Pp2 Tutorial 3

Front 1

Define sign.

Back 1

A sign is something you as a clinician can actually look at and tell your patient about. It is objective. For example, taking a patient's blood pressure, it is objective and you can tell the patient if it is normal/abnormal

Front 2

Define symptom.

Back 2

A symptoms is something the patient identifies and will prompt them to seek out a practitioner. A symptom usually precedes the phrase 'I feel'. For example, 'I feel pain in my left leg.' It is subjective.

Front 3

Define investigation.

Back 3

An investigation is something you have to send away for as it is something you can't see without an instrument. For example, a blood test or an X-ray

Front 4

Define asymptomatic.

Back 4

Means not symptomatic or a lack of symptoms. Disorders that are asymptomatic usually go unnoticed as there are no symptoms to prompt the patient to go see a practitioner.

Front 5

Define manifestation.

Back 5

A manifestation include everything: signs, symptoms, and investigations.

Front 6

The book you are using says that small to medium pulmonary emboli are asymptomatic. The manifestations of small to medium pulmonary emboli include dyspnoea. Based on this information only, has the book used them term "asymptomatic" correctly?

Back 6

No, the term "asymptomatic" for small to medium pulmonary emboli is used incorrectly as dyspnoea - a shortness of breath - is a symptoms as it is something that the patient can identify.

Front 7

Parathyroid hormone is involved in metabolic disorders of the bone. Describe the relationship between PTH, calcium, and vitamin D in a flow chart.

Back 7

- PTH release is stimulated by low levels of calcium. PTH increases the synthesis of active vitamin D (which is considered a hormone), stimulates osteoclast activity to release calcium from the bone, and increases reabsorption of calcium from the kidneys
- Active vitamin D stimulates absorption of calcium in the intestines as well as stimulating the release of calcium from the bone

Front 8

Using this flow chart, explain the manifestations of primary hyperparathyroidism with particular emphasis on levels of calcium in the blood, and type of bone dysfunction.

Back 8

What happens: Occurs at the parathyroid gland. If a person has a tumour for example it would produce lots and lots of PTH. Osteoclasts would be vigorously stimulated, breaking down more than we can build up.

Manifestations:
- Osteoporosis
- Excess amounts of calcium and phosphorus in the body; calcium is lost and phosphorus is kept; therefore there are low levels of calcium and high levels of phosphorus
- Calcium not reabsorbed in the intestines

Front 9

Using the flow chart, explain the manifestations of osteomalacia with particular emphasis on levels of calcium in the blood, and type of bone dysfunction.

Back 9

What happens: A disorder where there is decreased amount/levels of synthesis of vitamin D in the diet or we are not able to convert it for whatever reason, e.g. lack of PTH; no calcium being absorbed in intestines

Manifestations:
- Low levels of calcium in the blood; decreased absorption in the intestines
- Increased PTH due to low calcium levels; calcium released from the bone
- Rapid breaking down of bone

Front 10

Using this flow chart, explain the manifestations of renal disease (renal rickets) with particular emphasis on levels of calcium in the blood, and type of bone dysfunction.

Back 10

What happens: the kidneys are malfunctioning and reabsorption of calcium in the kidneys does not occur.

Manifestations:
- Decreased calcium levels in the blood/body
- Consequently increased phosphorus levels
- Increased PTH which increases the release of calcium from bone which breaks the bone down.

Front 11

Describe the structure and function of the components of a synovial joint.

Back 11

1. Articular cartilage - the surface the glides against other articular cartilages and yields almost no friction.
2. Synovial membrane: very, very rich is blood supply which allows nutrients to come very easily into the synovial fluid. It is set up this way as the nutrients are needed to maintain and protect the condrocytes of the articular cartilage. The articular cartilage itself has no direct blood supply so it cannot provide nutrients to condrocytes by itself.
3. Synovial fluid - highly viscous, egg-white consistency fluid; provides nutrients to the articular cartilage; helps aid in gliding of articulating surfaces.
4. Sub-condral bone - is the bone directly under the articular cartilage; condrocytes reside in both the sub-condral bone and the articular cartilage

Front 12

For an infective pathology of the synovial joint, what are the general structural changes and clinical manifestations expected; include systemic manifestations and an example.

Back 12

Example: Septic arthritis

- very hot, red, swollen joint
- joint very inflamed
- acute in presentation
- fever
- unilateral

Front 13

For the autoimmune rheumatic pathology, name the general structural changes and clinical manifestations you would expect to find; include systemic manifestations and give an example.

Back 13

Example: Rheumatoid arthritis

- bilateral, often symmetric
- not very acute; occurs in exacerbations and remissions; usually gets worse over time
- joint will feel spongey, warm or hot - but not as acute as septic arthritis
- as it gets worse there will be systemic manifestations such as a low grade fever due the body attempting to get rid of the autoantibodies

Front 14

For the degenerative rheumatic pathology, name the general structural changes and clinical manifestations you would expect to find; include systemic manifestations and an example.

Back 14

Example: osteoarthritis

- most of the time is unilateral due to degeneration from using one side more than the other or an injury on one side; can be asymmetric
- Does not feel hot or swollen
- crepitus can be heard
- Vague inflammation and warmth - but this is often not felt

Front 15

What are the manifestations of Rheumatoid Arthritis? (11)

Back 15

- Autoimmune disorder
- slow, insidious process
- chronic inflammation resulting in fibrosis
- ulnar deviation
- bilateral, symmetric
- warm joints feel fairly spongey
- low grade fever
- joint pain and stiffness; limitation in ROM
- swelling of the joint due to swelling and thickening of the synovium
- development of pannus
- systemic symptoms (later on): weight loss, anorexia, fatigue, weakness, low grade fever

Front 16

List the clinical manifestations of Osteoarthritis.

Back 16

- degenerative disorder
- can be sudden or insidious
- aching pain, difficult to localise
- pain worsens with use; pain can occur at rest
- crepitus and grinding of joint with movement
- swelling of joint
- stiffness of joint
- limited motion of joint due to pain

Front 17

Describe the process of Rheumatoid Arthritis.

Back 17

- The IgG complex is attacking a portion of the body - the joints
- This causes immune complexes to form and a cascade of event occurs
- The permeability of the capillaries increases which allows more blood to come to the area
- The extra blood dilutes the viscous synovial fluid which decreases its protectiveness of the joint
- Pannus (granulation tissue) starts to develop
- The granulation tissue starts to destroy the articular cartilage
- As more and more granulation tissue forms, it starts to push out the joints and the tendons are no longer long enough -- this causes ulnar deviation which is a late manifestation of RA

Front 18

Describe the process of Osteoarthritis.

Back 18

- Osteoarthritis is a degenerative disorder which occurs due to repeated use of one particular joint or an injury to one particular joint
- In a normal joint there is a normal amount of synovial fluid which serves as a cushion to impacts
- In osteoarthritis, the repeated impact upon this one joint causes the fluid to be pushed out of the area and it does not come back in
- As there is less synovial fluid the articular cartilage starts to wear out
- With the extra abuse there will be regular or irregular thickening of the sub-condral bone and the development of cysts in the sub-condral bone that can break through and crack the articular cartilage
- Eventually the articular cartilage is worn out to the extent that bone is rubbing against bone which can be very painful

Front 19

Why does gout manifest as it does? (Describe the properties of uric acid and the properties of the location of the first bout of gout in your explanation.)

Back 19

Gout manifests as excruciating pain, often in the big toe. The excrutiating pain is caused by 2 reasons: (1) The structure of uric acid, a break down product of purines, is sharp and needle-like which in itself is very painful; and (2) When uric acid crystals are deposited, macrophages come to the area and engulf them. Within 24 hours the macrophages die as the uric acid is actually toxic to them. The pain comes from the macrophages dying and bursting open to release all their toxic lysosomal enzymes into the area. The first bout of gout a person gets usually occurs in the big toe; this can be due to 2 reasons: (1) the viscosity of the synovial fluid is a good medium for the crystals, and (2) the big toe is one of the coolest parts of the body. In other parts of the body the temperature would be hotter and therefore the crystals would be dissolved; but as the uric acid crystals travel further down the body, the temperature gets cooler and cooler and less crystals are able to be dissolved at this temperature.