Give 3 contributing factors to this
Clotting risk goes UP
- Increased fibrinogen
- Increased platelet adhesiveness
- Early activation of coagulation system
In older adults, oxygen carrying capacity and oxygen delivery to tissues go [up/down]. Give reasons related to blood composition and peripheral blood changes as to why.
O2 carrying capacity goes DOWN
Blood compositon
- DECREASED space in bone marrow occupied by hematopoietic tissue
- Increased RED CELL rigidity
Peripheral blood
- Decreased HCT
- Decreased Hgb with levels remaining normal
