NTG Reviewer PDF

NTG REVIEWER 2013 Version: 4.3 Last update: June 28, 2013 FIRST EDITION  NTG |1 Table of Contents Page CELL, NERVE, MUSCLE PHYSIO 4 ENDOCRINE PHYSIO 9 BLOOD PHYSIO...

NTG REVIEWER 2013 Version: 4.3 Last update: June 28, 2013 FIRST EDITION  NTG |1 Table of Contents Page CELL, NERVE, MUSCLE PHYSIO 4 ENDOCRINE PHYSIO 9 BLOOD PHYSIOLOGY 13 CARDIAC PHYSIOLOGY (CV) 20 PULMO PHYSIOLOGY 30 GIT PHYSIOLOGY 43 RENAL PHYSIOLOGY 47 BASIC KINESIOLOGY 50 ANA/KINES HEAD, NECK, TMJ 55 ANA/KINES BACK AND SPINE 63 HEAD, NECK, BACK, AND SPINE CONDITIONS 69 SPECIAL TEST: HEAD, SPINE, PELVIS 76 ANA/KINES SHOULDER 85 ANA/KINES ELBOW 94 ANA/KINES WRIST & HAND 97 UE ORTHOPAEDIC CONDITIONS 105 SPECIAL TEST: UPPER EXTREMITY 113 ANA/KINES HIP 117 ANA/KINES LEG, ANKLE & FOOT 131 LE ORTHOPAEDIC CONDITIONS 140 SPECIAL TEST: LOWER EXTREMITY 150  NTG |2 Table of Contents Page GAIT ANALYSIS AND PATHOLOGY 156 EXERCISE PHYSIO 163 PERIPHERAL VASCULAR DISEASE (PVD) 166 ORTHOSES 171 PROSTHESIS 179 ASSISTIVE DEVICES 189 WHEELCHAIR 194 ORAD & ETHICS 197 RHEUMA 204 FRACTURE, D/L, AMPUTATION, & OSTEOPOROSIS 215 BURNS & ULCERS 223 CENTRAL NERVOUS SYSTEM 229 INTEGUMENTARY SYSTEM 247 PSYCHIATRY 253 MOVEMENT DISORDERS 257 TRAUMATIC BRAIN INJURY 266 MULTIPLE SCLEROSIS 272 MOTOR NEURON DISEASES 277 CEREBROVASCULAR ACCIDENT (CVA) 289 HUMAN GROWTH & DEVELOPMENT (HGD) 296 PERIPHERAL NERVE INJURIES 299  NTG |3 Table of Contents Page GMSC 307 PHARMACOLOGY 312 PHYSICAL AGENTS 316 THERAPEUTIC EXERCISES 1 327 THERAPEUTIC EXERCISES 2 332 ELECTROTHERAPY 1 338 SPINAL CORD INJURY (SCI) 348 RESEARCH AND EBP 358 THERAPEUTIC EXERCISES 3 366 TESTS & MEASURES 372 PEDIA CONDITIONS 378 ELECTROTHERAPY 2 383 VESTIBULAR PHYSIO & REHAB 397 PRESSURE SORES 403 HGD 2 406  NTG |4 CELL NERVE MUSCLE PHYSIO Cell Physiology: i. Cell: a. Centriole – direct spindle fibers for mitosis, important for the reproduction of cell. b. Plasma membrane, divides outer cell (ECF) and inner cell(ICF) i. Semi-permeable ii. Fluid, shift in position and shape, Not Solid iii. Charge: -25mV iv. Phospholipid bilayer o Center fat soluble (hydrophobic)/ more permeable
CO2, O2, Alcohol o Outer water soluble/ less permeable v. Proteins o Integral protein – serves as a water channel o Peripheral protein c. Endocytosis – bulk uptake of materials when it comes in contact with the cell membrane vi. Pinocytosis cell drinking vii. Phagocytosis cell eating viii. Receptor mediated – coated pits o Uptakes Cholesterol and growth factor d. Cytosol – clear fluid where organelles are suspended. Crystalloid and colloids e. Endoplasmic reticulum – bridge, connects the nucleus to cytoplasm 2 types: i. Rough ER – Protein synthesis ii. Smooth ER – Lipid synthesis “Smooth madulas, Lipids/ oils” a. Other functions: i. Enzymes from glycogen breakdown ii. Enzymes for detoxification f. Golgi Apparatus “Highway of the cell” a. Produces lysosomes b. Produces carbohydrates from SER g. Lysosomes vs Peroxisomes [Digestive system of the cell] Lysosomes Peroxisomes Produced by Golgi Apparatus Self Replicating Contains hydrolase Contains Oxidase Uptakes bacteria and damaged cell parts Uptakes Alcohol h. Mitochondria (Power house of the cell) a. Responsible in producing ATP  NTG |5 i. Nucleus (Control center) a. Contains DNA or genes b. Chromatin dark staining in nucleus that have not undergone duplication > Chromosome (undergoing duplication) c. Nucleoli – contains the RNA (Uses mRNA to duplicate/ provide the “recipe” from nucleus to cytoplasm, given to tRNA to transcribe the recipe to rRNA to RER to create protein) ii. Cell Division a. Mitosis i. Interphase: Before Mitosis or meiosis 1. Preparation for cell division 2. Duplication of DNA ii. Prophase – chromosomes pair, lose nuclear envelope iii. Metaphase – Aligning in the middle (equatorial plate) iv. Anaphase – Chromosomes are separated; moves towards opposite poles v. Telophase – 2 nuclei, cells cleaved into 2 MITOSIS P – Preparation of nucleus M – Middle chromosome A – Apart T – Talo b. Meiosis i. Interphase ii. P1M1A1T1 -> P2M2A2T2 Mitosis Meiosis Time of DNA replication Interphase Interphase Product Haploid Diploid F:(23) 1 egg cell, 3 polar bodies M:(23) 4 sperm cells Purpose Growth and repair Reproduction iii. Ions: ICF ECF Cations Potassium Sodium Anions Organic Chlorine extracellular Na iv. Carbohydrates Cl bicarbonate, a. Function: provide cellular nutrition ICF K, Mg, b. Glucse: readily available;Siimplest form c. Glycogen: storage form of glucose in the cell phosphate, Monosaccharides Disaccharides sulfate! 2x (frugalglu) (SLaM) Fructose + Glucose =Sucrose repeat Galactose + Glucose =Lactose (penpendesarap Glucose + Glucose =Maltose en)  NTG |6 v. Transport mechanisms: a. Passive transport/ Diffusion i. Does not need energy ii. Higher concentration to lower concentration iii. O2, CO2, Alcohol iv. Water (Least common pathway for ions) v. 3 types: 1. Passive/ Simple diffusion (Without carrier protein) 2. Facilitated diffusion a. With carrier protein, (+) binding site b. E.g. Glucose and Amino Acids 3. Osmosis – Solvent moves region of higher concentration to lower concentration a. Maintains the volume of the cell to prevent shrinking or bursting b. Active transport i. Requires the use of energy (ATP) ii. Uphill transport, Lower to higher concentration iii. 2 types: 1. Primary a. Uses direct ATP b. Na-K pump (Na: 3 K: 2) c. Ca pump 2. Secondary a. Uses indirect ATP (Uses ionic concentration from primary transport) i. Co transport: Glucose and amino acid and Cl ii. Counter transport : H+ and Ca+ Symport - 2 substances go in the same direction. E.g. Na + glucose transport in small intestine Antiport - 2 substances go to the opposite direction. E.g. Na + Ca in heart muscles Uniport - only one substance is transport Nerve Physiology: vi. Nerves: a. Action potential b. RMP of muscle: – 90mV c. RMP of nerve: -70mV d. Nerve cells at rest are positively charged outside and negatively charged inside (RMP) e. Period of Action potention prior to application to stimulus (RMP) f. Upon application of stimulus: Depolarization g. Hyperpolarization: Less than the RMP  NTG |7 vii. Propagation of action potential a. Direction of propagation b. Na influx: Depolarization c. K efflux: Repolarization d. All or nothing principle: Maximum intensity above the threshold orf resting state e. Aboslue refractory period: i. Cell is no longer stimulated ii. Peak of acion potential f. Relative Refractory period i. 2/3 of repoarization ii. Supramaximal intensity to stimulate the cell membrane viii. Sensory receptors a. According to source of stimulus i. Exteroreceptor ii. Proprioceptor iii. Enteroceptors/ visceroreceptors b. According to modality i. Nociceptors – pain A delta & C fiber ii. Thermoreceptor – Ruffini & Krausse Kold iii. Mechanoreceptor – Merkels, Meissner, Pacinian “Never mind the merkel light. Discrimination / light touch MeiSSner (2) S two point(s) Paccccciiiiniiiaaaaaannnnnn – vibration” Muscle Physiology ix. Muscle: a. Sarcomere i. Functional unit of the MS/ basic contractile units ii. Myofilaments > Myofibrils > Ms fiber > Fasiculus > Fasciculi > Muscle belly iii. Myofilament:Actin & Myosin iv. Sarcomere song Danananana! I band: Actin only A band: Myosin and Actin! H band M line: myosin only Z disc Z disc attachment of actin Nag contract nag contract nawala! Skeletal Cardiac Smooth Location Bones Heart Viscera Striation (+) (+) (-) Nucleation Multi Mono Mono Intercalated disc (-) (+) (+) Control Voluntary Involuntary Involuntary  NTG |8 x. Events of muscle contraction a. Action potential in nerve b. Release of calcium from synaptic vesicle c. Release of Ach at motor end plate d. Binding of Ach to ligand gated sodium channel e. Na+ influx of the muscle cell f. Action potential in muscle g. Calcium is released from the sarcoplasmic reticulum h. Calcium attaches to Troponin C, to unravel troponin-tropomyosin complex and reveals actin binding sites Troponin I – Binding site for actin Troponin C – Calcium attachment Troponin P – Myosin i. Formation of crossbridge between actin & myosin sliding of thin on thick filaments, producing shortening (power stroke). j. Ca is pumped back into sarcoplasmic reticulum Fast twitch Slow twitch Large diameter Small diameter Glycolytic Oxidative Low mitochondria More mitochondria More sarcoplasmic reticulum Endurance and posture 100m Dash xi. Other concepts: a. Summation (Addition of muscle twitches) i. Increase the force generated in a contraction ii. Multiple fiber summation (Size principle: Small muscles before larger muscle groups ) 1. Spatial: ↑ the # of motor units being stimulated 2. Temporal: ↑ Frequency of the stimulation a. Tetanic: 100x/ sec; 4x Greater than individual muscle twitch (Continuous) b. Incomplete Tetanic: 10-30x/sec, with rest period c. Trepe/ Staircase contraction: ↑ Frequency until plateau is reached  NTG |9 ENDOCRINE PHYSIO i. Endocrine system a. 2nd great controlling system in the body b. Ductless glands, and produce hormones in the blood or lymph system. c. Hormones: To arouse, mediator molecule that will activate the activity of the cell in the body. ii. Control of release a. Hormonal stimulus: Endocrine glands are stimulated by another hormone b. Hummoral stimulus: Blood borne ions -> chemicals c. Neural hormones: Nerve fibers are stimulated by hormones (E.g. Epinephrine and Norepinephrine) iii. Hypothalamus – Major part of limbic system a. Responsible for neuronal circuitry for emotional and motivational drive b. Function: i. Temperature regulation ii. Osmality of fluids iii. Control body weight iv. Drive to eat and drink v. Role of emotions iv. Pituitary Gland/ Hypophysis a. Small gland, 1cm in diameter b. 0.5 – 1g c. Lies in the Sella Turcica (Bony cavitation at the base of the brain and it is connected to hypothalamus by Pituitary stalk.) d. 2 lobes: i. Anterior pituitary lobe (Adenohypophysis) 1. The origin of this gland, from the pharyngeal epithelium that’s why it will always explain the epithiliod nature of its cells. 2. Secretion is controlled by hormone Hypothalamic releasing & inhibitory hormone. (from the hypothalamus) *MOST important hypothalamic releasing & inhibitory hormone a. TRH - Thyrotropin Releasing hormone, release of TSH b. CRH – Corticotropin Releasing hormone, release of Adenocorticotropin hormone (ACTH) c. GHRH – Growth hormone releasing hormone – Release of Growth hormone d. GHIH - Growth hormone inhibiting hormone - inhibit release of Growth hormone e. GnRH - Gonadotropin releasing hormone – release LH and FSH f. PIH- prolactin inhibiting hormone – inhibit Prolactin  N T G | 10 3. Anterior pituitary gland hormones a. Growth Hormone –aka Somatotropin, responsible for growth of all soft tissues in the body that are capable of growing. Function to similar to amino acid, decrease blood glucose. Too much = Gigantism, i. Increase at Adult, Acromegaly (Hand 2x size, Feet, from size 7 to size 14, nose, bosses of the forehead, lower jaw protruded, thickening of vertebra causing kyphosis) ii. Dwarfism, same height as 4-5 years old b. Prolactin – Production of milk i. Tenderness in the breast: Peak of prolactin ii. Excessive prolactin in males Erectile Dysfunction/ Impotence iii. Excessive prolactin in females Amenorrhea. c. FSH : From GnRH (Stimulate Gamete formation) i. Female: Follicular cells > estrogen (Secondary sex characteristics) Female sex drive (Libido) ii. Male: production of sperm cells. d. LH – from GnRH i. Female: Triggers ovulation, stimulates sex hormone production, and production of progesterone. ii. Male: Production of testosterone. e. MSH – Melanocyte stimulating hormone i. Increases skin pigmentation when present in excess f. TSH – from TRH: Stimulate release of thyroid hormone in thyroid gland. g. ACTH: Stimulate the release of aldosterone and cortisol. ii. Posterior pituitary lobe/ Neurohypophysis 1. Orginates from the neural tissues → explains the large number of glial cells in the area. a. Glial cells, Pituicytes, does not release hormones i. Support for terminal nerve fiber and nerve endings. Which glial cells are seen in the posterior pituitary? ii. Production of hormone for post. Pit. Gland comes from hypothalamus: 1. Supraoptic nuclei 2. Paraventricular nuclei b. Hormone: Oxytocin (Exitocin) i. Milk ejection via sucking reflex ii. Contractions of uterus c. ADH/ Vasopressin: Reabsorption of water  severe hypothyroidism characterized by firm N T G | 11 inelastic edema, dry skin and hair, and loss of mental and physical vigor, myxedema v. Thyroid gland a. Inferior to larynx i. Thyroxine T4 –Tetraiodothyronine: 93% & Triiodothyronine T3 7% (Form of iodine) 1. Maturation/ development and growth of CNS, regulate oxygen use, BMR, and cellular metabolism. Insufficient amount at child results to Mental Retardation Insufficient amount causes lethargy, Graves, myxedema hyperthyroidism ii. Calcitonin characterized by 1. Decrease blood Ca++ level goiter and often 2. Decrease osteoclastic activity/ bone matrix vi. Parathyroid gland a slight a. ParaTHORmone protrusion of the 1. Posterior surface of the lateral lobe of the thyroid gland eyeballs, graves 2. Increase blood Ca++ level 3. Increase osteoclastic activity vii. Adrenal Gland a. Superior to each kidneys i. Adrenal Cortex 1. 3 zones: a. Zona Glomerulosa – Aldosterone, water and electrolytes/ Na b. Zona Fasciculata – Cortisol, metabolism and resistance to stress c. Zona Reticularis – Androgen, secondary sex characteristics of males i. Stimulate growth of axillary and pubic hair ii. If more in females they develop male characteristics, clitoris develops similar to penis. (Androgenital syndrome) ii. Adrenal Medulla 1. Epinephrine/ Norepinephrine: Fight/ flight response viii. Pineal Gland a. Attached to the third roof ventricle of the brain b. Hormone: Melatonin i. Body biological clock ii. Sleepiness iii. Increased = sleepiness more during the dark iv. Decreased = more awake ix. Thymus Gland a. Behind the sternum between the lungs i. Thymosin 1. Maturation of the T-Cells 2. Retard aging  N T G | 12 x. Pancreas a. BOTH exocrine and endocrine system GABIDS i. Alpha cells – Glucagon, Increased blood glucose levels ii. Beta cells – Insulin, Decreases blood glucose levels iii. Delta cells – Somatostatin, balance/ controls the number of insulin and glucagon Type I DM, IDDM. Ketone prone. No insuli. Skinny because if there is no insulin, blood glucose is everywhere. No source of energy. Fat will be used instead/ triglycerides (natural fat form inside the body). If triglycerides are digested ketones will be released in the blood will result to atherosclerosis. Type II NM, NIDDM. Deficient or kulang sa insulin. Adjusted with diet and exercises. Ketone – resistant. xi. Ovaries and Testes a. Gonads: produce gametes (female: oocytes, male: sperm) i. Estrogen – Female sex characteristics/ sexual drive of females ii. Progesterone iii. Testosterone – maturation of male sex organ iv. Relaxin – increase flexibility of the pubic symphysis (During labor)  N T G | 13 BLOOD PHYSIOLOGY i. Blood functions: BLOOD PH Balance of acid/ base Delivers Levels Temperature Immunity Oxygen Transport Nutrients Osmosis Oxygen transport Delivers nutrient Guards Protection Osmosis Hormonal transport Acid-base balance Nourishment ii. Buffer system: pH 7.34 -7.45 CO2 = 35 – 45mmHg HCO3 = 22- 26 meq/L Vomiting will result to? Gag- sound of vomiting, “aaaalkk-” a. RAC b. RAL c. MAL d. MAC Diarrhea – HCO3 (Base) is released, acid is left. ASSidosis Hyperventilation – Throws away CO2 (acidic), results to RAL iii. Blood (Total circulating blood volume is about 8%) a. Plasma 55% b. Formed elements – 45% (RBC + WBC + Platelets = HCT)) i. RBC
Male : 5.2 – 6.5m/mm3
Female : 4.5 – 5.5m/mm3 ii. Hematocrit (HCT) – percentage of blood, viscosity
Male: 42-52%
Female: 37-47%
Dehydration = Increase in HCT %, Decrease blood volume
Bloated = Decrease in HCT % Increase blood volume iii. Erythrocyte Sedimentation Rate (ESR)(Determines how much inflammation is in the body)
Hallmark: Inflammation
Male: causes bronchial constriction * Antihistamine – slow acting, fast relief of signs v. D – activation B-cells, produced by bone marrow Types of hypersensitivity reaction I Anaphylactic II Cytotoxic “Cytwotoxic” E.g. Incompatible blood transfusion III Immune complex IV Cell mediated delayed E.g. Contact dermatitis/ Eczema  N T G | 15 vi. Types of immunity NA NP AA AP a. na natural active: Chicken pox, naturally created antibodies against chicken pox b. np natural passive: IgG mother passing IgG through placenta c. aa artificial active: Vaccines (mild form of virus to create antibodies) d. ap artificial passive: Tetanus Toxoid, given antibody i. RHOGAM, given 72 hours. Protection of fetus. – Rh Incompatibility Mother Rh- Father Rh+ = Fetus Rh+ (only allowed the first time to be normal/ healthy birth) Succeeding births with Rh-, mothers body has created antibodies for Rh+. Further children, will die or live c complications. Rhesus Dse, severe anemia, anti rh+ in the mother will destroy the fetus. Erythroblastosis Fetalis – Fatal vii. RBC – aka Erythrocytes a. Life span: 120 days b. Formation of RBC, Erythropoiesis c. Deprivation of oxygen causes the hormone, erythropoietin to produce RBC. d. From the kidneys 90%, liver 10% e. Blood formation- Hematopoiesis i. Infants In the middle of gestation the liver is the primary production of RBC’s ii. Adult – bone marrow f. RBC formation i. Proerythroblast ii. Basophil erythroblast – First generation cell iii. Reticulocyte iv. Erythrocyte- anuclear (Mature RBC) 1. Biconcave 2. Strong membrane 3. Designed to be small to fit through the smallest arteries. 4. Nutrients required to created RBC’s: i. B 12 vitamin, vit b12 deficiency anemia ii. I Iron, for Hgb iron deficiency, MC substance deficiency in anemia. iii. F Folic acid, folic acid deficiency viii. Cell Terminology: a. Amount: i. Increase in amount suffix –cytosis ii. Decrease in amount suffix –penia E.g. Thrombocytosis, Thrombocytopenia, Leukocytosis, leukocytopenia, polycythemia, anemia b. Cell size – Cytic, e.g. microcytic (small), normocytic (normal), macro/ megaloblastic (big) c. Cell color – Chromic e.g. hypochromic (decrease in color), normochromic  N T G | 16 ix. Oxygen related conditions: a. Anemia – Decrease in O2 carrying capacity of RBC Quanitative anemia: i. Increase in destruction of RBC ii. Decrease in production of RBC Qualitative anemia: iii. Abnormal maturation b. Hypoxemia – Decrease of O2 in blood c. Hypoxia – Decrease O2 tissue x. Common types of anemia: Anemia: Decrease in oxygen carrying capacity of the blood cell. a. IDA (Iron Deficiency Anemia) i. Microcytic, hypochromic ii. MC in females d/t menstrual cycle iii. S/Sx i. Headache ii. Irritability iii. Plummer – Vinson syndrome: Form of esophageal webs. Chronic IDA. Complete depletion of iron. Difficulty with swallowing. b. Post- Hemorrhagic Anemia i. Normocytic, normochromic Vicious cycle, bleeding causes decrease venous return> compensatory increase heart rate> increase blood flow > more bleeding (positive feedback) ii. Blood loss (amount in %) % Sx 20-30% Decrease BP, dizziness 30- 40% Decrease BP, Diaphoresis, Increase ADH 40-50% Hypovolemic Shock, potential death c. Vitamin B12 Deficiency Anemia Vitamin B12 is best absorbed in what part of the intestine? Ileum i. Affects CNS ii. Intrinsic factor – Protects Vitamin B12 to prevent Digestion > brush borders >ileum iii. (Pernicious Anemia: (-) intrinsic factor, Vitamin B12 is digested Macrocytic/ megaloblastic anemia, normochromic, Affects CNS) iv. S/Sx i. Decreased vibratory sense ii. (+) Rombergs Test v. Folic Acid anemia i. Digested Macrocytic/ megaloblastic anemia, normochromic ii. MC in pregnant females d. Aplastic anemia i. 2o to Aplasia ii. Bone marrows replaced with fat iii. Idiopathic iv. Dx: Bone marrow Aspiration  N T G | 17 e. Hemolytic anemia i. Increased destruction of RBC before its 120th day f. Thalassemia i. Problem with Hemoglobin ii. No problem with RBC production, but with reduced amount Which disease is the structure of hemoglobin’s that are produced normal but their amount reduced? Thalassemia g. Sickle Cell Anemia i. (+) Hemoglobin S (Abnormal type of Hgb) ii. Decrease O2 -> RBC will form a sickle-shape iii. Pain crisis, pain felt anywhere in the body or in any major organ of the body. h. Polycythemia i. Primary polycythemia (idiopathic) Polycythemia Vera (Associated with acquired myeloproliferative disorders) Other types: ii. Secondary polycythemia: Decreased O2> increase erythropoietin production> increase red blood cell count xi. WBC a. Only True Cell in the blood b. Lifespan i. 4-5 hours (Circulation) ii. 4-6 days (Tissue) Granulocytes B E N – G Count Agranulocytes Count Neutrophils 4-6 hours (1-3 days) 50-70% Lymphocytes 20-40% Eosinophils 1-4% Monocytes 2-8% Basophils (Contain Histamine) 0-1% monocytes 1st Increase Neutrophils = Bacterial infection, first line of defense line of defense Increase Lymphocytes = Viral infection / Chronic inflammation guyton Increase Eosinophils = Parasitic infection/ Allergic reactions/ Acute inflammation *WBC’s are able to leave the circulation. xii. Process of phagocytosis: “Si NED may CP” a. Neutrophils undergo margination b. Emmigration – getting out c. Diapedesis – amoeboid like movement, cells extend their cytoplasm to move. d. Chemotaxis – attract neutrophils e. Phagocytosis xiii. WBC related conditions: a. Immunity Virus (Lymphocytes) i. Cellular: T-Cell (origin Thymus gland, at the age of 8 years old, becomes smaller) i. Killer – first to be attracted ii. Helper – recruitment of B cells iii. Suppressor – suppresses activity ii. Humoral: B-Cell (origin from bone marrow) i. When cell death > becomes plasma cells memory cells > becomes antibody.  N T G | 18 b. HIV i. Opportunistic Virus (attacks when Immune system is low) ii. Attacks helper T-cells iii. No B cells, no memory cells, no antibodies c. GBS i. Attacks suppressor T cells. ii. Continuous activity d. Multiple Sclerosis i. Mimics appearance of the myelin sheath ii. Demyelination, the body kills the myelin sheath. e. Leukocytosis – increase in WBC, (+) infection f. Leukopenia – Felty’s syndrome, Blood d/o common in rheumatic conditions S – splenomegaly L - leukopenia A - anemia A - arthritis N - neutropenia T – Thrombocytopenia g. Leukemia i. Cancer of WBC ii. Types: i. Myelogenous – started in the bone marrow 1. Fragile bones ii. Lymphogenous – started in the lymph organs (spleen, liver, etc.) What is the largest lymphoid organ? The Spleen xiv. Platelets – Thrombocytes a. Function: to create clot. Platelet plug and clotting b. Life span: 8-10 days. c. Platelet plug process: (Stop bleeding, “Hemostasis”) 1. Vasospam 2. Platelet attraction/ cascade 3. Platelet plug 4. Desolution (Release of Plasmin, to dissolve clot) d. Clotting factor (12) There is no clotting factor VI Clotting Factors I Fibrinogen VIII Anti Hemophilic Factor A II Prothrombin IX AHF B (Christmas Factor) III Thromboplastin X Stuart IV- Calcium XI AHF C V Labile XII AHF D (Hagemen) VII Stable XIII Fibrin stabilizing factor  N T G | 19 e. Clotting Process: Blood vessel damage> thromboplastin > awakes prothrombin activator > calcium is added > resulting to prothrombin> thrombin> fibrinogen >fibrin stabilizing factor (CLOT) to dissolve (Plasmin). Sequence 3, 2 activator, 4, 2, thrombin, 1, 13 xv. Platelet related conditions: a. Thrombocytosis (Similar to polycytemia vera) b. Thrombocytopenia c. Hemophelia i. S/Sx: Hemarthrosis (MC in knee joint) ii. MC muscle affecting in muscle bleeding is Psoas iii. Pain is felt around the buttocks instead of the front. iv. Types: 1. A – Absence of clotting factor 8, Classic hemophelia 2. B Christmas – absence of clotting factor 9 3. C – absence of clotting factor 11 4. D – absence of clotting factor 12  N T G | 20 CV PHYSIOLOGY i. Heart a. Cone shaped muscle (tortora) Inverted pyramid (snell) b. The heart is innervated by the spinal segments from C3 to T4 c. Relatively small, roughly same size as a closed fist d. The heart rests on the diaphragm, and is located mediastinum (A mass of tissue extending from the sternum to the vertebral column between the two lungs) ii. Orientation of the heart a. 2/3 of the mass of the heart lies left on the bodies midline b. Orientation of the apex of the heart, (Anterior, Inferior, towards the left) c. Orientation of the base of the heart, (Posterior, Superior, towards the right) iii. Pericardium a. A fibrous connective sac that encloses the heart. b. Types: o Fibrous pericardium: Outermost layer
Prevents over stretching the heart
Anchors the heart to the mediastinum. o Serous pericardium: Innermost layer
Serves as a double layer of the heart
2 layers: Visceral SP : AKA Epicardium Parietal SP: outermost layer of the SP iv. Surfaces of the heart : a. Anterior surface: “Sternocostal surface” i. Right atrium and ventricle What forms the most anterior portion of the heart? b. Inferior surface: “Diaphragmatic surface” i. Right and left ventricle c. Posterior surface: “Base surface” i. Left atrium and right atrium What forms the most posterior portion of the heart? v. Chambers of the heart (4) a. Right and left atrium b. Right and left ventricle vi. Heart muscles a. Papillary Muscle – pulls on and tightens the chordate tendinae, preventing the valve cusps from everting. b. Pectinate ms - Anterior surface of the atrium is rough c. Trabeculae Carnea - Cardiac ridges fiber in the ventricles d. Chordae Tendineae – cord like structure, where the cusps of the valves are attached e. Papillary ms – cone shaped structure of trabeculae carnea Where is the trabeculae carnea located? Ventricles  N T G | 21 vii. Valves of the heart a. AV valves (Found between atrium and ventricle) i. Tricuspid (R) ii. Mitral (L) b. SL valves, prevents back flow of blood from the arteries in the inferior heart chambers. i. Aortic (L) ii. Pulmonic (R) Aortic valve is seen on the right or the left? Pulmonary artery comes from what chamber of the heart? ® Ventricle viii. Blood pathway a. Ascending Pathway Ascending Aorta > ® brachiocephalic > ® subclavian and common carotid a. Subclavian a.> vertebral and axillary a. Vertebral a.> Basilar a. > posterior cerebral a. Axillary a. > Brachial a. > radial a. and ulnar a. There is no left brachiocephalic, (L) subclavian and common carotid artery directly arise form aorta. Common carotid a. > internal and external carotid artery External carotid a. > terminates at the TMJ and supplies the superficial structures of the scalp Internal carotid a. > Anterior cerebral artery and Middle cerebral artery b. Descending pathway Descending aorta > Thoracic aorta> Abdominal Aorta > Common iliac a. > external and internal common iliac a. Internal > lumbosacral plexus External> Femoral a. > popliteal a. > Anterior tibial a. ix. Heart Sounds a. S1 – “Lub” Longer Louder Lower in pitch. Closure of AV valves b. S2 – “Dub” Shorter. Closure of SL Valves (Sounds not audible to the ear): c. S3 – Rapid filling of the ventricles (Samsung S3 phones are fast) a. CHF (3 letters C – H – F, S3!), Ventricular Gallop d. S4 – Atrial systole: MI or Hypertension, Atrial Gallop x. Conducting System a. SA node – “Sinus node” Primary pacemaker of the heart i. Below superior vena cava in the ® atrium. What is the other name of the SA node? b. AV node – “Junctional node” i. Between atrium and ventricle What is the MC site of heart block?  N T G | 22 c. AV bundle of His i. Location on the interventricular septum Foramen Ovale opening of the interatrial septum of the fetal heart, closes after birth and becomes the Fossa Ovalis d. Purkinje fibers (Largest pacemaker of the heart.) i. Surrounds the whole ventricles What is the largest pacemaker of the heart? xi. Coronary Arteries What supplies blood to the heart? a. From aorta > ® and (L) coronary artery b. ® coronary artery supplies ® atrium and ventricle, (L) ventricle (minor portion), Interventricular septum, SA node, AV node, Bundle of His 55-60% population, the SA node is supplied by ® C a. c. (L) coronary artery (MC obstructed) (L) atrium, (L) ventricle, ® ventricle (minor portion), Interventricular septum, SA node, Bundle of his 40-45% of population SA node is supplied by (L) C a. What is 1st to be damaged in (L) C a.? (L) coronary a. > LADCA and circumflex d. LADCA > Supplies Anterior, Superior, Lateral surface of the heart e. Circumflex> Supplies Posterior surface of the heart In MI, Muscles of the heart runs out of blood supply, d/t obstruction of coronary arteries. xii. Cardiac Action potential (5) a. Charge of the cell is -88mV latent b. Ions Na+, Ca2+,K+ late repolarization period Phase 0: Phase 1: Initial/ Partial Phase 2: Phase 3: Phase 4: Depolarization Repolarization Plateau Repolarization Resting membrane potential Inward current Decrease of Ca 2+ Inward current of Decrease Na+ influx of Ca2+ Influx Na + Outward current of K+ Return to -88mV Still outward current of K+ On phase 0 of Cardiac Action potential which Ion enters? Ca will always maintain the cardiac action muscle potential xiii. Cardiac Cycle a. Rhythmic pumping action of the heart b. Systole – Ventricular contraction c. Diastole – Ventricular relaxation Cardiac Cycle starts at diastole xiv. Diastole: a. Period of rapid filling of the ventricles i. On the 1st third of diastole 75% of blood from atrium to ventricles passively ii. Middle third of diastole, continuous blood flow iii. Last third of diastole 25% of blood from atrium to ventricles via atrial contraction (Atrial Kick) In this period are the AV valves are open or closed? When is the most amount of blood transferred to the ventricles from atrium in Period of rapid filling?  N T G | 23 xv. Systole: a. Isovolumetric Contraction i. Ventricular contraction will cause the tricuspid valve to close and builds pressure. ii. Both AV and SL valves are closed. What is the only period where both AV and SL valves are closed? b. Ejection Fraction i. Pressure must exceed 8mmHg (Pulmonic artery Po), in the ® ventricle to open Pulmonic valves. ii. Pressure must exceed 80mmHg (Aorta) in the (L) ventricle to open Aortic valves. iii. 1st 70% of blood is given to pulmonary a. and aorta. iv. The last 2/3 of ejection, 30% Ventricles > Aorta & pulmonary a. Pressures which the ventricles must overcome over the aorta/ pulmonary a. is called? Afterload c. Isovolumetric Relaxation i. SL valves will close to prevent backflow. ii. AV valves will open to restart the cycle. xvi. Hemodynamics a. Systolic: highest arterial pressure 120mmHg b. Diastolic: Lowest arterial pressure 80mmHg c. Pulse pressure (PP): Difference between Systolic BP & Diastolic BP (SBP-DBP) 120-80 = 40mmHg d. End Diastolic volume: Amount of blood left in the ventricles after diastole. 120mL What is the amount of blood after ventricular relaxation? e. Preload: Initial stretching of the heart. f. End Systolic Volume: The amount of blood left after systole. 50mL What is the amount of blood after ventricular contraction? g. Mean Arterial Pressure: Arterial pressure with respect to time. DBP + 1/3 PP (80mmHg + 13=93mmHg) h. Stroke Volume (SV): Amount of blood pumped by the ventricles per contraction. 70mL SV = EDV-ESV i. Cardiac output: Amount of blood pumped by the ventricles per minute. Avg. 4-6L CO = SV x HR CO/HR =SV  N T G | 24 xvii. ECG (Terminology: Interval: Longer Segment: Shorter) a. P- wave : Atrial depolarization b. QRS complex: Ventricular depolarization c. Premature Ventricular Contractions(PVC) Skipped heart beat d. T wave: Ventricular repolarization e. Segments/ Interval: f. P-Q Interval/ P-R Interval i. From the beginning of P-wave to beginning of QRS complex. What is the interval between the beginnings of Atrial Depolarization to Ventricular Depolarization? Prolonged P-R interval: 1o heart block g. Q-T Interval i. From the beginning of the QRS complex to the end of the T-wave What is the Interval between the beginnings of Ventricular depolarization to end of Ventricular repolarization? h. P-R segment i. End of the P-wave to the beginning of QRS-complex What is the Segment between the end of Atrial depolarization to the beginning of ventricular depolarization? i. S-T segment i. End of QRS complex to end of T-wave What is the segment between end of ventricular depolarization to the end of ventricular repolarization? Elevated ST segment: Infarction Depressed ST segment: Ischemia Heart rate: Calculate the number of QRS complex in a six second ECG strip multiplied by 10. xviii. Valves Auscultation of valves Location A – 2 ® ICS nd 3rd (L) ICS P – 2 (L) ICS nd 3rd (L) CC M – 5 (L) ICS th 4th (L) CC T – 4 (L) ICS th 4th ® ICS  N T G | 25 xix. Heart Conditions a. S/Sx i. Chest pain or discomfort/ Angina 1. (+) Levine sign 2. Referred pain to Jaw, shoulder, upper trapz, MC on (L) arm, always follows ulnar nerve distribution a. Heart is innervated by spinal segment C3 – T4, somatic areas of these segments will be affected. 3. Types of Angina a. Chronic Stable Angina i. Very predictable, precipitated by exertion. ii. Responds to rest and nitrates ( sublingual, max of 3 tables, c 5 min intervals, effects seen c/in 1 minute) b. Unstable / Crescendo/ Preinfarction/ Progressive Angina i. No response to rest and nitrates. ii. C/I to exercise c. Nocturnal Angina i. Exertion (Dreams) d. Prinzmetal Angina (Angina Inversia/ variant angina) i. MC in women, post-menopausal ii. Vasopasm of coronary artery s occlusion ii. Palpitations 1. “Arrhythmia/ dysrhythmia” 2. Excessive heart beat 3. Benign cause; caffeine, anxiety 4. Severe cause; coronary artery diseases 5. Mitral valve prolapsed iii. Dyspnea (SOB) iv. Fainting “syncope” (Decrease oxygen in the brain.) v. Cyanosis (Bluish Discoloration of lips, toes, nail beds d/t decreased hemoglobin.) vi. Fatigue xx. Laboratory findings: a. Cardiac enzymes i. CK-MB - creatine kinase myocardial bond. Peak 12-24hours ii. SGOT- Serum Glutamic Oxalo-acetic Transminase- peak24-48 hours iii. CPK - Creatinine Phosphokinase – peak 24hours iv. LDH – Lactate Dehydrogenase – peak 3-6 days Which cardiac enzyme will first rise? CKMB True myocardial infarction- S-T segment elevation + all cardiac enzymes elevated.  N T G | 26 xxi. Diagnostic Tools a. Chest X-ray i. Assess the size and shape of the heart b. Myocardial Perfusion imaging i. Thalium/ nuclear stress test, injected at the peak of exercise ii. Thalium 201 – isotopes c. Echocardiogram – use of US to see movement of valves, walls of the heart. d. Cardiac Catherization – inserted in the femoral artery in the inguinal area. i. Dye injected through cinefluoroscopy e. Central line/ Swan-ganz catherter i. Subclavian artery/ jugular vein ii. Determine i. Central venous Po ii. Pulmonary a. Po iii. Pulmonary capillary wedge Po xxii. Medical and Surgical Intervention a. PTCA – Percutaneous Transluminal Coronary Angioplasty – catheter with balloon tip catheter b. IV stents – Prevents recollapse c. CABG – coronary artery bypass graft i. Great Saphenous vein ii. Int. Mammary artery iii. Int. Thoracic artery iv. Radial artery of nondominant UE d. Heart transplant (Given immunosuppressive drugs to prevent rejection of drugs.) i. Heterotopics – New + old heart, (2) hearts ii. Orthotopics - New heart replaces old heart xxiii. Cardiac Conditions: a. Pericarditis (Pericardial friction rub d/t decrease in pericardial fluid.) i. Inflammation of pericardium, Inflammation d/t infection (HIV, sorethroat) ii. Mimics chest pain iii. Aggravating factors 1. Trunk movements aggravate condition especially, Lateral/ side to side movement. 2. Swallowing iv. Relieving factors 1. Kneeling on all fours (Quadruped, Cardiac workload is decreased in this position) 2. Holding breath b. Cardiac Tamponade (Excess pericardial fluid) chronic form of pericarditis i. Not painful. ii. Pt can suffer cardiac arrest d/t too much compression of the heart.  N T G | 27 c. CHF (congestive heart failure/ cardiac decompensation) i. Inability of the ventricles to contract effectively. ii. Types: 1. Right –sided heart failure 2. Left – sided heart failure Right – Sided Heart Failure Left – Sided Heart Failure (Left, Lung, PuLmonary) Backward heart failure Forward heart failure Congestion of peripheries and Pulmonary symptoms. organs S/Sx: (systemic) Cough S/Sx: SOB Bipedal edema Orthopnea/ dyspnea Ascites S3 Gallop Hepatomegaly PND Distended Jugular Veins Fatigue/ Muscle weakness Cyanosis Tachycardia CoR Pulmonale Diaphoresis Venous stasis Decreased urine output Spenomegaly d. Myocardial Infarction i. aka Coronary Occlusion Where is the most frequent location for a myocardial infarction to occur? Left Ventricle ii. Decrease in blood supply > infarction (Cell death of myocardium) iii. True MI has ST segment elevation and all cardiac enzymes elevated iv. S/Sx 1. Chest pain 2. Cyanosis 3. Dyspnea diaphoresis 4. Fatigue e. Heart valve Conditions i. Stenosis/ Narrowing: Inability of the valve to fully open. ii. Insufficiency/ Regurgitation: Inability of the valve to fully close. iii. Prolapse: Cusps of valves bulges d/t decrease in strength of cusp. 1. MC in Mitral Valve (MVP/ Barlow’s / Click Murmur/ Floppy valve Syndrome) 2. Etiology: (L) ventricle > right pressure 6x greater, wall of (L) ventricle > ® ventricle 3x, congenital anomalies. 3. Triad: 1. Palpitation 2. Dyspnea 3. Fatigue  N T G | 28 xxiv. Congenital Anomalies a. Atrial Septal Defect (ASD) i. Defect in interatrial septum ii. Blood passes through Left to Right. iii. Acyanosis b. Ventricular Septal Defect (VSD) i. Defect in interventricular septum. ii. Blood passes through Left to Right. (Pressure differences Right>Left) iii. Acyanosis c. PDA (Patent Ductus Arteriosus) i. Lungs are not developed as a fetus, oxygen is received via placenta from mother. Ductus Arteriosus connects pulmonary artery and descending aorta. ii. Remnant of Ductus Arteriosus is Ligamentum Arteriosus d. Coarctation of Aorta i. Constriction of proximal and distal aorta ii. Narrowing -> turbulent blood flow e. Tetralogy of Fallot (True blue baby) i. Pulmonary Artery Stenosis ii. (Overriding) Aorta – towards the right iii. (R) Ventricular hypertrophy/ aka Cor Pulmonale iv. Interventricular Septal Defect (VSD) xxv. Cardiac Rehabilitation IER Braddom (Old) Braddom (New) Phase I – In patient Phase I Acute Phase I In patient Phase II – Out patient Phase II Convalescent Phase II Transitional Phase III – Community Phase III Training Phase III Out patient Phase IV Maintenance Phase IV Maintenance *Descriptions remain the same, only name changes. IER combines training and maintenance called Community Exercise Program a. Acute/ Inpatient Phase: i. Pt is confined ii. Goal: Prevent deconditioning, family education, and instruction only. iii. Entry level level: 2-3 Mets iv. Discharge level: 3-5 Mets b. Convalescent/ Outpatient phase i. Period of recovery is 6 weeks ii. Goal: Promote strong scar formation iii. Entry level: 5 mets iv. Discharge level: 9 mets (ascending stairs, playing competitive basketball) c. Training phase i. Most difficult/vigorous phase with use of treadmill d. Maintenance phase i. Most important phase ii. Lifelong routine  N T G | 29 xxvi. Exercises intensity: target heart rate a. Karvonen’s Formula THR = (MHR – RHR) 60 – 80% + RHR MHR = 220 - age xxvii. Criteria for terminating an exercise program: a. Unstable Angina b. Resting BP 200/100mmHg c. Acute systemic illness/ Fever d. 2nd-3rd degree heart block e. Recent Embolism f. Uncontrolled Arrhythmias/ Dysrhythmias/ Palpitations g. Uncontrolled Diabetes Mellitus h. ST segment displacement > or = to 2mm i. Increase diastolic BP j. Active Pericarditis xxviii. Type’s of Heart Block: a. 1o heart block – Prolonged PR Interval b. 2o heart block – Progressive lengthening of PR Interval c. 3o heart block – Complete heart block, no more impulses arriving at bundle of His and Purkinje Fibers  N T G | 30 PULMO PHSYSIOLOGY i. Pulmonary system a. Function i. Ventilation – act of moving air in and out of the lungs ii. Perfusion – pulmonary blood flow iii. Respiration – Transfer of gases between body cells and the environment. 1. Internal respiration – between capillaries and tissues 2. External respiration – between capillaries and alveoli ii. Upper respiratory tract a. Nose i. Largest mucosal surface area ii. Vibrissae- for filtration iii. (3) Cartilages of the nose SALN (ose) 1. Septal 2. Alar 3. Lateral b. Pharynx – Common area for respiratory and GI system. i. aka Throat, passage way for food and air. ii. 3 parts: 1. Nasopharynx – filters and warms the air\ 2. Oropharynx – Conduits for air 3. Laryngopharynx – conduits for air. c. Larynx i. Aka voicebox ii. For sound production iii. Ensures air passes through trachea iv. 9 cartilages 1. Unpaired (U Try Epic Crying) a. Thyroid b. Epiglottis c. Cricoid 2. Paired (Pare, Aren’t Corns Cute?) a. Arytenoid b. Corniculate c. Cuneiform iii. Lower Respiratory Tract (Tracheobronchial tree, 23 generations. How many generations is coughing effective? 7 generations  N T G | 31 a. Trachea i. aka windpipe ii. tubular structure iii. 16-20 cartilaginous half ring (Ant) 1. T4-T5 angle of Louis/ carina (level of bifurcation) 2. T2 suprasternal notch 3. Last tracheal ring is the Carina Tracheostomy: common site of intubation 2nd-3rd ring , If emergency in the larynx, cricothyroid membrane. b. Trachea to terminal bronchioles (Conduction zone) c. Respiratory bronchioles to capillaries (Respiratory zone) What is the functional unit of the pulmonary system? Acinus iv. Primary Bronchi/ Mainstem bronchi (2) a. Left and right MC site of aspiration of large objects? ® Wide, Short, more Vertical v. Secondary Bronchi/ Lobar Bronchi (5) a. MC site of small aspirated objects b. (2) Left: superior and inferior c. (3) Right: Superior, Middle and Inferior vi. Tertiary Bronchi/ Segmental Bronchi (18) a. (10) Right b. (8) Left vii. Terminal bronchioles (aka) transition zone viii. Respiratory Bronchioles ix. Alveoli (300m each lung) x. Lungs a. Fissures i. Right lung 1. Horizontal 2. Oblique ii. Left lung: Oblique only b. Coverings i. Visceral Pleura(covers the lungs) 1. Stretch sensitive ii. Parietal Pleura(covers the inner ribs) 1. Pain sensitive  N T G | 32 c. Lobes & Segments: Lobe Right (10) Left (8) Upper Apical Apical-Posterior Anterior Anterior Posterior Linguila Sup & Inf Middle Lateral None Medial Lower Superior Superior Anterior basal Anterior basal Posterior basal Posterior basal Lateral basal Lateral basal Medial basal Medial basal xi. Innervation/ Blood supply a. Innervation i. Pulmonary plexus 1. Sympathetic nerves a. Thoracic-Lumbar 2. Vagus nerve b. Blood supply i. Bronchial artery supply: 1. Plurae 2. Airway 3. Connective tissue a. Elastin + Collagen (Elasticity of lungs (compliance)) ii. Pulmonary Artery supplies alveoli xii. Muscles for respiration a. Relaxed inspiration i. Diaphragm (dome shaped) 1. Piston action 2. Inhalation, it moves downward and outward 3. Exhalation, it move upward and inward ii. External Intercostals 1. Fiber runs downward and outward What is the origin of the external intercostals? Lower surface of the rib above b. Forced inspiration (SUPAS) i. SCM ii. Upper trapezius iii. Pectoralis major and minor iv. Anterior, Middle, Posterior Scalenes v. Serratus Anterior and Posterior-Superior c. Relaxed expiration i. There are no muscles involed in relaxed expiration ii. Elastic recoil of the lungs  N T G | 33 d. Forced expiration (e.g. coughing) ASI i. Abdominals ii. Serratus Posterior-Inferior iii. Internal intercostals ( fiber runs downward and inward) xiii. Mechanism to increase thoracic diameter Normal AP:Lateral ratio: 1:2 a. Piston action by the diaphragm i. Descent of the central trendon of the diaphragm , increase in vertical dimension b. Pump handle mechanism i. Increase AP diameter of the chest ii. Sternum, acts on 1st-6th ribs Simultaneous motions c. Bucket- Handle mechanism i. Increase in lateral diameter of the chest ii. Ribs (ribs 7-10) iii. Upward d. Caliper motion i. False ribs (8-12) ii. Flare out to the side) xiv. Mechanics of breathing a. Compliance = elasticity of airways and lung tissue i. Ability of a structure to expand b. Boyle’s Law i. Pressure is inversely proportional to the volume 1. Increase pressure, decrease volume (Expiration) 2. Decrease pressure, increase volume (Inspiration) xv. Control of respiration a. Automatic control i. Brainstem (Pons and medulla) 1. Medulla Sets the inherent rhymicity of breathing (Automatic Respiratory Center) a. If the medulla acts alone, the breathing is weak and irregular 2. Pons sets the rhythm and rate of breathing a. If the pons acts alone, breathing is stronger, regular, and more effective b. DRG (Dorsal respiratory group) i. Dorsal Medulla (Nucleus Solitarius) ii. For inspiration c. VRG (Ventral Respiratory group) i. Ventro-lateral medulla ( Nucleus ambiguous, Retroambiguus) ii. For expiration iii. Mnemonic: VEX d. Inspiratory ramp signal: on:off ratio 2:3  N T G | 34 e. Pons: (Pneumotaxic center) i. Location: upper pons (nucleus propius) ii. Function: “switching off of inspiratory ramp signal” f. Apneustic center i. Lower pons ii. Function: prevents switching off of the inspiratory ramp. mnemonic: PULA g. Chemoreceptors i. Central chemoreceptor (Ventral medulla) 1. Stimulus: increase in H+ ions ii. Peripheral chemoreceptor 1. Carotid- aortic bodies 2. Stimulus: decrease in order of a. O2 b. PaCO2 c. Acidosis iii. Response to either is increase in Ventilation iv. pH is direction proportional to CO2 but inversely proportional to HCO3 xvi. Lung volumes and Capacities VC(4500mL) IC (3500mL) IRV(3000mL) IRV+ERV+TV TLC (6000mL) IRV + TV OR TV (500mL) IRV+ERV+TV+RV IC+ERV FRC (2500mL) ERV (1000mL) RV (1500mL) ERV+RV RV (1500mL) a. Primary lung volumes i. Tidal Volume 1. Amount of air that goes in and out of the lunger (at rest) ii. Inspiratory reserve volume 1. Amount of air that is inhaled after normal inspiration iii. Expiratory reserve volume 1. Amount of air that is exhaled after normal expiration iv. Residual volume 1. Amount of air that is left in the lungs after a maximum expiration b. Capacities i. Functional residual volume 1. Amount of air that is left in the lungs after a normal expiration ii. Inspiratory capacity 1. Amount of air that is max inhaled after normal expiration iii. Total lung capacity 1. Maximum amount of air that the lungs can hold. Amount of air in the lungs after a maximum inspiration c. Dead space i. Normal volume of dead air space: 150mL  N T G | 35 Pulmonary Assessment xvii. Breathing Patterns Type Rate Depth Rhythm Eupnea (n) (n) Regular Bradypnea Slow (n)/ shallow Regular Tachypnea Fast Shallow Regular Hyperpnea (n) Deep Regular Hyperventilation Fast deep Regular Dyspnea Rapid Shallow Regular Cheyne-stokes Slow ↑ + ↓ + Apnea Regular Biot’s Slow Shallow + Apnea Irregular Hyperventilation is associated with Metabolic Acidosis xviii. 1st part of assessment a. History of patient and family b. Chest examination xix. 2nd part of assessment a. ABG Analysis b. PFT c. X-ray d. Graded exam technique xx. Common chest deformities a. Barrel chest AP:L 2:2 – associated with emphysema b. Pectus Carinatum c. Pectus Excavatum xxi. Chest Mobility/ Chest expansion tests Note for any asymmetry when the patient breathes in and out a. Upper lobes i. Thumbs at the sterna notch, fingers placed above the clavicle b. Middle lobes i. Thumbs at the xiphoid process, fingers placed on the lateral ribs c. Lower lobes i. Thumbs at the lower thoracic spine (back), fingers placed on the lateral ribs. xxii. Auscultation sites  N T G | 36 xxiii. Breath Sounds a. Normal i. Vesicular – soft pitch sound ii. Bronchial – hollow, loud, tubular, high pitched iii. Broncho-Vesicular – Softer than bronchial b. Adventitous i. Crackles/ Rales – fine discontinued sounds 1. Ex. Popping. Fizzing soda, hair rubbing ii. Wheezes – continuous high or low pitch sounds 1. Associated with asthma iii. Stridor – snoring c. Significance for auscultation (n) breath sounds (n) air filled lungs Decrease Hyperflation Increase Hypoinflation/ atelectasis Crackles Presence of secretions Wheezes Constricted bronchi Balloon rubbing Pleuritis/ pleurisy xxiv. Voice transmission a. Egophony i. “EEE” (N) ii. Consolidation/ pneumonia/ pleural effusion “AAA” – ab(n) b. Bronchophony i. “99” ii. Ab(n) – louder”99” c. Petriloquy (whispered) “1 , 2 , 3” Palpation xxv. Fremitus a. (n) vibration – (n) air filled b. Increased vibration = secretions c. Decreased vibration = hyperinflation xxvi. Percussion a. (n)resonant b. Dull/ hyporesonant– increased secretions or atelectasis hyperinflation c. Hyper resonant – increase air, emphysema  N T G | 37 xxvii. ABG findings Condition Mnemonics S/Sx Condition Respiratory DENTS Dizziness, Early tetany, Numbness, Associated with Alkalosis Tingling, Syncope hypervent HARDy Early – Headache, Anxiety, Respiratory DiSC Restlessness, Dyspnea Associated with acidosis Late – Disorientation (confusion) hypoventilation Somnolence, Coma Metabolic We Men ↑ Weakness, Mental dullness,↑ DTRs, MC with vomiting Alkalosis Ms Ms twitching Metabolic NaLoCo Nausea, Lethargy, Coma MC with diarrhea, assoc acidosis, with Kussmaul’s xxviii. Coughing ability a. Purpose of double cough (only good up to 7 generations!) i. 1st cough – to remove secretions ii. 2nd cough – to clear the air b. Tracheal tickle – for those unresponsive i. Used to elicit reflex cough ii. Circular rub on trachea How much secretions are produced in a day? 100mL/day xxix. Sputum color Color Findings Red/ scarlet Blood Rust Pneumonia Yellow Infection Green Pus Frothy Pink Pulmo edema Purple Neoplasm, CA Flecked Carbon Particles Clear (n) xxx. Other PE findings Empthysema Chronic bronchitis Chest shape Barrel chested (n) Use of accessory ms Clubbing of finger Appearance >tachypnea Peripheral edema Cor Pulmonale None, except at the late stages Prominent  N T G | 38 xxxi. Asthma a. Hypersensitivity to bronchial secretions due to various stimuli, resulting to wide spread bronchoconstriction b. 50% < 10y/o M:F 2:1, >30y/o M:F 1:1 c. S/Sx i. Triad 1. Wheezes 2. Cough 3. Dyspnea ii. Tachypneam use of accessory muscles iii. (+) barrel chested Kurschmann’s spirals – thick stringy mucus d. Trigger Factors i. Extrinsic Factors 1. Allergens (dust, polles 2. Food (chocolate, nuts, seafoods etc) 3. Animal fur 4. Drugs (Aspirin) 5. Changes in climate 6. Pollution ii. Intrinsic Factors 1. URT infection emotions 2. Psychological stress 3. Exercise iii. Status asthmaticus – most serious type of asthma xxxii. COPD vs CRPD a. V/Q ratio i. COPD: 0.8 1. Due to alteration of a. Lung parenchyma b. Chestwall c. Neuromuscular apparatus In a child with >0.8 V/Q ration is this normal? Yes xxxiii. Emphysma & Chronic Bronchitis Emphysema Chronic bronchitis Dysfuntion of air spaces distol to terminal bronchioles 3 mos productive cough for 2 consecutive Destruction of alveolar speta years d/t smoking d/t pollution, occupation increase proteolytic enzyme heavy smoker > 40 cigarettes a day alpha 1 antitrypsin (destroyed by smoking) inhibits proteolytic production of sputum 100mL/ day enzyme age bracket: >50 y/o +/- age bracket: >60 years old Aka Blue Boater aka pink puffer  N T G | 39 xxxiv. Continued emphysema vs chronic bronchitis Emphysema Chronic bronchitis Dyspnea Severe, hallmark Mild Less prominent More prominent Cough After dyspnea Before dyspnea, hallmark Sputum Scanty, mucoid Copious, purulent Bronchial infection Less frequent More frequent Body built Aesthenic, weight loss Overweight Increase broncho vesicular markings, Hyperinflated lungs, “Dirty lungs” x-ray flat diaphragm, (n) lung size small heart ® ventricular hypertrophy (cardiomegaly) xxxv. Bronchiectasis a. MC affected areas are the terminal bronchioles b. Ab(b) permanent dilatation of bronchi. Bronchioles c. S/Sx i. Hemoptysis, hallmark ii. Fever iii. Productive cough iv. Recurrent infection v. Dyspnea xxxvi. Cystic Fibrosis a. Widespread abnormalities of exocrine glands b. Triad i. Mucus glands ii. Exocrine cells of pancreas iii. Sweat glands c. S/Sx i. Productive cough ii. Bronchial infection iii. Weight loss d/t malabsorption iv. Salty sweat, increase in NaCL content (sweat test) d. X-ray: honeycomb lungs xxxvii. CRPD a. Interstitial pulmonary fibrosis aka Hammans-rich dse i. Idiopathic ii. Associated with smoking iii. Genetic predisposition iv. Collagen disease v. Hallmark: progressive dyspnea vi. Death after 5-6 years old  N T G | 40 b. Pneumonia (intraalveolar infection) i. MC to streptococcal virus ii. 3 types 1. Bacterial 2. Viral 3. Aspiration iii. S/Sx: 1. Fever and chills 2. Productive cough 3. Dyspnea iv. Common pneumonia HS 1. H. Influenza 2. S. Pneumoniae v. Hospital acquired 1. Heregenosa 2. Pseudomonas c. PTB d/t mycobacterium TB i. 2-10 week, incubation ii. 1st 2 weeks most infectious period iii. Keep Pt in negative pressure room iv. Hallmark: hemoptysis v. S/Sx: 1. Dyspnea 2. Fever 3. Enlargement of lymph nodes vi. TB in children is called primary complex d. Atelectasis i. 2 types 1. Primary Atelectasis a. Compressive atelectasis, e.g. pleural effusion 2. Secondary Atelectasis a. Obstructive atelectasis e. Pleuritis/ Pleural effustion i. Inflammation of pleura ii. Excess accumulation of pleural fluid iii. s/Sx 1. pleural rub 2. dyspnea 3. sudden acute pain  N T G | 41 f. Pulmonary Edema i. Findings of water entering the alveoli ii. d/t unequal capillary pressure iii. associated with (L) sided CHF iv. Hx of MI, mitral valve prolapsed/ stenosis v. S/Sx: 1. Pink/ forthy spututm (not productive) 2. (+) crackles 3. Dyspnea 4. Non productive cough 5. Sharp/ dull chest pain g. Pulmonary embolism i. Lodging of large or small particles in the venous pulmonary circulation 1. MC cause DVT a. C – lotting disorder b. O – ral contraceptives c. V – enous stasisi d. A – ir embolism 2. S/Sx a. Dyspnea b. Cough c. Sudden acute pain d. Doorstop breathing (same c pulmonary edema) e. FATAL h. Pneumothorax i. Gas/ air in the intrapleural space ii. Failure to cover a chest tube iii. Trauma iv. Treatment: P-tube inserted at 2nd-3d ICS, if air. If effusion 8th-9th ICS. v. S/Sx 1. Dyspnea, cough, sudden chest pain i. SARS (Severe Acute Respiratory Syndrome) i. CORONO virus, transmitted within 10 days ii. S/Sx 1. Lethargy, Sore throat, Dry cough, Dyspnea j. Bronchogenic Carcinoma i. Aka. Lung cancer 1. 3 types a. Oat cells b. Small cells c. Squamous cells 2. S/Sx: cough 3. Dyspnea 4. Hoarseness  N T G | 42 xxxviii. Postural drainage a. Rationale: to precent accumulation of secreations, and to remove secretions that have already been accumulated b. Duration: 20 – 30 – 45 minutes i. Never exceed >45 minutes c. Trendel3enburg posion (head down position) reverse trendelenburg (position head up) d. C/i: recent head injuy/ surgery, this treatment will cause increase in ICP e. Types of manula percussion used in PD, only perform 3-5 mins i. Vibration ii. Percussion (MC) iii. Shaking f. Postural drainage i. Initial position 5-10 minutes ii. Percussion 3-5 mines iii. Position: 5 mins, post iv. If there is productive cough perform up to 4x a day Segment Position Percussion Upper Lobes Anterior apical Sitting, leaning backward Below clavicle Posterior apical Sitting, leaning forward Above scapula Supine, flat Over nipple area (male) Anterior Above the breast (female) ¼ turn from prone on ®/(L) side, Scapula Posterior reverse T-position Middle Lobes ¼ turn from supine, T –posn 15-30o Bellow nipple Middle lobe + linguila or 12-16” of pillow Lower Lobes Anterior Supine T posn (30-45o) Anterior lower ribs Posterior Prone T posn (30-45 ) o Posterior lowr ribs Lateral SL T posn (30-45o) Lateral lower ribs Superior Prone bed flat Below inferior angle Posterior basal segment Prone bed flat Near lower thoracic spine  N T G | 43 GIT PHYSIOLOGY i. Organs of the digestive system Alimentary tract Accessory organs Mouth Teeth Pharynx Tongue Esophagus Salivary glands Stomach Liver Intestines Pancreas ii. Layers of the alimentary tract: a. Mucosa- Innermost layer, absorption b. Submucosa – Meissner’s/ Submucosal plexus c. Muscularis- Myenteric/ Auerbach’s plexus d. Serosa - Outermost layer iii. Enteric System- (Neural Control) Composed of 2 plexuses: a. Myenteric/ Auerbach’s Plexus –Found in the Muscularis layer i. Controls movement in the GIT ii. Excitatory : Promotes contraction of the intestinal wall iii. Inhibitory : Sphincters b. Meissner’s/ Submucosal layer i. Gastrointestinal secretions iv. Hormones in GI motility : a. Cholecystokinin i. Increased contractility of bile ii. Inhibits stomach motility b. Secretin i. Inhibitory effect in GI mobility c. Gastric Inhibitory peptide i. Decrease motor activity in the stomach (Still inhibitory, 2nd definition) v. 2 types of movement in GI tract: a. Peristalsis – Propulsion forward. b. Mixing movement – (Segmental) Does not require a strong contraction, utilizes small contraction to increase mixing. vi. GI blood supply: a. Sphlanchnic Circulation (Goes through hepatic circulation before the systemic circulation) i. Gut, spleen, and pancreas then liver. ii. Liver sinusoids  N T G | 44 vii. Ingestion of food What are the two stages in the ingestion of food? a. Mastication (chewing) i. Teeth (anterior – cutting, posterior – grinding) ii. Muscles (TIME) MCLO Medial: Closing Lateral: Opening, (Innervated by CN V) iii. Chewing reflex – Once food enters the mouth, it will cause relaxation of the ms of mastication, and as the jaw drops the stretch reflex is created closing the mouth. b. Swallowing (Deglutition) i. Voluntary stage 1. “Voluntarily” squeezes or rolls the bolus posteriorly towards the pharynx by pressure of the tongue. ii. Pharyngeal stage 1. Stimulates the swallowing receptor area. 2. Trachea is closed, the esophagus is opened and fast peristaltic wave from the pharynx forces the bolus towards the upper esophagus (Less than 2 seconds) iii. Esophageal stage 1. Primary peristalsis a. Continuation of the peristaltic wave that begins in the pharynx 2. Secondary Peristalsis a. Results from distention of the esophagus by retained food b. *Gastroesophageal sphincter (Achalasia, if this sphincter has problems with relaxing) viii. Digestion in the mouth: a. Chemical digestion by saliva i. Serous secretion for digestion of starches: Amylase (Star Amy) ii. Mucous secretion for lubrication ix. Digestion in the esophagus a. No actual digestion b. Propulsion via peristalsis c. Mucous secretion for lubrication x. Motor function of the stomach : a. Storage for large quantities of food Where are the foods stored in the stomach? The Fundus b. Mixing of food with gastric secretions (Bolus will turn into Chyme) c. Slow emptying of food d. *Body and antrum, Anatomical Terms e. *orad and caudad, Physiological Terms xi. Storage function: a. Vagovagal reflex (Occurs when food is stored in the stomach) i. Reduce the tone of the muscular wall (Food storage capacity ~1.5 liters) xii. Mixing and propulsion in the stomach: a. Gastric glands b. Peristaltic constrictor waves/ mixing waves c. Pyloric muscle can also contract d. Chyme e. Hunger contraction (Hunger pangs, occurs if no food is ingested within 12-24 hours (Guyton))  N T G | 45 xiii. Digestion in the Stomach a. Food is stored in the fundus b. LES prevent reflex of stomach contents c. Mechanical digestion via segmental contraction d. No absorption e. Chemical digestion by Oxyntic cell secretion Cell Secretion Function Mucous neck cells Mucus Lubrication and protection +HCl to produce a proteolytic enzyme Peptic chief cells Pepsinogen Pepsin for protein digestion HCl Parietal cells Intrinsic factor B12 absorption *Pernicious anemia (-) IF xiv. Emptying of the stomach a. Intense antral(below) peristaltic contraction – aka the Pyloric pump b. Gastrin c. Duodenal factors (What are the factors that will inhibit emptying of the stomach?) i. Too much chyme ii. The chyme is excessively acidic xv. Small intestine a. Where the greatest amount of digestion and absorption take place. xvi. Movement of Small intestine a. Mixing contraction (Segmentation) (Simultaneous contraction) b. Peristalsis (Successive contraction) c. Propulsive movement i. Gastroenteric reflex ii. Gastrin, Insulin, Serotonin iii. Secretin and glucagon iv. Segmentation movement v. *iliocecal valve (iliocecal sphincter) will relax to propulse chyme towards large intestine xvii. Digestion and absorption in the Small Intestine a. Dominating chemical digestion via i. Pancreatic secretions ii. Biliary secretions iii. Intestinal secretions Secretion Function Mucus Lubrication and protection Peptidase Split Peptides into individual Amino Acids (PAA) Maltase Split Maltose > Glucose + Glucose Lactase Split Lactose > Glucose + Galactose Sucrase Split Sucrose > Glucose + Fructose Lipase Split Fats into > Glycerol + Free fatty  N T G | 46 xviii. Absorption via transport processes: a. Water: diffusion through tight junction b. Carbohydrates: Na-Glucose cotransport; Fructose via facilitated diffusion c. Lipids: diffusion with bile salts d. Proteins: Na-Glucose co-transport or endocytosis e. Na: diffusion down a electrical gradient f. Cl: diffusion via solvent drag g. HCO3- indirectly by secretion of H+ xix. Biliary Secretions by the liver and gall bladder a. For fat digestion and absorption b. Emulsify large particles for more efficient