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Examine Complex Patient 6671 > Week5 6671/6611 > Flashcards

Week5 6671/6611 Flashcards

1
Q

Endocrine system checklist

A
  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
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2
Q

Main function of endocrine system

A

Maintain body homeostasis

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3
Q

Endocrine organs?

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

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

A

Primary- glands

Secondary- pituitary gland
(Can be iatrogenic)

Tertiary- hypothalamus

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5
Q

Endocrine pathology affecting pituitary gland

A

Diabetes Insipidus

SIADH: syndrome of inappropriate secretion of antidiuretic hormone

Acromegaly

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6
Q

Types of diabetes insipidus

A

CDI- central

NDI- nephrogenic

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7
Q

Clinical s/s of DI (diabetes insipidus)

A 
Polyuria 
Nocturia 
Polydipsia
Dehydration 
Decreased urine specific gravity
Increased serum sodium
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8
Q

CDI: central diabetes insipidus

A

Idiopathic or primary:
Autoimmune

Secondary: 
Pituitary trauma (neurosurgery/head trauma) 
Infections (meningitis, encephalitis)
Tumor 
Anorexia 
Vascular lesions
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9
Q

NDI: nephrogenic diabetes insipidus

A

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

Alcohol imbalances:
Hyperkalemia / Hypokalemia

Renal disease:
SLE, Sarcoidosis, Multiple myeloma, polynephritis

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10
Q

Risk factors of SIADH

A

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

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11
Q

Clinical s/s of SIADH

A

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)

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12
Q

Acromegaly in children

A

GH stimulates growth of long bones

Gigantism

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13
Q

Clinical presentation of acromegaly

A 
Degenerative arthropathy 
Hand stiffness 
Carpal tunnel syndrome 
Proximal myopathy and fibromyalgia 
Back pain
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14
Q

S/S Acromegaly

A 
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
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15
Q

S/S adrenal insufficiency

A 
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
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16
Q

Risk factors for thyroid disease

A

Genetics
> 50 years old
Women > Men

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17
Q

Clinical s/s goiter

A 
Increased neck size 
Pressure on adjacent tissue (ie Trachea, esophagus) 
Difficulty breathing 
Dysphagia 
Hoarseness
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18
Q

Clinical s/s thyroiditis

A

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)

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19
Q

Hypothyroidism

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

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
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20
Q

Hyperthyroidism

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

Thin hair

Exophthalmos

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

Heart failure- Tachycardia
Weight loss, diarrhea 
Warm skin, sweaty palms 
Hyperreflexia 
Pretibial edema
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21
Q

6 major functions of the liver

A
  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
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22
Q

Liver and gallbladder primary pain pattern

A

Mid-epigastrium
Or
Right upper quadrant of the abdomen

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23
Q

Liver and gallbladder secondary referral patterns

A

Liver:
T7-T10
Right shoulder

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

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24
Q

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

A

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.

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25
Q

S/S of hepatic disease

A
  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
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26
Q

Portal hypertension

A

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)

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27
Q

Cirrhosis

A

Progressive loss of normal tissue replaced with fibroids and nodular regeneration

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28
Q

Cirrhosis s/s

A 
Fatigue 
Weight loss 
Jaundice 
Coagulopathies 
Loss of ability to metabolize drugs 
Hypoalbuminemia has
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29
Q

Ascites

A

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

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30
Q

Ascites causes

A

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
31
Q

PT considerations- Ascites

A

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

32
Q

Cirrhosis defined

A

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

33
Q

Cirrhosis clinical s/s

A

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

34
Q

PT implications of cirrhosis

A

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

35
Q

Contraindications for liver transplant

A

Advanced cardiac disease

Myocardial infarction within previous 6 months

Severe COPD

Active alcohol use/other substance abuse
(Time required varies, usually > 6 months)

36
Q

Pre- liver transplant issues

A

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

37
Q

Post-op liver transplant

A

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

38
Q

CKD

A

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)
39
Q

ESRD

A

End stage renal disease

Final stage -Stage 5- CKD

High mortality rate

40
Q

____ is the functional unit of the kidney

A

Nephron

Glomerulus, renal tube, collecting duct

41
Q

CKD -> ESRD

Physiology

A

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

42
Q

Stages CKD

A

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

43
Q

CKD clinical manifestations

A

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

44
Q

CKD

Medical management

A

Meds:
HTN meds
EPO: erythropoietin

Renal replacement therapy:
HD: hemodialysis
PD: peritoneal dialysis

45
Q

PT implications- CKD

A
  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
46
Q

Most common type of dialysis?

A

Hemodialysis

47
Q

Peritoneal dialysis types

A

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

48
Q

Liver failure presentation (11)

A
  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
49
Q

Kidney failure presentation (7)

A
  1. Nausea/Vomiting
  2. Fatigue
  3. Confusion
  4. Progressive weakness
  5. Falls
  6. Malnutrition
  7. Neuropathy/Retinopathy
50
Q

PT implications pre-transplant

A 
SOB
Weakness 
Fatigue 
Pain 
Edema 
Fall Risk (balance/strength) 
Decreased mobility
51
Q

9 components of pre-transplant acute eval

A
  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
52
Q

Treatment in pre-transplant stage

A 
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
53
Q

Considerations s/p heart transplant

A 
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

54
Q

Considerations s/p Lung Transplant

A 
Changes in pulmonary status:
vO2max 
Ventilatory threshold 
Anaerobic threshold
Respiratory rate 
Minute ventilation
55
Q

Considerations s/p Liver Transplant

A

Delayed cognitive recovery
Malnutrition
Delayed liver function

56
Q

Considerations s/p Kidney Transplant

A

DM
Infections: UTI, upper respiratory
Anemia
CV disease

57
Q

Signs of transplant rejection-

Heart

A 
Low grade fever 
Fatigue 
Decreased exercise tolerance 
Ventricular dysrhythmias 
Increased resting BP 
Hypotension w/ exercise
58
Q

Signs of transplant rejection-

Lung

A 
GERD 
Low grade fever 
Leukocytosis 
Decreased arterial O2 saturation 
Decreased exercise tolerance
59
Q

Signs of transplant rejection-

Liver

A 
Fatigue 
Fever 
Abdominal pain or tenderness 
Dark yellow/orange urine 
Clay-colored stools 
Decreased exercise tolerance
60
Q

Signs of transplant rejection- Kidney

A 
Fever 
Flu-like symptoms 
Tenderness around kidney 
Fluid retention 
Weight gain (> 2-4 lbs in 24 hrs) 
Decreased urine output
61
Q

Therapy considerations s/p - heart transplant

A

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

62
Q

Therapy considerations s/p - Lung transplant

A 
CO2 retention
Pulmonary HTN precautions 
Incisional precautions 
Breathing retraining 
Airway clearance 
Postural considerations
63
Q

Therapy considerations s/p - liver transplant

A 
Pulmonary involvement 
CNS complications 
Abdominal scar can contribute to poor posture 
Poor balance, coordination, endurance 
Energy conservation education
64
Q

Therapy considerations s/p - Kidney transplant

A

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)

65
Q

Chronic stress response

A

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
66
Q

Chronic stress/ Cortisol

Brain

A 
Short term memory loss 
Sleep disturbance 
Decreased focus and concentration 
Low libido 
Altered plasticity 
Appetite changes
67
Q

Chronic stress/ Cortisol

Tissues

A 
Increased sensitivity 
Decreased inflammation 
Decreased blood flow 
Immune deficiency 
Potential failure 
Fatigue
68
Q

Metabolic syndrome

A 
Abdominal obesity 
Atherogenic dyslipidemia
Elevated BP
Insulin resistance 
Prothrombic and proinflammatory state of the blood

Screening:
BP
Glucose
Waist circumference

69
Q

Risk factors for NSAID-induced gastropathy

A
  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
70
Q

Any patient with bilateral carpal tunnel syndrome should be __

A

Screened for liver impairment

71
Q

Asterixis

A

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)

72
Q

Pancreas referral pain

A

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

73
Q

Pancreatic cancer- referral

A

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.

Examine Complex Patient 6671 (8 decks)

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