PCM 3 Final Exam With Complete Solutions.

left medial cerebral a. distribution 1. frontal lobe: - impulse control, attention - organizing, planning mvmt (apraxis) 2. anterior (pre) central gyrus - motor control (hemiplegia) 3. posterior (post) central gyrus - sensory reception 4. parietal lobe - orientation in space - lateropulsion (pushers) - limb position during mvmt (apraxia) 5. temporal lobe - sound perception, LTM 6. basal ganglia (deep brain) - motor planning - controls and regulates mvmt (apraxia) 7. Broca's area (left hemisphere) - expressive language (expressive aphasia) 8. Wernicke's area (left hemisphere) - receptive language (receptive aphasia) posterior parietal lobe 1. orientation in space: - lateropulsion (pushers) - impaired vertically 2. motor planning - impaired limb positioning during mvmt - apraxia left hemisphere damage - almost always has speech and swallowing impairments 1. aphasia: - mostly right handers - about 50% of left handers - expressive - receptive 2. dysarthria 3. apraxia 4. dysphagia renal system and kidney function 1. kidneys serve as: - endocrine organ - target of endocrine action - to control mineral and water balance 2. functions: - filter waster products - remove excess fluid chronic kidney disease (CKD) - alteration of kidney function 3 mths - common causes: 1. diabetes 2. HTN 3. glomerulonephritis end stage renal disease (ESRD) - final stage of CKD - loss of kidney function - requiring dialysis or kidney transplant uremia - cluster of sx - kidneys unable to: 1. excrete toxins 2. maintain fluid, pH, electrolyte balances 3. secrete important hormones (renin, vit D, erythorpoietin) uremia characteristics - n/v - anorexia - lethargy - pruritus (itching) - sensory and motor neuropathy - asterixis asterixis - characteristic of uremia - intermittent ability to sustain a posture - flapping like motion when lifts hand pathogenesis of kidney failure - reduced glomerular filtration rate (GTR): 1. 15 mL/min (normal= 90 mL/min) 2. damaged and decreased kidney surface area - increased phosphate levels - decreased calcium levels 1. increased PTH secretion 2. increased calcium resorption from bone 3. osteomalacia (demineralization of bone) cardivascular manifestations of kidney failure - coronary artery disease - HTN - CHF - pulmonary edema - dyspnea - pericarditis leading cause of death in ESRD - chest pain - nausea - shortness of breath - sweating MSK manifestations of kidney failure 1. renal osteodystrophy - renal rickets - osteomalacia - osteitis fibrosis 2. bone pain - spine and LE jts - worse /c exercise and WB activities 3. fx's - spine and long bones CNS manifestations of kidney failure - sleep disturbances - recent memory loss - poor concentration - confusion - sx improve /c dialysis PNS manifestations of kidney failure - death of sensory and motor axons - neuropathy 1. symmetrical 2. stocking glove distribution - sx improve /c dialysis stroke body structure/function impairments - ROM - hemiplegia / MMT - sensation - pain - spasticity - balance kidney failure body structure/ function impairments - sensory neuropathy - motor neuropathy - pain - SOB - decreased functional capacity (60-70% of normal) - HR unreliable as indicator of exertion stroke activity limitation - bed mobility - transfers - gait / locomotion - endurance - functional status - ADLs - task analysis kidney failure activity limitations - endurance - functional status transitional mobility (TM) - category of motor control - move from one posture to another - BOS and/or COM are changing static postural control (SP) - category of motor control - postural ability to hold (co-contract) - maintain postural stability - body not in motion - BOS is fixed dynamic postural control (DP) - category of motor control - mvmt within postures - weight shifting - unloading - BOS is fixed skill - category of motor control - coordinated sequencing of UE and LE mvmt for functional activity - locomotion (rolling, scooting, crawling, walking) - COM and BOS are changing positive effects of aerobic exercise on the brain 1. increased neuroplasticity - increases neurotrophic growth factors 2. increased cardiorespiratory fitness - decreases inflammation - increases cerebral blood flow 3. improved brain health - increased cognition, learning, memory - increased mood, arousal - decreases neurodegeneration cardiovascular guidelines to stroke pt - 20-60 mins per session - or multiples of 10 min bouts - 40-70% of HRR - 3-5x /wk ESRD exercise considerations 1. compromised autonomic function - limits max age predicted HR by 20-40 bpm - RPE is better tool for monitoring exercise tolerance 2. exercise is associated /c improved - autonomic cardiac function - functional abilities - endurance - QOL: most important predictor is usual level of exercise activity ESRD exercise guidelines - 4-6x/wk - low to mod intensity - 1st 2 hrs of dialysis need to check /c medical team - and day after dialysis - avoid exercise day before dialysis - monitor: 1. subjective sx 2. RPE 3. BP taken in arm opposite arteriovenus (AV) shunt 4. HR (don't rely on for monitoring intensity) ESRD strengthening exercises - seated, semi-recumbent, or supine - OKC or CKC hip and knee exercises - /c or /s resistance at submax intensity - 2-3 sets of 8-15 ESRD aerobic exercise - cycle ergometer or weighted stepper - intensity determined by: 1. RPE 2. target HR range 3. subjective sx - 5-30 minutes - intermittently or continuous based on individual's tolerance chronic kidney disease (CKD) - strong and independent risk factor for CVD traditional cardiovascular risk factors leading to CKD - HTN - advanced age - diabetes - dyslipidemia nontraditional cardiovascular risk factors that are CKD specific - anemia - volume overload - metabolism - proteinuria - malnutrition - oxidative stress - inflammation hemodynamic factors of HF and CKD - left ventricular hypertrophy (LVH): adaptive remodeling process of left ventricle - compensates for increased cardiac work: 1. pressure overload (HTN) 2. volume overload 3. both are common in pt /c CKD - high blood flow arteriovenous fistula HF syndrome - results from structural or functional cardiac disorder - impaired ability of heart to function as pump - result of either systolic or diastolic dysfunction right sided HF 1. failure of right ventricle - adequately pump blood to lungs - results in peripheral edema 2. dependent edema - early sign of right ventricular failure - baroreceptors sense decreased blood volume - relay message to kidneys to retain fluid dependent edema 1. retained fluid - accumulates in extracellular spaces of periphery 2. resultant edema - symmetrical - occurs in dependent parts of body - begins in feet and ankles - accends up lower legs - worse at end of day - improved after night's rest activity and exercise in CHF - activity restriction is no longer appropriate - exercise programs achieve results quantitatively similar to effective drug therapies - modified to pt tolerance - recommendations: 1. light resistance training 2. short or long bouts of aerobic exercise beneficial effects of exercise in CHF - increased muscle strength - increased exercise and functional capabilities - decrease sx (dependent edema) - decreased risk for future cardiac event - increased health and psychosocial status guidelines for CVD in dialysis pt's 1. lifestyle modifications - smoking, physical activity, depression, and anxiety 2. tx options - similar to general population - impact potentially more profound in dialysis pt's 3. exercise: - modify to match dialysis schedule - may be poorly tolerated immediately before or after dialysis 4. recommendations - increase PA level - referral to PT or cardiac rehab to increase strength and endurance MLD (manual lymphatic drainage) - cardiac related edema that overwhelms the lymphatic system - clearance: proximal to distal first 1. stimulates lymphangions 2. clears lymph to receive more - treatment: distal to proximal 1. moves interstitial fluid toward lymphangions 2. stimulates lymphangions and lymph motoricity 3. lymph system accepts and drains more fluid compression therapy - use of compression socks - 30-40 mm Hg - below the knee / if edema in lower leg only - worn during most of day and night - may need assistive device to don - worn during: 1. MLD 2. exercise promoting drainage of edema /c exercise - performed in sitting or semi-recumbent, not supine - legs not elevated above heart level / due to HF - begin /c diaphragmatic breathing / clearance of abdominal area - distal to proximal AROM of all LE jts / toes to hips chronic stroke & kidney disease pt tests & measures -edema measurement -RPE -BBS -STREAM (Stroke rehab assessment of mvmt) -TUG heart failure (HF) - is a syndrome - characterized by impaired cardiac pump function - inadequate systemic perfusion - inability to meet body's metabolic demands important facts about HF - 5 million Americans affected - 8 million by 2030 - 10% of pop. 75+ - 50% mortality in about 5 years - 50% readmitted within 6 months and 67% readmitted within one year risk factors of HF - HTN - CAD - cardiomyopathy - valvular disease - DM - aging - hypercholesterolemia - hyperthyroidism HF syndrome - inability of the weakened heart to maintain cardiac output - impaired cardiac pump function - blood backs up into venous and pulmonary circulation - congestion of blood into body tissues and in lungs resulting in congestive HR - high pressure in the pulmonary capillaries results in pulmonary HTN types of HF - left sided / right sided - biventricular - systolic / diastolic - acute HF: life threatening and aggressive medical mgmt - chronic HF: develops gradually over time left sided HF - reduced cardiac output - blood backs up into left atrium and lungs - SOB - cough right sided HF - raised pulmonary artery (PA) pressure - backs up into right atrium and venous vasculature - raised jugular venous distention - peripheral edema biventricular HF - LV pathology backs into lungs increasing PA pressure - fluid backs up into right side of the heart - backs up into the systemic venous vasculature systolic HF - weakness in contraction of the ventricles - reduces SV, CO, EF - HF /s reduced Ejection Fraction (HFrEF) diastolic HF - left ventricle is stiff and unable to relax - reduced SV, CO - EF is unaltered - HF /c preserved Ejection Fraction (HFpEF) pathophysiology of HF - damage to the heart muscle reduces cardiac output (CO) - reduction in CO triggers the renin angiotension aldosterone system (RAAS) - facilitates sodium and water retention in the renal tubules - increase in blood volume - cardiac tissue undergoes remodeling (cardiac muscles hypertrophy) to adapt to fluid overload New York Heart Association (NYHA) functional classification - Class I: cardiac disease /s limitation in physical activity - Class II: cardiac disease resulting in slight limitation of PA, comfortable at rest - Class III: cardiac disease /c marked limitation of PA - Class IV: cardiac disease affecting the pt's ability to carry out any PA /s discomfort HF clinical manifestations - dyspnea: worse when lying down or /c increased activity and PND - fatigue: heart muscle cannot adequately pump blood and O2 - cough: caused by backing up of fluid into the lungs - ejection fraction (55-70%): systolic decreased and diastolic normal diagnostic tools of HF 1. ECG - hx of ischemic disease - abnormal if EF is reduced 2. chest x-rays - cardiomegaly - opacities from pulmonary edema - blunting of costophernic angle 3. echocardiography: - wall thickness - chamber size - LV function 4. lab findings: - elevated brain nutriuretic peptide (BNP) - normal levels are less than 100 pg/mL - above 400 indicative of HF non pharmacological mgmt of HF - O2 therapy - heart healthy diet / Mediterranean diet - exercise - surgical: 1. LVAD 2. heart transplantation 3. implantable cardio-inverter defibrillator (ICD) 4. pacemaker pharmacological mgmt of HF - alpha and beta blockers - ACE inhibitors - angiotensin receptor blockers - vasodilators - positive inotropes (digoxin) - mineralocorticoid receptor antagonists - diuretics chronic obstructive pulmonary disease (COPD) - chronic airway inflammation and remodeling - characterized by: 1. airway narrowing 2. parenchymal destruction - pulmonary vascular thickening important facts about COPD - 4th leading cause of death and morbidity in US - global initiative for Chronic Obstructive Lung Disease (GOLD) - as per GOLD / COPD is preventable and treatable risk factors for COPD - cigs / 2nd hand smoke - organic and inorganic dusts - inhaling / toxins - pollutants: both indoor and outdoor - genetic: alpha 1 antitrypsin deficiency and lack of surfactant - host factors (make person more susceptible to COPD) - hyperactivity of airways - overall lung growth