Week5 6671/6611 Flashcards
Endocrine system checklist
- General health
- Psychological/Cognitive
- GI
- Urogenital
- MSK
- Sensory
- Dermatological
- Miscellaneous: temp intolerance, visual changes, orthostatic hypotension, increased bruising, increased thirst
Main function of endocrine system
Maintain body homeostasis
Endocrine organs?
- Pituitary
- Parathyroid
- Hypothalamus
- Thyroid
- Adrenals
- Pancreas
- Ovaries/Tested
- Adipose
Endocrine pathophysiology
Primary, Secondary, and Tertiary
Affects..?
Primary- glands
Secondary- pituitary gland
(Can be iatrogenic)
Tertiary- hypothalamus
Endocrine pathology affecting pituitary gland
Diabetes Insipidus
SIADH: syndrome of inappropriate secretion of antidiuretic hormone
Acromegaly
Types of diabetes insipidus
CDI- central
NDI- nephrogenic
Clinical s/s of DI (diabetes insipidus)
Polyuria Nocturia Polydipsia Dehydration Decreased urine specific gravity Increased serum sodium
CDI: central diabetes insipidus
Idiopathic or primary:
Autoimmune
Secondary: Pituitary trauma (neurosurgery/head trauma) Infections (meningitis, encephalitis) Tumor Anorexia Vascular lesions
NDI: nephrogenic diabetes insipidus
Medications:
Lithium (20% chronic users)
Demeclocycline, amphotericin, colchine
Alcohol imbalances:
Hyperkalemia / Hypokalemia
Renal disease:
SLE, Sarcoidosis, Multiple myeloma, polynephritis
Risk factors of SIADH
Pituitary damage due to infection, trauma or neoplasm
Secretion of vasopressin-like substances
Thoracic pressure changes from compression of pulmonary or cardiac pressure receptors or both
Clinical s/s of SIADH
HA, confusion, lethargy (most significant early indicators)
Decreased urine output
Weight gain without visible edema
Seizure
Muscle cramping
Vomiting, diarrhea
Increased urine specific gravity (> 1.03)
Decreased serum sodium (< 135 mEq/dL; caused by dilution of serum from water)
Acromegaly in children
GH stimulates growth of long bones
Gigantism
Clinical presentation of acromegaly
Degenerative arthropathy Hand stiffness Carpal tunnel syndrome Proximal myopathy and fibromyalgia Back pain
S/S Acromegaly
Bony enlargement (face, jaw, hands, feet) Amenorrhea DM Profuse sweating (diaphoresis) HTN CTS (carpal tunnel syndrome) Hand pain stiffness Back pain (thoracic and/or lumbar) Proximal myopathy Poor exercise tolerance Fibromyalgia
S/S adrenal insufficiency
Dark pigmentation of skin, esp mouth and scars (occurs only with primary disease; Addison’s disease) Hypotension Progressive fatigue Hyperkalemia (generalized weakness and muscle flaccidity) Anorexia and weight loss Nausea and vomiting Arthralgias, myalgias (secondary only) Tendon calcification Hypoglycemia
Risk factors for thyroid disease
Genetics
> 50 years old
Women > Men
Clinical s/s goiter
Increased neck size Pressure on adjacent tissue (ie Trachea, esophagus) Difficulty breathing Dysphagia Hoarseness
Clinical s/s thyroiditis
Painless thyroid enlargement
Dysphagia, “tight” sensation when swallowing, or choking
Anterior neck, shoulder or rib cage pain without biomechanical changes
Gland sometimes easily palpable over anterior neck (warm, tender, swollen)
Fatigue, weight gain, dry hair and skin, constipation (later symptoms assoc w/ hypothyroidism)
Hypothyroidism
Hair? Eyes? Face? Thyroid gland? Heart? GI? Temp? MSK? Edema?
Loss of hair
Coarse, brittle hair
Periorbital edema Puffy face Normal or small thyroid Heart failure- Bradycardia Constipation Cold intolerance Muscle weakness Edema of extremities
Hyperthyroidism
Hair? Eyes? Thyroid gland? Heart? GI? Temp? MSK? Edema?
Thin hair
Exophthalmos
Enlarged thyroid: diffuse (warm) , nodular, solitary “toxic” nodule
Heart failure- Tachycardia Weight loss, diarrhea Warm skin, sweaty palms Hyperreflexia Pretibial edema
6 major functions of the liver
- Produce albumin and other plasma proteins
- Bile production
- Conversion and excretion of bilirubin
- Produce clotting factors
- Store vitamins
- Immune system for gut
Liver and gallbladder primary pain pattern
Mid-epigastrium
Or
Right upper quadrant of the abdomen
Liver and gallbladder secondary referral patterns
Liver:
T7-T10
Right shoulder
Gallbladder:
Right shoulder
Right interscapular (T4/T5 to T8)
Right subscapular area
Any pain in the ____ should warrant inquiry ruling out visceral sources.
Mid thoracic spine
T4/T5-T8 gallbladder
T7-T10 liver
The patient’s main complaint may be of pain in the shoulder, lower lumbar and sacral spine or anterior groin.
S/S of hepatic disease
- GI- nausea, vomiting, diarrhea, constipation, heartburn
- Edema/Ascites
- Dark urine
- Light or clay colored stools
- Right upper quadrant abdominal pain
- Skin changes: jaundice, bruising, spider angina, palmar erythema
- Neuro involvement: confusion, sleep disturbance, muscle tremors, hyper-reflex, asterixis
- MSK pain
- Hepatic osteodystrophy
Portal hypertension
Increased venous blood pressure in portal vein
Pressure > 6 mmHg
Most common in cirrhosis
Increased pressure-> Reversal of blood back to stomach, esophagus, umbilicus, rectum -> vessels continue to enlarge (varices)
Cirrhosis
Progressive loss of normal tissue replaced with fibroids and nodular regeneration
Cirrhosis s/s
Fatigue Weight loss Jaundice Coagulopathies Loss of ability to metabolize drugs Hypoalbuminemia has
Ascites
Pathological accumulation of fluid within peritoneal cavity
Volume > 1.5L can be detected by physical exam
Grade I: no symptoms, dx by US (min: 100 mL fluid)
Grade II: 1000+ mL fluid, increased abdominal girth, weight gain
Grade III: diffuse abdominal pressure, dyspnea (if diaphragm elevated by fluid), pain uncommon
Infectious (spontaneous bacterial peritonitis): new abdominal discomfort and fever
Ascites causes
Hepatic:
Portal hypertension (>90% of cases), usually due to cirrhosis
Chronic hepatitis
Severe alcoholic hepatitis w/o cirrhosis
Hepatic vein obstruction (Budd-Chiari syndrome)
Heart failure Abdominal malignancies Nephrotic syndrome Infection Malnutrition
PT considerations- Ascites
Increased resting comfort in High Fowler position (HOB raised 18-20” above level position w/ knees elevated)
Monitor for peripheral edema
Patient may have more muscle wasting than evident due to masking effect of edema
Be aware of medical complications of meds used to decrease fluid retention
Cirrhosis defined
Chronic disease state characterized by:
Hepatic parenchymal cell destruction and necrosis
Regeneration w/ fibrosis or scar tissue formation
May take years to develop
Primary complications: Portal HTN, Ascites, Jaundice, Impaired clotting, Hepatic encephalopathy
Cirrhosis clinical s/s
1st symptoms may be nonspecific constitutional (generalized fatigue, anorexia, malaise, weight loss)
Jaundice, dry skin
Firm liver in palpation
Clubbing and hypertrophic osteoarthropathy
Dupuytrens contracture
Nail changes
PT implications of cirrhosis
Advanced liver disease is catabolic - leading to sarcopenia; Frailty rusk very high
Significant decrease in exercise capacity and muscle strength regardless of cirrhosis etiology
6MWT, Max inspiratory pressure, VO2max - predictors of mortality
Exercise training well tolerated
8 week HEP
Significant fall risk
Contraindications for liver transplant
Advanced cardiac disease
Myocardial infarction within previous 6 months
Severe COPD
Active alcohol use/other substance abuse
(Time required varies, usually > 6 months)
Pre- liver transplant issues
Often deconditioned and malnourished
Weakness and sarcopenia
Anasarca and/or Ascites add weight gain and May produce balance impairments
PT very beneficial and necessary during this time
Post-op liver transplant
Typical LOS 1-3 weeks, part of stay in ICU
Rejection
Anti-rejection meds required for life
Acute rejection: w/in first 1-2 months (~25%)
Delayed/chronic rejection: years post-op (2-5%)
1 year survival rate 88%
5 year survival rate 75%
PT critical during this time
CKD
Chronic kidney disease
Altered renal function or structure for 3 or more months
Causes: DM HTN Glomerulonephritis Risk increases w/ excessive OTC drug use (acetaminophen, aspirin, combo analgesics)
ESRD
End stage renal disease
Final stage -Stage 5- CKD
High mortality rate
____ is the functional unit of the kidney
Nephron
Glomerulus, renal tube, collecting duct
CKD -> ESRD
Physiology
2ndary to disease processes, angiotensin II is released and causes vasoconstriction of arterioles and arteries to the glomerulus to keep pressured for filtration intact
Attracting inflammatory cells which releases cytokines and growth factors that change the structure of the glomerulus -> fibrosis and sclerosis
GFR (glomerulus filtration rate) reduced
Stages CKD
I: Normal GFR > 90 mL/min
Asymptomatic
II: mild decrease GFR 60-89 mL/min
Small amts albumin in urine
HTN and anemia
III: mod decrease GFR 30-58 mL/min
Increased albumin in urine, decreased in blood (noticeable edema); BUN and creatinine increase
IV: severe decrease GFR 15-29 mL/min
Proteinuria
V: ESRD GFR < 15 mL/min
CKD clinical manifestations
Anemia -> fatigue
Erythropoietin, produced by kidneys, controls production of RBCs
CV disease (L ventricular hypertrophy to CHF, CAD)
Main cause of death in ESRD
Chest pain, nausea, SOB, sweating
GI issues (nausea, vomiting, anorexia; malnutrition, fatigue, weakness, malaise)
MSK: abnormal Ca2+, phosphate, Vit D metabolism Renal osteodystrophy (bone pain, fx) Calcification of soft tissues, vessels (tendon rupture, CAD)
Neuro: sleep disturbance, uremic encephalopathy (GFR < 10 mL/min)
Memory loss, confusion, perceptual errors, decreased alertness
CKD
Medical management
Meds:
HTN meds
EPO: erythropoietin
Renal replacement therapy:
HD: hemodialysis
PD: peritoneal dialysis
PT implications- CKD
- Fatigue (schedule flexibility, trial and error)
- Exercise - During first 2 hrs of HD, no mobility
Cycle ergometer, LE weight exercises (use RPE)
Blood chemistry at optimal level after dialysis- but fatigue - Variable exercise tolerance
- Monitor vitals and labs (fluid shifts common)
- Possible fluid restrictions
- Maintain integrity of arterio-venous fistula or graft (AKA shunt) - usu in UE or LE, no BP over shunt
- Slower progression
- Don’t forget what led to this: HTN, DM.. and where headed: CV disease
Most common type of dialysis?
Hemodialysis
Peritoneal dialysis types
CPAD- continuous ambulatory peritoneal dialysis
Done during day
CCPD- continuous cycling peritoneal dialysis
Done at night
Only about 10% get this type
No machine needed
Liver failure presentation (11)
- Jaundice
- Confusion
- Coma
- Nausea/Vomiting
- Edema
- Abdominal pain or distention
- Muscle wasting
- Fatigue
- Insomnia
- Anemia
- Peripheral neuropathy
Kidney failure presentation (7)
- Nausea/Vomiting
- Fatigue
- Confusion
- Progressive weakness
- Falls
- Malnutrition
- Neuropathy/Retinopathy
PT implications pre-transplant
SOB Weakness Fatigue Pain Edema Fall Risk (balance/strength) Decreased mobility
9 components of pre-transplant acute eval
- Social situation
- Vital signs
- Strength
- ROM
- Aerobic capacity
- FMS: functional mobility
- Balance
- HEP compliance
- Discharge recommendations
Treatment in pre-transplant stage
MSK strengthening Bed mobility and transfer training Balance skills and core strength Gait training Endurance training and energy conservation Edema control Postural training Pulmonary enhancement/Breath control Education
Considerations s/p heart transplant
Changes in CV status: RHR, BP HR and peak HR w/ exercise/activity CV response SV L ventricular ejection fraction
Changes in pulmonary status:
VO2max
Ventilatory threshold
Anaerobic threshold
Considerations s/p Lung Transplant
Changes in pulmonary status: vO2max Ventilatory threshold Anaerobic threshold Respiratory rate Minute ventilation
Considerations s/p Liver Transplant
Delayed cognitive recovery
Malnutrition
Delayed liver function
Considerations s/p Kidney Transplant
DM
Infections: UTI, upper respiratory
Anemia
CV disease
Signs of transplant rejection-
Heart
Low grade fever Fatigue Decreased exercise tolerance Ventricular dysrhythmias Increased resting BP Hypotension w/ exercise
Signs of transplant rejection-
Lung
GERD Low grade fever Leukocytosis Decreased arterial O2 saturation Decreased exercise tolerance
Signs of transplant rejection-
Liver
Fatigue Fever Abdominal pain or tenderness Dark yellow/orange urine Clay-colored stools Decreased exercise tolerance
Signs of transplant rejection- Kidney
Fever Flu-like symptoms Tenderness around kidney Fluid retention Weight gain (> 2-4 lbs in 24 hrs) Decreased urine output
Therapy considerations s/p - heart transplant
Sternal precautions:
No pushing/pulling > 10 lbs
No reaching over 90*
Denervation of heart:
Importance of warmup/cool-down
Use RPE to monitor intensity
Closely monitor vitals before, during, after
Therapy considerations s/p - Lung transplant
CO2 retention Pulmonary HTN precautions Incisional precautions Breathing retraining Airway clearance Postural considerations
Therapy considerations s/p - liver transplant
Pulmonary involvement CNS complications Abdominal scar can contribute to poor posture Poor balance, coordination, endurance Energy conservation education
Therapy considerations s/p - Kidney transplant
Effects of exercise on blood glucose control
Increased incidence of CV disorders, HTN, CA, osteoporosis
Close monitoring of vitals- esp BP
Prior to and during exercise
Recessive exercises and osteoporosis precautions
Increased tendency of tendon injuries (Achilles, Patellar)
Chronic stress response
Prolonged stimulation of sympathetic nervous system
Hypothalamic arousal Poorly regulated cortisol secretion Insulin resistance Elevated BP Visceral accumulation of body fat (central obesity) Pro inflammatory
Chronic stress/ Cortisol
Brain
Short term memory loss Sleep disturbance Decreased focus and concentration Low libido Altered plasticity Appetite changes
Chronic stress/ Cortisol
Tissues
Increased sensitivity Decreased inflammation Decreased blood flow Immune deficiency Potential failure Fatigue
Metabolic syndrome
Abdominal obesity Atherogenic dyslipidemia Elevated BP Insulin resistance Prothrombic and proinflammatory state of the blood
Screening:
BP
Glucose
Waist circumference
Risk factors for NSAID-induced gastropathy
- > 65 y/o
- Hx peptic ulcer or GI disease
- Smoking, Alcohol use
- Oral corticosteroid use
- Anticoagulants
- Renal complications in clients w/ HTN or CHF, or who use diuretics or ACE inhibitors
- Use of acid suppressants
- NSAIDS + SSRIs; antidepressants
Any patient with bilateral carpal tunnel syndrome should be __
Screened for liver impairment
Asterixis
AKA liver flap or flapping tremors
Sign of liver disease producing CNS dysfunction
Inability to maintain wrist EXT with forward flexion of UE
Tested: client hyperextend wrist and hand with rest of arm supported on a firm surface OR with arms held out in front of body
(May also be viewed when release pressure in BP cuff)
Pancreas referral pain
Head of pancreas:
Epigastric and mid thoracic (T5-9)
R shoulder pain if distention from inflammation, infection, obstruction (tumor)
Tail of pancreas:
(L of midline) refers to L shoulder
Pancreatic cancer- referral
Most is in head of pancreas and are likely to cause epigastric and mid thoracic pain.
Radiation of pain into lumbar region is common, and sometimes the only sign.