Questions about common comorbid conditions??

Questions about common comorbid conditions?? (Full Version)

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Dr.Wagner -> Questions about common comorbid conditions?? (December 17, 2005 3:52:00 AM)
Comorbid disease states are common in the diverse practice of Physical Therapy. Often times, there are multple states of disease. Are there any questions regarding the overall prognosis, common diseases, treatments, and emergency situations of which to be aware?

jma -> Re: Questions about common comorbid conditions?? (December 17, 2005 4:39:00 AM)
I'm curious to know about dialysis treatments and PT treatments. A patient can be getting treatment, gets dialysis and is completely wiped out until the next day. Then it feels like day one again starting over. What is the overall prognosis for this particular population, especially if kidney transplants are not feasible?

Synergy -> Re: Questions about common comorbid conditions?? (December 17, 2005 5:04:00 AM)
I'm just as curious as JMA is in regards to patients receiving dialysis. I recently began seeing a 64 y/o female with Goodpasture's Syndrome. She is very deconditioned and getting dialysis Monday through Friday and comes to therapy 3x/week. She's made great progress thus far in terms of endurance and strength, but she does get 'wiped out' after dialysis. I second JMA's question.

Dr.Wagner -> Re: Questions about common comorbid conditions?? (December 17, 2005 5:18:00 AM)
Patients are on dialysis primarily for kidney failure from various causes...the most common being diabetes. Dialysis (not peritoneal dialysis) is an exhausting procedure which may take liters off the circulating volume of a patient. Dialysis also drops the electrolytes of a patient, most notably potassium and calcium to lower than normal levels (this does vary from patient to patient). As a result, most patients are fatigued. Now, depending on the CAUSE of the dialysis treatment (end stage renal disease vs. chronic failure), the kidney disease may be enough to simply "wipe out" a patient. In addition to the kidney disease related to dialysis, older patients likely have congestive heart failure as a result(generally the worst patients cannot make urine to diurese), and I think we all understand the concepts of "orthopnea" and "dyspnea on exertion" as a result of CHF (if not, we can go over it). The prognosis depends on the cause, but likely it can be rather poor. Much of this depends on the patient compliance and the underlying kidney function. Physical Therapy in this case is either an attempt to PREVENT functional losses or to regain significant strength loss of the new dialysis patient. Most commonly dialysis is 3 times weekly.

jma -> Re: Questions about common comorbid conditions?? (December 17, 2005 5:45:00 AM)
Thank you for the information. Approximately how long after dialysis is completed can one resume therapy safely? I realize this too can vary as well. Are there emergency situations that individuals who undergo dialysis should be aware of, while getting PT treatment?

Dr.Wagner -> Re: Questions about common comorbid conditions?? (December 18, 2005 12:52:00 PM)
Any and all dialysis patients are susceptible to sepsis, CHF, hyperkalemia, hypercalcemia, pneumonia etc. PT can be initiated at any time as long as the patient is stable.

srcase -> Re: Questions about common comorbid conditions?? (December 18, 2005 2:56:00 PM)
Dr. Wagner, I've encountered a few situations in which a patient comes in for therapy complaining of new symptoms that raise red flags in my head, but when I call the primary physician to alert him/her, I usually get the blow-off. One patient in particular was in PT for general deconditioning/back pain secondary to Lyme disease. She had a history of internal bleeding, was on a antibiotic pump, and was anemic. One day, she came in and complained of not being able to sleep the night before due to "restless legs". Her pulse was irregular, BP was low, and she was cold and clamy. Overall, she just didn't look right to me. I called her primary physician and spoke to the nurse. She had an appointment with her physician to next day, so she wanted to wait instead of going to urgent care or ER. I did very gentle soft-tissue work and sent her home against my advice to go to ER. Turns out she had a cerebral hemorrhage and her husband found her passed out on the kitchen floor the next day. She was hospitalized and is stable now (not in PT anymore), but this is just one example of how frustrating it is for PT's to communicate with physicians. What could I have done differently, or communicated with the doctor?? Sarah

Dr.Wagner -> Re: Questions about common comorbid conditions?? (December 18, 2005 4:35:00 PM)
Well, this sounds like a fragile patient...history of GI bleed (I assume that is what you meant by internal bleeding), anemia (sounds like that GI bleed never was healed), and "antibiotic pump" (perhaps a picc line?)...add dialysis to this monstrously ill patient and you have an accident waiting to happen. If at ANY time you feel the patient is dangerously ill, send them to the ER. You don't have to call anyone. If you feel they are NOT in emergent danger, call the MD/DO and let them know they need a close follow up visit. But an emergency is exactly that...you have a right and an obligation to send the patient to higher medical care. I am sorry to hear about the patient.

JSPT -> Re: Questions about common comorbid conditions?? (December 22, 2005 6:04:00 AM)
I had a similar experience to Sarah's. I was seeing a patient for 1 month for ankle fusion. Exercises had not been changed in 1.5 weeks and she presented complaining of being "sore everywhere". Further questioning revealed she was sleeping 13 hrs/day, had no appetite, and was quite pale. When I asked about bowel changes, she said "come to think of it, I haven't pooped for the past 4 days". Palpation revealed abdominal tenderness. I called the patient's physician's office, described symtpoms, and was told that the patient had an appointment in 2 days, so just to have her report to the doctor then. I asked whom I was speaking to, was told a front desk manager, and then I asked to speak to a nurse. She said send the patient to the ER (which was my initial thought). Long story short, she resisted, I insisted, and offered to drive her; she finally went, was blown off, but finally got an x-ray, and sure enough, had a bowel obstruction. I'm not sure how the patient being known as a "chronic complainer" figured into this since I don't know the area well, but I have my suspicions. Again brings to mind "...and the malingerer died at 3 am."

Dr.Wagner -> Re: Questions about common comorbid conditions?? (December 22, 2005 6:28:00 AM)
I am sure there are a few things lost in translation in all of this (specifically regarding the final diagnosis), but there are NO HARDFAST RULES OF WHAT AN EMERGENCY IS. For all except the gravest of situations, an Emergency is based upon interpretation. The chronic back pain patient considers being out of vicodin "an emergency" while the 60 yr old diabetic smoker with chest pain would prefer to sit at home with his/her angina. It is always best, from YOUR VANTAGE to send the patient to the ER for ANY concern that may be emergent or dangerous. In 3 years as a PT, I sent only one (essentially an anxiety attack), so they don't happen frequently, but they happen.

connie.pt -> Re: Questions about common comorbid conditions?? (December 22, 2005 3:46:00 PM)
I've had what seems more than my share of pts. who I've sent to the ER or to thier Dr. immediately. One lady came in for LBP who could barely walk, turned out she had an acute lumbar fx. One man who I was treating for lumbar stenosis; next day he couldn't get out of bed (no wisecracks, please!). Turned out he had a liver infection. Another lady being treated for LBP, came in one day with abdominal pain and not feeling well the previous couple of days. She had upper right quarter rebound tenderness, turned out to be pancreatitis. A patient with knee OA with symptoms of TIA... Just last week a woman came in with acute LBP and urinary incontinence; she went to the ER, too. Usually I have called the refferring Dr. first, but it's good to hear again that I can send them straight to the ER. It's frightening to think of the refferal as my responsibility, but it really is my responsibility. I've decided it's really not my call to say whether or not the pt. belongs in the ER. If they have S/S that are serious, the Doc at the ER will decide if the person belongs in the ER.

Randy Dixon -> Re: Questions about common comorbid conditions?? (December 22, 2005 7:59:00 PM)
In home health, nursing home/SNF, and inpatients PT's deal with this a lot. When in home health we have lots of notes that basically say, "Day 5, patient is doing nicely and improving on PT goals, Day 6 patient appt. cancelled today due to death of patient" The ambitious PT's do PROM anyway.

Sean_Collins -> Re: Questions about common comorbid conditions?? (December 23, 2005 1:04:00 AM)
I love this thread! So - here is when the dang scientist/philosopher steps in with some silly questions. First, I remind people of the first thread started on this Medical Complexity topic: Medical Complexity (a proposal for defining the concept): "interrelated pathological processes interfere with the ability to maintain stability due to a new emergent whole with its own equilibrium, a set of elements that has REDUCED ability to adapt which may manifest as less range or variation." Is an emergency when the ability to adapt, over short time scales, has been abolished? One thing that is clear from the above discussion is that the clinicians are faced with so many inter related pathological processes - as Dr. Wagner points out with the connection between CHF and Dialysis - and clinicians are faced with, related to these interrelated processes, tremendous variation which leads to difficulty in using traditional empirical methods as a foundation for the epistemological aspects of practice. With a dialogue on these topics - where clinicians bring forward questions and concerns and propose the essence of a good solution, academics can try to help to define the question, organize the concern in a generalizable form, and to move toward solutions. I thoroughly look forward to seeing more posts about patients with the problems above - as to me - they bring into focus many of my thoughts on the need to address the complexity to attempt to improve what we can know about treating these patients (or in the case of emergency - not treating thembut allowing an MD/DO treat them!).

Yogi -> Re: Questions about common comorbid conditions?? (December 23, 2005 4:10:00 AM)
Randy, I actually knew a PT that did PROM on a deceased pt. in the ICU. They took it off the bill, of course.

Dr.Wagner -> Re: Questions about common comorbid conditions?? (December 23, 2005 8:49:00 AM)
I think we run into some very interesting situations with low back pain and emergency medical concerns. Keep the antenna on, but be aware that common things are common. I would rather you be cautious than cavalier. We will go over some cases VERY SHORTLY.

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