Week5 6671/6611

Question 1

Endocrine system checklist

Answer 1

1. General health
2. Psychological/Cognitive
3. GI
4. Urogenital
5. MSK
6. Sensory
7. Dermatological
8. Miscellaneous: temp intolerance, visual changes, orthostatic hypotension, increased bruising, increased thirst

Question 2

Main function of endocrine system

Answer 2

Maintain body homeostasis

Question 3

Endocrine organs?

Answer 3

1. Pituitary
2. Parathyroid
3. Hypothalamus
4. Thyroid
5. Adrenals
6. Pancreas
7. Ovaries/Tested
8. Adipose

Question 4

Endocrine pathophysiology
Primary, Secondary, and Tertiary
Affects..?

Answer 4

Primary- glands

Secondary- pituitary gland
(Can be iatrogenic)

Tertiary- hypothalamus

Question 5

Endocrine pathology affecting pituitary gland

Answer 5

Diabetes Insipidus

SIADH: syndrome of inappropriate secretion of antidiuretic hormone

Acromegaly

Question 6

Types of diabetes insipidus

Answer 6

CDI- central

NDI- nephrogenic

Question 7

Clinical s/s of DI (diabetes insipidus)

Answer 7

Polyuria 
Nocturia 
Polydipsia
Dehydration 
Decreased urine specific gravity
Increased serum sodium

Question 8

CDI: central diabetes insipidus

Answer 8

Idiopathic or primary:
Autoimmune

Secondary: 
Pituitary trauma (neurosurgery/head trauma) 
Infections (meningitis, encephalitis)
Tumor 
Anorexia 
Vascular lesions

Question 9

NDI: nephrogenic diabetes insipidus

Answer 9

Medications:
Lithium (20% chronic users)
Demeclocycline, amphotericin, colchine

Alcohol imbalances:
Hyperkalemia / Hypokalemia

Renal disease:
SLE, Sarcoidosis, Multiple myeloma, polynephritis

Question 10

Risk factors of SIADH

Answer 10

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

Question 11

Clinical s/s of SIADH

Answer 11

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)

Question 12

Acromegaly in children

Answer 12

GH stimulates growth of long bones

Gigantism

Question 13

Clinical presentation of acromegaly

Answer 13

Degenerative arthropathy 
Hand stiffness 
Carpal tunnel syndrome 
Proximal myopathy and fibromyalgia 
Back pain

Question 14

S/S Acromegaly

Answer 14

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

Question 15

S/S adrenal insufficiency

Answer 15

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

Question 16

Risk factors for thyroid disease

Answer 16

Genetics
> 50 years old
Women > Men

Question 17

Clinical s/s goiter

Answer 17

Increased neck size 
Pressure on adjacent tissue (ie Trachea, esophagus) 
Difficulty breathing 
Dysphagia 
Hoarseness

Question 18

Clinical s/s thyroiditis

Answer 18

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)

Question 19

Hypothyroidism

Hair? 
Eyes?
Face?
Thyroid gland? 
Heart?
GI?
Temp? 
MSK? 
Edema?

Answer 19

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

Question 20

Hyperthyroidism

Hair? 
Eyes?
Thyroid gland? 
Heart?
GI?
Temp? 
MSK? 
Edema?

Answer 20

Thin hair

Exophthalmos

Enlarged thyroid: diffuse (warm) , nodular, solitary “toxic” nodule

Heart failure- Tachycardia
Weight loss, diarrhea 
Warm skin, sweaty palms 
Hyperreflexia 
Pretibial edema

Question 21

6 major functions of the liver

Answer 21

1. Produce albumin and other plasma proteins
2. Bile production
3. Conversion and excretion of bilirubin
4. Produce clotting factors
5. Store vitamins
6. Immune system for gut

Question 22

Liver and gallbladder primary pain pattern

Answer 22

Mid-epigastrium
Or
Right upper quadrant of the abdomen

Question 23

Liver and gallbladder secondary referral patterns

Answer 23

Liver:
T7-T10
Right shoulder

Gallbladder:
Right shoulder
Right interscapular (T4/T5 to T8)
Right subscapular area

Question 24

Any pain in the ____ should warrant inquiry ruling out visceral sources.

Answer 24

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.

Question 25

S/S of hepatic disease

Answer 25

1. GI- nausea, vomiting, diarrhea, constipation, heartburn 2. Edema/Ascites 3. Dark urine 4. Light or clay colored stools 5. Right upper quadrant abdominal pain 6. Skin changes: jaundice, bruising, spider angina, palmar erythema 7. Neuro involvement: confusion, sleep disturbance, muscle tremors, hyper-reflex, asterixis 8. MSK pain 9. Hepatic osteodystrophy

Question 26

Portal hypertension

Answer 26

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)

Question 27

Cirrhosis

Answer 27

Progressive loss of normal tissue replaced with fibroids and nodular regeneration

Question 28

Cirrhosis s/s

Answer 28

``` Fatigue Weight loss Jaundice Coagulopathies Loss of ability to metabolize drugs Hypoalbuminemia has ```

Question 29

Ascites

Answer 29

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

Question 30

Ascites causes

Answer 30

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 ```

Question 31

PT considerations- Ascites

Answer 31

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

Question 32

Cirrhosis defined

Answer 32

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

Question 33

Cirrhosis clinical s/s

Answer 33

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

Question 34

PT implications of cirrhosis

Answer 34

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

Question 35

Contraindications for liver transplant

Answer 35

Advanced cardiac disease Myocardial infarction within previous 6 months Severe COPD Active alcohol use/other substance abuse (Time required varies, usually > 6 months)

Question 36

Pre- liver transplant issues

Answer 36

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

Question 37

Post-op liver transplant

Answer 37

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

Question 38

CKD

Answer 38

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) ```

Question 39

ESRD

Answer 39

End stage renal disease Final stage -Stage 5- CKD High mortality rate

Question 40

____ is the functional unit of the kidney

Answer 40

Nephron Glomerulus, renal tube, collecting duct

Question 41

CKD -> ESRD | Physiology

Answer 41

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

Question 42

Stages CKD

Answer 42

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

Question 43

CKD clinical manifestations

Answer 43

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

Question 44

CKD | Medical management

Answer 44

Meds: HTN meds EPO: erythropoietin Renal replacement therapy: HD: hemodialysis PD: peritoneal dialysis

Question 45

PT implications- CKD

Answer 45

1. Fatigue (schedule flexibility, trial and error) 2. 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 3. Variable exercise tolerance 4. Monitor vitals and labs (fluid shifts common) 5. Possible fluid restrictions 6. Maintain integrity of arterio-venous fistula or graft (AKA shunt) - usu in UE or LE, no BP over shunt 7. Slower progression 8. Don’t forget what led to this: HTN, DM.. and where headed: CV disease

Question 46

Most common type of dialysis?

Answer 46

Hemodialysis

Question 47

Peritoneal dialysis types

Answer 47

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

Question 48

Liver failure presentation (11)

Answer 48

1. Jaundice 2. Confusion 3. Coma 4. Nausea/Vomiting 5. Edema 6. Abdominal pain or distention 7. Muscle wasting 8. Fatigue 9. Insomnia 10. Anemia 11. Peripheral neuropathy

Question 49

Kidney failure presentation (7)

Answer 49

1. Nausea/Vomiting 2. Fatigue 3. Confusion 4. Progressive weakness 5. Falls 6. Malnutrition 7. Neuropathy/Retinopathy

Question 50

PT implications pre-transplant

Answer 50

``` SOB Weakness Fatigue Pain Edema Fall Risk (balance/strength) Decreased mobility ```

Question 51

9 components of pre-transplant acute eval

Answer 51

1. Social situation 2. Vital signs 3. Strength 4. ROM 5. Aerobic capacity 6. FMS: functional mobility 7. Balance 8. HEP compliance 9. Discharge recommendations

Question 52

Treatment in pre-transplant stage

Answer 52

``` 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 ```

Question 53

Considerations s/p heart transplant

Answer 53

``` 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

Question 54

Considerations s/p Lung Transplant

Answer 54

``` Changes in pulmonary status: vO2max Ventilatory threshold Anaerobic threshold Respiratory rate Minute ventilation ```

Question 55

Considerations s/p Liver Transplant

Answer 55

Delayed cognitive recovery Malnutrition Delayed liver function

Question 56

Considerations s/p Kidney Transplant

Answer 56

DM Infections: UTI, upper respiratory Anemia CV disease

Question 57

Signs of transplant rejection- | Heart

Answer 57

``` Low grade fever Fatigue Decreased exercise tolerance Ventricular dysrhythmias Increased resting BP Hypotension w/ exercise ```

Question 58

Signs of transplant rejection- | Lung

Answer 58

``` GERD Low grade fever Leukocytosis Decreased arterial O2 saturation Decreased exercise tolerance ```

Question 59

Signs of transplant rejection- | Liver

Answer 59

``` Fatigue Fever Abdominal pain or tenderness Dark yellow/orange urine Clay-colored stools Decreased exercise tolerance ```

Question 60

Signs of transplant rejection- Kidney

Answer 60

``` Fever Flu-like symptoms Tenderness around kidney Fluid retention Weight gain (> 2-4 lbs in 24 hrs) Decreased urine output ```

Question 61

Therapy considerations s/p - heart transplant

Answer 61

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

Question 62

Therapy considerations s/p - Lung transplant

Answer 62

``` CO2 retention Pulmonary HTN precautions Incisional precautions Breathing retraining Airway clearance Postural considerations ```

Question 63

Therapy considerations s/p - liver transplant

Answer 63

``` Pulmonary involvement CNS complications Abdominal scar can contribute to poor posture Poor balance, coordination, endurance Energy conservation education ```

Question 64

Therapy considerations s/p - Kidney transplant

Answer 64

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)

Question 65

Chronic stress response

Answer 65

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 ```

Question 66

Chronic stress/ Cortisol | Brain

Answer 66

``` Short term memory loss Sleep disturbance Decreased focus and concentration Low libido Altered plasticity Appetite changes ```

Question 67

Chronic stress/ Cortisol | Tissues

Answer 67

``` Increased sensitivity Decreased inflammation Decreased blood flow Immune deficiency Potential failure Fatigue ```

Question 68

Metabolic syndrome

Answer 68

``` Abdominal obesity Atherogenic dyslipidemia Elevated BP Insulin resistance Prothrombic and proinflammatory state of the blood ``` Screening: BP Glucose Waist circumference

Question 69

Risk factors for NSAID-induced gastropathy

Answer 69

1. > 65 y/o 2. Hx peptic ulcer or GI disease 3. Smoking, Alcohol use 4. Oral corticosteroid use 5. Anticoagulants 6. Renal complications in clients w/ HTN or CHF, or who use diuretics or ACE inhibitors 7. Use of acid suppressants 8. NSAIDS + SSRIs; antidepressants

Question 70

Any patient with bilateral carpal tunnel syndrome should be __

Answer 70

Screened for liver impairment

Question 71

Asterixis

Answer 71

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)

Question 72

Pancreas referral pain

Answer 72

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

Question 73

Pancreatic cancer- referral

Answer 73

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.