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214 Cards in this Set
- Front
- Back
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differential diagnosis
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comparison of symptoms to similar diseases so that a correct assessment can be made
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diagnosis
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collection of relevant signs and symptoms
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signs
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observable findings
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symptoms
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unobservable but reportable indications of disease perceived by patient
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PT (Clinical) Diagnosis
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1) examination
2) evaluation 3) diagnosis |
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History of present illness
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- Chief complaint
- pain/symptom assessment - medical treatment and medication - current level of fitness - sleep related history - psychogenic considerations - prior level of functioning |
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Pain assessment
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- location
- description - pattern - frequency - duration - intensity/affect - associated symptoms |
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Cutaneous Pain
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- pain arising from superficial somatic structures in the skin and/or subcutaneous tissue
- pain is well-localized, client can point to the area - cutaneous tenderness may occur with both referred or deep somatic pain |
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Deep Somatic Pain
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pain arising from: bone, nerve, muscle, tendon, ligaments, joints, arteries
- can be associated with nausea and faintness |
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Referred Pain
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- pain that is felt at a site distant from its cause
- relates to the source of pain - well-localized but occurs in remote areas |
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muscular pain
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- worsens with contraction of the muscle or stretch
- pain can be caused from ischemia - use can increase pain - rest brings from relief |
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heart pain
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- pain increases when there is an increased demand on the heart
- cardiac pain typically decreases with rest - as symptoms progress, pain may be present without an increase in activity |
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Arterial Pain
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- due to inflammation of an artery
- increased pain with increased systolic blood pressure |
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Pleural Pain
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correlates with respiratory movements
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GI/Visceral Pain
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- inc with ingestion or peristalsis
- dec with fasting, BM, or vomiting - distended organs - pain is not well localized |
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Radicular Pain
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- direct irritation or involvement of a spinal nerve causes pain in a dermatome, sclerotome, myotome
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Myofascial Pain
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referred from an active myofascial trigger point with associated dysfunction; a trigger point
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Pain at rest
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ischemia from vascular disease or tumor growth; neoplasm
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Acute Arterial Occlusion
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pain, pallor, pulselessness, parasthesia, paralysis
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Pain with Activity
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cramping pain can be from intermittent claudication; present during walking and decreases with rest
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Cardinal Cancer warning signs
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C hanges in bowel/bladder
A sore that won't heal U nusual bleeding or discharge T hickening or lump in breast elsewhere I ndigestion or difficulty swallowing O bvious change in wart or mole N agging cough or hoarseness proximal muscle weakness change in deep tendon reflexes bone pain (esp at night) |
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When do I refer?
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PT is contraindicated
treatment of condition is outside the scope of knowledge Medical diagnosis is required but none has been established |
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Screening Conditions: Cardiovascular
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- shortness of breath
- dizziness - pain or heaviness in chest* - pulsating pain anywhere in body* - constant and severe pain in lower leg* - discolored or painful feet - swelling |
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Screening Conditions: Cancer
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- persistent pain at night
- constant pain anywhere in body - unexplained weight loss - loss of appetite - unusual lumps or growths - fatigue |
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Screening Conditions: GI/GU
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- frequent or severe abdominal pain*
- frequent heartburn or indigestion - frequent nausea or vomiting - change in or problems with bladder function - unusual menstrual irregularities |
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Screening Conditions: Neurological
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- changes in hearing
- frequent or severe headaches* - problems swallowing or change in speech - changes in vision* - problems with balance or falling - fainting spells* - problems with coordination* - sudden weakness* |
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Screening Conditions: Miscellaneous
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- fever or night sweats
- recent severe emotional disturbances - swelling or redness in any joints - pregnant |
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Elements of Patient Management
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1. Examination
2. Evaluation 3. Diagnosis 4. Prognosis 5. Intervention 6. Outcomes |
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Genomics
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the study of functions and interactions of all the genes in the genome, including their interactions with environmental factors
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Genetics
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the study of single genes and their effects
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Genome
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all the DNA contained in a cell (including DNA in mitochondria)
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4 Bases of DNA
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ATGC
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Transcription
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DNA transcribed into RNA
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translation
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RNA is translated into a protein
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Genetic mutations
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mutations are "changes" in DNA to alter sequence; associated with disease (Parkinsons, etc.)
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Types of Genetic Mutations
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1. Deletion
2. Duplication 3. Insertion |
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Deletion
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loss of a piece of DNA from a chromosome
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Duplication
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produce a copy of a piece of DNA
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Insertion
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a DNA sequence is inserted into a gene, altering the normal structure and function of that gene
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polymorphism
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a common variation in the sequence of DNA among individuals
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single nucleotide polymorphisms (SNP)
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common variation in the sequence of DNA among individuals due to a single nucleotide substitution
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Benefits of Genomics
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- assess genetic risk
- preventative medicine and PT - individualized care based on genetics - imp understanding of genetic and molecular pathways |
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Anticipated benefits of pharmacogenomics
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- more powerful medicines
- better, safer drugs first time - more accurate drug dose - advanced screening for disease - better vaccines - imp in drug approval process - dec in overall cost of healthcare |
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Ultrasonography
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- noninvasive
- soft tissue - high frequency sound waves - position, size, shape |
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Doppler Study
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- info about circulation
- presence, quality, changing nature |
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Endoscopy
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- invasive
- direct vis of structure - fiber optic attached to flex tube |
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X-ray "Films"
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- plain radiography
- contrast radiography (barium, iodine) - fluoroscopy - computed tomography |
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Plain radiography
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- short wavelength electromagnetic vibrations that are absorbed or reflected by tissue
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Plain Radiography absorptions
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white: dense tissues
black: air-filled regions |
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Contrast Radiography
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two agents: barium, iodine
introduced: swallowing, enema, venously, arterially |
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Fluoroscopy
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- continuous stream of xrays
- real-time movement of structures or contrast - uses: central line, assessment of diaphragm, GI motility, swallowing dysfuntion |
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Computed TOmography
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- multiple x-ray beams
- computer-based calculations - cross sections - sometimes use contrast material |
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Uses of CT
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- CT angiography
- Colonography - Bronchoscopy |
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MRI
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- strong magnet with radio waves
- no radiation - brain, sc, soft tissues |
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T1 vs T2
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T1 - bones/fat brighter
T2 - fluid brighter |
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Angiography
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contrast medium in blood vessel
- aneurysm - AVM - thrombosis - vasospasm - narrowing of vessels |
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Nuclear Medicine Imaging
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- use agent with radioactive label
- inhale, ingest, inject - SPECT or PET |
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Additional Tests
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- EMG
- NCV - EEG |
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PDR: Manufacturer's Index (white/cream)
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info about naufacturers
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PDR: Brand and Generic Name Index (pink)
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alphabetical listing of products with page numers
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PDR: Product Category Index (blue)
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products listed according to what they are (ie analgesics)
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PDR: Product Identification (gray)
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picture of the products
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PDR: Product Information (white)
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full description of products (meat of the book)
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PDR: Diagnostic Product Information (green)
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info about common diagnostic agents such as TB tine test
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Elimination Half-Life
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time plasma concentration falls to half of original amount; tells how often to administer
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Biological Half-Life
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how long drug acts; falls to half of original duration
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Dose-Response Curve
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time in which drug is effective and maximal response (efficacy and effectiveness)
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Potency
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Drug A: 10mg for 25% dec
Drug B: 80mg for 25% dec doesn't mean Drug A is better |
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median effective dose
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dose at which 50% of population responds to drug in a specified manner
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median toxic dose
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dose at which 50% of population has side effects
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median lethal dose
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dose at which 50% of animals die; need to know therapeutic index
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Therapeutic Index
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median toxic dose/median effective dose
=TD50/ED50 |
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Routes of Administration
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1. Enteral
2. Parenteral 3. Topical 4. Transdermal |
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Enteral Administration
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Oral
First pass effect Sublingual Rectal |
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Oral
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- easy
- relatively safe - absorbed in small intestine |
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first pass effect
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what can survive the liver
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Sublingual
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- under tongue
- absorbed into venous system - no first pass effect - must be able to pass oral mucosa |
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Rectal
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- absorbed poorly
- unconscious or vomiting |
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Parenteral
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Inhalation
Injection 1. Intravenous 2. Intra-arterial 3. Subcutaneous 4. Intra-muscular 5. Intrathecal |
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Intravenous
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- know quantity that reaches target
- fast - can be left in |
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Intra-arterial
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- rare
- chemotherapy - dyes for diagnostic procedures |
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Subcutaneous
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- local response
- dentist or slow-release - insulin |
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Intra-Muscular
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- treating muscle or slow release
- can be sore |
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Intrathecal
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- subarachnoid space
- anesthetic for surgery - pass blood-brain barrier - baclifin for spasticity |
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Topical
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Ointments:
- not readily absorbed - depends on thickness of skin |
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Transdermal
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Nitro patch, Nicoderm:
- hormones, cardiac meds - slow, controlled release of drug - iontrophoresis |
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Variables in pharmacology
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1. Bioavailability
2. Drug distribution 3. Clearance |
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Bioavailability
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amount of medication that reaches the systemic circulation after administration
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Drug Distribution
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- how drug is dispersed
- Depends on: -- tissue permeability -- blood flow -- binding to plasma protein -- binding to sub-cellular components |
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Vd (Volume of distribution)
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= amount of drug administered/plasma concentration
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Drug Storage
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1. Adipose Tissue
2. Bone 3. Muscle 4. Organs |
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Clearance
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- Metabolism: Liver
- Excretion: Kidney |
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Factors that affect drug responses and metabolism
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1. Genetic Factors
2. Diseases 3. Diet 4. Age 5. Exercise 6. Drug Reactions |
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Effects of Aging
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1. systems not effective
2. blood flow impaired 3. dec liver and kidney function |
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Effects of Exercise: Bioavailability
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alters amount of absorption of any drug (increases bioavailability)
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Effects of Exercise: Drug Distribution
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alters distribution
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Effects of Exercise: Clearance
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- more blood to muscles
- less blood to organs dec liver and kidney function |
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Side effects:
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- predictable pharmacological effects
- occurs within therapeutic range - undesirable |
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Over-dosage toxicity
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- predictable toxic effect
- occurs in excess of therapeutic range |
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Analgesics
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Pain:
- Narcotic -- morphine, codeine, demerol - Non-narcotic -- aspirin, acetominophen |
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Muscle Relaxnts
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Muscle Spasm:
- baclofen, Flexoril, Parafon, Robaxin |
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Acetominophen
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blocks impulses that travel to the brain
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Aspirin
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blocks production of prostaglandins released in tissue damage irritant
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Narcotic (add info)
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- severe pain
- often opium-derivatives - work on CNS |
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Non-narcotic (add info)
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- mild to moderate pain
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Baclofen
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neurological problem
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Flexoril, Parafon, Robaxin
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musculoskeletal problem
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Corticosteroids
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Inflammation, allergies:
- Prednisone, Betamethasone, Medrol Dose pack |
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NSAIDS
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Reduce Inflammation
Reduce Pain Reduce Fever - ibuprofen, feldene, naprosyn, anaprox |
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Anticonvulsants
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Seizures (inc seizure threshold)
- tegretol, dilantin, Valproic Acid (Depakote), Phenobarbitol, Diazepan (Valium) |
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Tri-cyclic antidepressants
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Depression
- elevil, prozac, zoloft - long half-life |
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Tranquilizers
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Major: psychotic illnes
- thorazine, haloperidol (haldol) Minor: emotional tension anxiety - valium, ativan, xanax - suppress CNS activity |
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Beta-blockers
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hypertension, migraines, angina, arrythmias
- tenormin, inderal |
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Diuretics
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hypertension:
- thiazide - loop - potassium sparing - osmotic |
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Thiazide
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inc salt and water eliminated by kidneys leads to dec blood volume
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Loop
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inhibit Cl- that is absorbed, dec sodium and water in body
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K+ Sparing
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keep K+ in at distule convoluted tubule
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Osmotic
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inhibit reabsorption of water and sodium throughout nephron
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Immunosuppressants
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- corticosteroids
- cyclosporine - imuran |
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ACE Inhibitors
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hypertension:
- capoten, monopril - prevents angiotension I conversion to angiotension II which vasoconstricts arteries and releases aldosterone |
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Calcium-Channel Blockers
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angina, hypertension:
- cardizen, procardia, verapamil - calcium passage into muscle cells - prevent muscle tension to vasodilate arteries |
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Function of the Hematological System
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1. Deliver glucose and O2 to tissues
2. Defense against foreign invaders 3. Maintain pH |
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Components of Hematological System
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1. plasma
2. plasma proteins 3. erythrocytes 4. leukocytes 5. platelets 6. lymphoid organs |
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Plasma
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- 55-60% of blood volume
- water (90%) - electrolytes - proteins - gases - nutrients - waste products |
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Plasma Proteins
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- albumins
- globulins - clotting factors (fibrinogen) - synthesized in liver or lymphoid tissue |
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Albumin
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regulates amount of H2O drug dosage (bind to it)
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Globulins
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defense
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Fibrinogen
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precursor to clotting
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Erythrocytes
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- red color of blood
- most abundant blood cell - tissue oxygenation - life span: 80-120 days - non-nucleated (change shape) - carries hemoglobin |
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Hematocrit
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how many RBCs
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Hemoglobin
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overall level of HgB
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Leukocytes
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Granulocytes:
- neutrophils - basophils - eosinophils Agranulocytes - monocytes - macrophages - lymphocytes (immunocytes) |
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Neutrophils (p)
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- 1st cell in inflammation
- first responders - life span 1 to 2 days |
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Basophils and Eosinophils (p)
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- not as well understood
- release histamine - vasodilation - counteract each other |
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Monocytes (p)
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baby macrophages
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Macrophages (p)
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- antigen presenter
- garbage men - surveillance |
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Lymphocytes
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- T Cells and B Cells
- immune response |
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Natural Killer Cells
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shoot first, ask questions later
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Platelets
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- disk-shaped cytoplasmic fragments
- fragments of megakaryocytes - essential for coagulation - lives 10 days - adhere to wall of damaged vessel |
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Hematopoiesis
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- Proliferation (mitotic division)
- Maturation (differentiation) - Parent Cells (stem cells) - Bone Marrow -- Red (active) -- Yellow (inactive) |
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Location of Active Bone Marrow
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- Pelvis
- vertebrae - cranium and mandible - sternum and ribs - proximal portions of femur and humerus |
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Clinical Evaluation
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- CBC
- RBC Count - Hematocrit - Hemoglobin - WBC Count - Platelets - Clotting Studies |
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RBC Count
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M= 4.6-6.2 g/dL
F= 4.2-5.4 g/dL |
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Hematocrit
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M = 40-54%
F = 37-47% |
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Hemoglobin
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M = 14-18 g/dL
F = 12-16 g/dL |
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WBC Count
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4500-11000 cells/mm3
- neutrophil - lymphocyte - plasma cell count - monocyte - eosinophil - basophil |
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Platelets
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150K-350K cells/mm3
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Clotting Studies
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- prothrombin time (PT)
- international normalized rate (INR .9-1.1 ratio) - activated partial prothromboplastin time (PTT 30-40 secs) |
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Alterations in Hematologic System
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- anemia
- polycythemia - Hodgkin's Disease - thrombocytopenia - leukemia |
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Anemia
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- dec in O2-carrying capacity in blood
- impaired erythrocyte production - blood loss - inc erythrocyte destruction Symptoms: - fatigue, weakness, dyspnea, tachycardia |
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Polycythemia
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- neoplastic disease of stem cell
- too much Hgb and blood volume Symptoms: - ruddy skin color, elevated blood pressure |
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Hodgkins Disease
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- malignant lymphoma
- first sign: enlarged painless lump in neck - fever, weight loss, night sweats treatment: - irradiation and chemotherapy |
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Thrombocytopenia
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- decrease in platelet count below 150K cells/mm3
- inadequate platelet production or - increased platelet destruction - treatment depends on cause |
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Leukemia (Acute)
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- rapid course
- neoplastic, immature white cells in bone marrow - acute lymphocytic or non-lymphocytic |
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Leukemia (Chronic)
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- slower progression
- neoplastic, mature cells of blood - chronic myelocytic or lymphocytic |
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Leukemia (Clinical Manifestation)
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- anemia
- reduced tissue oxygenation - infection - bleeding tendencies - figure 13-2 |
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Hemophilia
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- bleeding disorder
- sex-linked autosomal recessive (young men) - usually missing Factor VII - bleeding into joint is common |
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Bone Marrow Transplants
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used for:
- leukemia - aplastic anemia - lymphomas - multiple myeloma |
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Allogeneic
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bone marrow from close genetic match
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Syngeneic
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identical twin
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Autologous
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donation from self, must be in remission
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Hemochromatosis
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- autosomal recessive hereditary disorder
- excessive iron absorption by small intestine - iron accumulates in liver, pancreas, skin, heart, and other organs - therapeutic phlebotomy |
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Inflmmatory Process
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cellular injury, acute inflammation, chronic inflammation, granuloma formation, healing
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Key Components of Inflammatory Reaction
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- blood vessels
- circulating blood cells - connective tissue cells -- fibroblasts -- mast cells -- macrophages - Chemical Mediators |
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Acute Inflammatory Responses
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rapid, non-specific response to cellular injury
Signs - Swelling - pain - redness - heat - loss of function? |
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Acute Inflammatory Response: Microscopic Signs
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- accumulation of fluids
- accumulation of cells |
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Exudates
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- serous: clear, small inflame
- fibrinous: cloudy, more severe - purulent: pus, bacteria - hemorrhagic: bloody |
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Steps in Inflammatory Process
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1. Vasoconstriction
2. Vasodilation 3. Inc in exudate leads to edema 4. leukocytes migrate to vessel walls 5. histamine and prostaglandins cause inc permeability 6. allows leukocytes to get into extracellular space |
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Steps in Inflammatory Process (cont)
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7. Blood cels and proteins move into tissue
- stim and control inflammation - interact with immune system 8. phagocytes move into area to clean 9. activtion of plasma systems to form clot |
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Players in inflammation
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- mast cells
- vasoactive amines - leukotrienes and prostaglandins |
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Why inflammatory process?
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1. Limit and control i.p.
- limit going to healthy tissue 2. prevent infection/neutralize toxin - activate plasma systems to kill bacteria 3. activates immune system-specific 4. preparation for healing |
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Mast Cells
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- degranulation occurs in response to
--trauma --chemical agents --immune hypersensitivity reaction |
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Vasoactive Amines
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1. serotonin (platelets)
2. histamine (mast cell) - constriction of smooth muscles - dilation of capillaries - retraction of endothelial cells lining capillaries causing vascular permeability |
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Leukotrienes and Prostaglandins
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- later stage of inflammation
- smooth muscle contraction - inc vascular permeability - chemotaxis - prostaglandins |
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Plasma Protein Systems (PPS):
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- Complement
- Clotting - Kinin |
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Plasma Protein Systems: Complement
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- non-specific self-defense
- activation -- antigen anti-body reaction -- bacterial secretions -- other plasma systems - two pathways -- classic -- alternate |
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Effects of Complement System
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- promotes inflammation
-- vasodilates capillaries -- chemotaxis -- opsonize bacteria -- forms membrane attack complex |
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PPS: Coagulation Cascade
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- stops bleeding
- localizes microorganism - prevents spread of infection - provides meshwork for repair - two pathways -- extrinsic -- intrinsic |
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Activation of Clotting System
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- collagen
- protease - plasmin - kallikrein - bacterial endotoxins |
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Results of Clotting System Activation
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- Activation of thrombin
- Fibrinopeptide enhance inflammatory reaction |
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PPS: Activation of Kinin System
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- Hageman Factor VIII
- Kallikrein causes synthesis of Bradykinin - Bradykinin |
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Bradykinin
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- vascular permeability
- vascular dilation - extravascular smooth muscle contraction - pain - leukocyte chemotaxis |
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Hageman Factor
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- activates the clotting system
- activates the complement system - activates the Kinin system - converts plasminogen to plasmin |
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Activation of Plasmin
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- thrombin
- Hageman factor - Kallikrein |
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Plasmin
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- degredation of fibrin
- activates the complement cascade (C1, C3, C5) - activates the Hageman factor |
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Cellular Components
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- phagocytic leukocytes (neutrophils, macrophages, eosinophils, basophils)
- platelets - lymphocytes |
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Cellular Components: Phagocytes
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Phagocytosis
- recognition of target - engulfment - fusion with lysosomes - destruction of target |
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Cellular Components: Phagocytes: PMNs
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- early inflammatory response
- primary phagocyte - short-lived action - remove debris - engulf bacteria |
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Cellular Components: Phagocytes: Eosinophils
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- Control inflammatory response
- Destroy parasites |
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Cellular Components: Phagocytes: Macrophages
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- arrive later
- garbage men - migrate to area slowly - restoration |
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Cellular Components: Phagocytes: Basophils
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- found in blood
- similar function to mast cells - healing phase |
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Cellular Components: Platelets
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- circulate in blood waiting for vascular injury
- stop any bleeding - release serotonin |
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Cellular Components: Lymphocytes
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- B and T Cells
- important in production of antiobodies - accumulate in subacute and chronic inflammation |
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Regeneratability
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High: liver, epithelium, hematopoietic tissue
Slight: bone, cartilage, glands None: neurons, muscle |
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Two types of wound healing
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1. Epidermal
2. Dermal |
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Two methods of dermal wound cleaning
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1. Primary intention
2. Secondary intention |
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3 Phases of Dermal Wound Healing
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1. Inflammatory
2. Fibroplastic or proliferative 3. Remodeling or Maturation |
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Inflammatory Phase
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1. Vasoconstriction
2. Vasodilation 3. Clot Formation 4. Phagocytosis 5. Neovascularization |
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Fibroplastic or Proliferative Phase
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1. Re-epithelialization
2. Collagen synthesis 3. Wound contraction 4. Phase ends when fibroblasts disappear |
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Remodeling or Maturation Phase
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1. Begins after 2-4 weeks
2. Scar changes in form, bulk, and strength 3. ROM helps in remodeling collagen tissue 4. Scar maturation takes 12-15 months |
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Factors affecting wound healing
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1. Nutritional status
2. Age 3. Body Build 4. Stress 5. Chronic illness 6. Immune status 7. Oxygenation/ circulation 8. Local wound conditions 9. Medications |
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Local Factors Affecting Healing
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1. Infection
2. Moisture level 3. Local Medications 4. Local blood supply 5. Improper dressings 6. Necrotic tissue and eschar |
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Systemic Factors Affecting Healing
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1. Age
2. Nutrition 3. Oxygenation 4. Comorbidities 5. Immune status 6. Systemic medications |
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Criteria for Donors
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- <50 (65) years old
- no malignancy, HIV, Hep B, Sepsis - no evidence of other diseases - within 20% of BMI - LVEF >40% |
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xenogeneic
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between individuals of different species
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orthotopic
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tissue transplant grafted into its normal anatomic position
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heterotopic
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transplant from one part of body to another part
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heterotopic homologous
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donor organ placed in parallel to diseased organ
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Classification based on
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- blood type
- body size - medical urgency - immediacy of need |
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Testing prior to transplant
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- blood work
- urinalysis - sputum cultures - creatinine clearance - purified protein derivative |
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Transplant Medications
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- cyclosporine (lots)
- imuran (kidney) - cellcept (heart or kidney) - prednisone |
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Post transplant complications
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1. histocompatability
2. graft rejection 3. graft versus host disease 4. immunosuppression |
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Late Complications
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hypertension, DM, osteoperosis, hyperlipidemia, hypertriglyceridemia, malignancy, steroid-induced myopathy, neurotoxicity
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Guidelines for activity and exercise
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- initial, duration until fatigue
- add 1-2 min per day - build to 30 min - denervation requires modification - side effects of immunosuppressants |
