Download Osteopathic Considerations of Renal Disease/ Hypertension

OMM 3 Hour 27
Wed, 10/8/03, 1pm
Lecturer: Mo Som
Natacha Torres
Page 1 of 5
Osteopathic Considerations of Renal Disease/ Hypertension
Checked by Mo Som
Points that were emphasized by the lecturer are in bold. Value explanations and tips for
practical in italics
A. Case Presentation
Eighteen year old female presenting with worsening headache and shortness of breath
for two days. She notes fatigue and general malaise that has been worsening despite
her attempts to rest. She is now short of breath walking around the house.
The patient was ill ten days ago with rigors, body aches, fever, and sore throat but this
resolved after five days. She had then been well with none of these symptoms until
two days ago.
She is nauseated with a decreased appetite. If asked she will admit to decreased urine
output and a reddish brown urine.
PMHx: Unremarkable. The patient was an athletic, healthy individual.
PSHx: None
Meds: None
Social: In senior year of high school, living with parents. Denies ETOH or illicit drug
use.
Allergies: None Known
B. Physical Examination
BP = 165/115 Pulse = 125 Resp = 30 Temp = 97.8 degrees F (orally)
The patient is a well developed, but ill appearing young female. She is in no acute
respiratory distress.
Cardiovascular: Tachycardic rate with no rubs, murmurs or bruits
Respiratory: Equal air excursion with rales 1/3 of the way up both lung fields
Liver is slightly enlarged and mildly tender
Extremities: 2 plus pitting edema of the lower extremities.* Think volume overload *
C. Laboratory Data
ECG: regular sinus tachycardia with a rate of 130. The PR, QRS, QT, and QTc
intervals were normal. The T-wave is normal. *overall normal values *
Chest radiograph: Acute pulmonary edema * this explains the rales in the P.E.*
ABG (room air): 7.25 (7.40); pCO2=19(40); pO2=80(100)
* metabolic acidosis and respiratory alkalosis.
K=5.5 mEq/L (3.5-5.1),, Bicarb=16 mEq/L(18-23), BUN=50 mg/dL (7-18), creat=4.6
mg/dl (0.6-1.1), WBC= 15k (4.5-11k)
Urine= 3+ protein, large blood, ketones are trace, and there are 20-30 WBC, and 60-70
RBC per high powered field. Red blood cell casts are present. * Remember this is
pathomnemonic for kidney damage*
All other laboratory data and physical exam are WNL.
D. Diagnosis?
1. Acute glomerulonephritis-most common cause of acute renal failure
Secondary to streptococcal infection the patient had ~ 10 days ago
OMM 3 Hour 27
Wed, 10/8/03, 1pm
Lecturer: Mo Som
Natacha Torres
Page 2 of 5
Dr. Puttoff mentioned that tubulointersitial dz. was the most common cause
but glomerulonephritis was the m/c cause of glomerular disease leading to acute
renal failure
2. She is now suffering from the complications of acute renal failure (ARF).
E. Differential Diagnosis *Mo said we’re not responsible for the whole list, but for the
practical know what other things might be on your differential
1.Glomerular disease
a. Rapidly progressive glomerulonephritis
b. Systemic lupus erythematosus
c. Wegener's granulomatosis
d. Henoch-Schönlein purpura , Goodpasture's syndrome
e. Acute proliferative glomerulonephritis
f. Endocarditis
g. Poststreptococcal infection, Postpneumococcal infection
2. Decreased effective circulating volume to the kidneys
a. Congestive heart failure
b. Cirrhosis or hepatorenal syndrome
c. Nephrotic syndrome
3. Intravascular depletion
a. Sepsis
b. Hemorrhage
c. Overdiuresis
d. Poor fluid intake
e. Vomiting
f. Diarrhea
F. Kidney:Viscerosomatic Response * This whole segment is VERY IMPORTANT*
1. Visceral afferent fibers travel in same fascial pathways as sympathetic nerves
2. Nociceptive fibers in diseased tissues travel to the same interneurons somatic
tissues send their nociceptive fibers to.
3. Spinal segments receive exaggerated input become a ‘facilitated segment’
4. Efferent motor and autonomic components stay stimulated-the viscerosomatic
response
a. Increased tone-Lloyds *These two are manifestations of increase in
b. Sweating
sympathetic tone
* In other words, if viscera becomes irritated, it will send signals to other areas
of the body using the spinal cord.
G. Chapmans Reflex and the viscerosomatic response * VERY IMPORTANT*
1. Reflex ganglion contraction blocking lymphatic drainage
2. Ipsilateral kidney one inch lateral and one inch superior to the umbilicus
3. Treatment: Apply firm pressure on the ganglionic mass slowly moving the tip of
the finger in a circular fashion to mobilize localized fluid
OMM 3 Hour 27
Wed, 10/8/03, 1pm
Lecturer: Mo Som
Natacha Torres
Page 3 of 5
H. Autonomic Nervous Innervation *VERY IMPORTANT
1. Sympathetic:
T10-T12 : Kidneys (notice this was corrected from the PPT during class)
Preganglionic fibers synapse on superior mesenteric ganglion
2. Parasympathetic:
a. Exclusively the Vagus nerve
i. Superior vagal ganglion sits in the jugular foramen
ii. Inferior vagal ganglion sits around body of C2
I. Lymphatic Drainage of Kidneys
a. Intrarenal plexi to lateral aortic nodes to thoracic duct to subclavian vein
b. Terminal drainage in left infraclavicular space
J. Osteopathic Considerations: Goals of Treatment
1.Autonomic Nervous System
a. Responds to volume overload induced by the destruction of the kidneys
b. Increased sympathetic tone leads to a decreased diameter of the renal
arteries leads to a decrease in GFR and a decrease of urine output
(decreased elimination of potentially toxic substances) * anuria*
c. Guyton (physiology text) suggests essential hypertension is a result of chronic
sympathicotonia
i. Balance with treatment of the parasympathetics
2. Lymphatic Drainage
a. Diaphragmatic descent of the kidneys is a chief factor in venous return and
lymphatic drainage. * It was stressed that the diaphragm is extremely
important for maintaining the pressure gradient to move lymphatic fluid
b. Osmotic gradient is maintained by lymphatic drainage
Interference raises oncotic pressure and renders the kidney incapable of
concentrating urine
3. Respiratory Mechanics
Diaphragmatic motion can be reduced by S/D in the thoracolumbar region
Treat the diaphragms as well as treating the S/D in the thoracolumbar region
K. T10-L2: NN, Supine, Indirect, Kimberly 4322.11E (p. 105) * This technique is very
useful for patients in pain, also, for the case presentation only need to address T10T12
1. Pt. supine; Doc sits opposite side of rotation and sidebend patient away from
you
2. Doc reaches under pt. and contacts spinous process of dysfunctional segment
3. Applying lateral distraction (towards the doctor) to “recreate” the S/D
4. Look for “point of maximum ease” and use respiratory force/cooperation to assist
release
* Added: Always diagnose N/N segment (SBx/Rx) first, then treat. Keep in mind
the patient is in pain so try to move him as little as possible
OMM 3 Hour 27
Wed, 10/8/03, 1pm
Lecturer: Mo Som
Natacha Torres
Page 4 of 5
L. Quadratus Lumborum
1. Origin: Iliolumbar ligament and iliac crest
2. Attachment: Tips of TP L1-L4 and Rib 12
3. Considered inferior extension of abdominal diaphragm * This is why we treat
Flattened diaphragm with quadratus spasm
M. Quadratus Lumborum Release: Prone, Direct, ME, Foundations p. 788
1. Pt. prone, with Doc standing at the side of the patient
2. Doc grasps opposite ASIS with caudad hand, and places cephalad hand lateral
to the spine at T11-12
3. Doc lifts ASIS up towards ceiling, bracing the patient with the opposite hand until
restrictive barrier is reached
4. Pt. instructed to push his/her hip back down into the table against Doc’s
counterforce
5. After contraction, take up the slack and repeat (~3x) *Remember~ wait between
ME reps. and ALWAYS reassess.
*Added: to diagnose check segment for spasm and TART changes
N. Diaphragm and Arcuate ligament
1. Lateral Arcuate
a. Covers the quadratus
b. Spans from L1 to midpoint of rib 12
2. Medial Arcuate
3. Continuous with lateral crus of the diaphragm
*Added: treat both the medial and lateral components
O. Arcuate Ligament Release – 12th rib inferolateral-Foudations p. 922 *TIP: 12th rib is
easier to find with the patient laying supine
1. With the patient supine, contact the 12th rib tip with guiding hand over palpating
hand lifting anteriorly
2. Palpate the tension in the lateral and medial arches of the arcuate ligament of the
diaphragm.
3. Apply lateral distraction to the rib. Follow this direction to feel the lateral arch
release, continue until you feel the medial arch release. This technique can be
continued to release the crus of the diaphragm.
*Explanation: pushing anterior releases the Medial arcuate ligament, applying
lateral distraction releases the Lateral arcuate ligament.
*Added: to diagnose check segment for TART changes
P. Sympathetic Chain Ganglia & Rib Raising
1. Thoracic sympathetic chain ganglia are segmentally located in fascias over each
rib head
2. Rib raising *VERY IMPORTANT
a. Initially stimulates sympathetic outflow
b. Longer lasting effect of decreasing sympathetic tone by reflex
OMM 3 Hour 27
Wed, 10/8/03, 1pm
Lecturer: Mo Som
Natacha Torres
Page 5 of 5
inhibition the higher sympathetic centers in the medulla
3. Treats lymphatic congestion
Q. Rib Raising: Supine, Direct, LVMA, Kimberly 4933.11E (p. 61)
1. Pt. supine; Doc sits at side of table
2. Patient crosses his hands to move the scapula to access ribs *Tip: for T10-T12 it
is not necessary to have the pt cross his arms
3. Doc places his/her finger pads on posterior angles of the ribs
4. Doc applies anterior pressure until observed anteriorly. Hold until tissues
relax, then allow ribs to fall posteriorly
5. May be applied once or rhythmically for several cycles
6. TREAT BOTH SIDES!
R. Additional Techniques *for your own time
 FB T11-L5: Prone, Direct, Springing, Kimberly 4411.11A
 BB T11-L5: Supine, Direct, ME Kimberly 4411.11A
 BB T11-L5: Sitting, Direct, ME, Kimberly 4412.11D
 Neutral T11-L5: Sitting, Indirect, Pt. coop., Kimberly 4421.11D
 Neutral T11-L5: Supine, Indirect, Pt. coop., Kimberly 4421.11G
 Neutral T11-L5: Lumbar Roll, Kimberly 4421.11E
 Non-Neutral T11-L5: Sitting, Direct, ME, Kimberly 4422.11B
 Non-Neutral T11-L5: Supine, Indirect, Pt. coop., Kimberly 4422.11E
 Neutral T11-L5: Supine, Direct, ME, Kimberly 4421.11F