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Med Con II - Coggle Diagram
Med Con II
GI
Peptic ulcer disease
- due to increased acid secretions eroding digestive mucosa
- bacteria involved is helicobacter Pylori 70% of the time
- complications include hemmorage, peritonitis, scarring
GI bleeding
- 75% is in the uppertract (SI, Stomach, Eso)
- Signs and symptoms include fatigue and weakness
- SOB
- Abdominal discomfort
Red flags for GI bleeding
- Syncope
- Hypotension
- Pallor
- Diaphoresis
- Tachycardia
Other major signs
- coffee ground emesis
*Melena - black tarry stools
- decreases in HCT
-
Celiac
- destroys GI villi
- leads to malabsorption and syptoms including diarrhea, fatigue, gas
- long term can lead to anemia and osteoporosis
Crohns disease
- is inflammation resulting in abdominial cramping and pain,diarrhea, obstruction and malabsorbtion leading to Wt loss
- can have joint pain and anemia
- can be treated with immunosuppressants, or steroids
Acute abdomen
- refers to a sudden severe abdominal pain that last less than 24h
- can be a medical emergency as it could be a sign of appendicitis, cholecystsitis, pancreatitis, ischemic bowel or AAA
PE
- Id location
- palpate for rigidity
- listen to bowel sounds
Colorectal cancer
- symptoms include bleeding
- pressure or pain with defecation
- Change in elimination
Mcburneys point for appendicitis
- 1/3 the way from navel to ASIS
- pain in region or rebound tenderness then think appendicitis
Iliopsoas signs for appendicitis or abdominal pain
- Active- in supine have patient perform SLR with resistance + is pain and requires more testing ( can do mcburney)
- Passive- sideling on L and move R into hip extension + is same as above
-
Murphys sign for cholecystitis
- place hand under R costal region and have them take a deep breath.
- is if they feel a sharp pain and stop inspiration
Renal
Basic renal functions
- filters waste
- Regulates ion levels in plasma
- Regulated blood pH
- conserves valuable nutrients
- Regulates blood volume
- Regulates RBC count (EPO)
Nephron
- the functional unit of the kidney
- filtration in glomerulus to tubule
- tubular reabsorption- return solutes to circulation
- tubular secretion- filtrate in the nephron tubule is modified by secretions that come in from capillary
- Urinary secretion- filtrate from tubule transported to bladder
Urine
- normal 800-2000ml / day pale yellow
issues when
- hematuria
- oliguria (reduced output under 400)
- Polyuria
- nocturia
- Anuria
UTI
- often only impact bladder and urethra (lower system)
Pyelonephritis
- when UTI progresses to upper system
- back or flank pain
- Fever
- Nausea and vomiting
- Confusion
- hematuria, cloudy urine, pain with urination, increased frequency
Manifestations of renal caliculi
- renal colic - pain in flank with anterior radiation
- nausea/ vomit
- hemauria
Rhabdomyolysis
- breakdown of muscle fibers and resulting release of myoglobin
- Myoglobin is toxic to kidneys and can cause renal failure
- Shift extracellular fluid into injured muscles can lead to comparment syndrome
Triad of symptoms
- Muscle pain
- Weakness
- Dark urine (reddish brown)
Lab findings
- Creatine Kinase normal is under 200 and we commonly see values 5x more in rhabdo
- marker for muscle injury
- rises within 2-12 h of injury peaks at 24
- high calcium, K, volemia and phosphate seen too
Rhabdo Rehab
- rest and hyration
- gradual return to exercise, start at low intensity
- ongoing monitoring
Chronic renal failure
- CDK as marker for GRF
- normal GFR is 90-120 ml/min
- GFR reduces serun creatinine exponentially increases
- Normal creatinine in blood is 1 mg/dl
3 assessments for renal function
- GFR
- Creatinine
- Albumin is a protein made by the liver that if found in urine implies nephron dysfunction. if over 30 in urine we should be concerned
Signs and symptoms of renal failure
- weight loss and poor appetite
- B edema
- SOB or DOE
- Fatigue
- Nocturia, hematuria
- insomnia
- muscle cramps
- ED
Normal values
- K 3.5-5 if hyper then muscle weakness, flaccid paralysis, paresthesia
- Ca 8.5-10.5 - if hyper then can get stones, bone pain
- Bicarb 22-28, if low then metabiilic acidosis and fatigue. muscle weakness, decreased heart contractility
Dialysis
- meant to replace renal function
- can have AV fistula(most stable) , tunneled cath, AV graft
- CRRT is a 24/h form
- Peritoneal uses abdominal cavity as machine
PT precautions
- no BP measurements on port arm
- protect from injury
- be aware of any bleeding
- thrill felt over port is normal
PT and dialysis
- typically contraindicated during dialysis with maybe an exception of CRRT which we should check stability first
- assess vitals
- Expect Fatigue post dialysis
- for PD - may have SOB or DOE
Murphys percussion
- locate costovertebral angle at rib 12
- place one palm over it and hit it with the other hand
- is pain which can indicate kidney inflammation
- use in those with suspicious back pain or urinary changes
RA
A chronic inflammatory autoimmune disorder
Characterized by synovitis and joint destruction
example of: inflammatory arthritis
What to ask in History
- Degree of joint pain
- Fatigue
- Sleep
- Morning stiffness time
- Wt loss
- Functional limits
Physical exam
- Get a count of inflamed joints
- mechanical problems like loss of motion, malalignment, crepitus, deformity
- Look for AA involvement
- Look for ulnar drift in the hands & FEET
- Swan neck and boutonniere deformity
- Tenosynovitis
- halluz valgus
- HAQ OM
Screening tool
- Significant discomfort with squeezing the MCP and MTP
- Presence of 3 or more swollen joints
- more than 1 h or morning stiffness
Medical treatment
- DMARDs (methotrexate) - should start within 2-3m, they downregulate immune system so be aware of immunocompromise.
- NSAID
- steroids for flares, osteoporosis can occur with long term use
5 extra articular manifestations *
- Scleritis
- Vasculitis
- RA nodules
- Interstitial lung disease
- Cardiac disease
Poor Prognostic factors
- Younger age of onset
- over 13 joints involved
- High anti CCP, ESR, C reactive Pro lab values
- Erosion or cartilage loss in x-ray in 1 y
- Extra articular manifestations
- Obesity
Adult Cancer
Cyclins checkpoints
- cyclins are proteins that double check cell before allowing it to replicate-
- p53 is a tumor supressor protein which interacts with other proteins to arrest division if there are mutations or damage to the DNA
Oncogenes
- Esentially cancer genes that tell the cell to skip all pathways and just replicate
- if there are more present than suppressor genes then cancer may occur
The 3 drivers of cancer
- increased proto-oncogenes or oncogenes ( increasd division and inhibition of cell death)
- Reduced tumor supressor genes
- Reduced DNA repair
Cancer screen
The 6 hallmarks of cancer cells
- Self sufficient growth signals
- Resistant to anti growth signals
- Immortality by inactivating cell death pathways
- Resistance to death (activated anti cell death signals)
- Sustained angiogenesis
- Invasion and metastasis( loss of cell to cell contact inhibiton)
Lymphomas - liquid
- Hodgkins- B cell, less common but curable
- NON- Hodgkins- B and T cells, more common
Multiple myeloma
- disease of plasma cells
- can lead to hypercalcemia
- Pain
- Anemia and bruising
- Lytic bone lesions that can lead to fracture
Goals of treatment
- diagnose tumor
- remove precancerous lesion
- debulk tumor
- Fracture prevention
- Palliation
- cure
-
-
Medications
Anthracyclines
- RUBICNS
- intercalate the base pairs
- main side effect is cardiotoxicity
- Highly associated with CHF risk
Taxanes and Vinca Alkaloids
- Both bind microtubules
- Peripheral neuropathy
- also cardiotoxicity
Alkylating Agents
- cross link DNA
Side effects
- Myelosuppression
- Hemorrhagic Cystitis
- Cardiotoxicity
- Neuropathy
Hormonal therapy
- only effective if the have + receptor cancers
- prevent sex hormones from impacting cell
Anti estrogenic agents like aromitase inhibitors
side effect is hot flashes, joint pain. osteoporosis
HER 2 receptors are over expressed in some breast cancers and these tend to grow and spread faster
-HER 2 antibodies used to slow
Androgen ablasion for prostate cancer
- side effects of hot flashes arthralgia, seizures, falls and fractures
Bone Mets
- back pain is the most common sign
- unrelieved with rest
- can also have motor changes
- bowel disruption
- DTRs
Lesions can be Lytic or blastic
Mirels Scoring system
- under 7 low fracture risk
- 8 needs clinical judgement for treatment decision
- 9 prophylactic surgery is recommended
Leukemia - liquid
- Hematologic disorder
- Initial symptoms are related to irregular marrow function
- anemia
- bruising (thrombocytopenia)
- recurrent infections
- Bone and joint pain
- Swollen lymph nodes
- SOB or DOE
Who should be screened
- Anyone with a history of cancer
- Ages over 50
- anyone with unexplained wt loss (10 pounds in 3m)
- unrelieved pain
- NIGHT SWEATS
- Bilateral painless weakness
Lymph node screen
- look in axillary region
- supraclavicular Virchows node
- infraclavicular (lateral)
Normal
- not really visible
- not easily palpable
- oval or bean shaped
- mobile
Concerning if
- Enlarged over 1cm
-irregular shaped
- matted
- Tender
TNM staging
- Tumor size
- spread to regional lymph nodes
- presence of metastasis
Tumor Grading, by growth and differentiation
- Gx- cant be graded
- G1- well differentiated, slow growing
- G2- moderately differentiated
- G3 - poorly differentiated - rapid growth and spread
- G4 - Undifferentiated - rapid growth and spread
Liver
Liver sizing
- percussion along mid clavicular line between 5-7 intercostal to costal border
- over 2-3 cm means enlarged
4 main functions
- synthetic (proteins, macros, coagulation)
- excretory of bile for digestions
- Metabolism
- detox
Jaundice hyperbilirubemia
Ascites
- abdominal swelling due to fluid in the peritoneum
- due to portal hypertension or HYPObilirubemia either way liver dysfunction
- these people will be dehydrated
- SOB
RIgid stomach
Hepatic Encephalopathy
- reversable decrease in neurologic function due to shunting of blood away from portal circulation
- associated with hepatic failure resulting in noxious metabolic accumulation of byproducts
- Key symptom of Asterixis (hand tremor when wrist extended)
urea cycle
- conversion of toxic ammonia to urea
- high ammonia can cause neuro problems
- with dysfucntion there could be levels of NH3 in blood
- this could happen with TIPS procedure where portal blood is bipassed
Fibromyalgia
A Chronic NON-inflammatory, NON-autoimmune diffuse central pain processing syndrome
Primarily effects young-middle age women
Cardinal manifestations
- Widespread pain
- Fibro fog (cog)
- Fatigue
- diffuse tenderness to pain
- somatic hyperawareness
- Poor sleep
Research
- higher levels of substance P (central pain marker) in CSF
- Higher levels of IL-8 (central pain and inflammatory marker) in CSF
- fMRI shows lower pain threshold
History and PE
- Reports pain everywhere
- Fatigue
- Sleep disturbances
- depression
- "normal labs and PE"
Medical treatment
- NON Pharm is best
- avoid opiods
- NSAIDS DONT work
- target central mechanisms
PT treatment
- Aerobic is #1 mod to high intensity, start low and slow then build
- Resistance training at mod to high intensity beneficial
- flexibility training may help
- Group workouts help adherence
- Aquatic therapy in warm water
VTE
4 Hallmark clinical features of PE
- Tachypnea
- Tachycardia
- Sudden onset of dyspnea
- Chest pain acute
PE notable signs
- Cough
- hypotension
- desaturation
Common symptoms
- sudden SOB most common
- Chest pain
- A feeling of anxiety
- Dizziness
- coughing, maybe coughing blood
- sweating
PE risk factors
- Obesity
- immobilization
- smoking
- cancer
- trauma
- surgery
- pregnancy
- oral contraception
PE action statements
- Mobilize patients with non massive (low risk) PE when therapeutic anticoagulation is achieved
- Do NOT mobilize massive PE (high risk) untill low risk and hemodynamically stable
Lab values
Hematocrit
- M 43-49
- F38-44
- Critical is 25 which aligns with Hb of 7
Hemoglobin / anemia
- F- 12-16
- M 14-18
- Mild anemia 10-12
- mod anemia 8-10
- severe is under 7
- at risk for cardiac event under 5
Moderate anemia precautions
- anticipate decrease cardiopulmonary capacity
- exercise intolerance, DOE, tachycardia, pallor
Severe anemia precautions
- Therapy may be contraindicated, check institution guidelines
30-50k
- typically not associated with spontaneous bleeding
- AROM and walking ad lib
10-20k
- risk of spontaneous bleeding
- therapy may be contraindicated
50-149k
- low intensity progressive resistive exercise is indicated
Neutropenia
- normal is 2500-7k
- Mild is 100-1500
- mod 500-100
- severe is less than 500
Symptoms
- fever
- chills
- fatigue
- mouth sores
- infections
-
can be treated with granulocyte colony stimulating factors
Hypermobility
Generalized joint hypermobility
- excessive joint motion throughout body
- Can be symp or asymp
- most prevelant in young F
- Part of criteria for multiple connective tissue disorders
Beighton score
- Test for hypermobility
- over 5/9 if under 50
- over 4/9 if over 50
- 6/9 for peds
- Measures B pinkies, thumbs, elbows, knees and a hands on floor
Hypermobility spectrum disorder
those who dont fit strict criteria for hEDS but present with widespread pain and generalized joint hypermobility
-
PT observations
- If you cant connect the issues think connective tissues
- observe for usually soft translucent skin
- May have lazy or over rigid gait or posture
- unusual bruising
- look at OMs
Outcome measures
- Beighton score
- Five part questionare (can ass point to beighton, asks about past mobility)
- UL and LL hypermobility assessment
- Spider questionnaire
- test for common comorbidities
The spider questionnaire
- Gives measure of their more involved systems
- can help guide exam and intervention
Physical exam priorities
- Assess ROM within tolerance
- Vitals
- balance
- Posture
- Functional tasks
- Avoid unesesary provocative testing
- test sensory profile- they have poor proprio
- Motor control
- dual tasking
Manual Therapy
- tend to avoid end range mainips or mobs in affected joints
- prioritize neuromuscular treatments
- Vojta therapy
-
Exercise therapy
- proper loading to stiffen tendons
- train full range but should start closer to neutral
- PNF
- work on coordination
- They are often deconditioned, should do aerobic but be aware of cardio comorbidities
- can work on developmental patterns (vonjta)
-
Proprioception
- taping
- compression
- biofeedback
- bracing
- mirror feedback
-
Other points
- Sleep position, sideling with support.
- can use external bracing for support
- can use modified equipment
-
EDS
- group of heritable connective tissue disorders
- all but hEDS have genetic markers
- hEDS 90%
- Classical EDS
- Vascular EDS
hEDS
- Generalized joint hypermobility
- Chronic pain
- Mild skin hyperextensibility and abnormal scarring
- cant be diagnosed in children
Diagnosis
- GJH (Beighton)
- Features of inherited connective tissue disorders 2/3
- Absence of alternative diagnosis
hEDS and HSD Clinical presentation
- can impact any body system
- Joint pain in multiple joints (11 on avg)
- ROM, laxity, motor control impaired
- strength
POTS
- common comorbidity of hEDS/HSD
- Form of orthostatic intolerance where there is a rise in HR without drop in BP upon standing with symptoms
- rapic HR
- lightheadedness
- nausea
- blurred vision
- overall symptoms include fatigue and brain fog
- will naturally pump legs or march when they stand to keep BP up
POTS diagnosis
- gold standard is tilt table
- PT we do NASA lean
criteria
- Increase in HR of 30 or more within 10m
- SBP does NOT drop more than 20
- Frequent symptoms (6m)
Mast cell activation syndrome MCAS
- immunologic condition which mast cells inappropriately release chemical mediators resulting in widespread symptoms across body
Diagnostic criteria
- Episodic multisystem symptoms consistent with MCAS
- Lab confirmed mast cell involvement
- Favorable response to meds
Classical EDs
- Extensive skin involvement
- Skin hyperextensibility and Atrophic scarring
- generalized joint hypermobility
- Easy bruising
Vascular EDS
- most rare and serious
- Thin translucent skin with visible veins
- peripheral joint hypermobility
- Unusual bruising without cause
- Possible organ rupture
- Aneurisms, dissections, ruptures