Screening for Hepatic, Biliary, & Hematologic Disease (Exam 2) Flashcards
What organs are included in the hepatic and biliary system? (3)
- Liver
- Gallbladder
- Common Bile duct
MSK symptoms associated with hepatic & biliary disease most often refer to? (3)
- Mid-back
- Scapular
- R shoulder
Signs and Symptoms of Hepatic/Biliary disease (5)
- Skin and nail bed changes
- Musculoskeletal pain
- Neurologic symptoms
- Gastrointestinal symptoms
- Ascities
Skin and nail bed changes with hepatic/biliary disease (8)
- Jaundice, pallor and orange/green skin (specific to hepatic)
- Sclera changes (specific to hepatic)
- Skin changes
- Pruritus (itching)
- Bruising
- Spider angiomas
- Palmar erythema
- Nails of Terry
What is a spider angioma?
Permanently enlarged and dilated capillaries visible on the surface of the skin caused by vascular dilation
Common in pts with liver impairment as a result of increased estrogen levels that are normally detoxified by the liver
Palmar erythema
Warm redness of the skin over the palms
Due to extensive collection of arteriovenous anastomoses
May c/o throbbing or tingling in the palms
Nails of Terry
Opaque nail plate with a narrow line of pink at the distal end instead of the more normal pink nail plate in the Caucasian
MSK pain associated with hepatic and biliary systems (5)
- Thoracic pain between shoulder blades
- R shoulder
- R upper trapezius
- R interscapular
- R subscapular
Rhabdomyolysis
- Potentially fatal condition
- Myoglobin and other muscle tissue contents released in bloodstream as result of muscle tissue disintegration
- May occur with acute trauma, severe burns, overexertion or liver impairment secondary to alcohol abuse, alcohol poisoning or statins
Neuro signs and the hepatic system
Secondary to increased serum ammonia and urea levels because of liver dysfunction
Confusion, sleep disturbances, muscle tremors, hyper-reactive reflexes, numbness/tingling and asterixis
Correlation exists between liver disease and bilateral carpal tunnel syndrome
Asterixis
- Outward sign of liver disease
- Also called flapping tremors or liver flap
- Inability to maintain wrist extension with forward flexion of UE
If someone has bilateral carpal tunnel what questions should you ask them to determine if they might have a hepatic system issue? (5)
- Ask about similar symptoms in the feet (bilateral tarsal tunnel)
- Ask about personal history of liver or hepatic disease
- Look for history of alcoholism
- Ask about current or previous use of statins
- Look for other signs of liver impairment
GI symptoms for hepatic/biliary disease (6)
- Light-colored stool (almost white)
- Potential causes
- Gallbladder disease
- Hepatotoxic medications
- Pancreatic cancer blocking bile duct
- Potential causes
- Urine the color of tea or cola
Ascites
Accumulation of fluid in the peritoneal cavity, causing abdominal swelling
Sign of hepatic disease
What are 3 hepatic patholgies? What is 1 biliary patholgy?
Hepatic:
- Hepatitis
- Cirrhosis
- Liver Cancer
Biliary:
- Cholelithiasis
Hepatitis
Acute or chronic inflammation of the liver
Caused by virus, a chemical, a drug reaction, alcohol abuse, or secondary to a disease condition
Viral Hepatitis:
- Acute infections inflammation of the liver caused by one of the following viruses: A, B, C, D, E and G
- Hep A and E most commonly spread via fecal-oral route
- Hep B, C, D, and G are primarily blood borne pathogens
Top 5 Risk factors for Hepatitis
- Injection drug use
- Liver transplant recepient
- Healthcare worker exposed to blood products or body fluids
- Severe alcoholism
- Travel to high risk areas
Other Risk factors for hepatitis (9)
- Acupuncture
- Tattoo inscription or removal
- Ear or body piercing
- Recent operative procedure
- Blood or plasma transfusion before 1991
- Hemodyalsis
- Exposure to certain chemicals or medications
- Unprotected homosexual/bisexual activity
- Consumption of raw shellfish
Signs and symptoms of chronic hepatitis (11)
- May refer pain to thoracic spine, R upper trap or R shoulder
- Fatigue
- Jaundice
- Abdominal pain
- Anorexia
- Arthralgia
- Fever
- Splenomegaly and hepatomegaly
- Weakness
- Ascites
- Hepatic encephalopathy
Cirrhosis (4)
- Chronic hepatic disease
- Characterized by destruction of liver cells and replacement of tissue with fibrous bands
- With increased scaring comes impaired blood and lymph flow causing hepatic insufficiency
- Causes vary but most common cause is alcohol abuse
Clinical signs and symptoms of cirrhosis (12)
- May refer pain to thoracic spine, R upper trap or R shoulder
- Mild R upper quadrant pain
- GI symptoms
- Anorexia
- Indigestion
- Weight loss
- Nausea and vomiting
- Diarrhea or constipation
- Dull abdominal ache
- Ease of fatigue (with mild exertion)
- Weakness
- Fever
Liver Cancer
what commonly causes liver cancer?
What cancers commonly metastasize to liver? 3)
What are 3 other cancers that might metastasize to the liver?
What other condition is liver cancer often associated with?
- More common that liver tumors are due to metastasis
- Stomach, colorectal and pancreas common to metastasize to liver
- Liver filters blood coming from GI tract
- Other primary cancers that metastasize
- Esophagus
- Lung
- Breast
- Primary liver tumors often associated with cirrhosis
Clinical signs and symptoms of liver neoplasm (8)
- May refer pain to thoracic spine, R upper trap or R shoulder
- Jaundice
- Progressive failure of health
- Anorexia/weight loss
- Overall muscular weakness
- Epigastric fullness and pain or discomfort
- Constant ache in the epigastrum or mid-back
- Early satiety
Liver percussion test
Patient Position: Supine
Examiner Position: Standing to right side of pt.
Dummy Hand: Over anteriolateral surface of right inferior ribs
Percuss with fist on dorsum of dummy hand
Abnormal Findings: Tenderness with percussion
Cholelithiasis
- The presence or formation of gallstones
- Gallstones: stone like masses aka calculi
- Possibly result of changes in normal components of bile
- Problems arise if stone leaves gallbladder and causes obstruction somewhere else
- Incidence increases with age
5 F’s associated with gallstones
- Fat
- Fair
- Forty (or older)
- Female (Secondary to elevated estrogen)
- Flatulent
Risk factors for gallstones (11)
- Age
- Greater incidence in women than men
- Elevated estrogen levels
- Obesity
- Diet: high cholesterol, low fiber
- DM
- Liver disease
- Rapid weight loss or fasting
- Taking statins
- Native American/Mexican American
- Family hx of gallstones
Most important signs and symptoms of gallstones (acute)
- Tenderness on tip of 10th rib on R
- Pain radiating into the R shoulder and between the scapulae
- May refer pain to R upper trap or R shoulder
other signs and symptoms of gallstones (7)
- Chills, low grade fever
- Jaundice
- GI symptoms
- Nausea
- Anorexia
- Vomiting
- Tenderness over the gallbladder
Murphy’s sign procedure/abnormal findings
- Patient Position: Supine in hook lying
- Examiner Position: On right side of the patient
- Ask patient to exhale
- Perform palpation below costal margin on the right at midclavicular line
- Have the patient take a deep breath in
- Abnormal Findings: Patient stops breathing/winces or reports tenderness
Clues to screen for hepatic disease (8)
- R shoulder/scapular and/or mid-back pain of unknown origin
- Presence of GI symptoms
- Bilateral carpal/tarsal tunnel syndrome (esp of unknown origin)
- Personal history of cancer, liver or gallbladder disease
- Hx of hepatitis (esp with joint pain)
- Statin use
- Changes in skin or eye color (jaundice, spider angiomas, palmar erythema)
- History of excessive alcohol consumption
Guidelines for immediate referral
Symptoms suggestive of Rhabdomyolysis
Guidelines for MD referral for hepatic disease (4)
- Obvious signs of hepatic disease
- Development of arthralgias of unknown cause (esp in pt with risk factors for hepatitis or hx of hepatitis)
- Presence of bilateral carpal tunnel syndrome accompanied by bilateral tarsal tunnel syndrome unknown to the MD
- Presence of sensory neuropathy of unknown cause accompanied by signs and symptoms associated with hepatic system impairment
What does blood consist of? (4)
- Plasma- carries antibodies and nutrients to tissues and removes wastes from tissues
- Erythrocytes-carry oxygen to tissues and remove carbon dioxide from them
- Leukocytes-act in inflammatory/immune responses
- Platelets (thrombocytes)-together with coagulation factors in plasma, control the clotting of the blood
Signs and symptoms of hematologic disorder with minimal exertion (5)
- Dyspnea
- Chest pain
- Palpitations
- Severe weakness
- Fatigue
Neuro signs and symptoms of hematologic disease
- Headache
- Drowsiness
- Dizziness
- Syncope
- Polyneuropathy
Other signs and symptoms of hematologic disease (3)
- Skin/fingernail changes
- Pallor of the face, hands, nail beds, and lips
- Cyanosis or clubbing of nail beds
- Presence of blood in stool
- Easy bruising
List hematologic disorders (8)
- Anemia
- Polycythemia
- Sickle Cell Anemia
- Leukocytosis
- Leukopenia
- Thrombocytosis
- Thrombocytopenia
- Hemophilia
What is anemia?
Reduction in oxygen-carrying capacity of blood
Result of abnormality in quality or quantity of erythrocytes
Most common causes of anemia (3)
- Excessive blood loss
- Increased destruction of erythrocytes
- Decreased production of erythrocytes
PT considerations for anemia
Diminished exercise tolerance is expected in pts with anemia and exercise should be approved by MD
Polycythemia
Increase in number of RBCs and concentration of hemoglobin
Increased whole blood viscosity and increased blood volume
PT considearations for polycthemia
Results in thickening of blood and increased risk for clotting
Sickle cell anemia
- Inherited, autosomal recessive disorders
- More common in African Americans
- Also in individuals from India, Mediterranean countries, Saudi Arabia, the Caribbean islands and South & Central America
- Characterized by presence of abnormal form of hemoglobin
- Altered shape of cell to sickled or curved shape
- Series of “crises” or acute manifestations of symptoms characterize the condition
clinical signs and symptoms of sickle cell anemia
- Pain caused by blockage of sickled RBCs
- May be in organ, bone, or joint of the body
- Joint pain most often occurs in shoulder or hip
- Painful episodes may last hours or up to 5-6 days
- May cause Hand-foot syndrome
- Painful swelling in dorsum of hands and feet
factors that may cause a crisis for someone with sickle cell anemia
Viral or bacterial infection, hypoxia, dehydration, emotional disturbance, extreme temperatures, fever, strenuous physical exertion or fatigue
Leukocytosis
- Sign of the inflammatory response
- Count of 10,000 leukocytes/mm3
When is leukocytosis helpful? (10)
- Bacterial infection
- Inflammation or tissue necrosis
- Metabolic intoxications
- Neoplasms
- Acute hemorrhage
- Splenectomy
- Acute appendicitis
- Pneumonia
- Intoxication by chemicals
- Acute rheumatic fever
Leukopenia
Reduction of number of leukocytes in blood
Below 5000/mL
Can occur due to chemo/radiation, in overwhelming infections, in dietary deficiencies and in autoimmune diseases
Leukopenia PT precautions
- Good hand washing practice so important in this population
- Pt with known leukopenia presenting with constitutional symptoms (ie fever, chills, sweats) requires immediate medical referral
Thrombocytosis
- Increase in platelet count
- Usually temporary
- Associated with tendency to clot
- Secondary to high platelet count and increased blood viscosity
Thrombocytopenia
- Decrease in number of platelets
- Result form decreased or defective platelet production or from accelerated platelet destruction
Thrombocytopenia PT precautions
- PT needs to be alert to severe bruising, external hematomas, joint swelling, multiple petechiae
- Strenuous exercise or exercise that involves straining/bearing down could cause hemorrhage (particularly of eyes and brain)
- Avoid valsalva
Causes of thrombocytopenia (6)
- Radiation/Chemo
- Bone marrow failure
- Aplastic anemia
- Leukemia
- Metastatic carcinoma
- Medications
- NSAIDs
- Methotrexate
- Coumadin/warfarin
Clinical signs and symptoms of thrombocytopenia (5)
- Bleeding after minor trauma
- Spontaneous bleeding
- Petechiae (small red dots)
- Bruises
- Purpura spots (bleeding under the skin)
- Epistaxis (nosebleeds)
- Excessive menstruation
- Gingival bleeding
- Melena
Hemophelia
- Hereditary blood-clotting disorder
- Caused by abnormality of functional plasma-clotting proteins
- Bleed longer but not faster than those without the condition
what is one of the most common clinical manifestations of hemophilia?
- Bleeding into the joint is one of the most common clinical manifestations of hemophilia
- May be result of trauma or may be spontaneou
- Most often affects knee, elbow, ankle, hip and shoulder
signs and symptoms of acute hemarthrosis (related to hemophilia) (6)
- Stiffening into position of comfort
- Decreased ROM
- Pain
- Swelling
- Tenderness
- Heat
What is the second most common site of bleeding related to hemophilia?
- Bleeding into the muscles is second most common site of bleeding
- Can be more insidious and massive than joint hemorrhages
- Common in flexor muscle groups
other clinical signs and symptoms of muscle hemorrage (related to hemophilia) (5)
- Gradually intensifying pain
- Protective spasm of the muscle
- Limitation of movement at the surrounding joints
- Muscle assumes the position of comfort (usually shortened)
- Loss of sensation
clues to screen for hemotologic disease (4)
- Previous history of chemotherapy or radiation therapy
- Chronic or long-term use of aspirin or other NSAIDs
- Spontaneous bleeding of any kind (esp with previous history of hemophilia)
- Recent major surgery or previous transplantation
Guidelines for an immediate MD referral
Signs and symptoms of thrombocytopenia
Guidelines for MD referral
New episodes of muscle or joint pain in pts with hemophilia
What hematologic disorders are associated with increase clotting risk?
- Polycythemia: results in thickening of blood and increased risk for clotting
- Thrombocytosis: Associated with tendency to clot secondary to high platelet count and increased blood viscosity
- Leukocytosis**: Possibly risk factor for thrombosis
What hematologic disorders are associated with patients receiving chemo/radiation?
Leukopenia: decrease in leukocytes (below 5000/mL)
PT Considerations:
- Good hand washing practice so important in this population
- Pt with known leukopenia presenting with constitutional symptoms (ie fever, chills, sweats) requires immediate medical referral
Thrombocytopenia: decrease in platelets
PT Considerations:
- PT needs to be alert to severe bruising, external hematomas, joint swelling, multiple petechiae
- Strenuous exercise or exercise that involves straining/bearing down could cause hemorrhage (particularly of eyes and brain) Avoid valsalva
Complications of overuse of NSAIDs can result in what hematologic disorders?
Thrombocytopenia: Decreased platelets
PT Considerations:
- PT needs to be alert to severe bruising, external hematomas, joint swelling, multiple petechiae
- Strenuous exercise or exercise that involves straining/bearing down could cause hemorrhage (particularly of eyes and brain) Avoid valsalva
hematologic disorders
Chronic or long-term use of aspirin or NSAIDs
