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final exam patho
endocrine, gi, ears/eyes
| Question | Answer |
|---|---|
| amsler grid | tests for macular problems |
| tonometry | measures intraocular pressure |
| perimetry testing | evaluates the field of vision |
| slit-lamp examination | enables the user to examine the eye with high magnification |
| color vision testing | tests the ability to differentiate colors |
| ultrasonography | used to identify lesions in the globe or the orbit |
| fluorescein angiography | dye is injected into retinal vessels |
| snellen chart | visual acuity |
| refractive errors | impairment due to shortened or elongated eyeball |
| myopia | nearsightedness (distant vision is blurred) |
| hyperopia | farsightedness (near vision is blurred) |
| presbyopia | aging |
| astigmatism | an irregularity in the curve of the cornea |
| amblyopia | lazy eye |
| strabismus | crossed eyes |
| color blindness | cannot see certain colors |
| blindness | vision that can't be corrected to better than 20/200; regular 20/20 |
| blepharitis | inflammation of eyelid (granulated eyelids) |
| appearance of blepharitis | dry, gritty sensation in eye, photophobia present |
| stye (hordeolum) | bacterial infection near root of eyelash that appears on the outside of the eye |
| most common cause of stye | s. aureus |
| chalazion | blockage of meibomian gland near margin of eyelid |
| keratitis | inflammation of cornea, often caused by HSV that begins superficially, but may go deeper |
| acanthamoeba keratitis | can occur if contact lenses are contaminated with ameba; usually localized infection that can lead to corneal scarring, uveitis, scleritis, and cataract |
| keratoconjunctivitis sicca | dryness of conjunctiva; common in autoimmune disorders; associated with reduced tear production |
| dacryocystitis | inflammation of lacrimal sac, fever is common, may occur in newborns; eye is red, watery with purulent exudate |
| scleritis | inflammation of sclera; severe pain may radiate to eyebrow or temple; photophobia; associated with autoimmune disorders |
| photophobia | sensitivity to light, especially in light |
| corneal abrasion | damage of epithelial surface of cornea; most common type of eye injury, usually heals within 24 hrs |
| most @ risk for corneal abrasion | contact lens wearers; may present with sense of foreign body in the eye, gritty eye, photophobia |
| what reveals corneal abrasion | slit lamp examination |
| prevention of corneal abrasion | antibiotic ointment |
| glaucoma | group of ocular conditions characterized by optic nerve damage related to increased intraocular pressure (IOP); related to the impedance of aqueous fluid outflow from the eye |
| two types of glaucoma | open-angle glaucoma and angle-closure glaucoma |
| open-angle glaucoma (POAG) | asymptomatic, progressive damage to optic nerve and visual field; most common form |
| angle-closure glaucoma (PACG) | inherited, acute; painful; halos, blurred vision, & ocular pain (vision loss) |
| glaucomas are not curable and have few early symptoms | management is centered on systemic and topical ocular medications |
| diagnosis of glaucoma | increase optic cup to optic disc ratio on fundoscopic exam |
| risk factors of glaucoma | age >40, ethnicity, history of migraine headaches, cardiovascular disease |
| presentation of glaucoma | history-age, use of lenses, fam history, anticholinergic medications; complaints-eye pain, redness, halos around lights, vision loss; fundoscopic exam necessary for central vision; signs-rapid in PACG, progressive in POAG |
| POAG patho not completely understood | changes in ciliary muscle, trabecular meshwork, and canal of Schlemm preventing drainage of aqueous fluid from anterior chamber; as ocular fluid cant drain, pressure is placed on retina and junction of optic nerve |
| POAG patho not completely understood 2 | optic cup enlarges under high IOP; high IOP not only factor resulting in optic nerve damage in glaucoma |
| PACG patho | people born w narrow angle bw iris and cornea @ greater risk; certain drugs like sympathomimetics, anticholinergics, antidepressants may inc risk for AACG; more common in hyperopic individuals; sudden inc in IOP causes sudden loss of peripheral vision |
| acute angular-closure glaucoma (aacg) | acute presentation, ocular emergency, immediate treatment needed |
| cataracts | due to excessive growth of epithelial layer of lens; present with gradual vision loss and seeing halos at night; may have opacity covering |
| senile cataracts | advancing age, smoking, obesity, diabetes, exposure to uv light |
| congenital cataracts | develop in fetus due to infection, such as rubella, syphilis, cmv |
| retinal detachment | retina pulls away from back of eye; patient reports photopsia; ophthalmoscopic examination, treatment depends on type and size of detachment |
| photopsia | floaters in vision and shadows in peripheral field |
| age-related macular degeneration (amd) caused by | genetic, environmental, and behavioral factors |
| macula | area of retina that provides central vision begins to deteriorate leading to development of blind spot and painless loss of vision |
| two types of amd | dry, wet; |
| dry (nonexudative) amd | 90% of those w disease |
| wet (exudative) amd | more severe |
| both dry and wet amd involve inability to remove cellular debris from retina | drusen deposits form and appear as yellow-white accumulations in macular region |
| diagnosis of amd | amsler grid to measure central vision; in macular degeneration central vision is compromised while peripheral vision remains intact |
| papilledema | swelling of optic nerve caused by inc ICP; patient complains of headache, nausea, double vision; sign of life=threatening intracranial HTN; borders of optic disc are unclear and undefined; treatment involves managing cause of inc ICP |
| diabetic retinopathy | high glucose levels, associated with diabetes mellitus, damage the vessels of retina |
| two forms of diabetic retinopathy | nonproliferative and proliferative |
| nonproliferative diabetic retinopathy | early in diabetes, fundoscopic exam reveals tiny aneurysms, microinfarcts, nerve damage "cotton wool spots" |
| proliferative diabetic retinopathy | later in diabetic course; diabetes stimulates vasoactive growth factors, inc vessels in retina |
| presentation of diabetic retinopathy | document glucose control, medications, prior ophthalmic exams; initially, may be asymptomatic; w disease progression, patient may complain of blurred vision, poor night vision |
| diagnosis of diabetic retinopathy | involves slit lamp examination and fundoscopic exam; inc optic cup to optic disc ratio on fundoscopic exam |
| conjunctivitis | inflammation of conjunctiva; major causes are microbial infection, allergy, irritating toxic stimuli |
| bacterial conjuctivitis | acute or chronic; results in redness, burning, and discharge-pink eye |
| viral conjuctivitis | acute or chronic; causes watery discharge |
| conjuctivitis is self-limiting | severe cases require topical antibiotics, eye drops, or ointments |
| manifestations of conjunctivitis | scratching/burning sensation, itching, photophobia, discharge/exudate; extreme pain (corneal disease) |
| allergic conjunctivitis | confused w infective forms; inflammation caused by airborne antigens, condition may occur in individual w asthma or eczema |
| palpebral conjunctiva becomes inflamed and swollen w cobblestone appearance | tearing and redness of eyes, accompanied by itching |
| anti-histamines, NSAIDS can be helpful for | allergic conjunctivitis |
| inner ear structures | labyrinth (bony and membranous), utricle, saccule, semicircular canals |
| fluids in inner ear | perilymph and endolymph |
| functions of inner ear | balance and hearing |
| oscillations in fluid due to physical movements in inner ear | detected by CN VIII |
| balance | depends on vision, inner ear, proprioception |
| hearing thru | cochlea, organ of corti (spiral-shaped, receptor for hearing); contains perilymph and stereocilia which respond to vibrations of sound waves being transmitted; activation of stereocilia sends signals along CN VIII |
| audiometry | most important hearing test |
| tympanogram | measures middle ear response |
| genetic testing of ear | connexin-26:marker for genetic deafness; mutation of protein (GJB2) that regulates endolymph in inner ear can cause hearing impairment |
| other diagnostics of ear | mri and ct can detect ear abnormalities; audio brainstem response testing; otoacoustic emissions (OAEs) and audiometry testing |
| decibel | unit to describe loudness of sound; o:threshold for sound |
| normal conversation in decibels | 60 dB |
| whisper in decibels | 0-20 dB |
| sounds greater than how many dB can cause hearing loss | 85 dB |
| hearing loss is classified based on range of | sounds that cannot be heard |
| mild hearing loss | lower than 26-40 dB; difficulty following conversations |
| moderate hearing loss | lower than 41-55 dB; hearing aid to hear normal conversation |
| severe hearing loss | lower than 60-90 dB; can hear speaking, but can not make out words (unless watching lips and mouth); hearing aid needed |
| profound hearing loss | lower than 90 dB; hearing aids, lip reading, sign language |
| hearing loss can be described as | genetic, acquired, progressive, sudden, unilateral, bilateral, partial, complete, reversible, irreversible |
| conductive hearing loss (CHL) | disorder of sound transmission from outer or middle ear to receptors of middle ear; common cause=impacted cerumen, otitis media |
| sensorineural hearing loss (SNHL) | disorder of inner ear, auditory nerve, or auditory pathway in brain; central hearing impairment; commonly due to loss of stereocilia in organ of corti; can be caused by noise trauma, infections, genetic disorders |
| central hearing impairment | damage to brain in which sounds are heard, cannot be understood |
| mixed hearing deficiency | combination of chl and snhl |
| conditions of external ear | cerumen impaction and foreign bodies |
| cerumen impaction | can be removed by irrigation, suction, or instrumentation |
| foreign bodies | can be difficult to remove but are treated in same way as impacted cerumen |
| otitis externa (swimmers ear) | mild to severe inflammation of external ear; infectious agents/allergies (water in ear canal can predispose infection); movement of external ear may be painful; once infection resolved, swimming w ear plugs may be recommended |
| tympanic perforation | caused by infection or trauma; causes whistling sounds upon sneezing and blowing nose, reduced hearing, purulent drainage, and pain; may heal spontaneously or require tympanoplasty |
| tympanoplasty | surgical repair of tympanic membrane |
| tympanic membrane perforation | complication of middle ear infection or trauma; symptoms of perforation (buzzing sound in ear, earache, and hearing loss); most small ruptures heal spontaneously (~4 weeks) |
| treatment tympanic membrane perforation | ear drops should not be used, systemic antibiotics may be needed; cauterization of membrane edges and patching may be needed; surgical tympanoplasty can be done |
| otitis media | infection of middle ear; can be related to URIs, most common in children (shorter, wider, and more horizontal eustachian tubes than in adults); pneumatic otoscope demonstrate dec movement of tympanic membrane |
| signs and symptoms include fever, earache | children may present w nonspecific symptoms such as ear tugging, poor feeding, irritability; tympanic membrane rupture is possible; physical exam reveals reddened tympanic membrane |
| otosclerosis | callus on stapes (stapes cannot transmit vibrations, progressive hearing loss, usually in one ear); audiogram shows conductive hearing loss; stapedial reflex; surgery only option for treatment |
| stapedial reflex | special type of testing will show limited ossicle movement |
| vertigo | misperception or illusion of motion of person or surroundings |
| nystagmus | involuntary rhythmic movement of eyes |
| inner ear conditions affect | balance and hearing |
| ménière disease | disorder of inner ear causing vertigo, tinnitus, a feeling of fullness or pressure in ear, and fluctuating hearing loss; results from changes in pressure within the inner ear or mixing of inner ear fluids |
| ménière disease affects | 40-50 years, unknown etiology; most patients successfully treated w diet and medication; some require antihistamines, tranquilizers, antiemetics, or surgery |
| tinnitus | roaring, buzzing, or hissing sound in one or both ears that may be irreversible |
| tinnitus symptom | underlying disorder of ear that is associated w hearing loss- red wine, caffeine, meniere's disease |
| vertigo | sense of "room spinning", an exaggerated sense of movement, dizziness; nausea and vomiting may accompany; alterations in inner ear, meniere's disease; must distinguish from dizziness |
| ototoxicity | results from medications that have adverse effects on the cochlea, vestibular appartus, or cranial nerve VIII; patients receiving potentially ototoxic medications should be counseled about this side effect |
| acoustic neuroma | slow-growing, benign tumor of cranial nerve VIII (vestibular schwannomas); causes tinnitus and hearing loss; treated surgically |
| hearing loss in older adults | presbycusis; begin @ around at 50 yrs; gradual loss of hair cells in cochlea; high-frequency sounds are lost first; hearing aids are often recommended |
| types of bone tissue | cancellous (trabecular) and cortical (compact) |
| bone cells | osteoblasts, osteocytes, osteoclasts |
| osteoblasts | build bone matrix |
| osteocytes | mature bone cells |
| osteoclasts | dissolve and resorb bone |
| categories of bones | long bones (femur), short bones (metacarpals), flat bones (sternum), irregular bones (vertebrae) |
| bone maintenance | constant and simultaneous resorption (removal/destruction of tissue) and osteogenesis (bone formation) |
| bone maintenance affected by multiple issues | calcium and vitamin d in the diet, physical activity, tobacco and alcohol, sex, size, age, race and family history; hormone levels-parathyroid, calcitonin, vit d, thyroid, testosterone; eating disorders and other conditions; certain meds |
| bone healing stages | 1. early inflammatory/hematoma formation stage 2. granulation tissue formation; fibroblasts to injury growth of vascular tissue 3. repair stage 4. remodeling stage |
| early inflammatory/hematoma formation stage | hematoma formation, granulation tissue, vascular tissue formation |
| repair stage | laying down of new bone tissue (cartilaginous callus), angiogenesis continues |
| remodeling stage | callus removed, bone strengthens returns to normal shape, size, structure, and strength |
| ball-and-socket joints | hip and shoulder |
| hinge joints | elbow and knee |
| saddle joints | joint at the base of the thumb |
| pivot joints | articulation bw radius and ulna |
| gilding joints | joints of carpal bones in wrist |
| ligaments | connect movable bones of joints |
| tendons | connect muscles to bones |
| synovial fluid | located in synovium of joint capsule lubricates and facilitates movement |
| bursa | sac w synovial fluid that cushions movement of tendons, ligaments, and bones at a point of friction |
| fascia | fibrous tissue that encases muscles |
| skeletal (striated) muscles | involved in body movement, posture, and heat-production functions |
| skeletal muscle | composed of skeletal muscle fibers; can undergo hypertrophy or atrophy |
| myofilaments | actin and myosin |
| healing process of skeletal muscle | regeneration heightened in response to injury, myocytes (muscle fibers), injury to surrounding nerves and blood vessels play a role in return to function, repaired muscle is not as strong as it was prior to injury |
| muscle tone (tonus) | state of muscle readiness |
| flaccid muscle | muscle that is limp and without tone |
| spastic muscle | muscle w greater-than-normal tone |
| atonic muscle | denervated muscle |
| hypertrophy | inc in muscle size |
| atrophy | dec in muscle size |
| diagnosis of musculoskeletal system | x ray, computed tomography, mri, arthrography, bone densitometry, bone scan, arthroscopy, arthrocentesis, electromyography, biopsy, lab studies |
| major trauma following life-saving measures (ABCDE) | airway w cervical spine protection, breathing and ventilation, circulation and hemorrhage control, disability and neurological evaluation, exposure and environmental control |
| closed (complete) fracture | fracture in which bone fragments separate completely |
| open (compound) fracture | fracture of bone that protrudes to the outside of the body |
| incomplete fracture | fracture in which the bone fragments are still partially joined |
| compression fracture | fracture that consists of crushing of cancellous bone |
| transverse fracture | fracture where parts of bone are separated but close to each other |
| comminuted fracture | fracture w more than one fracture line and more than two bone fragments, which may be shattered or crushed |
| stress fracture | failure of one cortical surface of bone, often caused by repetitive activity |
| avulsion fracture | separation of small fragment of bone at site of attachment of ligament or tendon |
| greenstick fracture | incomplete break in bone w intact side of cortex flexed (one side is broken and other is bent); usually in children |
| impacted fracture | one part of fracture is compressed into an adjacent part of fracture |
| fracture | complete or partial break in continuity of bone; trauma, overuse, diseases that weaken bone |
| manifestations of fractures | pain, lose of function, deformity, shortening, crepitus, swelling, and discoloration |
| priorities of fractures | immobilization, assessment of neurovascular status, infection prevention, and maintenance of hemodynamic stability |
| long bone and pelvic fractures inc | risk of fat embolism |
| fracture treatment | reduction , immobilization, and regaining of normal function and strength thru rehabilitation |
| reduction | restoration of fracture fragments to anatomic alignment and rotation; performed "open" (surgically) or "closed" (manipulation and manual traction) |
| open fractures management | wound irrigation and debridement necessary |
| potential complications of fractures | fat embolism syndrome (FES);delayed union, malunion, nonunion;venous thromboemboli;disseminated intravascular coagulation (DIC);avascular necrosis;reaction to internal/external fixation devices;complex regional pain syndome (CRPS);hetertropic ossification |
| treatments of fractures | self-limiting; RICE therapy; realign bones; measures to prevent DVTs (compression stockings, meds to prevent clotting) |
| closed reduction realignment | device worn outside |
| open reduction realignment | surgical insertion of hardware |
| ORIF stands for | open reduction and internal fixation |
| RICE therapy | rest, ice, compression, elevation |
| neurological and vascular injury | arterial injury is a concern in some fractures |
| to asses neurovascular status, check pulses and sensation distal to injury | 5 P's- pain, pulse, pallor, paresthesia, paralysis (add temp too) |
| patient exhibits what during neurological and vascular injury | pain, weakness, lack of sensation, decreased motor strength, absent or weak pulses |
| if neurological compression prolonged | severe atrophy of muscle |
| compartment syndrome | tissue pressure exceeds perfusion pressure in closed anatomical space; ischemia, necrosis, and functional impairment; weak distal pulses or pulselessness |
| patient complains of what during compartment syndrome | pain out of proportion of degree of injury--> immediate surgical evaluation |
| rhabdomyolysis | muscle breakdown; myoglobin accumulates in bloodstream; elevated CK levels; may occur in compartment syndrome |
| myoglobin in bloodstream | kidneys must filter myoglobin, which is toxic to nephrons in large amounts; leads to acute reanal injury |
| triad of symptoms in rhabdomyolysis | myalgia, weakness, and myoglobinuria |
| joint dislocations occur when | articular surfaces of bones forming the joint are no longer in anatomic alignment; forced out of normal position due to injury, fall, accident; common in shoulders, elbows, fingers, ankles, knees, hips, jaw |
| joint dislocation manifestations | pain and visible changes in alignment of joint, immobility of joint, swelling, muscle spasms |
| joint dislocations require | immobilization followed by reduction (put back in place) and rehabilitation for several weeks |
| hip fracture (proximal femur) | very high incidence among older adults and associated w high risk of mortality |
| surgical options for hip fracture | replacement of femoral head w prosthesis (hemiarthroplasty) or open/closed reduction of fracture and internal fixation |
| priorities for hip fracture | management of activity and mobility and prevention of postsurgical complications |
| total hip arthroplasty (tha) | surgical replacement of hip joint w artificial prothesis; preoperative care prioritizes patient education about positioning and assessment for infection |
| postoperative priorities for THA | positioning to prevent dislocation, promoting ambulation, monitoring for complications, monitoring wound drainage, preventing DVT and infection |
| contusion | soft tissue injury produced by blunt force; bruise |
| strain | injury to musculotendinous unit caused by overuse, overstretching, or excessive stress; pulled muscle |
| sprain | injury to ligaments and supporting muscle fibers that surround a joint; rolled ankle |
| treatments for contusion, sprain, strains | resting and elevating affected part, applying cold and using compression bandage (RICE) |
| important to monitor neurovascular status of injured extremity during injury | color, sensation, pulse, temp, movement (6 Ps- pain, pallor, parasthesia, poikilothermia, paralysis, pulselessness) |
| bursitis | inflamation of bursae of joints; pain, swelling, stiffness around joint; causes: repetitive movements, excessive pressure on joints, injury |
| tendonitis (ex lateral epicondylitis (tennis elbow)) | inflammation of tendons, common in 30-50; pain @ or around joint, gradual or sudden severe pain @ affected part, stiffness or loss of motion in affected join, tenderness, mild swelling or thickening; causes similar to bursitis |
| carpal tunnel syndrome | pain, tingling, numbness of hand, fingers, weakness in hands; occurs when median nerve @ wrist is compressed, pregnancy, trauma, occupation, diabetic neuropathy, hypothyroidism |
| ganglion | collection of gelatinous material near tendon sheaths and joints that appear as round, firm, compressible, cystic swelling |
| bone health | constant remodeling, dependent on calcium, hormones (vitamin d (calcium absorption), calcitonin, parathyroid hormone, testosterone and estrogen), mechanical stimulation |
| synarthrosis | no mobility in joints |
| diarthrosis | most movement; synovial joint |
| amphiarthrosis | moderately movable joint |
| arthropathy | joint disorder |
| arthritis | inflammation of joint |
| bone remodeling | destruction and reconstruction of bone |
| degeneration of bone involves | osteoclasts and osteoblasts; stimulated by stresses upon bone |
| osteoporosis | elevated osteoclast activity without adequate bone replacement |
| recommended calcium intake to maintain bone health | 1,000-1,200 mg/day |
| osteoarthritis affects certain joints and not others | cervical and lumbosacral spine, hip, knee, 1st metatarsal phalangeal joint; wrist, elbow, and ankle are often spared |
| chondrocytes produce cartilage | cartilage loss w age, cartilage along w synovial fluid provide cushioning |
| articular cartilage deterioration | excessive force causes cartilage to breakdown; subchondral bone deterioration |
| osteophytes | form @ margin of cartilage loss, hallmark of osteoarthritis (OA) |
| osteoarthritis | synovial membrane becomes inflamed; concentration of lubricin (glycoprotein that acts as lubricant) declines |
| osteoporosis "porous bone" | low bone density, structural deterioration of bone, breaks in travecular matrix |
| osteopenia | thinning of travecular matrix (before osteoporosis) |
| silent disease of osteoporosis | may present w pathological fracture or height loss |
| primary osteoporosis | prolonged negative calcium balance; poor dietary habits, lack of weight-bearing exercise, lack of daily exposure to sunlight |
| secondary osteoporosis | disorders that affect bone tissue; hyperparathyroidism, corticosteroids |
| hormones play role in bone material density (BMD) | estrogen slows osteoclast activity |
| female athlete triad w osteopenia | amenorrhea, dec body weight, excessive exercise |
| risk factors for osteoporosis | female, postmenopausal age, lack of estrogen, lack of testosterone, fam history, asian/caucasian women, thin/small-framed women, lack of Ca and vitamin d, lack of weight-bearing exercise, excess alcohol, excess caffeine, smoking |
| risk factors of osteoporosis 2 | long term use of corticosteroids, excess carbonated soft drink consumption, gastric bariatric surgery, eating disorders, hyperthyroidism or excessive intake of thyroid medican, hyperparathyroidism, anticonvulsant medications |
| osteoporosis diagnosis | dual energy x ray absorptiometry (DEXA); x-rays do not show osteoporosis until bone loss >40%; blood tests; urine; FRAX risk assessment |
| dual energy x ray absorptiometry (DEXA) | measures BMD, compared w reference population of healthy adults (30); reported at T score |
| osteoporosis blood tests | PTH, estradiol, osteocalcin (protein in bone, high level indicates bone breakdown) |
| osteoporosis urine | telopeptides, bone breakdown product |
| FRAX risk assessment | self-assessment tool to predict a person's risk of fracture; gives 10-year probability of a fracture in spine, hip, shoulder, wrist; age 40-90 |
| osteoarthritis (OA) | >40 yrs; associated w trauma to joints over course of life (slowly progressive, degenerative, inflammatory condition; changes in cartilage lead to inflammation and changes in joint surfaces); excess weight inc risk for OA in weight-bearing joints |
| risk factors osteoarthritis | aging, obesity, history of participation in team sports, history of trauma or overuse of joint, heavy occupational work, misalignment of pelvis, hip, knee, ankle, or foot |
| presentation of OA | deep, aching joint pain; pain relieved w rest; joint pain in cold weather; stiffness arising in morning; crepitus of joint during motion; joint swelling, deforming, tenderness; altered gait; limited/dec range of motion; fingers involved |
| heberden's nodes | distal interphalangeal joint (DIP); swelling in OA |
| bouchard's nodes | proximal interphalangeal joint (PIP); swelling in OA |
| OA diagnosis | no specific lab test, serum markers (osteocalcin and hyaluronic acid), physical exam, xray confirms diagnosis (joint space narrowing/osteophytes) |
| degenerative disc disease (DDD) | common cause of pain, motor weakness, and neuropathy; nervous system affected as vertebral disc distortions compromise spinal nerves; cervical/lumbar regions affected: L4, L5, S1 |
| degenerative disc disease causes spinal impingement | herniated disc, bulging disc, degenerated disc, osteophyte formation, slippage of disc and vertebrae |
| osteophyte formation for DDD | bony formations can narrow the spinal canal, spinal stenosis |
| slippage of disc and vertebrae for DDD | spondylolithesis: forward; retrolisthesis: backward |
| sings/symptoms of lumbar DDD | pain in lower back that radiates down back of leg; pain in buttocks or thighs;pain that worsens when sitting, bending, lifting, or twisting;pain that is minimized when walking, changing positions, or lying down;numbness,tingling,weakness in legs;foot drop |
| sciatica | pain in lower back that radiates down the back of leg |
| signs/symptoms of cervical DDD | chronic neck pain that can radiate to shoulders and down the arms; numbness or tingling in arm or hand; weakness of arm or hand |
| physical exam of DDD | muscle strength, deep tendon reflexes, sensory dermatomes (give info about which spinal nerve is affected) |
| diagnostics of DDD | physical exam tests, xray, mri, emg |
| osteomyelitis | infection of bone (s. aureus) acute or chronic; can result from extension of soft tissue infection, direct bone contamination, or hamatogenous (bloodborne) spread |
| osteomyelitis results in signs/symptoms of sepsis | recurrent/persistent fever, pain, malaise, poor incisional healing, drainage @ wounds |
| antibiotic therapy depends on results of blood and would cultures | surgical debridement may be indicated for DDD |
| bone | normally resistant to infection |
| bacterial infections most common | infection due to break in bone, infection from bloodstream |
| bacteria invades cortex via | haversian and volkmann canals |
| risk for bone infections | immunosuppression, comorbid diseases (diabetes mellitus), nutritional deficiency, prosthetic material |
| contiguous spread | invasion of microorganism via puncture or wound; s. aureus |
| hematogenous spread | spread via bloodstream, group a streptococci, or s. pneumoniae |
| cartilage covers the articular surfaces of bone | avascular w limited ability to repair and heal |
| synovial fluid | found in synovial joints, amount of fluid may in in disease states, joint effusion (edema of joint), limited blood supply: difficulty in delivering meds (use intra-articular injection) |
| stages of bone infection | 1. inflammation 2. suppuration 3. sequestrum 4. involucrum 5. resolution or progression to complications |
| inflammation | vascular congestion and inc pressure within interior bone |
| suppuration | infectious material enters Haversian system and abscess formed |
| sequestrum | inc pressure, vascular obstruction, and thrombi compromise blood supply, causing bone necrosis in approximately 7 days |
| involucrum | new bone formation from surface of periosteum |
| resolution/progression to complications | w antibiotics and surgical treatment early in disease process: osteomyelitis resolves; if no resolution: gangrene, necrotic tissue can develop |
| osteomyelitis | infection of bone; normally bacterial (s. aureus); sickle-cell anemia: salmonellae |
| presentation of osteomyelitis | assess for recent infections; chills, fever, malaise; localized tenderness, erythema, edema |
| 3 categories of osteomyelitis | hematogenous, contiguous, chronic |
| hematogenous osteomyelitis | rapid onset of symptoms; most cases in children (inc vascularity in growing bone) |
| contiguous osteomyelitis | trauma and surgery are common causes, as well as decubitus ulcers; individuals w DM, PVD are at inc risk |
| chronic osteomyelitis | defined by length of time (longer than 6-8 weeks), lack of response to meds; necrotic bone (inc gangrene risk) |
| diagnosis of osteomyelitis | CBC, ESR, C-RP; blood cultures (+ only 50% of patients); culture and aspiration may fail to identify pathogen; xray (normal at first, ct scan, mri) |
| treatment of osteomyelitis | long-term antibiotics, debridement, surgical drainage of wounds |
| septic arthritis (infectious arthritis or pyogenic arthritis) | direct invasion of joint space by pathogen; bacterial infections most common; present w inflammation and acute pain around joint, fever, and malaise may occur |
| diagnosis of septic arthritis | defective diagnosis-detection of bacteria from blood or synovial fluid; joint aspiration required; culture of aspirated fluid |
| gout | hyperuricemia triggers inflammation; affects specific joints (first metatarsal); primary and secondary forms |
| podagra | acute inflammation of metatarsophalangeal joint of great toe |
| with gout, uric acid crystals may be deposited in subcutaneous tissue (tophi) | patient presents w redness, warmth, swelling of joint; discomfort onsets during night or early morning |
| chronic gout involves several joints | can be confused w OA and RA; hyperuricemia can lead to kidney stones |
| diagnosis of gout | rule out other joint inflammatory conditions (24 hr urine uric acid); hyperuricemia may not be present and should not be used for as sole diagnostic criteria; aspiration of joint showing urate crystals is gold standard for diagnosis |
| risks for gout | diet high in meat (purines:uric acid); high alcohol consumption, obesity (yo-yo dieting); fam history; chemotherapy resulting in cell destruction; meds |
| endocrine glands secrete | chemical messengers (hormones) into bloodstream |
| hypothalamus | sends signals to pituitary gland |
| anterior pituitary | receives hormonal signals from hypothalamus |
| posterior pituitary | releases hormones synthesized by hypothalamus |
| end organs | targets for pituitary hormones, may or may not secrete additional hormones |
| hypothalamic-pituitary-hormonal axis | link bw hypothalamus-pituitary-end organ |
| pituitary aka | hypophysis |
| anterior pituitary aka | adenohypophysis |
| anterior pituitary | blood vessel connection w hypothalamus (hypothalamus-hypophyseal portal system); releases tropic hormones |
| posterior pituitary aka | neurohypophysis |
| posterior pituitary | neural connection w hypothalamus; hormones made by hypothalamus; stores and released by posterior pituitary |
| negative feedback mechanism | end-product hormone negatively feeds back to prevent further stimulatory signals (ex: thyroid hormones suppress thyroid-stimulating hormone production) |
| positive feedback mechanism | hormone response continues to inc to achieve desired response (ex: oxytocin is inc during labor to cause uterine contractions to birth baby) |
| upregulation | inc receptor sensitivity and # |
| downregulation | dec receptor sensitivity and # |
| 3 major types of endocrine conditions | hormone deficiency, hormone excess, hormone resistance |
| hormone deficiency | gland destruction; autoimmune, infection, tumor |
| hormone excess | tumor, autoimmune, genetic mutation |
| hormone resistance | usually genetic (lack hormone receptor or ability to respond) |
| hypofunction | inadequate amount of hormone |
| hyperfunction | excessive amount of hormone |
| 3 levels of endocrine dysfunction | primary, secondary, tertiary |
| primary endocrine dysfunction | endocrine gland itself |
| secondary endocrine dysfunction | abnormal pituitary activity |
| tertiary endocrine dysfunction | dysfunction of hypothalamic origin |
| causes of endocrine dysfunction | autoimmune, neoplasia, endocrine-disrupting compounds (edcs) |
| autoimmune | antibodies target endocrine gland, may cause hypofunction or hyperfunction |
| neoplasia | hypofunction or hyperfunction of gland itself or any endocrine tissue that gland affects; some cancers: paraneoplastic disorder in which cancer cells secrete hormone-like substances |
| endocrine-disrupting compounds (edcs) | chemical in environment that can alter endogenous hormone functions |
| assessment of endocrine disorderes | current and past medical history; some endocrine disorders present w wide-ranging, multi-system signs and symptoms; endocrine dysfunction may affect mood and behavior, can be misinterpreted as psychological issues |
| diagnosis of endocrine disorders | immunoassays or blood levels of hormones most importnant; urinary hormone levels assessed in some instances; urinary collection over 24 hrs; suppression/stimulation tests; ct scan/mri; ultrasound |
| hypothalamus is located | in brain and serves as coordinating center of brain for endocrine, behavioral, and autonomic nervous system; link bw nervous system and endocrine systems; controls pituitary gland |
| hypothalamus hormones | RIH, CRH/CRF, TRH, GHRH, GnRH, somatostatin, dopamine |
| releasing and inhibiting hormones (RIH) | controls release of pituitary hormones |
| cortico-releasing hormone (CRH/CRF) | stimulates secretion of adrenocorticotropic hormone (ACTH) |
| thyrotropin-releasing hormone (TRH) | stimulates release of TSH |
| growth hormone-releasing hormone (GHRH) | stimulates release of GH |
| gonadotropin-releasing hormone (GnRH) | stimulates secretion of luteinizing horome (LH) and follicle-stimulating hormone (FSH) |
| somatostatin | inhibits GH and TSH |
| dopamine | inhibits secretion of prolactin |
| pituitary gland (master gland) | controlled by hypothalamus (hypophyseal portal); divided into anterior and posterior lobes |
| anterior pituitary hormones | GH, ACTH, TSH, FSH, LH, prolactin |
| growth hormone (GH) | stimulates growth of bone and muscle, promotes protein synthesis and fat metabolism, dec carbohydrate metabolism |
| adrenocorticotropic hormone (ACTH) | stimulates synthesis and secretion of adrenal cortical hormones |
| thyroid-stimulating hormone (TSH) | stimulates synthesis and secretion of thyroid hormone |
| follicle-stimulating hormone (FSH) | female: stimulates growth of ovarian follicle, ovulation; male: stimulates sperm production |
| luteinizing hormone (LH) | female: stimulates development of corpus luteum, release of oocyte, production of estrogen and progesterone; male: stimulates secretion of testosterone, development of interstitial tissue of testes |
| prolactin | prepares female breast for breast-feeding |
| posterior pituitary gland stimulated | thru neural control |
| posterior pituitary hormones | ADH, oxytocin |
| antidiuretic hormone (ADH)/vasopressin | inc water absorption into bloodstream/antidiuretic function (inc blood osmolality) |
| oxytocin | stimulates contraction of pregnant uterus, milk ejection from breasts after childbirth |
| hypopituitarism | one or more of pituitary hormones; addison disease, di, dwarfism, panhypopituitarism |
| panhypopituitarism | complete loss of all pituitary hormones, rare |
| causes of hypopituitarism | pituitary tumor,brain surgery,radiation of brain tumor,congenital disorder(primary adenoma-->malignant/benign); trauma,ischemia,infarction cause sudden loss of pituitary function(sheehan's syndrome),tbi or brain herniation, hypothalamic dysfunction |
| sheehan's syndrome | anterior pituitary damaged; develops after childbirth with severe hemorrhage |
| signs and symptoms of hypopituitarism | depends on pituitary hormones suppressed, age of onset, if acute/rapid deterioration, neonate, adult |
| depends on pituitary hormones suppressed | most serious concerns are adrenal insufficiency, hypothyroidism, and diabetes insipidus |
| age of onset | children w hypopituitarism will have different complications than adults |
| neonate | dwarfism, developmental delay, various visual and neurological symptoms, seizure disorder, congenital malformation |
| adult | weakness, weight loss or gain, hypotension caused by adrenal insufficiency, sluggishness, depression, excessive urination and dehydration |
| diagnosis of hypopituitarism | blood tests to assess hormone levels (pituitary, hypothalamic, and end-organ levels may be needed); corticotropin stimulation test:give acth; mri, ct scan |
| corticotropin stimulation test | cortisol levels should rise; if cortisol levels rise w acth administration: pituitary problem; if cortisol levels do not rise w acth administration: adrenal gland problem |
| hyperpituitarism types: | cushing syndrome, siadh, acromegaly/gigantism |
| pituitary adenoma | most common cause of hyperpituitarism; may produce acth, tsh, or gh; prolactinoma most common form: secretes prl (high prl has antiestrogenic and antiandrogenic effects) |
| large tumors may cause headaches and visual disturbances | bc of proximity to optic nerves |
| children hyperpituitarism | acth-producing adenoma; corticotropinomas, common before puberty; cushing-like symptoms |
| gh-secretion adenoma | children-gigantism; adults-acromegaly |
| diagnosis of hyperpituitarism | serum hormone levels, urine hormone levels may also be assessed, dexamethasone suppression test to assess acth response |
| diabetes insipidus (DI) | posterior pituitary hypopituitarism; lack of adh or response to adh; dilute, large volume urine (plasma concentration inc) |
| categories of diabetes insipidus | central di and nephrogenic di |
| central DI | lack adh from posterior pituitary |
| nephrogenic DI | kidney fails to respond to ADH, distinguish by administering adh to see if kidneys can respond, if so central DI |
| signs/symptoms diabetes insipidus | frequent urination, thirst, dehydration, disorientation, seizures; blood test will show high osmolarity and hypernatremia; urine osmolarity and specific gravity will be low |
| diabetes insipidus differs from diabetes mellitus | no hyperglycemia in DI |
| syndrome of inappropriate adh (SIADH) | excesive adh-causes: brain injury or neurosurgery; paraneoplastic disorder; causes fluid retention-concentrated urine, dilute plasma, hypervolemia |
| thryoid | triiodothyronine (T3) and thyroxine (T4); iodine needed for synthesis |
| thryoxine | regulates body metabolism |
| thyroid disorders more common in | women |
| primary thyroid disorders | most common |
| enlarged thyroid can indicate | hypo- or hyperfunction |
| goiter | enlargement of thyroid; may or may not present w thyroid dysfunction signs and symptoms; may develop w excess tsh, low iodine levels, goitrogens |
| goitrogens | foods or other substances that promote thyroid gland enlargement |
| hashimoto's thyroiditis hypothyroidism | autoimmune disorder, anti-thyroglobulin antibody and anti-thyroperoxidase antibody |
| causes of hyperthyroidism | drugs, genetics, thyroiditis (postpartum period especially high incidence), congenital hypothyroidism: cretinism |
| systemic effects of hyperthyroidism | hyperlipidemia, yellow-orange skin (elevated carotene levels), anemia, dec filtration by kidney, pendred's syndrome, myxedema, subclinical hypothyroidism (elderly) |
| pendred's syndrome | defective iodine incorporation into thyroid hormone |
| myxedema | adult severe hypothyroidism |
| signs/symptoms hypothyroidism | cold intolerance, weight gain, lethargy, fatigue, memory deficits, poor attention span, muscle cramps, constipation, dec fertility, puffy face, hair loss, brittle nails |
| diagnosis of hypothyroidism | primary: high tsh, low free T3, low free T4; secondary: low tsh, low free T3 and T4; hashimoto's thyroiditis antibodies: antithyroglobulin (anti-Tg), antithyroperoxidase (anti-tpo); ultrasound; thyroid test in women 35, and every 5 years after |
| hyperthyroidism | elevated free T3 and free T4; graves disease |
| graves' disease | most common cause of hyperthyroidism, autoimmune stimulation of thyroid gland |
| causes of hyperthyroidism | subacute thyroiditis, thyroid adenoma, excessive TSH, subacute thyroiditis, toxic multinodular goiter, excessive iodine ingestion (jod-basedow syndrome), secondary to pregnancy, hcg is similar to TSH |
| Grave's disease | thyroid-stimulating antibodies bind to thyrotropin receptors=gland enlargement and continual synthesis thyroid hormones |
| Grave's disease symptoms | nervousness, insomnia, sensitivity to heat, weight loss, enlarged thyroid gland, atrial fibrillation, inc HR; inc sympathetic nervous system sensitivity; exophthalmos |
| exophthalmos | wide-eyed stare, extraocular area filled w mucopolysaccharides; graves opthalmopathy: periorbital edema and bulging of eyes |
| hypothyroidism | hypercholesterolemia, gains weight easily, dec fertility, delayed reflexes, sluggishness, feeling cold, constipation, lethargy, fatigue |
| hyperthyroidism | anxiety, tremor, tachycardia, feeling warm, loss of weight, exophthalmos, atrial fibrillation, dec fertility |
| hyperthyroidism diagnosis | primary, secondary, antibodies for graves' disease, ultrasound w color-doppler evaluation, radioactive iodine scanning and iodine uptake |
| primary hyperthyroidism diagnosis | low tsh, high free t3 and t4 |
| secondary hyperthyroidism diagnosis | high tsh, high free t3 and t4 |
| antibodies for graves' disease | anti-thyroid peroxidase (anti-tpo), thyroid stimulating immunoglobulin |
| thyrotoxic crisis (thyroid storm) | overwhelming release of thyroid hormones; stimulate metabolism (high fever, tachycardia, agitation, psychosis); often precipitated by surgery or trauma; medical emergency |
| thyroid nodules (most asymptomatic) | hypo/hyperthyroidism=single nodule (inc malignancy risk), multiple nodules (benign); ultrasound and needle biopsy for diagnosis; technetium scan |
| technetium scan | uses radioactive isotope, hot nodule (hyperfunctioning tumor), warm nodule (normal tissue), cold nodule (hypofunctional tissue, sometimes malignant) |
| malignant thyroid nodule | <20 or >70; male; history of neck irradiation; firm, hard, or immobile nodule; presence of cervical lymphadenopathy |
| parathyroid gland | four pea-sized glands on posterior thyroid; secrete pth (parathyroid hormone) |
| parathyroid hormone (PTH) | released when blood calcium low; activate bone resoprtion, intestinal calcium absorption by kidneys |
| hypoparathyroidism | rare, inadvertent damage w thyroid surgery, genetic disorders; presentation due to hypocalcemia (trousseau's sign, chvostek's sign, muscle cramps, tetany, convulsion) |
| hyperparathyroidism | due to parathyroid adenoma (unorganized neoplasm) |
| primary hyperparathyroidism | elevated PTH and calcium |
| secondary hyperparathyroidism | elevated PTH, low to normal calcium; any disorder that causes hypocalcemia can induce secondary hyperparathyroidism |
| presentation of hyperparathyroidism due to excess calcium | muscle weakness, poor concentration, neuropathies, kidney stones, osteopenia, pathological fractures |
| adrenal gland | cortex and medulla |
| cortex contains | glucocorticoids (cortisol), androgens, mineralocorticoids (aldosterone) |
| medulla contains | neurotansmitters (epinephrine, norepinephrine) |
| adrenal insufficiency | secondary (dec ACTH); primary (aka addison's disease) |
| Addison's disease | autoimmune destruction adrenal cortex; antibodies to adrenal cortex and steroid enzymes |
| hypoadrenalism | due to exogenous glucocorticoids; with prolonged glucocorticoid use, CRF-ACTH signals to adrenal cortex suppressed, adrenal gland down regulates receptors, steroid usage should not be abruptly stopped, individual may be unable to respond to stressor |
| to lessen adrenal atropy what is given to patient | smallest dosage of steroid |
| diagnosis of hypoadrenalism | rapid ACTH test; with ACTH administration, cortisol should rise w/in 30 mins; no cortisol rise: adrenal cortex insufficiency |
| symptoms of adrenal insufficiency | weakness, hypotension, easy fatigue, emotional lability, anorexia, hypoglycemia, electrolyte imbalances (hyponatremia/hyperkalemia); tanned appearance due to melanocyte-stimulating hormone (MSH); acth and msh arise from same precursor molecule |
| symptoms of adrenal insufficiency w women | loss of pubic and axillary hair; amenorrhea |
| hyperadrenalism/hypercortisolism | Cushing's disease, cushing's syndrome; exogenous steroids most common cause of cushing's syndrome |
| cushing's disease | elevated ACTH, tumor in pituitary |
| cushing's syndrome | elevated cortisol, hyperfunction of adrenal cortex; |
| causes of hyperadrenalism | pituitary adenoma (cushing's disease), cushing's syndrome=adrenal hyperplasia, adrenal neoplasm, carney complex (genetic disorder), mccune-albright syndrome (cushing's syndrome and precocious puberty), secretion of ACTH from tumors |
| symptoms of hyperadrenalism (cushing syndrome) | weight gain; redistribution of body fat to face, trunk, and abdomen; puffy face (moon facies); extra subcutaneous fat in cervicothoracic area (buffalo hump); inc in waist-to-hip circumference ration; striae; easy bruising and poor wound healing |
| symptoms of hyperadrenalism for women | hirsutism (sensitivity of the hair follicle to androgens.), male pattern hair growth, amenorrhea |
| effects of high cortisol levels | block action of insulin (glucose intolerance and hyperglycemia); inhibit bone formation and accelerates bone reabsorption (osteopenia, osteoporosis); suppress immune response; hypertension |
| diagnosis of hyperadrenalism | serum levels (inc wbcs, hyperglycemia, hypokalemia); salivary levels of cortisol (24 hr urine cortisol); dexamethasone suppression test; mri, ct scan |
| dexamethasone suppression test | administer dexamethasone, serum cortisol should be suppressed, cushing's syndrome (no cortisol suppression w dexamethasone) |
| pheochromocytoma | adrenal medulla tumor (secrete norepinephrine and epinephrine, excessive sympathetic stimulation); HTN, tremors, inc cardiac contractility, cardiac arrhythmias, tachycardia |
| diagnosis of pheochromocytoma | 24 hr urine for catecholamine metabolites |
| pancreatic islets (islets of langerhans) | pancreas lies transversely in upper abdomen |
| alpha cells--> glucagon--> | when glucose levels are low-->inc blood glucose level |
| beta cells-->insulin--> | transport blood glucose into body cell-->dec blood glucose level |
| delta cells-->somatostatin--> | reduce food absorption from GI tract-->dec blood glucose level |
| acini tissue in pancreas | secretes digestive juices |
| diabetes mellitus (DM) | too much glucose (hyperglycemia)--> prediabetes, type 1 DM, type 2 DM, gestational DM |
| prediabetes | blood glucose levels are elevated but NOT diabetes yet |
| type 1 DM | destruction of pancreatic beta cells-->no insulin production |
| type 2 DM | insulin resistance and impaired insulin secretion from beta cells |
| gestational DM | secretion of placental hormone-->inc insulin resistance and glucose intolerance |
| risks for DM | fam history/genetic factors, obesity/lack of physical exercise, ethnicity (afr amer, latino, native amer, asian amer, pacific islanders), age >45, HTN, high cholesterol levels, history of gestational MD |
| carbohydrate metabolism | insulin-supported process of facilitated diffusion moves glucose from blood into cells, insulin produced by beta cells of islets of langerhans in pancreas; after eating: synchronous rise and fall of glucose and insulin |
| glucose | used for energy, stored as glycogen, or converted to component of lipid molecules |
| glycogenesis | glycogen formation, primarily in liver and muscle |
| glycogenolysis | glycogen breakdown, occurs when blood glucose falls and body needs energy |
| gluconeogenesis | amino acids and glycerol of lipids (fats) converted to glucose |
| fatty acids remains as lipids | converted to acetoacetic acid, beta-hydroxybutyric acid, and acetone; known as ketones or ketoacids; fruity odor (breath, saliva, sweat); accumulation of ketones may lead to diabetic ketoacidosis (DKA) |
| normal blood glucose levels | 70-100 mg/dL (fasting) |
| hypoglycemia | <70 mg/dL; brain functioning affected |
| hyperglycemia | >200 mg/dL |
| fasting blood glucose | 100-125 mg/dL; impaired glucose tolerance (IGT) or prediabetes; greater than 126 mg/dL=diabetes |
| postprandial blood glucose | glucose after eating; >200 mg/dL is diabetes |
| role of insulin | facilitates glucose uptake by cells; stores extra glucose in muscle, adipose tissue, liver; glycogenosis in liver and muscle; fat sparer; anabolic hormome |
| hyperinsulinism | inc insulin level to overcome insulin resistance |
| hyperinsulinism hypoglycemia | low blood glucose levels from too much insulin |
| diabetes tests | fasting and random BG tests; oral glucose test (OGTT), glycated hemoglobin (A1C), eAG, glucosuria, ketonuria, islet cell autoantibodies, c-peptide test |
| oral glucose tolerance test (ogtt) | 75 g of glucose ingested, measure BG following |
| glycated hemoglobin (A1C) | diagnose diabetes and assess BG levels over preceding 3 months, use may be limited due to variability in results; pair w fasting BG on same day (if values of both are in diabetic range, diagnosis of DM confirmed) |
| eAG | average BG over last few months |
| glucosuria | BG exceeds transport maximum for glucose of nephrons |
| ketonuria | ketones are produced when glucose cannot be utilized, appear in urine when ketone formation elevated, more common in T1DM |
| islet cell autoantibodies (ICAs) | present in T1DM |
| c-peptide test | indicator endogenous insulin, c-peptide released when pancreas releases insulin, differentiate bw T1DM and T2DM |
| complications of DM | hypo/hyperglycemia; acute: DKA (T1DM), HHS (T2DM); long-term systemic: blindness, kidney failure, neuropathy, cardiovascular disease, amputation |
| hypoglycemia (medical emergency!) | bg <70mg/dL; excessive exogenous insulin, inadequate food intake, excessive physical activity, infection, illness, drug interaction |
| compensatory response to raise blood glucose | epinephrine, glucagon, activation SNS |
| activation of SNS accounts for many signs and symptoms | sweating, hunger, dizziness, headache, heart palpitations, confusion |
| need action plan to address hypoglycemia | fast-acting carbs (15g), avoid fats (delay glucose absorption), transient response (provide meal or snack even if bg >70 mg/dL) |
| somogyi effect | morning hyperglycemia present |
| somogyi effect due to | insulin therapy (excessive dosage) or insulin peak during sleep causes hypoglycemia, compensatory mechanisms raise bg by morning, adjust insulin as needed |
| dawn phenomenon | morning hyperglycemia present; nocturnal hypoglycemia doesnt occur; adjust meds, exercise, eating patterns |
| dawn phenomenon due to | nocturnal elevations of growth hormone, dec cell utilization of glucose, raising bg levels |
| 3 classic signs of dm | polydipsia, polyuria, polyphagia |
| polydipsia | high bg inc plasma osmolarity, fluid shifts from icf into ecf (cell dehydration), inc thirst |
| polyuria | inc thirst and drinking (polydipsia), osmotic diuresis (glucose appears in urine (transport max of kidney exceeded)), water follows glucose, inc urine output |
| polyphagia | if body cannpt use glucose: fat and muscle breakdown occur, weight loss w inc appetite, ketone levels may elevate |
| other signs of dm | blurred vision, electrolyte imbalance, glycogenolysis and gluconeogenesis |
| blurred vision | accumulation of glucose in aqueous fluid of eye, changes refractio of light |
| electrolyte imbalance | fluid shifts: icf to ecf may cause dilutional hyponatremia; K+ moves out of cells (IC depletion of K+), false hyperkalemia (serum levels of K+ are elevated, but total body K+ not inc) |
| glycogenolysis and gluconeogenesis | inc bg further, compounding problem; low bg is not problem, inability to use bg is the issue |
| diabetic ketoacidosis (DKA) requires immediate treatment | develops in those w no insulin reserves (T1DM); high levels of ketone formation; 1/3 of children w T1DM first present w DKA |
| insulin lacking | in presence of insulin, DKA does not occur, insulin prevents the lipolysis that leads to ketone formation, more common in T1DM than T2DM |
| without insulin (or glucose to use for fuel) ketone formation occurs | ketones=strong acids, alter blood pH, metabolic acidosis |
| presentation of DKA | nausea, vomiting, dehydration, tachycardia, hypotension, kussmaul's respirations, ketone body odor |
| diagnostic criteria DKA | bg >250 mEq/L; pH <7.3; HCO3- <15 mEq/L; ketonuria; ketonemia |
| life threatening causes of DKA | inadequate insulin, new onset of diabetes, stress of infection |
| cerebral edema is severe complication DKA | 70% mortality rate if severe cerebral edema present, do not overhydrate, early signs=headache, confusion, lethargy; papilledema |
| hyperosmolar hyperglycemic syndrome (HHS) more common | in T2DM than T1DM |
| ketones are not present, some insulin is present in Hyperosmolar Hyperglycemic Syndrome (HHS) | bg>600 mg/dL, pH >7.3, HCO3- >18mEq/L, blood osmolarity >320 mOsm/L |
| hyperglycemia and inc plasma osmolarity in HHS | hyperglycemia cant adequately facilitate glucose uptake, gluconeogenesis and glycogenolysis further inc bg; hyperosmolarity=osmotic diuresis and high bg, polyuria |
| hhs can develop | insidiously over day to weeks |
| hhs presentation | weakness, poor tissue turgor, tachycardia, rapid and thready pulse, confusion; 25% of patients present in coma |
| hhs causes | infection (pneumonia, sepsis), noncompliance of DM management, substance abuse, and coexisting diseases |
| chronic complications of DM | 1) diabetic foot ulcers/poor wound healings 2) infection 3) diabetic retinopathy-caused by damage to the blood vessels in the tissue at the back of the eyes, diabetic neuropathy and nephropathy, arteriosclerosis, |
| chronic complications of DM 2 | peripheral angiopathy lack of circulation, autonomic neuropathy, immunosuppression |
| long-term complications in DM | chronic hyperglycemia leads to damage of small and large arterial vessels; endothelial cells lining arterioles and arteries; poor wound healing (wbc functioning reduced); macrovascular angiopathy (cvd, pvd) |
| vascular damage (angiopathy) leads to downstream end-organ damage | retina, glomeruli, neurons, autonomic neuropathy |
| DM and atherosclerosis | acute cardiac events 2-4x more likely in DM patients; inc risk of atherosclerosis in both large and small arteries; vascular damage occurs due to several processes all resulting from hyperglycemia leading to oxidative stress |
| peripheral neuropathy | distal, symmetric polyneuropathy; neural arteries damaged, begins in feet, progresses superiorly |
| sensorimotor nerves | burning, tingling; pain sensation blunted (signs of injury or serious disease (MI) may be missed by patient (silent MI) |
| sensorimotor nerves 2 | motor weakness (gait abnormality), mechanics of foot altered (charcot joint) |
| autonomic neuropathy affects | cardiac system (tachycardia, hypotension),gi system (gastroparesis,gastric emptying abnormality,anorexia,nausea, bowel dysfunction);bladder problems(inc uti risk),erectile dysfunction,hypoglycemia(not apparent syptoms) dec sweating (hyperthermia/dry skin) |
| susceptibility to infection | dec wbc function, inc colonization: s. aureus, candida (yeast)= high glucose changes pH of vagina, allowing candida to proliferate; chronic candida vaginitis may be presenting feature of diabetes |
| diabetic food complications | most common cause of nontraumatic lower extremity amputation; peripheral neuropathy, poor circulation, suppressed immune response; inc infection susceptibility; can lead to gangrene/amputation or osteomyelitis (bone infection) |
| diabetic retinopathy and blindness | leading cause of blindness in adults, retinal circulatory damage from high bg; proliferative retinopathy; regular fundoscopic exam and opthalmological examinations |
| retinal circulatory damage due to high bg | signs: microaneurysms, macular edema, cotton wool spots (infarcted regions of retina) |
| proliferative retinopathy | new vessel growth, vessels are fragile and may rupture leading to retinal detachment |
| diabetic nephropathy | leads to renal failure; damage to glomerular capillary(microalbuminuria); glomeruluar basement membrane may eventually thicken due to glycosylation end-products; activation of RAAS w renal dysfunction compounds problem as bp elevates |
| gi system main functions | ingestion, digestion, absorption, and elimination |
| upper gi tract | mouth, esophagus, stomach, and small intestine |
| lower gi tract | large intestine, rectum, anus |
| accessory organs of gi tract | pancreas, gallbladder, spleen and liver |
| common disorders of gi tract | gastroesophageal refulx disease (GERD), peptic ulcer disease (PUD), gastroenteritis |
| esophagus | tube-like structure from mouth to stomach; has 4 sphincters=upper esophageal sphincter (UES), lower esophageal sphincter (LES), epiglottis-membrane protecting trachea, peristalsis-involuntary contraction and relaxation, wave like pushing food forward |
| stomach has | fundus, body, pylorus; 2 sphincters=LES and pyloric |
| 3 phases of digestion | cephalic, gastric, intestinal |
| cephalic phase of digestion | vagus nerve, Ach secretion |
| gastric phase of digestion | gastric goblin cells secrete mucus, parietal cells secrete HCl and intrinsic factor (vitamin B12 absorption), chief cells secrete pepsinogen, G cells secrete gastrin |
| intestinal phase of digestion | small intestine sends signals to slow stomach emptying |
| small intestine functions 1 | absorption of nutrients/digestion; lined w villi/microvilli; enterogastric reflex-opens pyloric sphincter; duodenum-bile, pancreatic enzymes, and chyme come tg; secretin-ormone released by small intestine that stops gastric secretion; |
| small intestine functions 2 | jejunum-absorb nutrients, glucose, iron, Ca, fat-soluble vitamins (ADEK); ileum-reabsorbs vitamin B12; enterophepatic circulation |
| enterophepatic circulation | bile acids from ileum to liver, gastroileal reflex opens ileocecal valve to large intestine |
| assessment of gi tract | swallowing, indigestion, eructation (belching), appetite, nausea/vomiting, appearance of emesis (vomit), meds (NSAIDS block protective mucus formation), unintentional weight loss or anorexia, last bowel movement, infections (candida albicans) |
| diagnosis of gi tract | esophageal/gi pain may present similar to coronary event, upper endoscopy (most accurate), videocapsule endoscopy, barium xrays, H. pylori testing (peptic ulcer disease bacteria), cbc, cmp, kidney function, liver function, pancreas |
| dysphagia | difficulty swallowing; begins w solid food, progresses to liquids |
| odynophagia | painful swallowing |
| dysphagia is ususally | neuromuscular dysfunction (cranial nerves) |
| structural abnormalities of esophagus | esophageal structures, tumors/rings (schatzki ring), achalasia |
| achalasia | esophageal motility problem |
| diagnosis of dysphagia | barium swallow test; CXR rules out aspiration PNA, |
| dysphagia treatment | thickened fluids/soft food, speech therapy and enteral feedings |
| esophagitis | inflammation of esophagus |
| esophagitis irritation of mucosa of esophageal lining | stomach acid, chemicals, vomiting; infection candida albicans, medications-NSAIDs bisphosphonates, H. pylori |
| who is at risk for esophagitis | obese, pregnant, smokers, alcohol/coffee use |
| Mallory-weiss syndrome | tear in lower esophagus |
| complaints of esophagitis | burning sensation, dysphagia, odynophagia, nausea/vomiting |
| lifestyle changes for esophagitis | stop smoking, weight loss, reduce alcohol/coffee intake, avoid NSAIDS |
| diagnosis of esophagitis | endoscopy |
| gastroesophageal reflux disease (GERD) | problem w tone of LES, regurgitation of stomach acid into esophagus |
| gastroparesis | delayed stomach emptying also a problem |
| metaplasia of cells may occur w gerd | esophageal epithelial cells transform to stomach-like columnar cells |
| barrett's esophagus | precancerous change of cells at gastroesophageal junction and at high risk for developing cancer of esophagus |
| GERD signs/symptoms | lying flat/bending over worsens symptoms, dysphagia, heartburn, epigastric pain, regurgitation, dyspepsia |
| dyspepsia | acid indigestion |
| diagnosis of GERD | endoscopy/manometry, barium studies and biopsy |
| upper gastrointestinal bleed (UGIB) | bleeding in esophagus, stomach, or duodenum |
| causes of UGIB | PUD, Esophageal varices, Esophageal cancer, Mallory-Weiss syndrome |
| acute UGIB | rupture, tear or perforation leading to immediate blood loss; severe bleed=hypotension, hypovolemia, shock, tachycardia, tachypnea, pale/clammy skin; anxious, dizzy, weak, SOB, change in LOC |
| chronic UGIB | small tear or opening causing gradual, small amount of blood loss; fatigue, lethargy, anemia, iron deficiency |
| UGIB signs/symptoms | melena-visible blood in stool-black, tarry appearance; occult blood-presence of blood but not seen w naked eye; hematemesis-vomitus w bright red blood (active bleed); coffee ground emesis |
| coffee ground emesis | indicates blood has mixed w acid of stomach (coagulated blood) |
| diagnosis of UGIB | cbc=reduced Hb and Hct; iron defiiciency; fecal occult blood test (FOBT-3 tests on 3 diff days); endoscopy |
| esophageal varices | engorged veins @distal end of esophagus: often due to portal vein HTN, veins may rupture-bleeding in esophagus, patient presents w signs of liver dysfunction, hematemesis, melena, hypotension, tachycardia, abdominal pain, confusion |
| diagnosis of esophageal varices | ultrasound, mri, ct scan, endoscopy; ruptured varices are an emergency |
| squamous esophageal cancer | cancer invades lining of esophagus |
| adenocarcinoma esophageal cancer | glandular tissue near stomach |
| risks for esophageal cancer | chronic alcohol use, smoking, barrett's esophagus (due to GERD) |
| signs/symtpoms of esophageal cancer | dysphagia, weight loss, change in eating pattern, chronic cough, hoarse voice, hiccups, odynophagia |
| diagnosis of esophageal cancer | endoscopy and tissue biopsy |
| hiatal hernia | stomach pushes up thru opening in diaphragm, LES does not close properly leading to gastritis and GERD; can be asymptomatic |
| signs/symptoms of hiatal hernia | dysphagia and epigastric discomfort |
| diagnosis of hiatal hernia | endoscopy and upper GI barium xray |
| treatment of hiatal hernia | weight loss, small meals, smoking cessation, HOB elevated when sleeping and not lie down after eating |
| pyloric stenosis | constriction of pyloric sphincter= gastric propulsion of contents is compromised, can be congenital in babies; surgical repair needed |
| signs/symptoms of pyloric stenosis | gastroparesis, abdominal pain, distention, nausea, vomiting, weight loss, dehydration; projectile vomiting-obstruction; firm abdomen over pylorus |
| acute gastritis | inflammation of stomach lining; med like aspirin, nsaids, corticosteroids; infection, acute stress, bile reflux, alcohol abuse; complaints of heartburn, epigastric pain |
| diagnosis of acute gastritis | endoscopy; must remove causative agents |
| chronic gastritis | nonerosive gastritis; helicobacter pylori (h pylori); burning and gnawing epigastric pain, hematemesis, weight loss, precursor for development of stomach cancer |
| h pylori affects fundus and most common cause of chronic gastritis | causes irritation and erosion of stomach mucosa, unlike acute gastritis, causes atrophy of glandular stomach lining (atrophic gastritis), dec intrinsic factor (b12 absorption), vicious cycle of bacterial replication and cellular tissue death occurs |
| diagnosis of chronic gastritis | endoscopy, biopsy |
| peptic ulcer disease (PUD) | inflammatory erosion of stomach or duodenum (more common in duodenum); hypersecretion of HCl, ineffective GI mucus production, and poor cellular repair |
| causes of peptic ulcer disease | H. pylori, nsaids, stress, alcohol abuse, excessive caffeine, smoking; nsaids=counteract prostaglandin signal needed for gastric mucus production; dec mucus inc risk of ulcers |
| other causes of peptic ulcer disease | genetic susceptibility, erosion-superficial layer of gastric mucosa affected, ulcer-extends beyond mucosa into muscularis layer |
| signs/symptoms of peptic ulcer disease | epigastric, abdominal pain; episodes of pain occur bw meals, ab 2-3hrs after eating; pain is intense, burning and gnawing sensation; perforation of stomach or intenstine |
| diganosis of peptic ulcer disease | serology=blood sample tested for presence of antibodiers to h. pylori; rapid urease test=endoscopic diagnostic test of choice for detection of h. pylori; endoscopy |
| zollinger-ellison syndrome | gastrin-secreting tumor, excessive HCl leading to ulcer, severe epigastric pain, gi bleeding, vomiting |
| diagnosis of zollinger-ellison syndrome | elevated gastrin in blood, ct/mri to visualize tumor |
| dumping syndrome | rapid gastric emptying; common after bariatric surgery; hypotonic fluid enters intestines, causing fluid shift into intestines (hypovolemia, hypotension, tachycardia) |
| two phases of dumping syndrome | early=30 mins after eating, cramping, nausesa, diarrhea, tachycardia, diaphoresis; late=2-3hrs after eating, epigastric fullness, palpitations, hypoglycemia |
| diagnosis of dumping syndrome | endoscopy and upper gi series |
| diet management-frequent, small meals and fluids in bw meals | dumping syndrome life changes |
| hernia | intestinal protrusion thru abdominal wall |
| risk factors for hernia | family history, obesity, ascites, pregnancy, heavy lifting, chronic cough or constipation |
| inguinal hernia | most common |
| reducible hernia | returned to normal position w manual pressure |
| incarceration hernia | loop of intestine trapped bw muscle fibers |
| strangulation hernia | blood supply to hernia compromised by pressure |
| gastroenteritis | irritation of lining of stomach, small or large intestine by pathogen or toxin; transmitted person to person, water or foodborne; inc fluid shift into lumen of intestine, resulting in diarrhea; damage of villi by pathogen or toxins |
| infectious microorganisms for gastroenteritis | norovirus, rotavirus, shigella, e. coli, giardia |
| gastroenteritis diarrhea osmotic | dec absorption inc osmotic load in lumen, attracting water |
| gastroenteritis diarrhea inflammatory | mucosal lining inflamed, unable to absorb fluid or nutrients |
| gastroenteritis diarrhea secretory | organism stimulates intestinal secretions |
| gastroenteritis diarrhea motility | intestinal neuromuscular disorders |
| symptoms of gastroenteritis diarrhea | nausea, vomiting, diarrhea and abdominal cramps; borborygmi |
| borborygmi | rushing of fluids and gurgling sounds |
| red flags of gastroenteritis diarrhea | severe volume depletion, abnormal electrolytes, renal damage, blood stool, weight loss, severe abdominal pain, symptoms more than a week, >65 yrs, pregnant, hospitalization or antibiotic use in previous 6 months, cormorbidities |
| celiac disease (sprue) (gluten-sensitive enteropathy) | hypersensitivity reaction to gluten (gluten-derived protein (gliadin), unknown cause/autoimmune disease |
| celiac disease | gluten ingestion results in bloating and gas, steatorrhea may develop, malnutrition is concern |
| steatorrhea | loss of fat in stools |
| diagnosis of celiac disease | serology, celiac panel, positive antibody titer of IgA antitissue transglutaminase (IgA TTG), intestinal biopsy |
| short bowel syndrome | any process that leaves <200cm of small intestine (normal is 600cm); several require removal of part of intestine (crohns disease, tumor, stricturesm ischemia) |
| pathology of short bowel syndrome | depends on amount of tissue removed and health of remaining tissue; remaining intestine eventually adapts and inc absorptive capabilities |
| diagnosis of short bowel syndrome | barium contrast xray, abdominal ct |
| small bowel obstruction (SBO) | acute, chronic, partial, complete |
| acute sbo | adhesions (post-surgical is major cause) or herniation |
| chronic sbo | inflammatory disease or tumors |
| partial sbo | dec the flow of intestinal contents |
| complete sbo | prevents passage of all contents and fluid, considered surgical emergency |
| signs/symptoms of sbo | presentation will depend on severity of obstruction; pain, nausea, vomiting, hyperactive bowel sounds; diarrhea may be present in partial obstruction |
| diagnosis of sbo | abdominal xray |
| treatment of sbo | nasogastric tube-decompression, surgery for complete obstructions |
| peritonitis | inflammation of peritoneum, caused by bacterial infection or leakage of intestinal content into peritoneal cavity |
| classification based on perforation of organ | primary (no perforation); secondary (perforation of organ, release of contents into cavity) |
| paralytic ileus | dec motility of intestine w peritonitis, undigested content not moved further |
| other peritonitis complication | abdominal abscess, cardiac arrhythmias and shock |
| classic triad of peritonitis | abdominal pain (inflamed tissues), abdominal rigidity, rebound tenderness |
| signs/symptoms of peritonitis | hypotension, tachycardia, tachypnea, clammy skin, dec or absent bowel sounds and oliguria; blood and fluid shift toward abdomen |
| diagnosis of peritonitis | abdominal xray w air or fluid in abdominal cavity, cbc w elevated wbc/neutrophils, paracentesis-remove peritoneal fluid to analyze; ct scan or emergency surgical laparotomy |
| alterations in integrity of GI wall of large intestine | inflammatory bowel disease (IBD)= crohns disease and ulcerative colitis; inflammatory conditions=appendicitis and diverticulitis |
| alterations in motility of large intestine | irritable bowel syndrome (IBS), bowel obstruction or intestinal herniation |
| large intestine is how long | 1.5 m long |
| large intestine functions | absorb water and electrolytes; store feces until defecation |
| parts of large intestine | cecum (blind pouch), appendix (at end of cecum), ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus |
| muscles of large intestine | longitudinal (taenia coli) and circular (haustra) |
| movements of large intestine | haustrations (shuffling effect) and propulsion (mass movements) |
| GI wall begins @ upper 1/3 of esophagus and has 5 layers | 1. inner (mucosa) layer 2. middle (submucosa) layer 3. circular layer-peristalsis 4. longitudinal layer-facilitate peristaltic movement 5. outer layer |
| inner (mucosa) layer | goblet cells-produce mucus to lubricate intestines and protect; columnar epithelial cells absorb fluid/electrolytes |
| middle (submucosa) layer | connective tissue, blood vessels, nerves and cells that secrete digestive enzymes |
| outer layer | peritoneal serosas is loosely attached to the entire outer wall of the intestine |
| large intestine absorption | smooth surface for absorption of water and electrolytes (Na and Cl)=water follow by osmosis; no digestive enzymes=most absorption in small intestine, normal flora bacteria break down proteins, carbs, bile salts; bacteria=1/3 bulk of feces |
| defecation uses | internal and external anal sphincter; reflex center; gas (flatus); and borborygmi |
| reflex center | sacral portion of spinal cord |
| gas (flatus) | swallowed air, bacterial fermentation |
| borborygmi | rushing of fluids and gurgling sounds |
| intestinal motility dysfunction | obstructive lesion, intestinal pseudo-obstruction, ibs, fecal incontinence, constipation, acute colonic pseudo-obstruction |
| acute colonic pseudo-obstruction | same symptoms of nonpropulsion, but no obstruction (neuromuscular dysfunction), medications affect motility (opiates, benzos) |
| assessment of GI | info about abdominal pain, nausea, excessive gas, rectal fullness, weight changes, bowel movements, diet, laxative, or enema usage, assess for bowel obstruction, pain location, pain type |
| colic pain | occurs in waves |
| right lower quadrant tenderness | appendicitis (inflammation of appendix) |
| left lower quadrant tenderness | diverticulitits (inflammation of diverticulum; often a tear resulting in inflammation) |
| upper right quadrant tenderness | murphy's sign, cholecystitis |
| acute abdomen | peritonitis triad (fever, abdominal pain, increasing ascites (fluid buildup) |
| rectal examination | pain elicited w appendicitis, hard stool w fecal impaction |
| female physical examination on GI | pelvic exam to rule out gynecological issues, pregnancy test to rule out pregnancy |
| diagnosis of GI issue | FOBT (fecal occult blood test), CBC, CMP, elevated serum amylase (pancreatitis), abdominal and chest xray, contrast barium images, ct scan, colonoscopy, pain (valuable diagnostic clue) |
| constipation common especially in elderly | less than 3 stools per week, primary or secondary to other diseases, meds |
| severe constipation results in | fecal impaction and obstipation |
| fecal impaction | hard stool lodged in sigmoid colon and rectum, can develop liquid stools to pass around impaction |
| obstipation | sensation to defecate w no passage of stool, liquid, or gas from colon |
| diagnosis of constipation | barium contrast studies, endoscopy studies, colonic transmit studies in select individuals |
| inflammatory bowel disease (ibd) | crohns disease and ulcerative colitis (uc), chronic/incurable; more prevalent in young adult, etiology unclear; may have autoimmune component, infectious agents, genetic component |
| crohn's disease | chronic, transmural (entire gi wall) inflammatory process; can affect gi tract from mouth to anus (terminal ileum and ascending colon most common) |
| skip lesions of crohns disease | areas of disease separated by healthy areas |
| cobblestone of crohns | granulomas form in intestine |
| toxic megacolon (chrons) | extreme dilation of disease colon; can cause complete obstruction or life-threatening perforation |
| remissions and exacerbations of crohns w | episodes of diarrhea and abdominal pain |
| characteristics seen w crohns | hyperactive bowel sounds, abdominal tenderness, weight loss, anorexia, nausea, vomiting, diarrhea, pallor, fever |
| malabsorption and nutritional deficiencies are common w crohns disease | anemia from loss of blood in stool, dehydration, arthritis, uveitis, cheilitis, and dermatology issues may be present |
| uveitis | eye inflammation |
| cheilitis | lip inflammation |
| diagnosis of crohns disease | colonoscopy (differentiaties bw crohns and UC), biopsy, crohns disease activity index (CDAI) |
| crohns disease activity index (CDAI) | patient symptoms grading system and considered to be in one of 4 disease states= clinical remission, mild, moderate, severe |
| complications of crohns disease | obstruction, chronic inflammation leading to stricture, microperforations, inc DVT and PE risk |
| ulcerative colitis (UC) | involves large intestine, begins in rectum and moves upward; not transmural |
| ulcerative colitis (UC) inc risk for colon cancer | peak age of onset=15-25 w another peak at 55-65 |
| etiology of ulcerative colitis | is unclear, autoimmune, infection and genetic component |
| pseudopolyps | markers of severe inflammation in ulcerative colitis |
| toxic megacolon and severe uc lead to | damage to nerves |
| uc has similar presentation of symptoms as crohns | diarrhea, abdominal pain, and distention; fever, leukocytosis, uveitis, erythema nodosum (red bumps), arthritis |
| diagnosis of ulcerative colitis (UC) | distinguished from crohns |
| ULCERATIVE COLITIS vs crohns | affects large intestine, affects rectum upward toward colon, only affects upper layers of intestinal wall, pseudopolyps, no fistula or anal fissure, @ risk for colon cancer |
| fistula | abnormal tunnel from colon to the surface of skin or to an internal organ like bladder, small intestine or vagina |
| ulcerative colitis vs CROHNS | affects mouth to anus, affects gi tract w skip lesions, affects entire thickness of intestinal wall (transmural), cobblestone, anal fistula and anal fissure, does not predispose to cancer |
| large bowel obstruction (LBO) | mechanical or nonmechanical; bowel becomes dilated proximal to obstruction, distention of abdomen induces peristalsis and perforation may occur |
| mechanical large bowel obstruction | physical block (adhesion) |
| nonmechanical large bowel obstruction | dysmotility, neurological |
| large bowel obstruction blocks | moving of contents, partial or complete, acute or chronic, reversible or irreversible |
| peristalsis | involuntary constriction of muscles of intestine |
| perforation | hole that develops thru the wall of a body organ |
| if diagnosis/treatment for large bowel obstruction does not occur in first 24hrs | high mortality rate |
| symptoms of large bowel obstruction | abdominal pain, distention, tenderness, rigidity; partial obstruction, complete obstruction |
| partial obstruction | high-pitched bowel sounds, gas or bowel movements possible, diarrhea |
| complete obstruction | no bowel sounds, no feces in rectum, no bowel movement or gas production |
| diagnosis of large bowel obstruction | abdominal xray, ct scan or mri; colonoscopy |
| appendicitis | inflammation of appendix (blind-ended pouch off cecum); narrowing of appendix lumen can result from nearby blockages, development of medium for bacterial growth |
| common cause of appendicitis | acute abdomen |
| appendix may rupture causing peritonitis | abdominal pain originates umbilical region and move to rlq (mcburney's point); 1-3 days from onset of vague umbilical pain to the localized rlq pain |
| abdominal distention and rebound tenderness | females: pelvic exam and pregnancy test |
| appendicitis signs | positive psoas sign and obturator sign, legs may be drawn up in fetal position due to pain |
| psoas sign | flex right leg against resistance or roll on left side and extend leg; pain in ruq |
| obturator sign | flex knee and hip to 90 degrees, internally rotate thigh and extened calf outward; pain in rlq |
| appendicitis diagnosis | physical examination, females: pregnancy test; ct scan (most accurate); elevated crp (inflammation) and wbc levels; urinalysis to rule out kidney stones and pyelonephritis; high 5-HIAA (serotonin breakdown product) may be present in urine |
| irritable bowel-syndrome (IBS) | abdominal pain and altered bowel activity; abdominal discomfort and alterations of diarrhea and constipation |
| IBS has no specific pathology and unknown etiology | should not be confused w inflammatory bowel disease; chronic abdominal pain lasting at least 6 months, w bouts of diarrhea and constipation |
| risk factors for IBS | female, <40, stress; alarm symptoms require further testing weight loss, iron deficiency anemia |
| diagnosis of IBS | patient symptoms, diagnostic tests to rule out other conditions |
| diverticulosis | bowel wall has weakened areas; can collect intestinal contents and form a colonic obstruction; most common in sigmoid and descending colon |
| diverticula | small outpouchings formed |
| diverticulitis | diverticula inflammation |
| diverticular disease develops due to | weakness of bowel wall, inc intraluminal pressure |
| risk factor for diverticular disease | low fiber diet |
| signs/symptoms of diverticular disease | depend on severity of inflammation and location in bowels, bowel habits may be altered; LLQ or RLQ depending on area affected; low grade fever, tachycardia, and anorexia; diverticulosis may be asymptomatic |
| diagnosis of diverticular disease | abdominal xray, lower gi series, ct scan |
| volvulus | twisting of large intestine; sigmoid volvulus most common; results in obstruction and ischemia |
| symptoms of volvulus | bilious vomiting, abdominal pain (colicky and then steady), abdominal tenderness, anorexia, blood and mucus in stool and eventually shock |
| diagnosis volvulus | abdominopelvic ct scan, abdominal xray |
| treatment for volvulus | surgical |
| hemorrhoids are in | varicose veins in perianal region |
| venous pooling in rectal blood vessels | constipation and straining during defecation, high pressure w/in portal vein of liver, anal intercourse, pregnancy, prolonged sitting, aging, lack of fiber in diet |
| signs/symptoms of hemorrhoids | hemorrhoids can bleed, hematochezia, prolapsed hemorrhoid, |
| hematochezia | bleeding from hemorrhoids, small amounts, bright red |
| prolapsed hemorrhoid | straining at defecation pushes an internal hemorrhoid thru anal meatus |
| diagnosis of hemorrhoid | digital rectal exam, anoscopy |
| liver located in | right upper quadrant (RUQ) |
| blood supply of liver | hepatic artery (25%) and portal vein (75%)(venous drainage from GI tract) |
| hepatocytes | functional cells of liver |
| kupffer cells | macrophages of liver to help detoxify blood |
| bile made by liver and stored in | gallbladder |
| hepatic duct empties into common bile duct | empties into duodenum |
| enterohepatic recylcing | bile salts reabsorbed from ileum recycled back to liver |
| bilirubin found in liver | yellow-colored compounds, rbc breakdown |
| bilirubin metabolism 1 | hemoglobin broken down to heme & globin; heme broken to down to iron & porphyrin; porphyrin converted to biliverdin; biliverdin converted to free or unconjugated bilirubin; unconjugated bilirubin travels to liver |
| bilirubin metabolism 2 | in liver, unconjugated bilirubin converted to water-soluble form (conjugation); conjugated bilirubin excreted in bile, some conjugated bilirubin in colon converted to urobilinogen by bacteria, later excreted in urine (yellow color) |
| unconjugated bilirubin | aka indirect bilirubin, not water soluble |
| conjugated bilirubin | aka direct bilirubin, water soluble |
| functions of liver | fat metabolism, protein metabolism, carbohydrate metabolism, hematologic role, endocrine role, detoxification, |
| other functions of liver | storage of vitamins, iron, copper produces insulin-like growth factor 1; synthesizes thrombopoietin for platelet synthesis; produces angiotensinogen (RAAS), immune system |
| fat metabolism of liver | bile from liver emulsifies fat, fats broken down in intestines, absorbed in portal vein and returned to liver, liver synchronizes cholesterol |
| protein metabolism of liver | synthesizes albumin, performs deamination, removes nitrogen from proteins and converts to NH3; NH3 reabsorbed into blood and integrated into urea and excreted in urine |
| carbohydrate metabolism of liver | glycogenesis, glycogenolysis, gluconeogenesis |
| glycogenesis | produces and stores glycogen in liver |
| glycogenolysis | breakdown of glycogen during stress or starvation |
| gluconeogenesis | convert amino acids and glycerol into glucose |
| hematologic role | synthesizes fibrinogen, coagulation factors |
| endocrine role of liver | glucagon acts in liver to help w glycogenolysis and gluconeogenesis; stimulates lipolysis-converts fatty acids to ketones |
| detoxification of liver | ingested substances and drugs; portal vein brings venous drainage from gi tract to liver; biotransformation and first pass effect-reduce bioavailability |
| liver dysfunction | dec clotting factor synthesis, dec albumin, dec detoxification on activity, dec storage of nutrients, dec conjugation of bilirubin, dec deamination activity |
| jaundice | yellowing of skin and sclera |
| hyperbilirubinemia | high bilirubin levels in blood, leads to jaundice (icterus) |
| 3 specific etiologies of liver dysfunction | excessive rbc hemolysis, hepatocellular injury, bile duct obstruction |
| excessive rbc hemolysis | prehepatic jaundice, elevated direct and indirect bilirubin |
| hepatocellular injury | intrahepatic jaundice, elevated indirect bilirubin |
| bile duct obstruction | posthepatic jaundice, elevated direct bilirubin |
| hepatocyte inflammation | caused by virus, drugs, or toxic substances |
| hepatitis virus= a,b,c,d,e | cmv and epstein-barr virus can also cause inflammation, viral hepatitis may become chronic; inc risk for hepatocellular cancer |
| toxic hepatitis | liver affected by drugs (acetaminophen), enzymes (cytochrome P450 system) |
| nonalcoholic fatty liver disease (NAFLD) | fatty buildup in liver, can lead to cirrhosis |
| severe hepatocellular injury may progress to hepatic failure | lead to hepatic encephalopathy |
| other things that can affect hepatocyte inflammation/infection | alcohol damage and nonalcoholic steatosis (NASH) |
| biliary obstruction | blockage of any duct that carries bile from liver to intestines; hyperbilirubinemia |
| cholelithiasis | gallstone |
| cholecystitis | inflammation of gallbladder |
| cholestasis | conjugated bilirubin backs up; builds up in blood |
| liver disease risk factors | excessive alcohol abuse, certain medications, high cholesterol or triglycerides, chronic hbv or hcv, iron overload, malnutrition, metabolic syndrome/obesity, rapid weight loss, toxins/chemicals |
| signs of liver disease | anorexia, ascites, dark urine, hepatomegaly, hyperbilirubinemia, jaundice, RUQ tenderness, splenomegaly, steatorrhea, pruritis, spider angioma, capsut medusa |
| steatorrhea | fatty stool |
| pruritis | sensation causes wanting to scratch |
| spider angioma | dialtion of end vasculature found beneath skin surface |
| capsut medusa | distended and engorged paraumbilical veins that radiate from umbilicus across abdomen to join systemic veins |
| diagnostic tests for liver disorders | liver enzymes, direct (conjugated) and indirect (unconjugated)bilirubin levels, albumin level, prothrombin leve, hepatitis serology, ultrasound, ct scan, mri, liver biopsy (GOLD STANDARD) |
| liver enzyme tests | alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatasre |
| hepatits a virus (HAV) (vaccine available) | transmitted by the fecal-oral route=virus shed in feces; virus killed by thorough cooking; endemic in asia, africa, mexicp, and south america |
| hepatitis b virus (HBV) (vaccine available) | transmitted by blood products, body fluids, or sexual contact; doesnt directly kill cell, but host's immune sytem destorys viral-infected cells; most dont recover completely and chronic hbv can lead to hepatocellular cancer |
| diagnosis of hbv | IgM-type=anti-HBc antibodies//acute infection; IgG-type=anti-HBc antibodies//chronic infection; contacts can obtain HBIg for rapid, passive immunity |
| hepatitis c virus (HCV) (vaccine available) | transmitted via blood and iv drug use, sex transmission not as likely; acute infection usually mild, most develop chronic hepatitis, long incubation period=2wks-8mths and patient is asymptomatic and can spread virus |
| diagnosis of hcv | HCV-RNA assay and HCV genotyping |
| hepatitis d virus (requires helper function of hbv) | transmission thru iv drug use or sex contact |
| hepatitis e virus (similar to hav) | fecal-oral transmission |
| signs/symptoms of hepatitis | fever, abdominal pain, flu-like symptoms, nausea/vomiting, fatigue, malaise, myalgias, arthralgias, mild headache, anorexia, loss of taste for food, smokers lose their taste for tobacco, hepatomegaly,jaundice,stool w pale appearance,dark urine,pruritis |
| nonalcoholic fatty liver disease (NAFLD) | most common cause of chronic liver disease in us |
| etiology of NAFLD | unclear, associated w metabolic syndrome, insulin resistance, ad obesity |
| NAFLD is when | hepatocytes accumulate triglycerides (steatosis), accumulation of fat disrupts cell function, cells can rupture causing inflammatory response damaging to liver; most common cause of chronic liver disease in US |
| steatosis | >5% liver contains fat |
| nonalcoholic steatohepatitis (NASH) | extreme form of NAFLD in which scarring and inflammation of liver occurs; leads to hepatocellular carcinoma |
| signs/symptoms of NAFLD | mild cases=none, abnormal liver enzyme levels may be present; NASH=obvious signs of liver impairment like edema, jaundice, fatigue-->can lead to hepatocellular carcinoma (HCC) |
| diagnosis of NAFLD | no specific biomarkers or blood test; liver biopsy is key test (can have false negative if sample not taken from high fat content area); NAFLD fibrosis score |
| patient who is obses, metabolic syndrome w elevated liver enzymes should be | evaluated for NAFLD |
| NAFLD fibrosis score | age, hyperglycemia, body mass index (BMI), platelet count, albumin level, and ratio of AST to ALT |
| alcohol liver disease | aka alcohol cirrhosis, develops over long period of time and is permanent |
| alcohol hepatitis | acute disorder that develops reversible and transient symptoms, will resolve w cessation of alcohol ingestion, long-term effects often remain |
| men alcohol consumption | 60-80g of alcohol/day for 10 yrs usually develop cirrhosis |
| women alcohol consumption | 20-40g of alcohol/day for 10 yrs usually develop cirrhosis |
| ingestion of 160g of alcohol per day | 25-fold inc risk of developing alcoholic liver disease |
| one beer | 12 g |
| alcohol is potent toxin to hepatocytes | hepatocytes can regenerate but are susceptible to repeated damage |
| steatosis | initial cellular change |
| alcoholic liver disease | can progress to cirrhosis |
| common for patients to not | provide accurate history of alcohol intake |
| acute alcoholic hepatitis | RUQ pain/tenderness, nausea, malaise, low grade fever, jaundice, dark urine, hepatomegaly |
| severe alcoholic hepatitis | hepatic encephalopathy, coagulation dysfunction, spontaneous bruising and bleeding, jaundice, hematemesis |
| alcoholic liver disease | hepatomegaly and splenomegaly, portal HTN w esophageal varices, ascites, spider angioma, proximal muscle wasting, gynecomastia in males, withdrawal symptoms=restless, mood, disturbance, delirium tremens, seizures |
| diagnosis of alcoholic liver disease | AST and ALT elevation, hypertriglyceridemia and hypercholesterolemia, hyperbilirubinemia and hypoalbuminemia, coagulation disturbances, liver biopsy to confirm changes |
| cirrhosis | silent and gradual; severe scarring of liver |
| liver is irreversibly damaged w | collagen and connective tissue; portal HTN develops |
| causes of cirrhosis/liver failure | hcv, alcoholic liver disease, NAFLD |
| liver failure complications | portal hypertension, caput medusa, dec bile synthesis (dec fat digestion and steatorrhea), dec coagulation factors (bruising, bleeding) |
| portal hypertension | esophageal varices, hematemesis, ascites |
| dec albumin synthesis | edema; liver failure complication |
| lack of thrombopoietin | low platelets; liver failure complication |
| dec conjugation of bilirubin | jaundice; liver failure complication |
| loss of detoxification | high level of drugs, ammonia levels inc leading to encephalopathy; liver failure complication |
| loss of deamination process | high nitrogen in blood, lyses rbcs and platelets; anemia and thrombocytopenia; liver failure complication |
| dec fat-soluble vitamins absorbed | hypocalcemia; liver failure complication |
| hepatic encephalopathy | confusion, stupor, asterixis, cerebral edema and poor prognosis; liver failure complication |
| asterixis | flapping tremor of wrists |
| hepatorenal syndrome | renal failure asz well; liver failure complication |
| diagnosis of liver failure | cbc, metabolic panel, liver panel |
| gallbladder function | digestion and elimination; stores bile (synthesized in liver) which emulsifies fat; releases bile into cystic duct which empties into common bile duct; enterohepatic circulation |
| bile | consists of bile acids, phospholipids and cholesterol; |
| released in response to signal from small intestine | hormone cholecystokinin (CCK) |
| pancreas has | endocrine and exocrine component |
| exocrine component of pancreas | digestive secretions; lipase, amylase, peptidases; bicarbonate=neutralize acid in intestines |
| exocrine secretions ar secreted into | pancreatic duct which drains into common bile duct |
| exocrine enzymes are triggered by | hormone secretin produced in the intestines when we eat |
| gallbladder dysfunction | motility disturbances and stasis of bile |
| choledocholithiasis | stones in common bile duct-back up of bile |
| cholelithiasis | stones in gallbladder itself |
| biliary sludge | precursor to gallstones, combination of bile acids, bile pigments, and cholesterol |
| biliary stasis | delayed emptying of the gallbladder, leads to stone formation |
| cholangitis | gallstones enter the cystic duct, cause obstruction and ductal inflammation |
| gallstones | can obstruct flow in the common bile duct, leading to backup of bile into liver leading to hepatic dysfunction; can move into the pancreas and cause pancreatitis |
| biliary colic | pain associated w irritation of gallbladder, secondary to gallstones |
| biliary colic has steady and intense pain | can last from 30 mins to several hrs; nausea, vomiting, and RUQ pain; murphy's sign |
| murphy's sign | take a deep breath and pain with palpating RUQ- acute cholecystitis |
| pain from biliary colic often radiates to | scapula and upper thoracic region |
| biliary colic leads to | dilation of biliary tract, elevation of plasma liver enzymes, elevation of serum bilirubin |
| cholecystitis | acute or chronic inflammation of gallbladder; due to gallstones (most common), cholecystectomy performed, gallstones are 2-3x more common in women |
| acalculous cholecystitis | inflammation without stones |
| risks for cholecystitis | female, >40yrs, obesity, high-calorie diet, oral conceptives |
| empyema | infection of gallbladder leading to purulent effusion |
| cholecystitis is associated episodic | colicky pain after eating and positive murphys sign |
| collins sign | pain may refer to right scapular |
| symptoms w cholecystitis | anorexia, nausea, vomiting, feeling of fullness |
| ruptured gallbladder | medical emergency leading to peritonitis and sepsis |
| cancer of gallbladder | >65; intense pain, weight loss, jaundice, anorexia, nausea |
| cancer of biliary tract (cholangiocarcinoma) | is very rare |
| courvoisier sign w cancer of gallbladder | palpable mass in RUQ |
| virchow's node w cancer of gallbladder | enlargement of left sided supraclavicular lymph node |
| signs/symptoms occur late in cancer of gallbladder | frequently metastasis occurs; high mortality rates//die w/in 1 yr |
| diagnosis of gallbladder cancer | elevated wbc, esr, c-rp, liver function tests; serum amylase and lipase elevate w pancreatic inflammation; abdominal ultrasound/ct scan; cholecystogram; cholescintigraphy (HIDA scan); percutaneous transhepatic cholangiopancreatography (PTC); ERCP |
| cholecystogram | swallow pill and have xrays |
| cholescintigraphy (HIDA scan) | tracer travels into bile and track the tracer |
| percutaneous transhepatic cholangiopancreatography (PTC) | dye injected directly into liver and take xrays |
| endoscopic retrograde cholangiopancreatography (ERCP) | invasive procedure that use an endoscope w camera to inspect the anatomy of the biliary tract |
| pancreatic exocrine dysfunction | digestive secretions |
| pancreatitis | inflammation of pancrease, causes pancreatic insufficiency, malabsorption, and diabetes; acute vs chronic; |
| acute pancreatitis | forms caused by alcohol, gallstones, high triglycerides, meds or surgery; potentially lethal |
| autodigestion by pancreas' own | digestive enzymes |
| chronic pancreatitis | repeated episodes of inflammation leading to fibrosis and atrophy |
| acute pancreatitis --> lethal | dysfunctional pancreas undergoes inflammation and cell injury; leakage of pancreatic digestive enzymes into glandular parenchyma; hemorrhagic pancreatitis=retroperitoneal blood accumlation |
| acute pancreatitis risk factors | biliary disease (cholelithiasis), excessive alcohol ingestion, hypertriglyceridemia, infections |
| severe abdominal pain w acute pancreatitis | sudden in onset, gradually intensifies; located in epigastric region, pain can radiate to the back |
| symptoms of acute pancreatitis | nausea, vomiting, diarrhea, anorexia, tachycardia, dec bowel sounds |
| signs of acute pancreatitis | abdominal tenderness, guarding, distention, pale, diaphoretic, lethargic; cullen sign, grey turner sign; patients may be pale and diaphoretic; may exhibit jaundice |
| cullen sign | discoloration around umbilicus due to hemorrhage around stomach |
| grey turner sign | discoloration around flanks, retroperitoneal bleeding around flanks |
| ransom criteria on admission | age>55, wbc>16,000; liver enzyme=lactic dehydrogenase>600 U/L; liver enzyme=aspartate aminotransferase >120 U/L; glucose>10mmol/L |
| ransom criteria w/in 48 hrs | hematocrit dec<10%; BUN rise>0.9mmol/L; calcium <2mmol; PO2 <60mmHg; base deficit>4; fluid sequestration>6L |
| diagnosis of acute pancreatitis | cbc, calcium, glucose, BUN, amylase and lipase (elevated lipase key sign of acute pancreatitis); abdominal US; ct scan; MRCP (magnetic resonance cholangiopancreatography) |
| complications of acute pancreatitis | infected pancreatic necrosis; pseudocyst |
| pseudocyst | occurs in 10-20% of acute cases of pancreatitis; collection of fluid rich pancreatic enzymes, blood and necrotic tissue |
| complications of acute pancratitis | cardiovascular (hypotension); renal (kidney failure due to dec perfusion); respiratory (atelectasis, respiratory failure) |
| chronic pancreatitis | chronic inflammation does not heal and leads to permanent damage; chronic, heavy alcohol use is primary risk factor |
| chronic pancreatitis commonly develops after several bouts of acute pancreatitis | fibrosis and scarring; upper abdominal pain radiating to back or no pain at all; weight loss, anorexia, nausea, vomiting, diarrhea, steatorrhea, malabsorption; serum amylase and lipase-slightly elevated or may be normal |
| acute pancreatitis think | acute, isolated episode, active inflammation, sudden and severe, short-term (days-weeks); elevated pancreatic enzymes; common causes=alcohol, gallstones |
| chronic pancreatitis think | chronic, ongoing disease, chronic changes/damage; symptoms fluctuate, long term (months-years); normal pancreatic enzymes; common causes=recurrent acute episodes, alcohol, hereditary, diseass |
| pancreatic cancer risk factors | cigarette smoking, obesity, diabetes mellitus, chronic pancreattitis, consumption of nitrites; exocrine or endocrine cell=exocrine ducts=ductal adenocarcinomas |
| pancreatic cancer | tumor may compromise bile duct, leading to bile backup and jaundice (painless jaundice 1st common sign of cancer) |
| pancreatic cancer may present with vague back pain and worsens, especially in supine position | weight loss, nausea, vomiting, anorexia, pruritis, darkening of urine, hyperbilirubinemia, steatorrhea |
| pancreatic cancer signs | virchows sign and courvoisier's sign |
| courvoisiers sign | jaundice and gallbladder that is enlarged but not painful |
| common w pancreatic cancer | portal vein HTN, ascites, hepatomegaly, splenomegaly |
| new diagnosis of DM at later age and may | present w DVT |
| diagnosis of pancreatic cancer | ct scan of abdomen and tumor markers |
| chvostek's sign | facial contraction when touch facial nerve |
| trousseau's sign | spasm in upper arm bc of ischemia and pressure |
| function of t3,t4 | control basal metabolic rate |
| function of calcitonin | regulate levels of calcium & phosphate in blood |
| symptoms of addison's disease | darkened pigmentation on skin (bronzing) across knuckles or around neck |
| prolactin-releasing hormone (hypothalamus) | stimulates secretion of prolactin |
| 4 main cells of stomach | mucus cells, parietal cells, chief cells, G cells |
| mucus cells | secrete alkaline mucus that protects epithelium against sheer stress and acid |
| parietal cells | secrete hydrochloric acid |
| chief cells | secrete pepsin (proteolytic enzyme) |
| G cells | secrete gastrin |
| 2 valves of small intestine are | pyloric sphincter and ileocecal valve |
| contents move from small intestine to large intestine | cecum-->ascending colon-->transverse colon-->descending colon-->sigmoid colon-->rectum-->anus |
| rovsing's sign (appendicitis) | firmly press llq and pain in rlq |
| rebound tenderness | pain when removed pressure from abdomen, not when applied |
| hemorrhoid | dilated, swollen vessels in perianal region and can be either internal or external |
| risk factors for pancreatic cancer | cigarette smoking, obesity, diabetes mellitus, chronic pancreatitis, consumption of nitrites |
| symptoms w pancreatic tumor on head of pancreas | jaundice, itchy skin, dark pee, pale poop, loss of appetite, weight loss, tired/no energy |
| symptoms w late stage pancreatic cancer | pain in back/abdomen, weight loss, anorexia, nausea, stool color change, abdominal bloating, dark urine, changes in breathing |
Created by:
cat9210
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