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Differential Diagnosis > Screening for Hepatic, Biliary, & Hematologic Disease (Exam 2) > Flashcards

Screening for Hepatic, Biliary, & Hematologic Disease (Exam 2) Flashcards

1
Q

What organs are included in the hepatic and biliary system? (3)

A
  • Liver
  • Gallbladder
  • Common Bile duct
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2
Q

MSK symptoms associated with hepatic & biliary disease most often refer to? (3)

A
  • Mid-back
  • Scapular
  • R shoulder
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3
Q

Signs and Symptoms of Hepatic/Biliary disease (5)

A
  • Skin and nail bed changes
  • Musculoskeletal pain
  • Neurologic symptoms
  • Gastrointestinal symptoms
  • Ascities
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4
Q

Skin and nail bed changes with hepatic/biliary disease (8)

A
  1. Jaundice, pallor and orange/green skin (specific to hepatic)
  2. Sclera changes (specific to hepatic)
  3. Skin changes
  4. Pruritus (itching)
  5. Bruising
  6. Spider angiomas
  7. Palmar erythema
  8. Nails of Terry
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5
Q

What is a spider angioma?

A

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

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6
Q

Palmar erythema

A

Warm redness of the skin over the palms

Due to extensive collection of arteriovenous anastomoses

May c/o throbbing or tingling in the palms

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7
Q

Nails of Terry

A

Opaque nail plate with a narrow line of pink at the distal end instead of the more normal pink nail plate in the Caucasian

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8
Q

MSK pain associated with hepatic and biliary systems (5)

A
  • Thoracic pain between shoulder blades
  • R shoulder
  • R upper trapezius
  • R interscapular
  • R subscapular
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9
Q

Rhabdomyolysis

A
  • 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
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10
Q

Neuro signs and the hepatic system

A

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

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11
Q

Asterixis

A
  • Outward sign of liver disease
  • Also called flapping tremors or liver flap
  • Inability to maintain wrist extension with forward flexion of UE
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12
Q

If someone has bilateral carpal tunnel what questions should you ask them to determine if they might have a hepatic system issue? (5)

A
  • 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
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13
Q

GI symptoms for hepatic/biliary disease (6)

A
  • Light-colored stool (almost white)
    • Potential causes
      • Gallbladder disease
      • Hepatotoxic medications
      • Pancreatic cancer blocking bile duct
  • Urine the color of tea or cola
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14
Q

Ascites

A

Accumulation of fluid in the peritoneal cavity, causing abdominal swelling

Sign of hepatic disease

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15
Q

What are 3 hepatic patholgies? What is 1 biliary patholgy?

A

Hepatic:

  • Hepatitis
  • Cirrhosis
  • Liver Cancer

Biliary:

  • Cholelithiasis
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16
Q

Hepatitis

A

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
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17
Q

Top 5 Risk factors for Hepatitis

A
  • Injection drug use
  • Liver transplant recepient
  • Healthcare worker exposed to blood products or body fluids
  • Severe alcoholism
  • Travel to high risk areas
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18
Q

Other Risk factors for hepatitis (9)

A
  • 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
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19
Q

Signs and symptoms of chronic hepatitis (11)

A
  • 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
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20
Q

Cirrhosis (4)

A
  • 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
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21
Q

Clinical signs and symptoms of cirrhosis (12)

A
  • 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
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22
Q

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?

A
  • 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
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23
Q

Clinical signs and symptoms of liver neoplasm (8)

A
  • 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
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24
Q

Liver percussion test

A

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

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25
Q

Cholelithiasis

A
  • 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
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26
Q

5 F’s associated with gallstones

A
  • Fat
  • Fair
  • Forty (or older)
  • Female (Secondary to elevated estrogen)
  • Flatulent
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27
Q

Risk factors for gallstones (11)

A
  • 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
28
Q

Most important signs and symptoms of gallstones (acute)

A
  • 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
29
Q

other signs and symptoms of gallstones (7)

A
  • Chills, low grade fever
  • Jaundice
  • GI symptoms
  • Nausea
  • Anorexia
  • Vomiting
  • Tenderness over the gallbladder
30
Q

Murphy’s sign procedure/abnormal findings

A
  • 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
31
Q

Clues to screen for hepatic disease (8)

A
  • 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
32
Q

Guidelines for immediate referral

A

Symptoms suggestive of Rhabdomyolysis

33
Q

Guidelines for MD referral for hepatic disease (4)

A
  • 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
34
Q

What does blood consist of? (4)

A
  • 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
35
Q

Signs and symptoms of hematologic disorder with minimal exertion (5)

A
  • Dyspnea
  • Chest pain
  • Palpitations
  • Severe weakness
  • Fatigue
36
Q

Neuro signs and symptoms of hematologic disease

A
  • Headache
  • Drowsiness
  • Dizziness
  • Syncope
  • Polyneuropathy
37
Q

Other signs and symptoms of hematologic disease (3)

A
  • 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
38
Q

List hematologic disorders (8)

A
  • Anemia
  • Polycythemia
  • Sickle Cell Anemia
  • Leukocytosis
  • Leukopenia
  • Thrombocytosis
  • Thrombocytopenia
  • Hemophilia
39
Q

What is anemia?

A

Reduction in oxygen-carrying capacity of blood

Result of abnormality in quality or quantity of erythrocytes

40
Q

Most common causes of anemia (3)

A
  • Excessive blood loss
  • Increased destruction of erythrocytes
  • Decreased production of erythrocytes
41
Q

PT considerations for anemia

A

Diminished exercise tolerance is expected in pts with anemia and exercise should be approved by MD

42
Q

Polycythemia

A

Increase in number of RBCs and concentration of hemoglobin

Increased whole blood viscosity and increased blood volume

43
Q

PT considearations for polycthemia

A

Results in thickening of blood and increased risk for clotting

44
Q

Sickle cell anemia

A
  • 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
45
Q

clinical signs and symptoms of sickle cell anemia

A
  • 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
46
Q

factors that may cause a crisis for someone with sickle cell anemia

A

Viral or bacterial infection, hypoxia, dehydration, emotional disturbance, extreme temperatures, fever, strenuous physical exertion or fatigue

47
Q

Leukocytosis

A
  • Sign of the inflammatory response
  • Count of 10,000 leukocytes/mm3
48
Q

When is leukocytosis helpful? (10)

A
  • Bacterial infection
  • Inflammation or tissue necrosis
  • Metabolic intoxications
  • Neoplasms
  • Acute hemorrhage
  • Splenectomy
  • Acute appendicitis
  • Pneumonia
  • Intoxication by chemicals
  • Acute rheumatic fever
49
Q

Leukopenia

A

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

50
Q

Leukopenia PT precautions

A
  • 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
51
Q

Thrombocytosis

A
  • Increase in platelet count
  • Usually temporary
  • Associated with tendency to clot
    • Secondary to high platelet count and increased blood viscosity
52
Q

Thrombocytopenia

A
  • Decrease in number of platelets
  • Result form decreased or defective platelet production or from accelerated platelet destruction
53
Q

Thrombocytopenia PT precautions

A
  • 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
54
Q

Causes of thrombocytopenia (6)

A
  • Radiation/Chemo
  • Bone marrow failure
  • Aplastic anemia
  • Leukemia
  • Metastatic carcinoma
  • Medications
    • NSAIDs
    • Methotrexate
    • Coumadin/warfarin
55
Q

Clinical signs and symptoms of thrombocytopenia (5)

A
  • Bleeding after minor trauma
  • Spontaneous bleeding
    • Petechiae (small red dots)
    • Bruises
    • Purpura spots (bleeding under the skin)
    • Epistaxis (nosebleeds)
  • Excessive menstruation
  • Gingival bleeding
  • Melena
56
Q

Hemophelia

A
  • Hereditary blood-clotting disorder
  • Caused by abnormality of functional plasma-clotting proteins
  • Bleed longer but not faster than those without the condition
57
Q

what is one of the most common clinical manifestations of hemophilia?

A
  • 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
58
Q

signs and symptoms of acute hemarthrosis (related to hemophilia) (6)

A
  • Stiffening into position of comfort
  • Decreased ROM
  • Pain
  • Swelling
  • Tenderness
  • Heat
59
Q

What is the second most common site of bleeding related to hemophilia?

A
  • 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
60
Q

other clinical signs and symptoms of muscle hemorrage (related to hemophilia) (5)

A
  • 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
61
Q

clues to screen for hemotologic disease (4)

A
  1. Previous history of chemotherapy or radiation therapy
  2. Chronic or long-term use of aspirin or other NSAIDs
  3. Spontaneous bleeding of any kind (esp with previous history of hemophilia)
  4. Recent major surgery or previous transplantation
62
Q

Guidelines for an immediate MD referral

A

Signs and symptoms of thrombocytopenia

63
Q

Guidelines for MD referral

A

New episodes of muscle or joint pain in pts with hemophilia

64
Q

What hematologic disorders are associated with increase clotting risk?

A
  • 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
65
Q

What hematologic disorders are associated with patients receiving chemo/radiation?

A

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
66
Q

Complications of overuse of NSAIDs can result in what hematologic disorders?

A

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

Differential Diagnosis (14 decks)

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