Other Systems 2

Question 1

System interactions in pregnancy

Answer 1

1. Postural changes
2. HR and BP changes

Question 2

Side lying in pregnancy

Answer 2

LEFT S/L
AVOID Supine hypOtensive Syndrome

Question 3

Pregnancy complications

Answer 3

Pre-eclampsia vs Eclampsia
Gestational DM

Question 4

Pregnancy exercises

Answer 4

Posture
Precautions

Question 5

Changes w/ Pregnancy

Weight GAIN
How much and why?

Answer 5

20-30lbs
ESSENTIAL for baby’s nourishment

Question 6

Changes w/ pregnancy

MSK System
Talk about posture

Answer 6

Posture changes!
Forward head-> kyphosis-> incd lordosis-> APT—think COM moves forward
Postural stress continues post-partum d/t lifting and carrying of baby

Question 7

Changes w/ pregnancy

MSK Changes
Posture
How do we TREAT this?

Answer 7

• Posture edu., stretch tight mm’s/strengthen weak mm’s, pelvic stab. ex’s, POST. pelvic tilts

Question 8

CVS Changes: Pregnancy
ALL first…summarized

Answer 8

1. BP LOW in first and second trimesters then INCs last trimester
2. Supine lying compresses IVC (after 4th mo.)–> NO supine lying after 1st trimester
3. RHR INCs 10-20bpm
4. L. S/L== BEST

Question 9

CVS Changes: Pregnancy
BP

Answer 9

LOW in first/second trimesters
INCs last trimester

Question 10

CVS Changes: Pregnancy
Supine lying

Answer 10

• compresses IVC
• DEC in CO==> supine hypotensive syndrome
• NO supine after 1st trimester!!!

In gen, CO INCs, but Decs in supine!!

Question 11

CVS Changes: Pregnancy
RHR

Answer 11

INCs 10-20 bpm

Question 12

CVS Changes: Pregnancy
LEFT S/L

Answer 12

• BEST!!!
• DECs compression IVC, maximizes CO, DECs GERD bc int. organs relaxed, improves maternal and fetal circ.

Question 13

System Interactions in Pregnancy

Answer 13

See chart

Question 14

Practice!
34yo pregnant female doing pelvic floor ex’s in supine. Dizzy, sweating, nausea. Which cond?

Answer 14

Supine HypOtensive syndrome bc supine compresses IVC
A: Incd pressure on IVC causing hypOtensive syndrome

Question 15

Pre-Eclampsia think….

Answer 15

Acute HTN!!!
*usually BP inc’s 3rd trimester, but this is acute/sudden HTN

Question 16

Pre-Eclampsia
How is this dx confirmed??

think pregnancy induced HTN

Answer 16

BP reading in excess of 140/90.. THEN
2nd abnorm BP reading 4hrs AFTER first CONFIRMS dx
EMERGENCY!

Question 17

Pre-Eclampsia
what is it and s/s?

Answer 17

Pregnancy induced HTN after the 20th wk of gestation
- S/S: Inc in PRO in urine, hypERreflexia, edema, HA, sudden wt gain

Question 18

This pregnancy complication is ALWAYS ACCOMPANIED W/ SEIZURE

Answer 18

Eclampsia

Question 19

Practice!
Pt seen AFTER UNcomp’d vaginal delivery of 3rd child. During tx, pt begins to complain of HA, vis. disturbs, suddenly develops SZ. MOST likely cond?

Answer 19

A: Eclampsia– AFTER pregnancy, or DURING delivery– ALWAYS assocd w/ SZ
Other answers:
- PREeclampsia== DURING pregnancy– preg induced HTN
- Gestational DM== INC BG during pregnancy, usually returns to NORM (remember FBG >126, Total BG >200)
- Ectopic preg== fert egg implants OUTSIDE uterine cavity

Question 20

Practice!
PT educating one of their pts regarding effects of pregnancy and implications for positioning and posture. Which is LEAST approp?

Answer 20

INAPPROP== small wedge under L. hip during 2nd trimester– WRONG! you want L. S/L!!! (so put it under R hip)
Other answers (all approp):
- Pt w/ preg induced HTN must NOT do high int ex’s
- breath-holding, valsalve’s should be AVOIDED
- Borgs 12-14 during ex is acceptable for UNcomp’d preg

Question 21

Pregnancy and Contraindications to Ex.

DO NOT EX when…

Answer 21

• Hemodynamically sig. heart dis/comps
• Restrictive Lung Disease
• INcompetent cervix- EARLY dilation of cervix BEFORE full term
• Vaginal bleeding- esp 2nd/3rd trimesters
• Placenta previa after 26wks gestation- placenta in descended pos and may detach before delivery
• Preeclampsia or preg induced HTN
• Rupture of membranes–lose amniotic fluid
• Premature labor- labor before 37th week of preg
• Maternal T1DM- Diabetic ketoacidosis
• Severe anemia- HbG lvls low

Question 22

Practice!
20yo female after UNcomp’d delivery has 3cm diastasis recti w/ weak abs. what ex is MOST approp?

Diastasis Recti Guidelines

Answer 22

A: Head lifts w/ arms bracing abdomen
Guidelines:
- >2cm –> abd bracing + exercise
- 3cm–> Abd bracing + Head lift (just lift head); Progression= Abd bracing + Head lift + PPT
- 4cm–> Abd bracing + NO exercises!
- Split < 2cm–> Bracing not important, do head lifts + PPT

Question 23

More on Tx for Diastasis Recti

Head lifts and Pelvic tilts

Answer 23

• Head lift: Hook-lying and cross arms around stomach for support–> Exhale and lift only head off floor while simultaneously using hands to gently approximate rectus mms towards midline–> lower head and relax
• Head lift w/ Pelvic tilt (progression): Hooklying pos–> arms over diastasis for support as in “head lift”–> slowly lift head while approx. rectus mm’s and perform PPT– lower head and relax

NOTE: ALL abd contractions w/ exhale to minimize intra-abd pressure

Question 24

GU recap

Answer 24

• tx for functional incont?– prompted voiding, strengthen LE, cueing
• Incont seen w/ DM– Overflow (dribbles, distended bladder)
• BP changes in preg?– LOWER 1st/2nd trimesters, HIGHER 3rd
• Ex to AVOID w/ diastasis? double leg lifts, crunches, scissors, curl-ups

Question 25

GastroEsophageal Reflux Dis (GERD) **Sx's, Complications**

Answer 25

Reflux of gastric content of the gastroduodenal contents INTO esophagus **Sx's:** - Heart burn-- 30mins AFTER eating & @ night lying down - Dysphagia, sour taste, hoarse voice, Atyp pain head/neck **Comps:** - Aspiration PNA, asthma - Esophagitis

Question 26

Practice! All of following are guidelines in Tx pts w/ GERD except....

Answer 26

WRONG: encourage R S/L to sleep for noturnal reflex--- NO, we want **LEFT S/L** Other answers: - Anything in supine should be scheduled BEFORE meals and avoided after just eating - Encourge **LEFT S/L for nocturnal reflex (bc GI organs relaxed when LEFT-- think anatom pos of stomach)** Nocturnal reflex== regurg. @ night - Mod of pos twrds more **UPRIGHT pos** is req'd

Question 27

Tx of GERD:

Answer 27

- maintain UPRIGHT - Eat 3-4hrs before sleep - **AVOID supine**- tends to straighten esophagus - Sleep on **L. side**-- prevents nocturnal reflex (regurg @ night) - Exercise comp'd 2-3hrs after eating or BEFORE meals - **AVOID spicy, chocolate, fatty, peppermint** - Drugs: Antacids, H2 receptor blockers, Proton pump inhibitors

Question 28

Practice! 44yo male excessive amts of alcohol referred for knee pain. During Tx pt reports **R. sided shoulder pain.** Which structure MOST likely source of referred pain?

Answer 28

LIVER! -- refers to **RUQ/R. shoulder** Others: - Prostate: refers to low back - Appendix: refers to RLQ - Kideny: refers to Mid back, I/L shoulder | Remember: R= Liver/gallbladder, appendix; L= stomach

Question 29

# Pain referral patterns: ALL FIRST

Answer 29

**Mid-back/Scapula:** esophagus, gallbladder, stomach, pancreas **Shoulder** - L: heart, **diaphragm,** sp**l**een, tai**l** of pancreas - R: gallbladder/liver, **head** of pancreas (**head is always RIGHT)** **Pelvis/Low back/Sacrum:** colon, appendix, pelvic viscera **Pancoast Tumor (upper lung tumor):** pain referred in C8-T2 nerve distribution; **Mimics TOS**

Question 30

# Pain Referral Patterns: **Midback/Scapula**

Answer 30

esophagus, gallbladder, stomach, pancreas

Question 31

# Pain Referral Patterns: Shoulder: **LEFT shoulder**

Answer 31

Heart, **diaphragm,** sp**l**een, tai**l** of pancreas

Question 32

# Pain Referral Patterns: Shoulder: **RIGHT shoulder**

Answer 32

Liver/gallbladder, **head of pancreas (head is always RIGHT)**

Question 33

# Pain Referral Patterns: Pelvis/Low Back/Sacrum

Answer 33

Colon, appendix, pelvic viscera

Question 34

# Typical Pain Patterns: Quadrants ALL first

Answer 34

**RUQ:** peptic ulcers, gallbladder patho, head of pancreas **RLQ:** appendix, Chron's **LLQ:** diverticulitis, ulcerative colitis, IBS **LUQ:** tail of pancreas, spleen patho

Question 35

# Typical Pain Patterns: Quadrants RUQ "Good Luck Hot Pack" RLQ "Air Conditioning"

Answer 35

**RUQ: "Good Luck Hot Pack"** - Gallbladder, Liver, Head of pancreas, Peptic ulcers **RLQ: "AC (Air Conditioning)"** - Appendix, Chron's

Question 36

# Typical pain patterns: Quadrants LUQ "Dont Banana Split" LLQ "DUI"

Answer 36

**LUQ: "Dont Banana Split** - Diaphragm, Body/tail pancreas, Spleen **LLQ: "DUI"** - Diverticulitis, Ulcerative colitis, IBS

Question 37

Practice! 44yo male evald by PT. Referred pain in the L. shoulder (spleen, heart, diaphragm, tail of pancreas). Dx of **+Kehrs sign (SPLEEN)** All causes of this?

Answer 37

Recent laproscopy, intra-abd bleed, rupture of **spleen** NOT a cause--> trauma to Head of pancreas (**remember Head is always RIGHT (RUQ and R shoulder)** Kehrs Sign==> pain in LEFT shoulder caused by air or blood in abd cavity; **+Test= perform SLR & causes L shoulder pain**

Question 38

# Hernia and Refer pain Hiatal hernia (the one to know!!!) causes _ pain. What else to know?

Answer 38

**Shoulder!** Hiatal hernia think **weak diaphragm, L shoulder pain** | Sx's similar to GERD

Question 39

# Hernia referral pain **Femoral vs Inguinal vs Umbilical**

Answer 39

**Femoral-->** Lateral pelvic wall + groin pain **Inguinal-->** Groin pain **Umbilical-->** Pain around umbilical ring in mid-lower abdomen

Question 40

Practice! 44yo male eval'd. Underwent **hernia repair 3wks ago. AVOID which activity?**

Answer 40

A: Stretching ANTERIOR spinal and hip mm's BEFORE incision healed DO NOT DO THIS!--- stretching posterior is ok! **Remember: Hiatal hernia think WEAK diaphragm, L. shoulder pain**

Question 41

Cholecystitis **think gallbladder**

Answer 41

Blockage or impaction of **gallstones** in **cystic duct** resulting in **inflamm of gallbladder** - Pain in **RUQ (Good Luck Hot Pack),** radiates to **R shoulder** - nausea, vom, low grade fever - **PAIN INCS WITH INGEST OF FATTY FOOD!** -

Question 42

Cholecystitis: **Special Test?**

Answer 42

Murphy Sign - palp near R subcostal margin, deep breath, if **pain/tender during insp==> (+) Test**

Question 43

Peptic Ulcers (2): Think...

Answer 43

RUQ "Good Luck Hot Pack" 1. Gastric (stomach) ulcers 2. Duodenal

Question 44

Peptic Ulcers: **Gastric (stomach) ulcers**

Answer 44

- In **stomach**--> chronic use NSAIDs, stress, anxiety, H pylori bacteria - Pain **INCs** w/ presence of food--> acid secretion--> pain after eating (acid burns ulcer) - Pain **relieved** w/ antacids, med tx of H pylori

Question 45

Peptic Ulcers **Duodenal ulcers**

Answer 45

- Ulcerative lesions in **duodenum**--> MAIN cause H pylori - Pain **incs** w/ **absence of food (bc duodenum, not stomach)**, early mornings, in bw meals - Pain **relieved** by med tx of H pylori

Question 46

Peptic Ulcers **More characteristics**

Answer 46

- Pain=> burning, cramping in epigastric area, **refers to R shoulder, RUQ** - **Coffee ground emesis (both types)** and **melena (dark) tarry stools (more duodenal)**==> peptic ulcer dis.

Question 47

Inflammatory Bowel Disease **2 components**

Answer 47

1. U**L**cerative Colitis-- **L**LQ (DUI) 2. C**R**ohn's Disease-- **R**LQ (AC)

Question 48

Inflammatory Bowel Disease **1. Ulcerative colitis**

Answer 48

* ONLY **Lg intestine & rectum** * CONTINUOUS lesions * S/S: rectal pain, bleeding, **bloody diarrhea w/ mucus/pus**, fecal urgency, wt loss, LBP * **LLQ**-- U**L**cerative

Question 49

Inflammatory Bowel Disease **2. Crohn's Disease**

Answer 49

* Autoimmune, **think pass gas, aggravated w/ stress** * Occurs **ANYWHERE in GI tract** * **Skip lesions=> lesions "skip" around** * S/S: **pain relieved by passing gas,** abdom pain, Wt loss (same as UC), **jt reactive arthritis** * **RLQ--** C**R**ohn's

Question 50

Practice! Pt c/o **L lower abdom pain (LLQ= DUI)**. Pt reports LBP accompanied w/ wt loss, nausea, vom, bloody stool lately. MOST LIKELY dx?

Answer 50

A: Ulcerative colitis Others: - CRohns== RLQ (AC) - Appendicitis== RLQ (AC) - Acute pancreatitis== R (Good Luck Hot Pack) or LUQ (Dont Banana Split)

Question 51

IB**S** Irritable Bowel **Syndrome** LLQ= "DUI" bc where do you get DUI? in the LLQ! | IBS think "**Your colon is nervous/spastic**

Answer 51

**Spastic, nervous or irritable colon** - **Causes:** Emo. stress, anxiety, **high fat, lactose foods** - Pain relieved by **defecation (rememer Crohns relieved by passing gas)** - Sx's disappear while sleeping - **Ribbon like stools-- bc spastic colon** - LLQ - **Tx:** Stress reduce, diet mods, Exercise****

Question 52

Appendicitis:

Answer 52

**Inflamm of appendix--progress leads to swollen/gangrenous appendix** - **Perforated==> peritonitis (fluid in abdomen)** - RLQ (AC) - Tender @ **McBurneys pt,** **Rovsing's sign (opp palp of McBurneys)** for pain migration, **Blumber's sign** for Rebound tenderness IMMEIDATE MEDICAL ATTENTION!

Question 53

Speaking of Appendicitis and RLQ **More tests on this?**

Answer 53

Psoas sign= pain w/ passive hip EXT Obturator sign= pain w/ passive hip IR Hop sign= hop Markel sign= heel raise & lower= heel raise pain

Question 54

McBurneys Pt vs Rovsing's for **Appendicitis**

Answer 54

see pics Note that Rovsings is just palpating OPP of Mcburneys but getting pain @ McBurney's

Question 55

Practice! 30yo w/ **R lower abom pain (RLQ= AC)**. PT performs "pinch-an-inch" test which is +. Which cond?

Answer 55

Appendicitis--> +Pinch-an-inch in RLQ Others: Diverticulitis (LLQ)-- Pinch-an-inch + in LLQ== divertic Crohn's== RLQ IBS== LLQ (DUI)

Question 56

GI Recap

Answer 56

- stools seen w/ **duodenal ulcer?** Black (melena), tarry - Cond's w/ pain in RLQ (AC)-- appendicitis, crohns - Referred pain for diaphragm-- LUQ, L shoulder (Dont Banana Split) - Pain incs after ingest fatty food? Cholecystitis (Gallbladder--> R shoulder/R scapula, RUQ: "Good Luck Hot Pack)