Complex Medical Oral

Explain the pathophysiology for coronary artery disease:

• what is it

• cause

• effects

• What: atherosclerosis of the coronary arteries

  • plaque build up in coronary arteries

• Cause:

  • excess cholesterol

  • too many LDLs

• Effect:

  • blood flow restriction

  • ischemia (plaque, thrombus formation)

  • ischemia (lack of O2) —> infarction (tissue DEATH) —> MI (heart attack)

Explain the difference between stable and unstable angina and its clinical relevance

• stable

  • comes on during exertion but goes away at rest

  • predictable, doesn’t last

  • patient okay to treat/work with

• unstable

  • comes on with exertion but continues after activity stops

  • MEDICAL EMERGENCY —> get this checked out!

What are the stages of a myocardial infarction?

1. ischemia

   1. lack of oxygen due to plaque build up, thrombus, O2 not getting to heart tissue = bad!

2. injury

   1. ischemia has gone on too long and is starting to damage tissue

3. infarction

   1. NON-REVERSIBLE cell death in cardiac tissue

What are characteristics of a STEMI and what does this mean for us as PTs?

• STEMI = ST segment elevated myocardial infarction

• severe type of heart attack where ST on EKG looks like a tomb stone

• PATIENT IS NOT SAFE TO WORK WITH

Which coronary artery causes major issues if blocked and why?

• LAD: left anterior descending artery

• supplies blood to L ventricle

• if there is occlusion, then this will cause MI in this area of the heart, L ejection fraction will decrease which means blood is not being pumped out effectively to the rest of the body

• leads to cariogenic shock and acute heart failure

What is cardiogenic shock?

• LIFE THREATENING CONDITION

• when there is too much cardiac dysfunction for the heart to pump adequately to perfuse blood

• MI —> not enough blood perfusion —> widespread organ failure

How does the body try to compensate in response to cardiogenic shock? Which organ is most sensitive to loss of perfusion?

• body will increase sympathetic activation

  • tachycardia

  • vasoconstriction

• this all causes even more stress on the heart which makes the symptoms worse

• kidneys are most sensitive to loss of perfusion and hypotension

  • look at BUN and creatinine levels which indicate kidney dysfunction or failure

What is a normal left ventricular ejection fraction percentage? What is the LVEF for patients with L-sided heart failure?

• normal: 55-70%

• L-sided heart failure: < 40%

What are the normal lab values for troponin? What is the significance of it being elevated?

• normal: < 0.04

• elevation: > 0.04 during MI

• PATIENT NOT SAFE FOR THERAPY

  • immediately refer to doctor or nurse

What are the normal lab values for CK-MB? What is the significance of it being elevated?

• Normal: 0-5

• elevation: 4-6hrs post MI (so an MI has occurred)

• Need to confirm stabilization prior to functional mobilization

What are the normal lab values for BNP? What is the significance of it being elevated?

• normal: < 100

• elevated: > 400 = acute heart failure from fluid overload

• exercise intensity should be adjusted + monitor lung sounds for crackles during inspiration

What are the normal lab values for creatine kinase? What is the significance of it being elevated?

• normal: 22-220

• elevated: muscle damage; during MI this means heart muscle damage

• look for signs and symptoms of rhabdomyolysis

  • LIFE THREATENING CONDITION

  • muscle pain, weakness, cola-colored urine, nausea, vomiting, fever, rapid HR

What are the normal lab values for lipids? What is the significance of it being elevated?

• normal:

  • LDL < 100

  • HDL > 40-50

• elevated:

  • > 200 total cholesterol

  • > 150 triglycerides

• elevated cholesterol can lead to atherosclerosis which can lead to MI (if thrombus/ischemia occurs)

• patient education on risk factors and prevention/lifestyle modification

What does MONATASS stand for and what is it an acronym for?

• medications a person who has experienced a heart attack might be taking

• M: morphine; pain reliever

• O: oxygen

• N: nitroglycerin-vasodilators; relaxes smooth muscle in vessels, reduces heart workload, helps w/ angina

• A: aspirin; prevents formation of new clots

• T: thrombolytic; clot buster

• A: anticoagulant; also prevents blood clots

• S: stool softener; prevents straining which could provoke arrhythmia

• S: sedatives; patient might be lethargic

What are sternal precautions (modern) following heart surgery?

• move within your tube

  • patients can move as if they are hugging a pillow, just need to move sternum and arms together

  • some mobilization is necessary to prevent shoulder ROM issues like frozen shoulder

• no lifting > 5-10lbs

• no pushing or pulling

  • can use hand for BALANCE during transfers

  • likely will NOT have patient use arm to push self up/pull to side of bed during bed mobility (teach log roll method with modification)

• no OH arm elevation > 90*

• no reaching behind back

As a PT what should you be aware of when it comes to information presented in an EKG?

• be able to recognize new symptoms or rhythm changes

• if arrhythmia present ask: IS IT NEW? and CHECK BP

• knowing when to stop activity if changes in patient status occur

As a PT what should you be aware of when it comes to information presented in an echo?

• understand ejection fraction values/indications

• expect with lower LV function (like with heart failure) patient will have reduced exercise reserve/capacity

  • monitor patients for symptoms like angina, dyspnea, and arrhythmia

As a PT what should you be aware of when it comes to information presented in a angiography?

• understand post-procedure restrictions based on access site used during the procedure

  • radial artery vs. femoral

• monitor hemodynamic stability

Explain the pathophysiology for heart failure:

• what is it

• cause

• effects

• what: heart is not pumping or filling up with blood properly to keep up with body’s needs

• causes:

  • CAD

  • HTN

  • cardiomyopathy

  • valvular disease

• effects

  • hypertrophy (not the good kind; heart is working harder and not smarter)

  • fluid retention in kidneys —> kidney failure

  • pleural effusion (L-sided HF)

Explain reduced ejection fraction HF vs. preserved ejection fraction HF

• reduced

  • heart can’t pump

  • heart can fill

  • heart fills —> weak pump —> less blood pumped out

  • results in lower EF; < 40%

  • S3 heart sound

• preserved

  • heart can pump

  • heart can’t fill

  • heart starts with less blood —> less blood pumped out

  • S4 heart sound

Explain L-sided HF vs. R-sided HF

• L-sided (L —> LUNG)

  • causes fluid to back up into lungs (pleural effusion)

• R-sided (R —> Rest of body)

  • causes fluid to back up into body

  • edema in legs/ankles, ascites in abdomen, weight gain from fluid retention

What are common symptoms of L sided HF?

• SOB

• orthopnea

• cough or wheezing

* mainly causes breathing problems because fluid backs up into the Lungs

What are common symptoms of R sided HF?

• peripheral edema

• weight gain

• ascites

*mainly causes body swelling because fluid backs up into the Rest of the body

What are the AHA stages of HF?

• A: at risk

  • no symp

  • HTN, CAD, DM, obesity, cardiomyopathy

• B: pre-HF

  • no symp

  • structural heart disease or increased filling pressures

• C: HF

  • symptomatic

  • current or previous symp

• D: advanced HF

  • symp disrupt life function or cause hospitalization

What is the NYHA classifications of HF? Which stages of the AHA do they correspond to?

• correspond to stages C + D from AHA stages of HF

• Class I:

  • no limitation in PA

  • no symp (palpitations, SOB, fatigue)

• Class II:

  • slight limitation in PA

  • no symp at rest

  • ordinary PA causes symp

• Class III:

  • marked limitation of PA

  • no symp at rest

  • less than ordinary PA causes symp

• Class IV:

  • symp of HF at rest

  • any PA causes further symp
    
    

Which lab value if trending upward is highly indicative of HF? (what is normal; what value would indicate HF)

• BNP (B-type natriuretic peptide)

  • normal: < 100

  • HF > 200

When it comes to electrolyte lab values, what would you expect in a patient with HF for sodium and potassium + signs/symp that might present? What is the significance of patients taking diuretics and its effect on potassium?

• sodium

  • lab values may be LOW (< 135)

  • S/S of lower sodium levels: headache, nausea, vomiting, muscle cramps, fatigue, dizziness

• potassium

  • lab values may be LOW (< 3)

  • S/S: fatigue, lethargy, heart palpitations, numbness/tingling

• if a patient is taking diuretics for Tx for fluid accumulation, this might cause lower potassium levels

• need to remind patients to take supplemental potassium to avoid risk of arrhythmias

What are normal lab values for BUN and creatinine? What does elevated levels indicate? Which heart conditions might cause this?

• normal BUN: 5-20

• normal creatinine: 0.6-1.2

• elevated: kidney dysfunction or failure

• heart conditions: HF

What is the treatment for HF and what might you need to be aware of as a PT?

• typical medical management involves:

  • diuretics: watch out for potential low potassium levels + S/Sx

  • vasodilators

  • beta blockers: use RPE for exercise tolerance rather than HR

  • pacemaker

  • lifestyle changes: smoking cessation, low sodium diet, regular PA, monitoring weight for fluid retention

___1___ HF is more common and is either __2__ HF or __3__ HF. It causes fluid back up in the___4___

1. L sided

2. reduced EF

3. preserved EF

4. lungs

___1___ HF is often caused by __2__, ___3__, and __4__. It causes fluid back up in the ____5____

1. R sided

2. L-sided HF

3. pulmonary HTN

4. COPD

5. body

__1__ results from reduced EF HF while ___2__ results from preserved EF HF

1. systolic failure

2. diastolic failure

In reduced EF HF, the heart can _______ but it can’t_______ so EF is _______

1. FILL

2. PUMP

3. EF > 40%

In preserved EF HF, the heart can _______ but it can’t_______ so EF is _______

1. PUMP

2. FILL

3. EF normal: 50-70%

True or false: For patients in the Class I NYHA classification for heart failure ordinary PA causes symp

FALSE; ordianry PA does NOT cause symp for patients considered a class I

True or false: For patients in the Class II NYHA classification for heart failure ordinary PA causes symp

TRUE; ordinary PA does cause symp for patients considered a class II

For patients in the class III NYHA classification for HF, _______ causes symp

less than ordinary PA

When doe patients in the class IV NYHA classification for HF experience symptoms?

• all the time, even at rest

• symp get worse with PA

________ is when there is narrowing of a valve causing it to fail to open completely

stenosis

_____ results from a valve not closing completely. Blood back flows into previous space

regurgitaiton

______ is when a valve bulges backward into its chamber. The gate is supposed to be closed but it is open. This can lead to _______

1. prolapse

2. regurgitation

______ is turbulent blood flow in or near the heart. It can be caused by: ______, _______, or ________.

1. murmur

2. stenosis

3. regurgitation

4. high output stakes

Explain the pathophysiology for valvular stenosis:

• what is it

• cause

• effects

• what

  • increase in pressure due to lack of blood flow through the valves

• cause

  • calcific: damage to fibrosa layer eventually leads to deposition of calcium crystals + type I collagen

  • rheumatic: common with mitral stenosis; chordae tendinae fuse together and shorten

• effect

  • ventricular hypertrophy

  • increased outflow resistance and afterload

    • (pressure/resistance heart must overcome to eject blood out of ventricles during contraction)

  • ischemia

  • HF

You can typically hear a ________ upon auscultation of mitral stenosis at the L 5th intercostal space

low-pitched rumbling murmur

What are red flags related to valve stenosis?

• massive spike or drop in systolic BP during exertion

• lightheadedness

• onset of crackles during inspiration or irregular pulse

What should be avoided with patients with valvular stenosis? Why?

• exercises that cause sudden or rapid spike in systolic BP or HR

  • BP: could increase myocardial oxygen demand which could lead to ischemia and exertion syncope

  • HR: could cause fluid to back up into the lungs

Explain the pathophysiology for valvular regurgitation:

• what is it

• cause

• effects

• what

  • backflow of blood in the reverse direction usually due to valves failing to close completely (such as with a prolapse)

• cause

  • Mitral

    • prolapse

    • rheumatic endocarditis: destruction of valve due to bacteria

    • L ventricular remodeling

  • Aortic

    • leaflet disease

    • aortic root/ascending pathology

• effect

  • heart failure

  • atrial fibrillation

  • pulmonary HTN

What should be avoided with patients with valvular regurgitation?

• high after-load exercises: heavy weightlifting, HIIT workouts

• UE isometric holds

• valsalva maneuver

What are red flags related to valvular regurgitation?

• spike in L ventricular end-diastolic BP

• massive drop in stroke volume can lead to cardiogenic shock

Explain the pathophysiology for valvular prolapse:

• what is it

• cause

• effects

• what

  • defect in cusp of heart value leads to parachuting of valve backwards into previous chamber (flap opens up)

• cause

  • myxomatous degeneration (typically affects mitral valve)

  • accumulation of GAGs causing weakening of valve

• effects

  • could eventually lead to regurgitation

What are red flags/signs valvular prolapse has progressed to regurgitation?

• fatigue

• orthopnea

• new onset of arrhythmia

A patient comes in for treatment of his rotator cuff tear but he also has a mitral prolapse. What should you NOT do with the patient?

• ISOMETRICS!!!

• they can cause a spike in BP

Explain the pathophysiology for infective endocarditis:

• what is it

• cause

• signs + symp

• effects

• what

  • infection of inner lining of heart chamber

• cause

  • bacteria or fungi entering and attaching to damaged heart from:

    • brushing teeth, skin infections, dental work, dirty needles

• S/Sx:

  • fever, chills, new or changed heart murmur, extreme tiredness, small spots on skin or fingernails

• effect

  • heart failure

  • heart block

  • stroke

What are red flags related to infective endocarditis?

• new or worsening murmur, chest pain

• sudden weakness or facial droop (stroke), severe headache, seizure

• sudden SOB, chest pain hyoxemia

• lesions on palms/sores

Explain the pathophysiology for cardiac tamponade

• what is it

• cause

• effects

• what

  • LIFE THREATENING EMERGENCY

  • buildup of excess fluid around the heart

• cause

  • pericarditis

  • pericardial effusion

• effects

  • can press onto heart and cause it to stop filling up with blood

  • leads to drop in BP (especially during inspiration) and lack of blood flow

What are signs/symp of pericarditis? What can this condition eventually lead to?

• chest pain

  • typically increased with coughing, swallowing, or deep breathing in supine position

• relief of sharp stabbing pain when sitting upright/forward or bending over

________ results in elevated pressure and reduced filling of chambers in the heart, causing a decrease in venous return

pericardial effusion

Explain the pathophysiology for aortic aneurysm

• what is it

• cause

• effects

• what

  • permanent dilation of aortic segment

• cause

• effects

  • progressive expansion can lead to rupture

Explain the pathophysiology for aortic dissection

• what is it

• cause

• effects

What is worse type A or type B?

• what

  • intima of aortic vessel becomes torn through

• cause

• effects

  • rupture

  • cardiac tamponade

  • acute aortic regurgitation

• TYPE A IS WORSE

  • effects ascending aorta

  • has a higher risk for rupture and above effects

What are S/Sx of aortic dissection (type A vs. type B)

• type A

  • anterior chest pain

  • syncope

  • hypotensive shock

  • new aortic regurgitation murmur

  • cardiac tamponade

• type B

  • back or abdominal pain

  • HTN

  • limb, renal, spinal cord ischemia

What are red flags associated with aortic dissection?

• pulse and BP difference btw lilmbs

• altered mental state

• stroke-like symp

• unexplained lower extremity ischemia

What two questions should you ALWAYS ask a patient if you see that they have an arrhythmia?

1. IS IT NEW?

2. how is their cardiac output? (check their BP)

Explain the pathophysiology for heart blocks

• what is it

• cause

• effects

• what

  • delay or interruption of an electrical signal traveling from the atria to the ventricles

• cause

• effect

  • can result in the need for a pacemaker

  • 3rd degree block is most severe can result in damage that is complete and unresponsive to medication

If the R is far from the P then you have… (which heart block)

a first degree (heart block)

Longer, longer, longer, drop! Then you have a … (which heart block)

wenkeback (mobitz I)

If some Ps don’t get through, then you have … (which heart block)

mobitz II

If Ps and Qs don’t agree, then you have a … (which heart block)

third degree

Is it more or less common to have heart block after valve surgery?

more common

• need to be cautious of people with temporary pacemakers

What are characteristics of a first degree heart block?

• signal slows through AV node but still reaches the ventricles

• PR interval > 0.2 seconds

• not usually treated

What are characteristics of Mobitz Type I heart block?

• successive atrial impulse conductions gradually slow until one atrial impulse fails to conduct to the ventricles

• PR interval progressively gets longer

• QRS drops (P wave not followed by QRS periodically)

• Homer is a slowpoke but he is at least consistent

What are characteristics of Mobitz type II heart block?

• wider QRS complex

• regular dropped QRS every 2nd, 3rd, 4th P wave

• consistent RR pattern

What are characteristics of third degree heart block

• no conduction or communication between atria and ventricles; SA node signal doesn’t reach ventricles

• MARGE AND HOMER NOT GOING TO MAKE IT

• patient needs a pacemaker

What are red flags for the cardio portion of the complex medical case?

• conditions

  • v-tachycardia

  • v-fib

  • 3rd degree heart block

  • cardiac tamponade

  • aortic dissection

  • torsades de pointes

  • DVT

  • heart attack (MI)

• signs/symp

  • unstable angine

  • new arrythmia

  • UE pain (referred)

  • ST segement elevation on EKG

  • increase in troponin > 0.04

  • spike in systolic BP

  • sudden SOB

If a patient is experiencing an arrhythmia, what two things should you ask/do?

1. is this new?

2. how is their cardiac output; check BP

What are the phases of a cardiac action potential and how do they relate to an EKG reading?

• phase 0: depolarization; Na+ channels open

  • rising part of QRS complex

• phase 1: prolonged action potential; Ca channels open

  • top of QRS complex (ventricular contraction)

• phase 2: outward flow of K+ and prolonged Ca —> plateau

  • between Q and beginning of T wave

• phase 3: closing of Ca channels and opening of K channels (ventricular relaxation)

• phase 4: resting phase

  • right after P wave/atrial contraction

What do the following letters relate to on an EKG?

• P wave

• PR interval

• QRS complex

• QRS duration

• ST interval

• T wave

• P wave: atrial contraction (depolarization)

• PR interval: time between atrial contraction and ventricular contraction

• QRS complex: ventricular contraction (depolarization)

• QRS duration: time for ventricular contraction

• ST interval: time between ventricular contraction and ventricular relaxation

• T wave: ventricular relaxation (repolarization)

Put simply, an EKG reading shows: (3 things)

• activation of the atria: P wave

• activation of the ventricles: QRS complex

• recovery of the ventricles: T wave

Where is the best place to assess for heart blocks on an EKG?

PR interval

• if > 0.20 seconds

When it comes to the heart, whatever depolarizes must ________ before it can depolarize again (tip for reading EKGs)

repolarize

What are characteristics of supra ventricular tachycardia (SVT) arrhythmia? (what, symp, EKG)

• what

  • sudden, rapid HR > 150 bpm

  • onset is random and can last minutes to hours

• symp: palpitations, dizziness, SOB, angina, fatigue

• EKG:

  • high rate: 150-250

  • regular rhythm

  • no visible P wave, PR not measurable

    • contraction of ventricles is so strong, you don’t see the atrial contraction (which would be in P wave)

  • QRS < 0.12 sec

What is the treatment for SVT? Is it usually life threatening?

• cardioversion

• catheter ablation

• not usually life threatening but symp can be significant

What are characteristics of atrial flutter? (what, symp, EKG)

• what

  • rapid atrial activity of 300 bpm

  • HR sometimes shows up normal if ventricular rate is normal

  • symp: palpitations, fatigue, lightheadedness, SOB, exercise intolerance, hypotension, syncope

  • EKG:

    • sawtooth P wave

    • rate 250-450

What is the treatment for atrial flutter? What are serious complications of atrial flutter?

• rhythm control: ablation, cardioversion

• anticoagulant to prevent stroke

• if a flutter causes irregular ventricular response —> blood becoming static and clot formation

Does atrial flutter always show up on EKG? Why or why not? What is the effect of a fib + a flutter on CO?

• No, atrial flutter might not show up if ventricular rate appears normal (ex: HR shows 70 but atria are doing 300)

• a fib + a flutter = lose atrial kick which decreases CO

What are characteristics of atrial fibrillation? (what, symp, EKG)

• what

  • abn electrical activity results in fibrillation of the atria (rapid, uncoordinated irregular contractions of muscle fibers)

• symp

  • can be asymp; angina, palpitations, SOB, syncope

• EKG:

  • irregular rhythm, chaotic P waves, can lead to decreased CO

What is the treatment for a fib?

• anticoagulants: to reduce stroke risk

• beta blockers: HR control

• Ca channel blockers: HR control

• cardioversion: help return rhythm of heart to normal

What are characteristics of premature atrial contraction (PAC)? (what, symp, EKG reading)

• what: atrial contraction that doesn’t originate from SA node but is triggered by atrial myocardium

• symp: asymp; skipping sensation, palpitations, SOB

• EKG: abn P wave, normal QRS,

What is the treatment for premature atrial contraction?

• beta blockers

What are characteristics of premature ventricular contraction (PVC)? (what, symp, EKG)

• what

  • additional beat caused by random ventricular contraction

• symp: fluttering, pounding, skipped beats

• EKG:

  • no P waves

  • wide, early, random QRS

  • bigeminy = 1 PVC every beat; trigeminy = 1 PVC every 3rd beat

True or false: every patient might have some premature ventricle contractions (PVC)

• true

• need to notify nurse if patient is having a lot; likely will have PVC counter (# in the last minute)

When does a PVC become concerning?

• if a person is regularly having a lot of them

• if a person has a heart condition

What are characteristics of ventricular tachycardia? (what, symp, EKG)

• what

  • wide complex tachycardia

  • MEDICAL EMERGENCY due to potential cardiac arrest

• symp: palpitations, SOB, dizziness/lightheadedness, angina, cardiac arrest

• EKG:

  • 3 or more PVC and HR > 100 bpm

What is the treatment for v-tach?

• if cardiac arrest occurs: CPR with defibrillation

• no cardiac arrest: cardioversion

What are characteristics of torsades de pointes? (what, symp, EKG)

• what

  • specific form of V-tach with prolonged QT interval

  • ALSO MEDICAL EMERGENCY

  • can lead to v fib —> cardiac arrest

• EKG

  • prolonged QT interval

What are characteristics of ventricular fibrillation? (what, symp, EKG)

• what

  • ventricles chaotically quivering rather than pumping

  • MEDICAL EMERGENCY

  • can lead to immediate collapse + cardiac arrest

  • blood no longer being pumped!

• symp: sudden collapse, loss of consciousness, no pulse

• EKG

  • no organized rhythm

What is the treatment for ventricular fibrillation?

• Use AED + CPR

What is rhabdomyolysis? What is a common symp? What is its typical onset? What lab values do you expect a patient to have regarding creatine kinase?

• what:

  • skeletal muscle breakdown

  • releases creatine kinase into blood

  • leads to acute kidney injury, electrolyte disturbances, intravascular coagulation

• symp:

  • severe muscle soreness, cola-colored urine (due to myoglobinuria), local swelling

• onset:

  • symp can start 1-3 days after muscle injury or extreme workout

• lab values:

  • elevated creatine kinase: 5 x normal limit (20-200), so 1000-5000

If a patient has a decreased respiration rate, then this means there is more _____ in the blood, making the pH _____ and blood more ______

1. CO2

2. lower

3. acidic

How do the kidneys respond to the blood having a lower pH level/more acidic due to more CO2?

• kidneys will retain more HCO3- (bicarbonate) to neutralize the excess H+ which are making the blood acidic

If a patient has an increased respiration rate, then this means there is less _____ in the blood, making the pH _____ and blood more ______

1. CO2

2. higher

3. basic