Medical Conditions & Answers: AR Diseases, Hypoxia, Pulmonary Edema, Urinary Incontinence, Exams of Nursing

Download Medical Conditions & Answers: AR Diseases, Hypoxia, Pulmonary Edema, Urinary Incontinence and more Exams Nursing in PDF only on Docsity! CPR 2 Clinical Correlates with diagnostics Most Passed 2024 Lymphadenopathy - Correct answer- Enlargement of Lymph Nodes - 2 Types: Follicular Hyperplasia: Increase in number and size of cortical lymphoid follicles; Humoral Response - Paracortical hyperplasia: Expansion of paracortical zone - viral infection Sinus Hyperplasia - Correct answerMedullary sinuses are extremely prominent - draining necrotic tumor Metastasis of Lymph Nodes - Correct answer- Lymph draining from an organ or area with malignancy - Cancer cells invade into lymphatic channels draining the primary tumor and so gain access to the regional lymph nodes through the afferent lymphatic channels - These malignant cells enter the subscapular sinus (SS) of the lymph node and get stuck and thus settle at this site where they could proliferate to form a secondary tumor mass. Sentinal Lymph Node Biopsy - Correct answerTechnique to remove a minimal number of key lymph nodes near the size of metastasis to determine spread of the tumor - Diagnosis Purpose Tonsilitis - Correct answerAcute or Chronic inflammation of the tonsils Sometimes they become enlarged and can block airway Adenoid Hypetrophy - Correct answerPharyngeal Tonsils enlarged and inflamed are called adenoids. DiGeorge Syndrome (22q11.2 Deletion Syndrome) - Correct answer- Defect in 3rd and 4th brachial pouches and arches which leads to the absence of thymus. Due to this, there is an absence of T lymphocytes in the individual. - Catch 22 (Cardiac Anomalies, Abnormal Facies, Thymic Aplasia, Cleft Palate and Hypocalcemia) From FTM 2: Detailed review - Most common microdeletion disorder - Microdeletion 22q11.2 Clinical Features: - Abnormal pharyngeal pouch development - Defective development or absence of parathyroid glands or thymus - immune dysfunction - Conotruncal region of heart; cardiac anomaly causing congenital heart defects - Learning disability - Facial anomalies include long midface, narrow palpebral fissures, prominent nasal root and bulbus nasal tip, ear dysmorphology - Cleft lip and palate, maybe speech difficulty - Increased risk for schizophrenia - Genes in deleted region interacted with Drosha in miRNA regulation - Easiest to detect with FISH Splenomegaly - Correct answer- Enlargement of the spleen - Usually associated with blood disorders - Followed by Hepatomegaly - We can leave without a spleen with side effects although when the spleen ruptures, it is a life-threatening issue that needs immediate intervention. Sickle Cell Anemia Association with Spleen - Correct answer- Spleen shrinks as blood flow is blocked by the sickle cell, due to this there is more damage and the filtration is blocked leading to its shrinkage. Thoracocentesis - Correct answer- "Pleural tap" to sample fluid from pleural space or to also remove excess fluid - All incisions/tube placed above/superior border to rib to avoid VAN - Depending the amount of fluid and distribution into the pleural cavity Thoracostomy - Correct answerChest tube inserted to drain fluid or air from pleural cavity. It is inserted 4th or 5th intercostal space between the anterior axillary and midaxillary - All incisions/tube placed above to rib to avoid VAN Surface Landmarks of Pleura - Correct answerBetween these points above the ribs this sides can be access the pleural cavity for thoracocentesis Pneumothorax - Correct answer- Presence of air or gas in the pleural cavity - Causes: Spontaneous - Absence of lung disease, no prior provoking event, ruptured bleb or bullae Traumatic - introduction of air or gas in pleural cavity secondary injury to the pleura by blunt or penetrating trauma Other: Inflammation, Smoking, and Underlying Pulmonary disease Two types: Non-Tension Pneumothorax and Tension Pneumothorax Physiology of the disease: - The transpulmonary pressure becomes zero and elastic recoil causes the lung to collapse. The mediastinal membrane prevents from the other lung collapsing. - The intrapleural pressure becomes positive, either equal to atmospheric pressure or greater than it. Neonatal Respiratory Distress Syndrome - Correct answer- Affects approx 2% of live newborns; and those born prematurely are the most susceptible. - These infants develop rapid, labored breathing shortly after birth. - RDS is also known as hyaline membrane disease - An estimated 30% of all neonatal diseases result from RDS or its complications - Causes: Surfactant deficiency, prolonged intrauterine asphyxia (impaired or absent exchange of O2 and CO2) may produce irreversible changes in the type II alveolar cells, making them incapable of producing surfactant. - Treatment includes supplementary oxygen and artificial surfactant - more than 90% of neonates with RDS survive. - Corticosteroids are potent stimulators of fetal surfactant production and may be given to the mother if early delivery is a risk. FTM1 throwback: Role of phospholipid in surfactant Dipalmitoylphosphatidylcholine (DPPC): important component of surfactant - Lecithin-Sphingomyelin (L/S) ratio measured in amniotic fluid to determine fetal lung maturity - DPPC are low in premature neonates and they have a high risk for RDS due to collapse of alveoli - L/S ratio > 2: fetal lung is mature; low risk of RDS; usually seen in 1st term infants - L/S ratio < 1.5: fetal lung is not mature enough and there is a higher risk of RDS in these infants Physiology: Decreased Surfactant leads to Increase Surface tension Atresia - Correct answerComplete obstruction/blockage of a passage. Here it is due to failure of recanalization of lumen or incomplete division of the foregut Stenosis - Correct answerNarrowing/Partial closure of a passage. Here it is mainly due to unequal partitioning of the foregut Fistula - Correct answerAbnormal communication between two epithelial surfaces, due to incomplete division of a tube (e.g., incomplete division of cranial part of foregut into respiratory system and esophagus) Tracheo-esophageal fistula (TEF) - Correct answer-An abnormal communication between trachea & esophagus -Results from incomplete division of the foregut into esophageal and respiratory portions during fourth week - Hence the incomplete fusion of tracheoesophageal folds will result in a defective tracheoesophageal septum and a TEF between the trachea and esophagus - Most common birth defect of the lower respiratory tract -Polyhydramnios is often associated with esophageal atresia - Four main varieties of TEF may develop, the usual defect is for the superior part of the esophagus to end blindly (esophageal atresia) and for the inferior part to join the trachea near its bifurcation. - Infants with the most common type of TEF and esophageal atresia have dysphagia so they frequently drool saliva and immediately regurgitate milk when fed. - Gastric and intestinal contents may also reflux from the stomach through the fistula into the trachea and lungs. This refluxed acid, and in some cases bile can cause pneumonitis Pneumonitis - Correct answerinflammation of the lung Polyhydramnios - Correct answerThe excess amniotic fluid develops because fluid cannot enter the stomach and intestines for absorption and subsequent transfer through the placenta to the mother's blood for disposal Diaphragmatic Hernia - Correct answer- Failure of diaphragm to completely separate abdomen and thorax. - In other words failure of fusion of one of the four structures - In imaging pleuroperitoneal membrane defect - Most common sites/hernias: 1) Between the xiphoid process and the costal margin on the right (Morgagni's hernia) 2) Posterolateral region (Bochdalek's hernia) 3) Esophageal hiatus (congenital hiatal hernia) Morgagni's Hernia - Correct answer- Between the xiphoid process and the costal margin on the right - aka retrosternal, parasternal - rare, represent only 3% of all congenital diaphragmatic hernia. - It is caused by congenital defect in the fusion of septum transverses of the diaphragm and costal margin - More common on the right side - Allows abdominal contents to enter the thoracic cavity Bochdalek's Hernia - Correct answer- Most common diaphragmatic hernia. - Located posterolateral region - Due to defective formation or fusion of the pleuroperitoneal membrane - Most common on the left side - Allows abdominal contents to enter the thoracic cavity Congenital Hiatal Hernia - Correct answer- esophageal hiatus opening may be abnormally large allowing the fundus of the stomach to herniate into the posterior mediastinum - causes symptoms of acid reflux - Signs and symptoms: The abdomen is empty when lying flat as abdominal contents herniate into the thorax The lung is compressed and hypoplastic (high mortality rates) - requires urgent surgery Eventration of the Diaphragm - Correct answer- Relatively uncommon condition - In which half of the diaphragm has defective musculature, causing it to balloon into the thoracic cavity as a membranous sheet, forming a diaphragmatic pouch, consequently, the abdominal viscera are displaced superiorly into the pocket-like outpouching of the diaphragm. - This birth defect results mainly from failure of the muscular tissue from the body wall to extend into the pleuroperitoneal membrane on the affected side. - In imaging you can see the muscular deficit and intact Conduction Zone Diseases - Correct answerFunction: Airflow: Heat, Hydrate, and Clean Structure: Airways Pathology: Ventilation Problem - Flow Velocity problem Examples: Asthma, COPD, Bronchitis, Bronchiolitis, Bronchiectasis, and Cystic Fibrosis Respiratory Zone Diseases - Correct answerFunction: Gas exchange Structure: Alveoli/Lung Parenchyma Pathology: Gas exchange problems - may present with volume problems Examples: Pulmonary Fibrosis (including pneumoconiosis), hypersensitivity pneumonitis, pneumonia Chronic Bronchitis - Correct answer- Inflammation of the bronchi - Commonly caused by cigarette smoking, others are toxic fumes, heavy air pollution, recurrent infections - Chronic immune cells infiltrate submucosa - Number of goblet cells may increase and the mucous glands may hypertrophy and undergo hyperplasia and mucosal smooth muscle also goes under hypertrophy - Cilia movement often is impeded due to increased mucous as it destroys mucociliary escalator - Increased mucous gland secretion and increased viscosity of mucus, leads to coughing and obstruction - Cough with sputum expectoration for at least 3 months a year during a period of 2 consecutive years Pulmonary Fibrosis - Correct answerRestrictive lung disease caused by low lung compliance which indicates a stiff lung. Requires more work to inflate the lung Emphysema - Correct answer- Obstructive lung disease is caused by high lung compliance which indicates an easily distensible lung - Lost elastic recoil thus additional effort is required to force air out of the lungs - The elastic fibers are destructed by the destruction of the alveolar wall. This occurs from chronic inhalation of irritants such as smoke, coal, textile fibers, and dust. This leads to inflammation where neutrophils, macrophages, and monocytes accumulate which release proteases like elastase and eventually lead to the breakdown of elastic fibers. - Signs of air trapping - prolonged expiratory phase, barrel chest, flat diaphragm Capillary Permeability Increased - Correct answerExamples of Disease States: Inflammation due to inhalation of Lung Irritants, Acute respiratory distress syndrome Spirometry - Correct answer- Common pulmonary function test used to assess lung function - Uses FEF25-75 as it has the greatest sensitivity for the detection of early airflow obstruction - Obstructive - Expiratory flow rate is significantly decreased resulting in decreased FEV1 and FVC, the FEV1/FVC ratio is low - Restrictive - Lung inflation is decreased resulting in decreased FEV1 and FVC, the FEV1/FVC ratio is normal or increased. Obstructive Lung Diseases - Correct answer- Expiratory flow rate decreased - Little Elastic Recoil - Airway occlusion air trapping - High Compliance - Examples: Chronic Bronchitis Emphysema COPD Asthma Bronchospasm Cystic Fibrosis - Obstructive - Expiratory flow rate is significantly decreased resulting in decreased FEV1 and FVC, the FEV1/FVC ratio is low Restrictive Disease - Correct answer- Lung inflation is decreased - Large Elastic Recoil - Low Compliance - Intrinsic - lung tissue; Extrinsic - Chest wall, Pleura or Neuromuscular - Examples: Pulmonary Fibrosis IRDS Scoliosis Asbestosis Fibrotic pleurisy Pleural Effusion Pneumothorax Silicosis Tuberculosis Kyphosis Mitral Obstruction Rheumatic heart disease - Restrictive - Lung inflation is decreased resulting in decreased FEV1 and FVC, the FEV1/FVC ratio is normal or increased. Peak Flow Device - Correct answerUsed for monitoring lung disease Provides information about exacerbations Objective data collected by practitioner Helium Dilution Technique - Correct answer- Useful in healthy individuals with no lung obstruction - Helium does not get beyond obstruction, thus yielding a false FRC - The person is asked to breathe until the gas equilibrates between the spirometer & the lungs - Measures RV,FRC and TLC Body Plethysmograph - Correct answer- Airtight box that measures changes in pressure and volume on inspiration and expiration - Boyle's law is used to estimate lung volume. Medulla oblongata damage - Correct answerDeath - no maintenance of respiratory cycle Hypoxemia - Correct answer- Deficient amount of oxygen in the blood - Sensed by peripheral chemoreceptors - Low O2 in blood - Generalized Hypoventilation does not affect the A-a O2 gradient - Although regional low VA/Q ratio (90%), Anatomic shunt and Diffusion block increase the A-a O2 gradient Methemoglobin - Correct answer-contains ferric iron (Fe3+)- the oxidized form in the porphyrin ring - ferric ion does not bind to O2 - Remaining 3 O2 sites do not release the bound O2 -blood normally contains a small amount - Causes either genetic due to deficiency in enzyme cytochrome (MetHb) reductase - causes methemoglobinemia or excessive consumption of nitrites/nitrates which are oxidant - Treatment: Methylene Blue, Vitamin C Hexokinase deficiency - Correct answer- Reduced 2,3-BPG levels - Left shift on binding curve - Increased O2 affinity - Hemolytic Anemia caused by osmotic imbalance in Na+ which causes cell to lyse and burst - Serum lactate dehydrogenase (LDH) is elevated Pyruvate Kinase deficiency - Correct answer- Elevated 2,3-BPG levels - Right shift on binding curve - Decreased O2 affinity - Hemolytic Anemia caused by osmotic imbalance in Na+ which causes cell to lyse and burst - Serum lactate dehydrogenase (LDH) is elevated Carboxyhemoglobin - Correct answer- Carbon monoxide bound with hemoglobin - CO is colorless and odorless so undetectable - Binds to heme 25000x more tightly than O2 - CO stabilizes the R state of Hb --> Decreases O2 unloading by other subunits. The patient comes with a cherry-red appearance in the ER. Physicians say cherry red is dead. Sometimes there are no physical signs - The 1st organ affected is the brain: Sxs include slow reaction time, blurred vision, and coma. - A hyperbaric Chamber is used to manage CO poisoning as it helps remove toxic CO with 100% O2. Sometimes under elevated pressure. YOu also need to administer O2 mixed with 5% CO@ to increase alveolar ventilation Hemoglobin S - Correct answer- Point mutation in Beta-Globin Gene on 6th Codon - Glutamic Acid Substituted by Valine at position 6 of Beta-Globin Chain - Hbs moves slower to anode than HbA in electrophoresis - Homozygous inheritance (HbSS) causes sickle cell disease - Autosomal Recessive - Painful episodes 'sickle cell crisis' and hemolytic anemia - Reduced life-span of RBCs - Causes of sickling: Acidosis, Volume depletion and Hypoxemia - Painful crises caused by anemia, hemolysis, and vaso-occlusive ischemia in abdomen and long bones: Dactylitis, Acute chest syndrome, avascular necrosis of femoral head, autosplenectomy, stroke - Treatment: Increase fetal globin expression. Drugs are 5-azacytidine (Decitabine and demethylating agent) and Hydroxyurea, Butyrate compounds (inhibit histone deacetylation) - Hydroxyurea: Increases HbF levels which has higher affinity for O2 which inhibits sickling - Heterozygote - Sickle Cell trait. Generally benign but develop sickling crisis in low O2 saturation. Have survival advantage against falciparum malaria - More Frequency in Africa, Mediterranean basin, Middle East and India - Gain of function - shape of sickle cell. Not suppose to polymerize hemoglobin & cause distortion HbSC disease - Correct answer- Two different mutations of β-globin gene One β- globin gene has 'S' mutation and other has 'C' mutation - HbSC: Sickling episodes similar to sickle cell disease (milder) - 25% chance of a child getting both - Severity: HbC < HbSC < HbS Hemoglobin C - Correct answer- Point mutation 6th codon of beta globin gene - Missense mutation Glutamate to Lysine - HbC moves slowest to anode (positively charge electrode) on electrophoresis - Hemorrhage into joints and muscles, easy bruising, and prolonged bleeding from wounds - Prolonged APTT, PT normal, Bleeding time normal Inheritance Pattern for Hemophilia - Correct answerInheritance is affected male --> Carrier female --> Affected male (skipped generations) - No male to male transmission - Carrier mother has 50% chance of passing the faulty X-chromosome to her daughter - Affected father always passes on affected gene to all his daughters (Obligate Carriers) - Usually females are asymptomatic since random X inactivation/Lyonization results in approx. equal proportions of somatic cells in which either normal X or mutant X chromosome is active and clotting factor synthesis is adequate for hemostasis - Some carrier females have increased bleeding tendency (Manifesting heterozygote due to skewed X-chromosome inactivation leading to a higher percentage of inactivation of normal X-chromosome Treatment: - Recombinant factor VIII (or IX) replacement therapy. Antibodies against recombinant protein in approx. 10% of patients. - Hemophiliacs received clotting factor from pooled blood. Risk of HIV and Hep B and C via contaminated blood. More than 50% of hemophiliacs contracted HIV/hepatitis from transfusion of infected blood Alveolar Blockage - Correct answerWith blockage you will have alveolar dead space that needs to be taken into consideration while counting Physiological dead space Fowler vs Bohr Method - Correct answer- Fowler's methods measures anatomic dead space only - Physiological dead space and can be measured by Bohr method. - So fowler is not a good method for someone with normal lung Hyperventilation - Correct answerAs alveolar ventilation increases Pa/A CO2 decreases and PaO2 increases Hypoventilation - Correct answerAs alveolar ventilation decreases Pa/A CO2 increases and PaO2 decreases Hypercapnia - Correct answerIncreased carbon dioxide in blood Hypopnea - Correct answerDecreased ventilation in response to lowered metabolic CO2 production Hyperpnea - Correct answerIncreased ventilation in response to increased metabolic CO2 production (e.g. exercise), which should purge CO2 Eupnea - Correct answerNormal Breathing Tachypnea - Correct answerIncreased frequency of breathing. Ventilation may or may not change depending on tidal volume Dyspnea - Correct answerShortness of breath/Labored Breathing Apnea - Correct answerTemporary Cessation of breathing Fluoride - Correct answer- Inhibits Enolase - In clinical lab, blood collected in fluoride containing tubes for estimation of plasma glucose - If fluoride is not added, plasma glucose is used by RBC and WBC, resulting in erroneously low values The Warburg Effect and Cancer - Correct answer- Usually glycolysis is anaerobic - But many cancer cells produce ATP through increased glycolysis followed by lactate production - Cancer cells: aerobic glycolysis is used to rapidly produce ATP and is termed the Warburg Effect - Glucose analog 'fluorodeoxyglucose (FDG) used in positron emission tomography (PET) - Inhibitors of glycolysis are explored for sure as therapeutic agents in cancers Lactic acidosis - Correct answerObserved when - Increased NADH/NAD+ ratio: Indicates anaerobic respiration - Inherited deficiency of pyruvate dehydrogenase (Impaired aerobic metabolism) - Decreased blood supply due to cardiac failure: Anaerobic metabolism in peripheral tissues. Defect in Cori cycle and lactate is not efficiently transported to liver. - Pulmonary embolism (poor oxygenation) - Hemorrhage and circulatory shock Causes Metabolic Acidosis: - Weak acid and gives off protons. H+ ions buffered by bicarbonate used for buffering H+ from lactic acid - pH is low; serum HCO3- is decreased; PCO2 is decreased as compensatory response; Results in high anion gap acidosis Arsenate - Correct answerInhibits Glyceraldehyde-3-phosphate dehydrogenase Partially blocked airway - Correct answerCauses the region to be underventilated relative to blood flow. A low regional ratio causes venous admixture and will increase the physiologic shunt Partially Obstructed Pulmonary Arteriole - Correct answerCause an abnormally high ratio in a lung region. The region is overventilated leading to an increase in physiologic dead space Hypoxic Vasoconstriction - Correct answerFor low V/Q ratio (lots of blood or too little ventilation); causes the blood coming into the area to be directed to other parts of the lung. Bronchoconstriction - Correct answerFor high V/Q ratio, the bronchi will constrict slightly to increase the resistance and decrease the amount of ventilation coming into an area that is not well perfused thus limiting the amount of alveolar dead space Acclimatization - Correct answeris the process in which an individual organism adjusts to a change in its environment (such as a change in altitude, temperature, humidity, photoperiod, or pH), allowing it to maintain performance across a range of environmental conditions. These responses are often reversible should environmental conditions revert to an earlier state. Death Zone - Correct answerAltitudes at which PO2 is insufficient to sustain human life (8,00 m or 26,000 ft) Altitude-Acute Responses - Correct answer- Low PO2 causes hypoxia-induced stimulation via the carotid bodies - An immediate rise in cardiac output occurs - After 8 hours of chronic hypoxia, minute ventilation levels off and is sustained - The small rise in ventilation in this is due to significant decrease in PaCO2 as a result of excess CO2 blown off with altitude-induced hyperventilation - The hypocapnia and rise in blood pH strongly blunt the hypoxic drive - The kidneys excrete bicarbonate and the pH is lowered - Carotid bodies become more sensitive to PO2 Altitude-Chronic Responses - Correct answer- Referred to as ventilatory-induced acclimatization. - This occurs over days of continuous exposure to hypoxia and reaches a stable plateau after 2 weeks - Function state that can be reversed if altitude changes - Polycythemia-low PO2 of the kidney stimulates the release of erythropoietin - which in turn stimulates the bone marrow to increase RBC production - Hypoxemia - induces a higher RBC count per unit volume, greater carrying capacity for oxygen - Blood viscosity is greatly increased - 2-3 DPG levels rise resulting therefore In increased oxygen unloading Mountain Sickness: Pulmonary Effects - Correct answer-Pulmonary hypoxic vasoconstriction increases pulmonary vascular resistance increasing hydrostatic pressure in pulmonary circulation -Cardiac output is also increased - increased sympathetic stimulation due to arterial chemoreceptor stimulation -These factors favor pulmonary edema - Complications: Infection, Urinary Obstruction. Renal Failure - Diagnosed with US and X-ray - Three Constriction where the stone is found: 1) Pelviureteric Junction or UPJ (ureteropelvic junction) 2) Where it crosses the pelvic brim aka crossing the iliac artery 3) Where is passes through the bladder wall aka UVJ (ureterovesical junction) - Small Stones give more pain as there is more contraction Varicocele - Correct answerVeins in the scrotum become dilated, incompetent and cause retention of blood in the testicle. These dilated veins can be felt as a bag of worms on physical exam - Can be caused by the compression of left renal vein Cystocele - Correct answer- Prolapse of the bladder into the vaginal canal - Fullness of vagina Common causes: - repetitive straining for bowel movements - constipation - chronic or violent coughing - heavy lifting - being overweight or obese Cystoscopy - Correct answer- The interior of the bladder and its three orifices can be examined with a cystoscope - During transurethral resection of a tumor, the instrument is passed into the bladder through the urethra. - Using a high frequency electrical current, the tumor is removed in small fragments that are washed from the bladder with water - Can be used as diagnostic tool Hemisected Female Pelvis - Correct answerFemale pelvis, with the bladder empty, the normal disposition of the uterus shown here bent on itself (anteflexed) at the junction of the body and cervix of the uterus and tipped anteriorly (anteverted) causes its weight to be borne mainly by the bladder. The urethra lies anterior and parallel to the lower half of the vagina Hemisected Male Pelvis - Correct answerMale Pelvis, the urinary bladder is distended, as when full. Compare its relation to the anterior abdominal wall, pubic symphysis, and level of the supravesical fossa to that of the nondistended bladder in part. Urinary Bladder Pain - Correct answerInvolved in increase in urinary frequency due to increased urinary urge Urinary bladder Catheterization - Correct answerPerformed for both therapeutic and diagnostic purpose External Catheter - Correct answerAdhere to the external genitalia in men or pubic area in women and collect the urine. They are useful for the management of urinary incontinence. Puborectalis Muscle damaged during urinary incontinence. Urethral Catheters - Correct answer- Inserts through the urethra, with the tup advanced into the base of the bladder - In the male the shape of the urethra has 2 bends. 1st bend is in the spongy urethra and can easily be manipulated. 2nd bend is located at the membranous urethra and is fixed • If not inserted carefully the catheter may damage the bulb of penis -just deep to the first bend Suprapubic catheters - Correct answer- Inserted into bladder surgically via suprapubic approach - It is inserted under a general or local anesthetic. • Used for closed drainage and may be left in place for a time, sutured to the abdominal skin. - Pros: Lower incidence of urinary tract infection, ease of voiding naturally when the catheter is clamped, and ease of ambulation. • Cons: Must initially be inserted through the abdominal wall by a physician and the insertion site must be cleaned daily using sterile technique if the patient is in the hospital. Urinary Bladder Fistula - Correct answerFistula: Can develop after traumatic tissue damage following surgery, childbirth, infections, cancer, or a chronic condition Obstetric Fistula: Caused by prolonged, obstructed labor without timely medical treatment. Leaves women leaking urine, feces, or both. Often leads to chronic medical problems and subsequent depression, social isolation, deepening poverty Vaginal Fistula: Connects vagina to another organ such as the bladder, rectum or bowel. World Health Organization claims 100,000 individual affected per year. Estimated that there are more than 2 million untreated women in Asia and Sub-Saharan Africa Treatment options are often surgical Urinary Incontinence (UI) - Correct answerInability to control urination Post-void residual (PVR) is small Stress Incontinence - Correct answerDue to increased abdominal pressure under stress (weak pelvic floor muscles) Urge Incontinence - Correct answerDue to involuntary contraction of the bladder muscles Overflow Incontinence - Correct answerDue to blockage of the urethra Neurogenic Incontinence - Correct answerDue to disturbed function of the nervous system Nutcracker Syndrome - Correct answer- Vascular compression disorder that refers to the compression of the left renal vein most commonly between the superior mesenteric artery (SMA) and aorta - Clinical manifestations are left flank pain, pelvic pain, hematuria and gonadal varices. Hematuria can be microscopic or macroscopic - Before making diagnosis rule out cancer Polycystic Kidney - Correct answer- Autosomal Dominant (more common): Cysts form from all segments of the nephron. Approx. 50% of individuals will have end- stage kidney disease by age 60. - Autosomal Recessive: Cysts progressively form from the collecting ducts. Kidneys become large and renal failure occurs in infancy or childhood Hysterectomy - Correct answerSurgical removal of the uterus Water under the bridge so if the vessels are not ligated there is a leakage of urine from abdominal incision Anti-GBM antibody-induced glomerulonephritis - Correct answer- Autoimmune response to type IV collagen (alpha chain affected) in the glomerular basement membrane (GBM). In some individuals, anti-GBM antibodies may cross react with the alveolar basement in the lungs, producing Goodpasture Syndrome. - So basically the things that can't filter can now filter - Features: Linear deposition of immunoglobulin G antibodies in the GBM. Rapidly progressive glomerulonephritis (inflammation in the glomeruli) causing crescent glomerulus Pulmonary hemorrhage Alport's Syndrome - Correct answerMutation in gene encoding the alpha 5 chain of type IV collagen It is hereditary glomerulonephritis Symptoms: Hematuria, Proteinuria, and Progressive Renal Failure - The GBM becomes irregularly thickened with laminated lamina densa and fails to serve as an effective filtration barrier. Hematuria - Correct answerPresence of blood in the urine Proteinuria - Correct answerPresence of significant amount of protein in urine - Urea Osmolarity increases Causes: CNS infections, Trauma, Lung infections, cancers and drugs Potassium-Sparing Diuretics aka Sodium Channel Blockers - Correct answer- Triamterene, amiloride - Sodium channel blockers and the aldosterone antagonists reduce Na+ reabsorption so K+ secretion diminished ---> decrease urinary excretion of K+ and act as K+-sparing diuretics. - K+-sparing agents have a weak diuretic effect because less than 5% of filtered Na+ is reabsorbed at this site. - SOA: Collecting tumbles Tumor of adrenal cortex - Correct answer- Primary Hyperaldosteronism (Conn's syndrome) --> Hypertension (high plasma Na+), hypokalemia (less plasma K+), and metabolic alkalosis (high plasma HCO3-) - Spironolactone can be helpful in treating patients with Conn's Syndrome Spironolactone - Correct answerUsed to treat patients with Conn's Syndrome Aldosterone - Correct answerSOA: Collecting tubule and duct Effects: Increases NaCl and H2O reabsorption, Increases K+ secretion, Increases H+ secretion Angiotensin II - Correct answerSOA: Proximal tubule, thick ascending loop of Henle/distal tubule, collecting tubule Effects: Increases NaCl and H2O reabsorption, Increases H+ secretion Antidiuretic Hormone (ADH, vasopressin) - Correct answerSOA: Distal tubule/collecting tubule and duct Effects: Increases H2O reabsorption - Low ADH does not absorb water, collecting duct is impermeable to water, no urea reabsorption. Medulla slightly hyperosmotic. Dilute Urine - High ADH absorbs too much water, collecting duct permeable to water (AQP2), urea reabsorption, medulla highly hyperosmotic, Concentrated urine Atrial Natriuretic peptide - Correct answerSOA: Distal tubule/collecting tubule and duct Effects: Decrease NaCl reabsorption Parathyroid Hormone - Correct answerSOA: Proximal tubule, thick ascending loop of Henle/distal tubule Effects: Decrease PO4- reabsorption and increase Ca2+ reabsorption Osmotic Diuretics - Correct answer- Mannitol - Inhibit water and solute reabsorption by increasing osmolarity of tubular fluid - SOA: Mainly proximal tubules Aldosterone antagonists - Correct answer- Spironolactone, Eplerenone - Inhibit action of aldosterone on tubular receptor, decrease Na+ reabsorption and decrease K+ secretion SOA: Collecting tubules Sodium channel blockers - Correct answertriamterene, amiloride (potassium sparing diuretics; work in the aldosterone-sensitive principal cells in the cortical collecting tubule) Early Proximal Tubule - Correct answerMajor Function: Isosmotic reabsorption of solute and water Cellular Mechanism, Hormone and Diuretic Actions: 1. - Na+-glucose, Na+ amino acid and Na+ phosphate cotransport. - PTH inhibits Na+ phosphate transport - Osmotic Diuretics 2. - Na+-H+ exchange - Angiotensin II stimulates the Na+-H+ exchange - Carbonic anhydrase inhibitors Late Proximal Tubule - Correct answerMajor Function: Isosmotic reabsorption of solute and water Cellular Mechanism: NaCl reabsorption driven by Cl- gradient Diuretic Actions: Osmotic Diuretics Thick Ascending Limb of the Loop of Henle - Correct answerMajor Functions: - Reabsorption of NaCl w/out water - Dilution of tubular fluid - Single effect of countercurrent multiplication - Reabsorption of Ca2+ and Mg2+ driven by lumen positive potential Cellular Mechanisms: Na+-K+-2Cl- cotransport Hormone Actions: ADH stimulates Na+-K+-2Cl- cotransport Diuretic Actions: Loop Diuretics Early Distal Tubule - Correct answerMajor Functions: - Reabsorption of NaCl w/out water - Dilution of tubular fluid Cellular Mechanisms: Na+-Cl- cotransport Hormone Actions: PTH stimulates Ca2+ reabsorption Diuretic Actions: Thiazide diuretics Late Distal Tubule and Collecting Ducts (Principal Cells) - Correct answer1) Major Function: Reabsorption of NaCl; Cellular Mechanism: Na+ channels (ENac); Hormone Actions: Aldosterone stimulates Na+ reabsorption 2) Major Function: K+ Secretion; Cellular Mechanism: K+ channels; Hormone Actions: Aldosterone stimulates K+ secretion 3) Major Function: Variable water reabsorption; Cellular Mechanism: AQP2 water channels; Hormone Actions: Aldosterone stimulates water reabsorption - Diuretic Actions: K+ sparing diuretics Late Distal Tubule and Collecting Ducts (Alpha-Intercalated Cells) - Correct answer1) Major Function: Reabsorption of K+; Cellular Mechanism: H+-K+ ATPase 2) Major Function: Secretion of H+; Cellular Mechanism: H+-ATPase; Hormone Actions: Aldosterone stimulates H+ secretion Diuretics Actions: K+-sparing diuretics TBW measuring Dye Techniques - Correct answer- Isotopic Water (D2O) - Titrated water (THO) - Antipyrine ECF measuring Dye Techniques - Correct answer- Sulfate - Mannitol - Inulin PV measuring Dye Techniques - Correct answer- Radioactive Albumin - Evans Blue Isosmotic Volume Expansion - Correct answer- Isotonic NaCl - Ringers Solution Hyperosmotic Volume Expansion - Correct answer- High intake of NaCl - 3% NaCl solution infusion (rarely used) - 5% Dextrose in 0.9% Saline infusion Hyposmotic Volume Expansion - Correct answer- SIADH - Increased Water intake in short time (2L in 15 min) - Infusion of 0.45% Saline - Infusion of 5% Dextrose Isosmotic Volume Contraction - Correct answer- Diarrhea - Burn - Loss of Blood Hyperosmotic Volume Contraction - Correct answer- Water deprivation (hiking no food and water for 2 days) - Sweating - Increases vasoconstriction of efferent arteriole which increases Hydrostatic pressure of glomerular capillary which ultimately leads to increased GFR and increased Na+ reabsorption. - Increases thirst, increase water intake, increase plasma/blood volume - increase ADH release from posterior pituitary which leads to increase water reabsorption from the DCT and CT which increases plasma/blood volume Hypoalbuminemia - Correct answerCauses a lot of shit: - Low Colloidal osmotic pressure (oncotic pressure) which leads to fluid accumulation in interstitial space leading to pitting edema - Low transportation of Ca2+ would leads to hypocalcemia since you have less albumin transporting it - Low protein diet (Kwashiorkor) would lead to decrease albumin synthesis - Chronic liver disease commonly from alcohol abuse lead to decrease albumin - Severe burns cause loss of albumin - Albuminuria or loss of albumin in urine due to nephrotic syndrome where the glomerular basement membrane is damaged which allows filtration and excretion of albumin will leads to pitting edema and edema of eyelids Increased plasma pH and Normal Albumin - Correct answerMore negative charges on albumin and higher binding of Ca2+, so it won't let go. This would predispose to hypocalcemia and tetany since you have lower free ionic Ca2+ normal calcium levels Alpha-1-Antitrypsin (AAT) Deficiency - Correct answer- Autosomal Recessive, Codominance and Allelic Heterogeneity - Normal Function: AAT inhibits neutrophil elastase and protects kung tissue. Neutrophil release elastase as part of immune response - Synthesized in liver - Exist in polymorphic form (allelic heterogeneity) - M allele is the normal functional allele - Z allele is the most frequency and severe pathogenic allele - S allele is the lest frequent and the lesser severe pathogenic allele - Smoking causes oxidation of AAT and reduces its activity - Risk of severity highest to lowest: PiZZ > PiSZ > PiMZ > PiSS > PiMS > PiMM - Lung Pathology is loss of function and is the most common manifestation. Here you have unopposed neutrophil elastase activity as you can't inactive elastase. Leads to COPD and emphysema. Worsens with smoking asked to quit smoking. Age of onset is 30-50 years. It is managed by intravenous augmentation therapy with pooled human alpha1-antitrypisun slows progression of lung disease. - Liver pathology is gain of function and only occurs if you PiZZ allele. Here the hepatocyte is damage due to protein misfolding leads to cirrhosis occurs in childhood - Heavily influenced by environmental and behavior factors (air pollution and smoking) Alpha-fetoprotein (AFP) - Correct answer- Alpha 1 globulin Abundant in fetus - Elevated AFP levels: Tumor marker for liver cancer, ovarian or testicular cancer - Maternal serum screen identify fetal anomalies - Elevated maternal serum AFP - Neural tube defects (spina bifida and anencephaly) - Low Maternal serum AFP: Trisomy 21 (Down Syndrome) Transcortin - Correct answerTransport protein for cortisol (steroid hormone) Retinol-binding protein - Correct answerA protein that is necessary to transport Vitamin A (retinol) from the liver to other tissues Alpha-2-Macroglobulin - Correct answer- Inhibits many proteases like plasmin and thrombin - Levels elevated in nephrotic syndrome - Loss of glomerular basement membrane --> loss of albumin --> stimulates synthesis of all proteins by liver - Levels of Alpha-2-Macroglobulin elevated because it is very large/big so it is retained Wilson's Disease (copper overload disorder) - Correct answer- Low ceruloplasmin levels Normal Functions: - Ceruloplamin is a copper containing α2-globulin plasma protein (from liver). - It has ferroxidase activity (Fe2+ -> Fe3+). Fe3+ can bind to transferrin. Effects: - Inability to incorporate copper into ceruloplasmin - Low excretion of copper in bile - Liver - Hepatomegaly - Corneal Ring - Kayser- Fleischer ring - Basal Ganglia involvement - involuntary movement and mood changes - Arthritis, cardiomyopathy and renal tubular dysfunction can also be caused Haptoglobin - Correct answerBinds free hemoglobin after RBC lysis to be destroyed by spleen. Decreased levels in sickle cell, thalassemia, lead poisoning, etc. - low levels basically indicator of hemolysis Hemopexin - Correct answerBinds free heme in blood Conserves iron Protects from heme-induced cell damage Transferrin - Correct answer- Transport protein for ferric iron and transports it between intestine, liver, bone marrow, and reticuloendothelial system (spleen and macrophages) - Each transferrin can bind 2 Fe3+ atoms - 1/3rd binding site on transferrin are filled with iron - Low serum iron and low transferrin saturation: iron deficiency anemia - High serum iron and high transferrin saturation: Iron overload LDL (low density lipoprotein) - Correct answer- Beta-lipoprotein - Elevated LDL in Familial hypercholesterolemia (Type IIA) and Nephrotic syndrome (Elevated serum total cholesterol and LDL levels) - Increases risk of atherosclerotic cardiovascular disease Postive acute phase reactants - Correct answer- Increased Synthesis during Inflammation/Immune response List: - C- Reactive Protein (CPR). Used to monitor inflammation, trauma and infection. It is increased after surgery if does not fall during recovery there is a high chance there is some kind of infection which needs to be treated. - Alpha 1 antitrypsin - Ceruloplasmin - Haptoglobin - Hemopexin - Immunoglobulins - Ferritin - Complement proteins Negative acute phase reactants - Correct answer- Decreased Synthesis during Inflammation/Immune response List: - Albumin - Retinol binding protein - Transcortin - Transferrin IgM - Correct answer- First antibody produced in response to an antigen - Largest - Pentamer IgG - Correct answer- Produced on repeated exposure to same antigen - Most abundant - IgG crosses placenta and confers passive immunity to fetus and newborn IgE - Correct answerSecreted in an allergic response IgA - Correct answerSecretory immunoglobin - Presents in body secretion like saliva, breast milk IgD - Correct answerFunction not known Multiple Myeloma - Correct answer- Plasma Cell tumor - production of a single type of immunoglobulin - monoclonal gammopathy - Affects bones and presents as fractures or bone pain due to lytic lesion in bones Stimulate ammonia formation Stimulates formation of new HCO3- and increases serum HCO3- so hypokalemia maintains and worsens alkalosis. (remember for every H+ secreted you have one HCO3- taken in) - So to treat alkalosis if you have underlying hypokalemia that needs to be treated instead of trying to treat alkalosis Decreased ECF Volume (Volume Contraction) - Correct answer- Stimulates RAAS secretion - Angiotensin-II increases Na+-H+ antiporter to increase Na reabsorption (H+ secreted --> increased reabsorption of HCO3-) - Aldosterone increases sodium reabsorption + Cl- and H2O reabsorption - Stimulates H+ secretion - Volume contraction and metabolic alkalosis there is increased Na+ reabsorption and H+ secretion in urine (paradoxical aciduria) Loop and Thiazide diuretics - Correct answerDecrease Na+ reabsorption in tubules increasing Na+ delivery to distal tubule which leads to increase K+ secretion and H+ secretion in urine which leads to Metabolic alkalosis, hypokalemia and aciduria Respiratory acid base disorders - Correct answerDysfunction of the respiratory system and characterized by primary changes in PaCO2 Metabolic acid base disorders - Correct answerMetabolic or renal disorders and characterized by primary changes in HCO3- Acute Respiratory Acidosis - Correct answer- Characterized by decrease rate of respiration/decreased lung function/decreased air entry into the lungs - As a result CO2 is not washed out and is accumulated resulting in elevation of PaCO2 - pH decreased - PaCO2 Elevated - HCO3- is almost Normal Chronic Respiratory Acidosis - Correct answer- During compensation, renal system comes to the rescue. - Kidneys excrete more H+ and generate more HCO3- and serum HCO3- levels increase - Increased excretion of phosphate and ammonium in urine - pH is lower than normal - closer to normal pH when compared to acute state - PaCO2 - Elevated (Primary defect is still not corrected - respiratory system is still not functioning optimally) - HCO3- Elevated due to renal compensation Causes of respiratory acidosis - Correct answer- Hypoventilation - Airway obstructed by foreign body - Disease/Injury to phrenic nerve (supplies diaphragm) - Guillain-Barre syndrome (Demyelinating - PNS Schwann cells) - Multiple Sclerosis - (Demyelinating - CNS Oligodendrocytes) - Lung diseases: COPD, RDS, fibrosis of lung, collapse of lung, chronic smokers - Central causes which inhibit respiratory center: Opioids, anesthetics - Chest wall disorders: muscle diseases (muscular dystophy) Metabolic Acidosis - Correct answer- Characterized by low HCO3- and low pH - HCO3- is low due to increased nonvolatile acids or due to increased loss of HCO30 - Acidosis stimulates respiratory center --> Hyperventilation and a fall in PaCO2 due to increased washout of CO2 - If kidney is function, it can also compensate to increase H+ excretion, increase the formation of new HCO3-. It can also increase excretion of acid phosphate and ammonium - However until the cause of acidosis is treated, pH does not come back to normal Anion Gap - Correct answerCations - Sum of Anion Anion gap = Na+ - (Cl- + HCO3-) Normal anion gap is 8-14 Presence of unmeasured anions: Phosphate, sulfate, lactate and ketone bodies - In some forms of metabolic acidosis, there is increase in unmeasured anions, resulting in increased anion gap Metabolic Acidosis (High anion gap) - Correct answerIncreased production of non- volatile acids (high anion gap metabolic acidosis) - increased unmeasured anions - Diabetic Ketoacidosis (increased ketone body production) - Hyperkalemia - Lactic acidosis (increased lactate production) - Chronic renal failure (decreased excretion of sulfate, phosphate) - Methanol and ethylene glycol poisoning Metabolic acidosis (normal anion gap) - Correct answerIncreased loss of HCO3- (base) - normal anion gap metabolic acidosis - Hyperchloremic acidosis - Diarrhea (increased loss of HCO3- rich intestinal secretions - Renal tubular acidosis (failure to secrete H+ and reabsorb HCO3-) - Acetazolamide treatment (inhibits renal carbonic anhydrase) Acute Respiratory Alkalosis - Correct answerRespiratory alkalosis characterized by an increase in rate of respiration (hyperventilation) --> Increased washout of CO2 --> Decreased PCO2 (primary disturbance) - pH is increased - PaCO2 decreases - HCO3- is almost normal Chronic Respiratory Alkalosis - Correct answerRenal system tries to bring the pH back towards normal - Kidneys do NOT secrete H+ into urine - Increased urinary HCO3- excretion (Beta intercalated cells) and pH of urine becomes alkaline and serum HCO3- falls - pH is higher than normal - closer to normal pH, when compared to acute stage - PCO2: Decreased (as primary defect is still not corrected - respiratory system is still hyperventilating) - HCO3- Decreased (due to renal compensation) Cause of respiratory Alkalosis - Correct answer- Cause of hyperventilation - Anxiety, fever, somatic symptom disorder - High altitude: Hypoxia stimulates the respiratory center and increases rates of respiration. When a person stays for a long time at elevated altitude, renal compensatory mechanisms are active and HCO3- levels falls - Mechanical Ventilation (Overventilation) - Drugs that stimulate respiratory center (salicylate) Metabolic Alkalosis - Correct answer- Characterized by increased HCO3- - Increase in pH inhibits the respiratory center, there is a decrease in rate of respiration (hypoventilation) ---> Decreased washout of CO2 (CO2 retention) --> Increased PaCO2 - pH is higher than normal - HCO3 is increased (primary abnormality) - PaCO2 is increased (compensatory mechanism) - Renal compensates if it is functioning normally, by excreting more HCO3- (alkaline urine). Beta-intercalated cells secrete bicarbonate into urine. - Although if there is volume contraction and renal system is not working due to this volume depletion then you will have paradoxic aciduria due to kidneys try to conserve sodium and secrete protons in urine Causes of metabolic alkalosis - Correct answer- Vomiting, pyloric stenosis (Gastric outlet obstruction). Loss of acidic contents of stomach, results in relative HCO3- excess - Nasogastric suction: A tube removes acidic contents of stomach - Excessive consumption of antacids - Primary hyperaldosteronism causes hypokalemia and metabolic alkalosis - Hypokalemia - Diuretics (cause bulk flow of NA in tubules) which increase K+ secretion --> hypokalemia --> alkalosis Renal Compensation in respiratory/metabolic acidosis - Correct answer- Chronic acidosis (if kidney normal) - Increased H+ secretion by tubule - Filtered bicarbonate is reabsorbed - Urinary Acid Phosphate (titratable acidity) is increased - Ammonium in urine is increased - Urine pH becomes acidic Renal Compensation in respiratory/metabolic alkalosis - Correct answer- Alkalosis (if kidney normal and fluid volume normal)