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342 Cards in this Set

  • Front
  • Back
3 Levels of Defense System
1. Skin
2. Inflammatory Response
3. Immune Response
Effects on Immune Response (9)
1. trauma
2. pollutants
3. drugs suppress
4. age (TCells)
5. gender
6. nutrition
7. stress
8. rest
9. exercise
Functions of the Immune System (3)
1. protect the body from foreign substances
2. identify the foreign material
3. synthesize antibodies to destroy foreign cells
Immunity Players
1. Antigens
2. Antibodies
3. Lymphocytes (T and B)
4. Other Cells (Natural Killer, Dendritic, Macrophages)
Antigens
- no characteristic cell markers
- elicits immune response
Antibodies
- protect host
- neutralize bacterial toxins
- neutralize bacteria
- opsonize bacteria
- activate inflammatory response
How do antibodies work?
Direct vs indirect
direct:
1. agglutination
2. precipitation
3. neutralization
Indirect
1. enhance phagocytosis
2. activate plasma proteins
Lymphocytes
-originate from stem cells in bone marrow
- B Lymphocyte
- T Lymphocyte
T Cell Lymphocytes (function)
- hand to hand combat
- differentiate in thymus
- CELL MEDIATED IMMUNITY
-- seeks out hidden invaders
-- kills on a cell to cell basis
Types of T Cell Lymphocytes
1. T-Killer Cells (cytotoxic, Tc)
2. Helper Cells (T4, CD4 receptor)
3. Memory Cells
4. Suppressor Cells
Function of Helper Cells
- B Cell Maturation
- Activate macrophages
- Assist T-killer cells
Function of Memory Cells
remember antigen for accelerated next response
Function of Suppressor Cells
control cytotoxic and helper cells
B Lymphocytes - Function
- differentiate in bone marrow and other places
- HUMORAL IMMUNITY
- makes antibodies/immunoglobulins
B Cells differentiate into
- Plasma Cells
- Memory Cells
B Lymphocytes: Antigen-Binding Fragment (Fab)
- binds to antigen
- recognition sites for antigens
- gives specificity
B Lymphocytes: Crystalline Fragment (Fc)
- starts inflammatory process
- activates complement system
- binds to phagocytes
- transport of maternal antibodies to fetus
1. IgG
2. IgA
3. IgM
4. IgE
5. IgD
1. major class/ secondary response
2. body secretions (mucous membranes/external)
3. first response (made early in neonatal life)
4. allergic response ( lysis of mast cells)
5. unknown, surfaces of developing B Cells
Types of Immunity
1. Natural
2. Acquired
a. Active
b. Passive
Types of Responses
1. Primary (IgM)
2. Secondary (IgG)
Mechanisms of Immunity
1. Humoral
2. Cell Mediated
B Lymphocytes: Memory Cells
- remembers the antigen
- system acts faster when exposed again
Mechanisms: Humoral Immunity
1. B Lymphocytes
2. Antibody Production (Immunoglobulins)
3. Memory Cells
Age Effects on the Immune System
1. Declines with age
2. T Cell function declines
3. Increased autoantibody production
4. Diminished cell-mediated immunity
Alterations: Immunodeficiency
- failure of self-defense mechanisms
- Hallmark sign: unusual or recurrent infections
- congenital or acquired
Infections Associated with Immunodeficiency: Cell Mediated vs Humoral
Cell Mediated:
- viral
- fungal
Humoral:
- bacterial
Alterations: Hypersensitivity
- inappropriate
- directed at host tissues
- directed at beneficial foreign tissue
- exaggerated response against environment
Alterations: Hypersensitivity Autoimmune Responses
- breakdown in tolerance of self
- see p 179 for options
Alterations: Hypersensitivity Alloimmune Responses
- reaction to tissue of another member of same species
- transplant rejection
- transfusion reactions
Alterations: Hypersensitivity Allergic Reactions
- increased immune response due to the presence of allergen
- results in tissue destruction
- IgE released (histamine and anaphylotoxine)
senescence
aging process of cells
- lose ability to divide
- die and body rids the body of the cells
apoptosis
cell suicide due to multiple mutations
Tumor Grading:
Grade I
Grade II
Grade III
Grade IV
Grade I: well differentiated
Grade II: moderately differentiated
Grade III: poorly to very poorly differentiated
Grade IV: very poorly differentiated
Carcinogenesis
1. Initiation
2. Promotion
3. Transformation
4. Progression
Oncogene
gene expression that will cause a gene to be cancerous
Proto-oncogene
normal gene that becomes oncogene
DNA Repair Gene
detect damage and repair it
Benign Tumor
- appear in any part of the body
- slow growing
- well-defined cystology and histology
- well-defined edges
- do not invade surrounding tissues
- frequently encapsulated
- lethality usually d/t organ compression
Malignant Tumor
- rapidly growing
- abnormal mitosis
- loss of differentiation
- increased motility- can spread
- poorly defined edges
- directly invade surrounding tissues
- no encapsulation
- usually has own blood supply
Primary Tumor
- originating tumor
Secondary Tumor
- metastatic tumor
- similar to primary tumor
- less well differentiated
- may appear several years after primary tumor
- frequently migrates to well vascularized site
Direct extension
invades organs/tissues next to primary tumor
Hematogenous
through blood
Common metastatic sites
- bone
- lymph nodes
- lung
- liver
- brain
differentiation
process of acquiring specific characteristics that result in changes in cellular function
anaplasia
cancer cell does not function normally
- no differentiation or control over growth/division
hyperplasia
increase in tissue size
- due to increase in # of cells
- may not be abnormal
metaplasia
fully differentiated cell is replaced by another type
- reversible, generally benign
dysplasia
abnormal disorganized cell growth
- no normal division
In Situ cancer
pre-invasion tumor
- haven't broken through basement layer
- hasn't invaded other tissue
Carcinoma
epithelial tissues; organ secretes something
Sarcoma
connective tissues; muscle, bone, blood vessels, nerves
Lymphoma
lymphoid tissue, spleen
Leukemia
blood forming tissue, bone marrow
benign
-oma
malignant
-sarcoma
adeno
gland
chondro
cartilage
erythro
RBC
hemangio
blood vessels
lipo
fat
myelo
bone marrow
myo
muscle
osteo
bone
T
N
M
T=size of primary tumor
N=extent of lymph node involvement
M=presence/absence of metastases
Screening for Cancer
- age older than 50
- previous hx of cancer
- female with chest, breast, axillary pain, unknown origin
- back, pelvic, groin, hip pain with vague abdominal complaints, palpable mass
- change in size, shape of lymph nodes >1 location, >4 weeks
- weight loss of 10 lbs or more within 1 month
C
A
U
T
I
O
N
Change in bowel/bladder
A sore that won't heal
Unusual bleeding or discharge
Thickening or lump
Indigestion or difficult swallowing
Obvious change in wart/mole
Nagging cough or hoarseness
PT-specific diagnosis
- bone pain-burning, aching, poorly loaclized
- Hx of cancer and back, shoulder, joint pain of unknown origin
- proximal muscle weakness
- change in DTR's
- unexplained fatigue
Blood Tests
- CBC
- alkaline phosphatase
- uric acid
- calcium
- electrolytes
- cancer-specific proteins
CBC
- decreased Hgb, Hct in hematological cancers
- increased WBC in leukemias
alkaline phosphatase
increase in liver and bone disease
uric acid
increase in hematological cancers
calcium
increased in cancer that has metastasized to bone, multiple myeloma
electrolytes
Na, K, Cl - nutritional status
Cancer-specific proteins:
1. PSA
2. IgG, IgA
3. CEA
4. CA 15-3, CA 27-29
5. AFP
1. prostate cancer (<4-5 mg/ml)
2. multiple myeloma
3. cancers of colon, rectum, lung, breast
4. breast cancer
5. liver cancer, testicular cancer
Imaging Techniques
- x-rays
- nuclear scans
- CT scan, MRI
- ultrasound
- mammography
Genetic Screening
- HER-2
- BRCA1
- BRCA2
Methods of Cancer Diagnosis
1. self-exams/routine screening
2. CAUTION
3. Blood Tests
4. Tests of fluid and stools
5. Bone Marrow Analysis
6. Biopsies
7. Imaging Techniques
8. Endoscopy
9. Genetic Screening
10. Cytological Studies
Signs/Symptoms of Cancer for the PT
1. Bone Pain
2. Hx of cancer + back, shoulder, or joint pain of unknown cause
3. Proximal muscle weakness
4. Change in DTR's
5. Unexplained fatigue
Complete Remission
tumor completely gone
- temporary or permanent
Cure
CR for at least 5 years
Partial Remission
tumor decreased more than 50% but not gone
stabilization
tumor neither shrinks nor grows
progression
tumor keeps growing
clinical remission
# of abnormal cells less than 1 billion
Cancer treatment options
1. surgery
2. radiotherapy
3. chemotherapy
4. biological therapy
Cancer treatment determination
- type and location of tumor
- stage and grade of disease
- pt's general health and age
- pt and family beliefs and desires
Uses for surgery
- prevent/lower risk for developing cancer
- diagnose/stage disease
- tumor removal
- reconstruction
- RTX, chemo adjunct
Side effects of surgery
- loss of function
- infection
- increased pain
- deformity
- swelling
If you patient has cancer...
1. avoid superficial heat
2. deep heat increases tumor growth
3. avoid cold for chemotx-induced nerve injury
4. pathologic fracture risk
Goals of radiation therapy
1. cure
2. control of cancer
3. decrease tumor size
4. palliation
dosage of radiation
rads, or centigray (cGy)
- site-specific, size and stage
- fractionated schedule
- 5x/week, 2 to 8 weeks
- dosage limited by normal tissue toxicity
radiosensitization
given drug to make cells more sensitive to radiation
hyperfractionation
smaller doses more often
Side effects of radiotherapy:
1. immunosuppression with long bones, ilium, sternum (dec WBC, platelets, Hgb)
2. integumentary: skin reactions, burns, tissue fibrosis, myofascial adhesions
3. GI: nausea, vomiting
4. fatigue: may continue after treatment
Side effects of radiation (cont)
5. avascular necrosis
6. mouth: dry, loss of taste, sores, cavities
7. doesn't stop with treatment (6-12 months)
PT implications of Radiotherapy
1. fatigue after RTX (energy conservation, active rest)
2. skin care
3. lymphedema
4. proper hydration and nutrition
5. seating solutions
chemotherapy
- systemic using drugs
- stops cells from growing/dividing
- lacks tumor cell specificity
- usually involves combo of drugs
Goals for chemotherapy
1. cure
2. slow progression
3. shrink the tumor to decrease cancer load
4. shrink the tumor to allow surgical resection
alkylators
damage proteins that control growth in the genes of the tumor cell
antimetabolites
act as false building blocks in cancer cell's genes, causing it to die as it gets ready to divide
antitumor antibiotics
inhibits gene replication
antimitotics/alkaloids
inhibit the ability of cellular genes to replicate during division; blocks mitotic spindle or microtubule formation
Hormones
give messages that either encourage or stop growth or activities in certain cells or organs
How chemo is given
1. topically
2. by injection (IM, SC)
3. by mouth
4. by IV (catheter, port, pump)
CSF
Neupogen
- stimulates WBC production
EPO
Procrit
- stimulates RBC production
Chemo side effects (8)
1. drug specific
2. nausea, vomiting
3. mouth sores
4. hair loss
5. neuropathies
6. immunosuppression
7. sterility
8. chemobrain
immunosuppression from chemo
1. anemia
2. leukopenia
3. thrombocytopenia
PT Implications for Chemo
1. cancer-related fatigue
2. deconditioning
3. careful monitoring/precautions
4. peripheral neuropathies
5. fall precautions
6. pathological fracture
Biological Therapy (definition)
using biological response modifiers (BRM) to activate immune system
Biological Agents
- immunomodulating agents
- interferons (IFNs)
- Lymphokine-activated killer cell (LAK) therapy
- colony stimulating factors
- bone marrow/stem cell transplants
Immunomodulating Agents
- inject tumor with bacterium
- activate immune system
- tumor growth is slowed down
Interferons (Types)
1. IFN-alpha
2. IFN-beta
3. IFN-gamma
Interferons (Effects)
- makes tumor cells more foreign
- inhibits tumor growth
- enhance natural killer cells
Interferons (uses)
- Leukemia
- Kaposi's sarcoma
- melanoma
- renal cell CA
LAK Therapy
- experimental
- Tc cells taken from patient
- grown in culture with interleukin-2
- injected back in
- infiltrate tumor and kill
- melanoma and renal cell carcinoma
Side Effects of Biological Therapy
1. injection site swelling/redness
2. flu-like symptoms
3. fatigue
4. elevated liver function tests
5. CNS toxicity
6. arrythmias, hypotension
7. edema
8. skin rash
Top 2 infectious diseases that lead to death in US
#8: pneumonia/influenza
#10: septicemia
Factors of spread of infection
1. new organisms
2. increased environmental mobility
3. organisms linked to other diagnoses
4. antibiotic resistant strains
pathogenicity
ability of organism to cause disease
- depends on ability to divide
- extent of tissue damage
- strength of toxins
colonization
successful invasion, not sick
subclinical
presence of colonization, no signs/symptoms
incubation period
time from exposure to clinical signs
latent infection
replicated but inactive
carriers
carrier, no evidence of disease (HIV)
nosocomial infections
acquired in hospitals/ long term care/ direct exposure
types of organisms
1. viruses
2. bacteria
3. rickettsiae
4. protozoa
5. prions
6. fungi (mycoses)
Bacteria:
- Classification
- Shapes
1. shape
2. staining
3. motility
4. spore producing

1. cocci
2. bacilli
3. spirilla (spirochetes)
Rickettsiae
- animal pathogen
- vectors
- susceptible to antibiotics
- Typhus and Rocky Mountain Fever
Protozoa
- single cell unit or group of cells
- malaria
-amebic dysentary
Prions
- proteinaceous particle
- neurodegenerative
- Creutzfeldt-Jacob Disease
- Mad Cow disease
Fungi (Mycoses)
- single-celled yeast
- multicellular molds
- often skin and mucosa
- like warmth and moisture
- athlete's foot and candida (thrush)
Signs and Symptoms of Infection
1. fever
2. chills
3. malaise
4. others
Modes of transmission of infection
1. contact (casual, sexual, blood borne)
2. airborne
3. enteric
4. vectorborne
Host susceptibility
1. general health
2. nutritional status
3. living conditions
4. life style
5. age
6. comorbidities
7. invasive equipment
Staphylococcus Aureus
- common but can't invade skin
- enters through traumatic break in skin
Manifestations of Staph Infection
1. furuncles
2. carbuncles
3. osteomyelitis
4. infections of burns or surgical sites
5. URI
6. endocarditis
7. toxic shock syndrome
furuncles
small round tender central area of pus
carbuncles
2 or more furuncles
endocarditis
inflammation of heart valves
MRSA
-methicillin resistant
- produce penicillinase (deactivates penicillin
Myobacterium Tuberculosis: transmission
- airborne droplets
- tubercle
- may remain dormant for life
Group A Streptococci
Causes:
- pharyngitis
- scarlet fever
- impetigo
- necrotizing fasciitis
- gangrene
Hepatitis C Virus
- bloodborne pathogen
- leading indication for liver transplant
- chronic liver disease (70%)
- jaundice, fatigue, N&V, abdominal pain
Hepatitis B Virus
- major cause of viral hepatitis
- weakness, fatigue, headache, jaundice, N&V
- can survive in dried blood
HIV
- virus causes AIDS
- attacks T4 lymphocytes
- intimate contact
- 8-10 year incubation
- never dormant, always transmittable
HIV testing
- enzyme immune assay
- enzyme-linked immunosorbent assay
- Western blot
- Oraquick test
pneumonia
- inflammation of lung accompanied by bronchitis and pleurisy
types of pneumonia
1. aspiration pneumonia
2. community acquired
3. nocosomial pneumonia
4. immunocompromise
aspiration pneumonia
- hacking productive cough
- pleuritic chest pain
- dyspnea
community acquired pneumonia
- streptococcus pneumoniae
- haemophilus influenzae
- influenza virus
nosocomial pneumonia
- psuedomonas
- staphylococcus aureus
- klebsiella pneumoniae
- E-coli
immunocompromise
- pneumocystitis carinii (jerovici)
- myobacterium tuberculosis
- fungi
- protozoa
TB: symptoms
- fatigue
- weight loss
- lethargy
- anorexia
- low grade fever
- cough with purulent sputum
Hepatitis C: Risk Groups
- highest: IV drug users, risky sexual behavior
- hemodialysis pts
- organ transplant prior to July 1992
- recipient of blood prior to 1987
- healthcare workers
West Nile Virus
- flavivirus (Africa, West Asia, Middle East)
- in US since 1999
- humans, birds, mosquitoes, horses
- mild flu-like symptoms
- severe: encephalitis, meningitis
Leishmaniasis
- Baghdad Boil
- 4 cases in TX
- bite of sand flies or wood rat bitten by sand fly
- up to 1 year to heal
Avian Influenza
- bird flu
- carried by wild birds
- viruses in saliva, nasal secretions and feces
- low or high pathogenic
Subtypes of Human Bird Flu
- H1N1
- H1N2
- H3N2
- H5N1: deadly
Bird Flu: symptoms
- flu-like symptoms
- eye infections
- pneumonia
- severe respiratory distress
H5N1 Virus
- largest # of cases/deaths
- Cambodia, Thailand, Indonesia, Viet Nam
- does not spread easily human to human
Pandemic
- whn new virus subtype emerges
- infects humans
- spreads easily among humans
- concern b/c no vaccine
Standard Precautions
any body fluid infectious
Universal Precautions
blood products or contaminated with blood infectious
Transmission-Based Precautions
- more cautious depending on what's going on
exocrine
secretes products into a duct
endocrine
secretes products into extracellular space
Classification of Hormones
1. amines
2. proteins and peptides
3. steroids
amines
- simplest hormone molecules
- epi- and norepinephrine
proteins and peptides
- chains of amino acids
- pituitary or parathyroid
- water-soluble
steroids
- from cholesterol, liipid soluble
- end in -one except estrogen
Hormonal control
- negative feedback
- indirect: hypothalamus
- direct: pituitary gland
Neural Control
- norepinephrine
- epinephrine
- oxytocin
positive feedback
- high levels of a substance stimulate secretion
- low levels suppress
negative feedback
- high levels suppress
- low levels suppress
water-soluble receptors
- substance binds to receptor
- 2nd messenger does action
lipid-soluble receptors
- cross cell membrane
- bond in cytosol
- direct effect
Hormonal Interactions
- permissive effects
- direct effect
- antagonistic effect
permissive effect
- estrogen and progesterone
- two hormones have to be there together
direct effect
obvious change in cell due to hormone
antagonistic effect
- insulin and glucagon
- calcitonin and PTH
Overall effects of Hormones
1. controls internal environment
2. responds to changes in environment
3. smooth, sequential integration of growth and development
4. coordination of reproductive systems
5. regulates organic metabolism and energy balance
Changes with age
- inc dysfunction
- Pituitary: anatomic and histologic changes
- Thyroid: shrinks and dec T3 T4
- adrenal gland: more fibrous, dec clearing of glucocorticoids
Hypothalamus
- master of the pituitary
- hypothalamic regulating hormones
- ADH
-oxytocin
Pituitary Gland
1. anterior
2. posterior
1. adenohypophysis
2. neurohypophysis
Anterior Pituitary Hormones
1. Human Growth hormone
2. prolactin
3. adrenocorticotropic hormone
4. thyroid stimulating hormone
5. follicle stimulating hormone
6. luteinizing hormone
Human Growth Hormone
- increased protein synthesis
- fat breakdown
- inc blood glucose
prolactin
lactation after pregnancy
ACTH
stimulates adrenal gland to release glucocorticoid hormones
TSH
stimulates thyroid to make thyroxine (T4) and triiodothyronine (T3)
FSH
- follicle growth
- secretion of estrogen
- spermatogenesis
LH
- promotes ovulation
- secretion of progesterone
Dysfunction of Anterior Pituitary:
Hypofunction
1. panhypopituitarism
2. pituitary dwarfism
3. post-partum ischemic necrosis (Sheehan's syndrome)
panhypopituitarism
decrease in all pituitary hormones (life threatening)
pituitary dwarfism
decrease in growth hormone
- don't grow but proportional
- not same as achondroplasia
Post-partum ischemic necrosis
- Sheehan's syndrome
- woman after delivery
- hemorrhage, shock
- pituitary gland does not receive blood
Dysfunction of Anterior Pituitary: hypersecretion
Symptoms
1. giantism
2. acromegaly
- arthritic pain
- jaw pain
- increased blood sugar
- increased ring size
- increased shoe size
- increased hat size
giantism
- inc GH before growth plates close
- overgrowth of long bones
- proportions normal
acromegaly
- inc GH after growth plates closed
- tumor of pituitary gland
- inc growth in hands, feet, frontal, mandible, maxilla
Posterior (Neurohypophysis)
1. ADH: vasopressin; vasoconstriction
2. Oxytocin: stimulates uterine contractions-milk let down while nursing
Diabetes Insipidus
- hyposecretion of ADH
- polyuria
- polydipsia
- no problem with glucose
- treat with synthetic ADH
Diabetes Insipidus: Causes
- damaged pituitary gland (head trauma)
- cranial surgery
- anoxic encephalopathy
- tumor
Components of Adrenal Gland
1. adrenal cortex
2. adrenal medulla
Adrenal Cortex
1. mineralocorticoids
2. glucocorticoids
3. androgens
mineralocorticoids
- aldosterone
-- released during dehydration and blood loss
-- makes kidneys retain Na and H2O
hormones that retain water
- ADH
- aldosterone
glucocorticoids
cortisone:
- increases rate of protein breakdown
- provides additional glucose
- blood vessels more responsive
- suppresses inflammatory response
- interferes with connective tissue regeneration
androgens
- low production relative to gonads
- may not be physiologically important
- can affect secondary sex characteristics
Adrenal Medulla
- epinephrine
-norepinephrine
- fight or flight response
- mimics sympathetic nervous system response
Dysfunction of Adrenal Gland
1. Cushings syndrome
2. Addison's Disease
Cushing's Syndrome: causes
- tumors of pituitary
- tumors of adrenal gland
- external source of cortisol
Cushing's Syndrome: treatment
- remove tumors
- wean off cortisone
Cushing's Syndrome: symptoms
- moon face
- buffalo hump at neck
- protuberant abdomen
- muscle wasting
- osteoporosis
- easy bruising
- women become masculinized
Addison's Disease: causes
- autoimmune process
- infectious disease
- vascular occlusion
- abrupt withdrawal from corticosteroids
Addison's Disease: treatment
- exogenous cortisol
- aldosterone?
Addison's Disease: symptoms
- dark pigmentation of the skin
- hypotension
- lethargy
- hyperkalemia
- weight loss
Thyroid Gland
1. thyroxine (T4)
2. tri-iodothyronine (T3)
3. calcitonin
T4
- increased protein synthesis, breakdown carbs, fats
- regulate growth/development
- regulate nervous system
Calcitonin
- calcium homeostasis
- from blood to bones
- decreases blood Ca+
- inhibit osteoclasts to prevent bone breakdown
- "thyrocalcitonin"
Dysfunction of Thyroid Gland
1. goiter
2. hyperthyroidism (thyrotoxicosis, Graves disease)
3. hypothyroidism
3.
Goiter
- deficiency in iodine
- symptoms:
-- enlarged thyroid gland
-- possibly dysphagia or hoarseness
- treatment: iodine supplement
hyperthyroidism
- autoimmune disease: produces long-acting thyroid stimulator (LATS)
- treatment:
-- inhibit thyroid hormone synthesis
-- destory thyroid tissue
-- surgically remove
hyperthyroidism: symptoms
- symmetrical goiter
- exopthalmos
- heat intolerance
- tachycardia
- palpitations
- UE tremors
Hypothyroidism disorders
1. cretinism
2. throiditis (Hashimoto's disease)
3. myxedema
Cretinism
- newborn
- causes:
-- thyroid agenesis
-- insufficient iodine in mother's diet
Thyroiditis: Hashimoto's Disease
- autoimmune response
- symptoms:
-- enlarged hard painless thyroid
-- dysphagia
- treatment:
-- thyroid hormone
-- surgery to remove goiter
Myxedema
- decrease in thyroid function
- treatment: thyroid hrt
- symptoms:
- periorbital edema
- non-pitting puffiness of face
- sluggishness
- irritability
- dry skin
- muscular weakness
- slow heart rate
Parathyroid Hormone
- antagonist to calcitonin
- activation of osteoclasts
- inhibition of osteoblasts
- release of Ca+ from bones
- reabsorption of Ca+ by kidneys
- conversion of VitD to most active form
Hyperparathyroidism: types
- primary: something wrong with gland
- secondary: chronic renal disease
-- loss of Ca+ in dialysis
-- increased PTH-PTG's fine
Hyperparathyroidism: treatment
Primary: removal of gland
- all four, radio-guided minimally invasive to remove part
- renal transplant
secondary: restore normal Ca and P balance
Hyperparathyroidism: symptoms
- moans: psychological
- stones: kidney stones
- bones: fx or osteoporosis
- groans: abdominal distress
Hypoparathyroidism: causes and treatment
- decreased plasma Ca+
- elevated phosphate levels
-treatment:
-- Ca supplement
-- Vitamin D
-- decrease phosphorus intake
Hypoparathyroidism: symptoms
- paraesthesis
- muscle spasm and tetany
- psychiatric disturbances
Pancreas
1. Glucagon
2. Insulin
Glucagon
- secreted from alpha cells
- glycogen breakdown in liver
- gluconeogenesis
Insulin
- secreted from beta cells
- promotes glucose entry into cells
- promotes glycogen synthesis
- promotes lipogenesis
- promotes protein synthesis
Type 1 DM (Immune Mediated, IDDM, Juvenile, Type I)
- little or no insulin
- autoimmune response
- mostly in adolescence
- less genetic tendency than type 2
- more rare
Type 2 DM (NIDDM, Adult-onset, Type II)
- ineffective insulin
- strong genetic component
- associated with obesity and lack of exercise
- receptor ineffective or insulin ineffective
- more genetic tendency
Risks for developing Type 2 DM
- overweight
- under 65 with little to no exercise
- between 45 and 64 years of age
- woman who gave birth to a baby over 9 lbs
- sibling with DM2
- parent with DM2
Symptoms of DM 2
- polyuria
- polydypsia
- polyphagia
- weight loss
- hyperglycemia
- glycosuria
- ketonuria
Diagnosing Diabetes
- fasting blood glucose levels (70-110 mg/dl)
- Oral Glucose Tolerance Test (normal: glucose rises than drops rapidly to normal)
glucose tolerance tests
1. normal response
2. impaired fasting glucose
3. impaired glucose tolerance
4. Diabetes
1. 2-hour level <= 100 mg/dl
2. fasting >100 but <126 mg/dl
3. 2-hour level >=140 but <200
4. 2-hour level is >200 mg/dl
Blood Tests for Cardiovascular Diseases (6)
1. arterial blood gases
2. O2 saturation
3. fasting lipid profile test
4. C-reactive protein test
5. total homocysteine
6. ischemia modified albumin
arterial blood gases
pH, PaO2, PaCO2
C-reactive protein test
- synthesized in liver in response to inflammation
- predictive of 1st CV event and recurrence
- > 3.0 mg/dl
total homocysteine
>15 mmoles/L
ischemia modified albumin
- appears within minutes of onset of ischemia, returns to baseline in 6 hours
- marker of ischemia BEFORE infarction
fasting lipid profile test
- LDL >130
- cholesterol >200
- HDL <40
Serum Enzymes that indicate MI
1. lactate dehydrogenase (8x above normal)
2. troponin (I or T) (30x above normal)
3. creatine kinase (6x above normal)
Chest sounds: gallop
- fast, soft rhythmic extra-sound mimicked by saying ken-tuc-ky or ten-nes-see
Chest sounds: murmur
soft blowing or rasping sound following the 1st or 2nd heart sound
rub
described as squeaky, screechy, or grating (pericarditis)
snap
sounds like the wind snapping a sail (mechanical valve replacement)
click
high pitched and relatively loud (valve replacement)
Thallium Stress Test
- nmi that assesses myocardial perfusion
- extent of coronary artery blockage
- prognosis following MI
- causes of chest pain
- level of exercise patient can safely perform
Thallium Stress Test: procedure
- stress test
- injection with thallium
- immediate scan
- delayed scan
Ultrafast Computed Tomography
- noninvasive
- 3D view of heart at work
- measures calcification of coronary vessels
Holter Monitor
- portable ECG
- detects arrhythmias
- find silent ischemia
- see if arrythmia meds working
-non-invasive
- very reliable
Echocardiography
- non-invasive
- finds if valves closed properly
- finds hypertrophy of tissue
Cardiac catheritization
- invasive
- monitors narrowing of vessels
- ejection fraction
- RA, RV pressure
hypertension
- persistent elevation of systolic blood pressure over 140 mmHg or diastolic blood pressure over 90 mmHg
- measured 2 occasions, 2 wks apart
Types of hypertension
1. primary hypertension (idiopathic, 90%)
2. secondary (identifiable cause, alcohol, renal, stress, etc.)
3. borderline - intermittent increase in BP mixed with normal readings
risk factors for hypertension
- age older than 55
- ethnicity: african americans, hispanic
- family history of cv disease
- stress
- smoking
- DM
- long-term alcohol use
- high Na intake
- obesity
hypertension: clinical manifestations
- usually asymptomatic
- headache - occipital; worse on waking
- vertigo
- SOB
hypertension: treatment
- increased activity
- reduction in Na+
- diruetics
- vasodilators
- ACE inhibitors
- Ca channel blockers
Mechanisms of atherosclerosis
1. injury to intimal layer
2. macrophages to site, collect LDL
3. migrate under intima; fatty streak
4. smooth muscle cells penetrate lining
5. plaque formation
6. cracks in wall as plaque enlarges
7. platelets stick
Risk factors for ischemic heart disease: modifiable
1. smoking
2. hypercholesterolemia
3. HTN, DM
4. physical inactivity
5. obesity
6. Personality
7. excessive alcohol
8. elevated homocysteine
9. elevated C-reactive protein
Risk factors for ischemic heart disease: non-modifiable
1. age
2. gender
3. ethnicity
4. family hx
Defense for elevated homocysteine
1. Vitamin B12
2. Vitamin B6
3. Folic Acid
Areas of body affected by atherosclerosis
1. brain
2. heart
3. kidney
4. aorta and/or visceral arteries
Precipitating factors of angina
1. exposure to cold
2. heavy meals
3. exercise
4. emotion
Types of angina
1. stable angina
2. unstable angina
3. prinzmetal angina
4. asymptomatic "silent" angina
Stable Angina
- most common
- effort angina
- relieved by rest, vasodilators
- narrowed vessels can't deliver sufficient blood
Unstable Angina
- crescendo angina
- unpredictable
- pre-infarction angina
- pain at rest
- may predict imminent MI
- symptoms longer than 15 min
Prinzmetal angina
- variant (rest) angina
- cause: coronary spasm
- intermittent pain at rest at night
Stable Angina: clinical manifestations
-squeezing, burning, pressing
- substernal, C3-4 dermatome
- 1-3 min, up to 20 min
- relieved by rest, nitroglycerin
- HR, BP elevated
- EKG ST depression
transmural MI
- necrosis transverses entire ventricular wall
- "Q wave infarction"
subendocardial MI
- necrosis limited to 1/3 of ventricular wall
- problem with ST segment
treatment for MI
- monitoring
- pharmacological
-- thrombolytics
-- anticoagulants
- surgery
--PTCA
--coronary stents
--CABG
- stem cells
PT considerations post MI
- monitoring
- post-surgical precautions
- gentle exercise w/i 24 hrs
- watch valsalva
- watch hypotension 2nd meds
- avoid tissue trauma-ac
- avoid hot-tubs 6 wks
peripheral vascular disease
- venous disorders
- arterial or occlusive disorders
- vasomotor disorders
- inflammatory disorders
risk factors for PVD
- smoking
- trauma
- previous DVT
- DM
- age > 60
- oral contraceptives, pregnancy, HRT
- bed rest
- air travel
diagnosis of DVT
- Homan's sign + in 30% of cases
- Doppler ultrasound
- contrast venography
treatment for DVT
- medications; anti-coagulants, heparin, coumadin
- smoking cessation
- elastic stockings
- thromboectomy
Arterial Disorders
- tissues not oxygenated
- ischemia
- gangrene can develop
- pulses poor or absent
- intermittent claudiaction
- pale
Goal: inc O2 w/o inc demand
Venous
- tissues oxygenated
- blood not moving-stasis
- skin discolored
- edema prominent
- normal arterial pulses
goal: create compressive pumping force to move fluid
Raynaud's Disease
- intermittent small artery constriction
- pallor and cyanosis of digits
- 2ndry to cold, strong emotion, anxiety
- women>men
Congestive Heart Failure
- heart unable to pump sufficient blood to meet needs
1. Left Heart Failure
2. Right Heart Failure "cor pulmonale"
CHF: systolic dysfunction
dilated LV with impaired contractility
CHF: diastolic dysfunction
normal or intact LV with impaired ability to relax and receive blood
FACES
F - fatigue
A - altered activity
C - congestion in chest
E - edema
S - short of breath
NYHA Functional Classification
Class 1
Class 2
Class 3
Class 4
1 - no limitation of activity
2 - slight limitation of activity
3 - marked limitation of physical activity, comfortable at rest
4 - unable to carry on activity w/o discomfort at rest also
Risk factors for CHF
- HTN
- pre-existing CAD
- past MI
- other heart diseases
- obesity
- pulmonary, renal disease
- long-term NSAID use
- Paget's disease
Clinical Manifestations of LV failure
- progressive dyspnea
- paroxysmal nocturnal dyspnea
- productive cough
- fatigue
- pulmonary edema
- use of accessory breathing muscles
Clinical Manifestations of RV failure
- dependent edema
- jugular vein distension
- abdominal distension
- weight gain
- R upper quadrant pain (liver)
- cyanosis
Diagnosis for CHF
- clinical symptoms and signs
- echocardiogram
- chest x-ray
- elevated BNP - from ventricles in response to wall tension and pressure overload
Treatment for CHF
- Na+ restriction
- pharmacological
-- cardiac glycosides (digoxin, lanoxin)
-- diuretics (furosemide, hydrodiuril, lasix)
-- B blockers, ACE inhibitors, vasodilators
dilated cardiomyopathy
- ventricular dilation
- impaired systolic function
- diminished contractility
- decreased EF
- increased EDV
- biventricular failure
Dilated Cardiomyopathy: symptoms
- dyspnea
- fatigue
- weakness
- palipations
- pulmonary emboli
- HTN
Dilated Cardiomyopathy: treatmnet
- salt restriction
- meds to inc contractility (Digoxin)
- vasodilators
- anticoagulants
Hypertrophic Cardiomyopathy
- autosomal dominant
- thickening of interventricular septum
- increased contractility
- increased EF
- angina, syncope, palpitations, dyspnea, exercise intolerance, left heart failure
- treatment: B blockers
Restrictive Cardiomyopathy
- infiltrative disease of myocardium
- rigid and noncompliant
- increased filling pressures
- rt heart failure
- ex intolerance, dyspnea, fatigue, neck vein distention, peripheral edema
- treat: heart transplant
- death from failure or dysrhythmia
Valvular Heart Disease: causes
congenital or rheumatic fever
VHD: types
1. stenosis: narrowing, does not open completely
2. insufficiency/regurgitation: does not close completely
3. prolapse: 50% mitral, shaped different, won't close completely, congenital
Mitral Stenosis
cause: bacterial infection, rheumatic fever

severe: LA pressure inc, pulmonary congestion
Mitral regurgitation
causes: bacteria, RF
- backflow of blood from LV into LA
severe: LV hypertrophy - failure
- pulmonary congestion
Mitral valve prolapse
- benign
- floppy valve syndrome
- blood leaks back into LA not significant
- most asymptomatic
- no significant tx
aortic stenosis
cause: congenital
- most common valve lesion in US
- dec peripheral pulse
tx: balloon angiography or O.R.
aortic regurgitation
- blood leaks back into LV during diastole
- dec cardiac output
- ventricle dilates and hypertrophies
- diastolic murmur
Fetal Circulation/Post-natal circulation problems
- foramen ovale/ductus arteriosus
- murmur on auscultation
- cyanosis (inc with crying)
- high RR
- dec ability to suck
Ventricular Septal Defect
- most common heart defect
- blood shunts left to right
- systolic murmur
- usually discovered at first check-up
- cardiac catheterization
Atrial Septal Defect
- 2d most common defect
- systolic murmur and splitting of 2d sound
- discovered by echo
- surgery
Patent Ductus Arteriosus
- prostaglandin PGE1 and dec O2 keeps it open
- assess: wide pulse pressure and continuous machinery murmur
- prostaglandin inhibitor (indomethacin)
Tetralogy of Fallot
1. VSD
2. ovveriding aorta
3. pulmonary valve stenosis
4. right ventricle hypertrophy
Coarctation of the aorta
- stricture of aorta
- usually above ductus
- inc pressure in upper body
CoA: Assessment and Management
-headache
-HTN in UE, pounding pulse
- weak or no femoral pulse
- leg pain
- left congestive heart failure
- go in and open aorta
Pulmonary Stenosis
- stricture of pulmonary artery and/or valve
- RVH
- manage: PGE2 to open ductus or balloon angioplasty
Transposition of the Great Arteries
- mixed defect
- blind end circulation
- critical, life threatening, hypoxemia, cyanosis
- open heart surgery to repair
Rheumatic Fever
- strept throat, scarlet fever
- autoimmune to group A beta hemolytic streptococcus
- inc in 6-15 year-olds
- antibiotics, ASA, motrin, corticosteroids, phenobarbitol for chorea
FEV1
forced expiratory volume in 1 second
status asthmaticus
dilator does not work, life threatening
Asthma: diagnosis
- history and physical exam
- allergy testing
- dec FEV1 and FEV1/FVC ratio (<75%)
- marked response to bronchodilator (15% change in FEV1)
- dec FEV1 after exercise
- inc eosinophil
Acute Bronchitis: S/S
- dry, irritating cough
- wheezing
- sore throat
- malaise
- mild fever
- laryngitis
risk factors for COPD
- genes
- exposure to particles
- lung growth/development
- oxidative stress
- gender
- age
- respiratory infections
- socioeconomic status
- nutrition
- comorbidities
Chronic Bronchitis: S/S
- early stages: smokers cough
- frequent clearing of throat
- dyspnea, prolonged expiration
- dec exercise tolerance
- cyanosis
Blue Bloater
- cyanotic
- edematous
- productive chronic cough
- typical of chronic bronchitis
- overweight
Etiology of Emphysema
- environmental pollutants
- deficiency of alpha-1 antitrypsin
- factors cause inflammatory response
COPD: diagnosis
- symptoms progressive and persistent
- Hx of smoking
- PFT changes (dec FEV1 & FEV1/FVC ratio <75% predicted)
- dec O2 stats
- chest x-rays, flattened diaphragm, inc pulmonary vascular markings, bullous lesions
- alpha 1-antitrypsin in blood
Emphysema/COPD: Treatmen
- smoking cessation
- bronchodilators
- antibiotics for infections
- O2 therapy
- exercise training
- surgery (LVRS, lung transplant, segment, lobe
Cystic Fibrosis: Diagnosis
- genetic test
- positive sweat test (NaCl >60 mEq/liter)
- pulmonary function tests
- glucose tolerance test
Cystic Fibrosis: Treatment
- proper diet
- vitamin supplement
- replace pancreatic enzymes
- remove pulmonary secretions
- prompt treatment of pulmonary infections
- gene therapy
- prevent cross infection from Burkholderia Cepacia
Maturation causes of RLD
1. abnormal lung development (hyaline membrane disease-respiratory distress syndrome)
2. normal aging
Pulmonary causes of RLD
1. idiopathic pulmonary fibrosis
2. occupational lung disease
3. lung cancer
4. pleural effusion
Cardiovascular causes of RLD
1. pulmonary edema
2. pulmonary emboli
Neuromuscular causes of RLD
1. SCI
2. ALS
3. GBS
4. Myasthenia Gravis
5. muscular dystrophy
Musculoskeletal causes of RLD
1. diaphragmatic paralysis
2. kyphosis of scoliosis
3. ankylosing spondylitis
Other causes of RLD
1. pregnancy
2. obesity
3. trauma
4. burn
5. surgery
6. radiation Rx
7. drug-induced
Pulmonary Fibrosis: S&S
- rapid, shallow respiratory pattern
- limited lung expansion
- dry cough
- exertional breathlessness
- fine crackles on auscultation
- digital clubbing
Pulmonary Fibrosis: Diagnosis
- spirometry (dec TLC, pulmonary compliance, pCO2, impaired CO2 diffusing capacity)
- chest x-ray
- CT scans
- lung biopsy
Pneumonia: Types
- aspiration pneumonia
- viral pneumonia
- bacterial pneumonia
- walking pneumonia
- lobar pneumonia
- bronchopneumonia
Pneumonia: Tx
- anti-microbial agents
- rest and fluids
- supp O2
- most cases resolve in 1-2 weeks
- vaccine - 65 yo
- deep breathing, coughing