Test 2 (Pharmacology Concepts, Screening CV and Respiratory, Screening GU, Renal and Integumentary)

What are racial, ethnic, and genetic factors that many increase risk of CV conditions?

heart disease is the leading cause of death for people of most racial and ethnic groups in the US (including African American, American Indian, Alaska native, hispanic, and white men)

What are risk factors for cardiac issues?

- age (males >45, women >55)

- family history of heart disease

- cigarette smoking

- physical inactivity

- obesity

- hypertension

- dyslipidemia

- diabetes

What risk factors can PTs help with?

- blood pressure

- blood sugar/diabetes

- BMI

- chronic inflammation

- diet

- exercise

- HDL cholesterol

- smoking

- stress

- total cholesterol

Do PTs typically get patients (referrals or direct access) based on constitutional signs/symptoms?

NO

What constitutional signs/symptoms might suggest CV system involvement?

palpitations, angina, extreme fatigue, pallor, chest pain

What are possible physical examination skills that we can use if report of possible CV involvement is provided during intake?

vitals

What pain patterns may indicate CV involvement?

pain referrals are variable and extensive!

most likely not instigated or responsive to movement (rules out MSK injuries)

most common: chest pain, LUE, discomfort in jaw, neck, back, arm, or shoulder

most common for women: feeling nauseous, light-headed or unusually tired

What are other causes of chest pain?

chest pain can happen more many reasons, often other signs that occur with it will give an idea of why chest pain occurs

Which artery carries deoxygenated blood away from the heart?

pulmonary artery

Which vein carries oxygenated blood to the heart?

pulmonary vein

What is the only cardiac muscle?

heart

Which ventricle in the heart is thicker?

LEFT = pumps blood through the whole body

What are signs/symptoms for respiratory system issues?

- dyspnea

- cough (duration, positional, productive, sputum)

- palpitations

- syncope (fainting)

- sweats

- edema

- cold distal extremeties

- skin discoloration

- open wounds/ulcers

- clubbing of the nails

- wheezing, stridor

What is dyspnea?

shortness of breath

What are some common causes for dyspnea?

medications, allergies, CV/pulmonary issues, etc.

When is a referral for dyspnea indicated?

when there is little effort exerted and there is shortness of breath, when pt experiences dyspnea when laying down and during sleep

What is dyspnea often associated with?

chronic heart and lung disease

What is a common pulmonary condition that mimics MSK conditions?

pneumonia > makes overall body weak, COPD, pulmonary embolism

What is the number one cause of pneumonia, and common risk factors?

aspiration > nursing facilities, patients who are not upright when eating

Can PT positively impact/ make it less likely that someone will develop pneumonia?

YES, movement is key to not pool liquid in the lungs

exercise lets gravity do work on the body

How do structures which contact the diaphragm influence pain referral to the shoulder?

phrenic nerve (C3, C4, C5) has the same nerve roots for the diaphragm and the shoulder

Why is it often difficult to detect pulmonary disorders? (think parietal vs visceral pleura)

referral of pain is less localized, different layers of pleura, parietal pleura isn't innervated whereas the visceral pleura is

What are considered to be immediate referrals for the pulmonary system?

pulmonary embolism, significant changes/pain, low O2 stats over prolonged period, ongoing cough, symptom after traveling/scuba diving

What constitutional signs/symptoms might suggest respiratory system involvement?

- fever

- diaphoresis (unexplained perspiration)

- sweats

- nausea

- vomiting

- diarrhea

- pallor

- dizziness/syncope

- fatigue

- weight loss

What pain patterns may indicate respiratory/pulmonary involvement?

not localized to a specific area

Wells Score for pulmonary embolism

score > 6 = high probability

score 2-6 = moderate probability

score < 2 = low probability

What does a Wells Score for PE > 4 indicate?

PE likely, consider diagnostic imaging

What does a Wells score for PE < 4 indicate?

PE unlikely, consider D-dimer to rule out PE

What are symptoms of hypertension?

- facial flushing

- headaches

- altered vision

- dizziness

- nose bleeds

- shortness of breath

- chest pain

- unsteady "rubbery" legs

- feeling faint, syncope

Untreated, _______ can lead to CVA, MI, CHF, PVD, renal failure, neuropathy, retinopathy. It is the "silent killer"

hypertension

What is heart failure?

complex clinical syndrome in which there is inability of the heart to eject blood to meet the demands of the body

What are symptoms of heart failure?

shortness of breath, fluid retention, fatigue, orthopnea, paroxysmal nocturnal dyspnea

What are complications of heart failure?

impaired exercise tolerance, increased risk of vent arrhythmias, and shortened life expectancy

Why do we study pharmacology?

for its impact on patients!

medications can affect response to exercise, pain perception, motivation, interactions between drugs can have adverse affects, affect modalities

Only ___% of the time do providers know ALL the medicines/substances someone takes

2%

What are factors influencing pharmacokinetics (ADME)

absorption, distribution, metabolism, excretion

What are examples of routes of administration for medications?

- oral

- sublingual (under tongue)

- buccal (cheek)

- rectal

- inhalation

- IV

- intra-arterial

- subcutaneous

- intramuscular

- intrathecal

- topical

- transdermal (patch)

What is important in medications regarding the distribution?

where in the body the medication goes

With aging, total body water (decreases/increases), total body fat (decreases/increases)

decreases, increases

If a medication is hydrophilic (water loving) what happens if the patient is dehydrated?

increased effect of medication = more medicine per amount of water

If a medication is lipophilic (fat loving) what happens when a patient loses 40 pounds?

increases affect of medication = higher concentration

What is important in regards to metabolism of medications?

break down- how the medication is broken down in the body

What organ is mainly responsible for metabolism?

liver

Why does it matter if some enzymes in the liver aren't active until around age 5?

some medications could be deadly and have adverse effects on a child when it has normal effects on an adult

Why does it matter if some enzymes in the liver aren't active in older ages?

the same dosage of medication they have been taking since their 40s might have a different effect in their 80s

How is the medication eliminated from the body?

feces, urine

_____________ function gradually declines with age after about the age of 40

renal

What are beta blockers used for?

blood pressure, heart failure, after a myocardial infarction

What are beta agonists used for?

asthma treatment

What are possible systemic effects of medications?

- upregulation or downregulation of receptors

- alterations in the physiologic response to medications

What are key factors we should consider that people bring to the table regarding medications?

age, sex, concomitant medical conditions, diet, exercise, environment, smoking, alcohol, genetics

T/F: Pharacokinetics can be both linear and nonlinear

TRUE

What is important regarding nonlinear pharmacokinetics?

it is important for prescribers to understand that different medications have different potencies depending on their dosage

an increased dosage of one medication can have little effect, whereas an increased dosage of another can have a significant change

What is important in regards to the "narrow therapeutic index" in pharmacokinetics?

there are some drugs where small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity

aka: become toxic quickly!

Where can GU/Reproductive system issues refer pain?

low back, thighs, abdominal wall

_____________ is filtered by the glomerulus and secreted by the proximal tubule

creatinine

Creatinine clearance can be a good estimate of?

glomerular filtration rate

What is the BIG DEAL with CYP450?

enzymes essential for medication metabolism; these enzymes can have a lot of genetic variability where they can be inhibited or induced > chance of clinically significant drug-drug interactions and adverse effects

What are the advantages for the new labeling for medications during pregnancy?

align with physician labeling rule format, helps to assess benefit vs. risk, counsel patient appropriately, removed perception that one drug might be better than others

What does the new/current pregnancy and lactation labeling rule include?

- pregnancy, includes labor and delivery

- lactation, includes nursing mothers

- females and males of reproductive potential

Many medications have cough, flu, cold symptoms in their list of possible adverse effects? Why?

the clinical trials were most likely conducted during the winter/flu season, therefore they couldn't rule out these symptoms during testing

What are important factos to consider when deprescribing?

- triage changes

- coordinate changes

- one or very few at a time

- taper, especially if impacts thinking

- closely monitor during taper

How many schedules are there for controlled substances?

5

What are the 5 schedules of controlled substances based on?

- currently accepted medical use

- relative abuse potential

- likelihood to cause dependence

examples of schedule 1

non-regulated: heroin, LSD, canabis, peyote, ecstacy, qualuuds

examples of schedule 2

most regulated/approved: morhpine, hydromorphone, oxycodone, codeine, Adderall, Ritalin

examples of schedule 3

Tylenol with codeine, suboxone, ketamine, Depo-testosterone

examples of schedule 4

alprazolam (xanax), lorazepam (ativan), diazepam (valium)

examples of schedule 5

codeine cough syrup (up to 2 mg/ml)

What are some medication-related problems?

- medication errors

- suboptimal drug, dose, regimen, dosage form, and duration of use

- unnecessary drug therapy

- therapeutic duplication

- drug-drug disease, drug-food, or drug-nutrient interactions

- drug allergies/intolerances

- adverse drug effects, clinically significant (some are preventable)

- not take a medication when one can help

What is the GI system?

vast, complex system of organs that functions to digest and absorb ingested nutrients, and to excrete waste products of digestion

What system supports the GI system?

biliary

What system is considered the "second brain" due to its millions of neurons, neuropeptides, and hormonal influences?

GI system

Where can GI disorders refer pain in the body?

sternal region, shoulder/neck, scapular region, midback, lower back, hip, pelvis, sacrum

What is a visceral pain?

site of pain corresponds to dermatomes from which the diseased organ receives its innervation; not well-localized; multi-segmental innervation

What are clinically meaningful symptoms for GI?

- abdominal pain

- dysphagia

- odynophagia

- melena

- epigastric pain radiating to the back

- symptoms affected by food

- constipation

- diarrhea

- referred shoulder pain

- arthralgia

- McBurney's point

Where is referred pain common of GU/Reproductive systems?

low back, thighs, abdominals

Conditions of GU/Reproductive systems can have symptoms often mimicking MSK pathology!

Who are the main patient populations affected by UTIs?

women, older adults

What is the main symptom of an older adult with a UTI?

quick onset of confusion

What can UTIs develop into if left untreated?

pyelonephritis (kidney infection)

What is the largest organ of the body that forms a physical barrier between the external and internal environment that serves to protect and maintain?

integumentary system

Wy can PTs detect integumentary system conditions?

PTs see the skin a lot more than other providers during examination and treatment, longevity of care

How to test dehydration?

pinch the skin, lift up slightly, then release

testing locations: under the clavicle, extensor surface of forearm, dorsum of hand

What is seen with a negative dehydration assessment? Positive?

negative: the skin should lift up easily and return to place quickly

positive: pinched skin remains lifted for 5 seconds or more after its release and returns to normal very slowly

(Positive/Negative) dehydration assessment indicates signs of dehydration

positive

What patient populations is the dehydration test commonly seen?

children, older adults

What does unilateral edema usually indicate?

DVT/post-thrombotic syndrome (blood clot), local inflammation

What does bilateral edema usually indicate?

chronic heart failure, chronic venous insufficiency, liver failure, renal disease

What does pitting edema usually idicate?

chronic condition

What are signs of skin infection?

warm.hot skin

What are signs of arterial insufficiency?

cool skin

What are signs of venous insufficiency?

warm skin

What does cyanosis ("blue colored fingers") usually indicate?

lung disease, CHF, venous obstruction, or cold environments (hypothermia, etc)

What does Rubor of Dependency (redness) usually indicate?

peripheral vascular disease

What does yellowing/jaundice of skin usually indicate?

bilirubin levels, hepatic (liver) disease

WHat does darkening-hyperpigmentation of skin usually indicate?

Addison's disease

Where is it best to observe skin color changes?

white part of eyes, palms of hand, soles of feet

What are the ABCs for skin cancer screening?

Asymmetry, Border, Color, Diameter

Evolution

Round, symmetric skin lesions such as common moles, freckles, and birthmarks are considered?

normal

Common moles or other "normal" skin changes usually have what types of borders?

usually smooth, even borders or edges