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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