patho exam 3

hemostasis

* the physiological process that stops bleeding at the site of the injury

normal platelet count

* 150,000-400,000 cells/uL

coagulation factors

* intrinsic pathways (tissue damage)
* extrinsic pathway (stimulated by trauma)
* calcium
* vitamin K

tissue plasminogen activator

enzyme converts plasminogen to plasmin

plasminogen

inactive precursor of plasmin

plasmin

enzyme that breaks down the clot

hypercoaugulability

* increases risk of blood clots
* thrombocytosis
* increased platelet activity (smoking, high cholesterol, diabetes)
* increased coagulation factor production
* cancer
* pregnancy
* oral contraceptives
* immobility
* atrial fibrillation

clinical manifestations of clotting

* leads to the congestion of circulation in the venous or arterial system
* pain, pale, red and swollen, hot or cool skin, decreased pulses
* shortness of breath, diminished oxygen, cough and pain
* brain (ischemic stroke)
* heart (acute myocardial infarction)

thrombocytopenia

low platelet count

* decreased platelet lifespan (aspirin, ibuprofen)
* decreased synthesis in the marrow

defective coagulation

* inherited disorder of coagulation (hemophilia)
* diseased liver (cirrhosis)
* vitamin k deficiency

clinical manifestations of bleeding

* large nursing
* ant bites
* nose bleeds
* bleeding gums
* vaginas bleeding
* gastric bleeding
* prolonged bleeding

hyperlipdemia

* elevation of lipid profile or lipoproteins in the blood which can be read as a laboratory value

LDL

* bad
* 50% cholesterol
* 10% triglycerides
* 25% protein

HDL

* good
* 20% cholesterol
* 5% triglycerides
* 50% protein

Evidence of high cholesterol

* familial hypercholestolemia (LDL levels over 500mg)
* xanthomas - cholesterol in eyes, skin, tendons
* coronary artery disease

atherosclerosis

hardening of the arteries

* causes injury to the endothelial lining
* increases narrowing of the arteries
* leads to heart attacks, strokes and loss of limbs

peripheral arterial disease

* obstruction of large arteries that serve the peripheral structure
* 80% of persons smoke
* some have diabetes
* pain in the legs
* arterial ulcers

thromboangitis obliterates

* burger disease
* inflammation and thrombosis of arteries and veins of the feet and lower legs
* age < 35
* heavy smoker
* intermittent classification in the feet
* amputations

raynaund phenomenon

* vasospasm of arteries in the hands and someone’s toes
* cold and emotional disturbance
* may indicate a collagen disorder
* pallor - cyanosis - intense red
* numbness, tinginling, painful

aortic aneurysm

* out pouching or sac like dilation in the wall of blood vessel usually caused by leaking of the vessel
* a dissecting aneurysm is a tear in the layers resulting in bleeding within the pouch

dissections of an aneurysm

* hemorrhage due to tear of the vessel wall
* pain (chest-anterior) (back-descending) “tearing or ripping”
* paralysis, kidney failure, syncope
* most patients have high BP when the tear occurs $

normal blood pressure

* newborn 50/40
* infant - 78 systolic
* adolescence - 120 systolic
* adult - 120/8-
* older adult - systolic increases and diastolic decreases

primary hypertension

* family
* age
* race
* gender
* salt
* increased calories
* obesity
* insulin resistance

secondary hypertension

* renal disease
* obstructive sleep apnea
* danger to brain, heart, kidneys, lungs

orthostatic hypotension

* abnormal drop in systolic blood pressure by 200mmhg
* blood pools in the lower extremities or flank area after sitting
* blood flow to the brain is diminished
* people with low blood volume, elderly, bedrest and BP meds are at risk
* increase fluid, salt, compression stockings, avoid heat

varicose veins

* dilated veins that lead to insufficiency
* at risk if prolonged standing repeated heavy lifting
* pressure increased on valves of the veins
* aching legs, edema

venous insufficiency

* increased pressure in incompetent veins where there is reflux, obstruction or impaired muscle movement
* edema, loss of SQ fat, brown pigmentation
* ulcers develop and commonly located at the medial malleolus

deep vein thrombosis

* inflammatory response to thrombosis
* pain, swelling, deep muscle tendernerness, fever, increased WBC
* venous Doppler studies
* monitor for signs of pulmonary complications

arthersclerosis

* fixed lesions
* unstable plaque
* thrombosis

acute coronary syndrome

* layers affected by impaired coronary flow (endocardium, myocardium, epicardium)
* degrees of injury (ischemia, injury, necrosis)

clinical manifestations of acute coronary syndrome

* sternal chest pain, jaw, tooth, arm
* dyspnea or shortness of breath
* nausea/vomitting
* low BP

diagnosis of acute coronary syndrome

* a 12 lead EKG is used to determine whether the heart attack is NSTEMI or STEMI
* repurfusion is needed to save muscle
* serum blood sample

atrial and super ventricular disorders

* located above the ventricles (SA node, AV node, juncrional tissues

heart block

* impulses of conduction through the AV node is blocked
* first, second and third degree heart blocks
* fainting, dizziness, shortness of breath, chest pain
* EKG diagnosis
* pacemaker

premature contractions

ectopic beats that interrupt the normal conduction causing an early heartbeat

* caffeine, alcohol, stress, fatigue, excercise, electrolyte disturbances
* palpations, flutter, pounding
* EKG, heart monitor
* avoid stimulants, use medications

fibrilation

* disorganized current flow that interrupts the normal contraction
* causes a quivering and does not allow a normal output of blood from the affected chamber
* atrial fibrillation is the most common but is not life threatening
* ventricular fiburlation is life threatening

heart failure

* weakened muscle that loses ability to pump blood to meet the demands of the body
* caused by functional or structural impairment of ventricular filling or ejection of the blood
* hypertension
* coronary artery disease
* valvular disease
* cardiomyopathy
* chronic obstructive pulmonary disease

cardiac output

* the amount of blood that the heart pumps per minute
* stroke volume x heart rate
* mL of blood ejected per ventricular contraction
* normal is 70mL

preload

* the volume of blood that stretches the ventricle at the end of diastole which is determined by the venous return to the heart
* end diatonic volume
* measured at the right and left atria

afterload

* represents the force that the contracting heart muscle generates to eject blood from the ventricle
* systemic vascular resistance
* the greater the resistance the less the stroke volume

inotropy

* strength of muscle contraction
* positive inotropes increase force of contraction
* negative inotropes decrease force of contraction

stroke volume

volume of blood pumped out of the left ventricle for minute

left sided heart volume

* systolic or diastolic
* decreased peripheral flow
* pulmonary edema
* nocturnal dyspnea

right sided heart failure

* caused by lefts sided heart failure
* tricuspid valvular disease
* peripheral edema
* water weight gain

causes of valvular disease

* rheumatic heart disease
* congenital heart defects
* MI
* arterischoloris
* aging

S1 sounds

\-closure of the mitral and triscupid valves during systole creates the first sound lub

s2 sound

* closure of the aortic and pulmonic valves during diastole creates the second sound dub

s3 sounds

gallop is vibration of blood flow from the atria to ventricle during diastole

s4 sounds

atrial contraction heart just before S1

valvular disease

for blood to flow efficiently through the chambers of the heart valves need to open and close

stenosis

* narrowing of the valve; does not open normally; causes a turbulent flow

regergiation

does not close properly; allows a backflow of blood

aortic valve

* located between left ventricle and the aorta
* caused by aging and congenital
* gain, syncope, systolic murmur, heart failure, peripheral cyanosis
* echocardiogram
* replacement

mitral valve

* located between the left atrium and left ventricle
* caused by rheumatic heart disease and other infections
* pulmonary congestions dyspnea, non-life threatening palpations, diastolic murmer
* echocardiogram
* valve replacement or repair

functions of the skin

* Temperature control
* Barrier protection
* Secretion and absorption
* Vitamin D production
* Immunological surveillance 
* Mirro for internal disease processes
* Indicator of general health

assessment of the skin

* describe/measure any lesions
* Initial appearance of the lesions 
* Symptoms associated with its eruption
* History of allergies 
* Medication use 

erythema

* reddened skin

bulla

large blister > 5mm

telangiectasia

* fine, irregular red lines produced by dilation

bustle

papule filled with pus

ulcer

loss of epidermal and dermal tissue

* ulcerations are staged

disorder of the nails

* can reflect nutritional status
* can reflect disease status
* clubbing (chronic hypoxia)
* infections (bacterial or fungal)
* onychomycosis (fungal or yeast infection of nail folds)

acne vulgaris

* multifactorial inflammation of these glands condone
* most common during puberty
* bacterial component

acne rosacea

* middle age adults
* inflammatory process

hemangiomas

* benign tumors of blood vessels
* 30% of newborns

port wine stains

* permanent blood vessel abnormalities
* 0.5 of population

Actinic keratosis

* Premalignant lesion
* Rough, scaly, red plaques 

Lentigos

* Premalignant skin lesion
* Brown spot 
* Aka - liver spots, age spots 
* Benign but should be watched

Malignant Melanoma 

Most lethal form of skin cancer

* Incidence has increased 300% in last 40 years
* Originates in melanocytes
* Begin on surface, but penetrate and metastasize
* UV radiation plays a role

\

malignant melanoma continued

* Most at risk
* Fair skin, 50-100 moles, history of sunburn or indoor tanning 
* ABCDE
* Asymmetry, border, color, diameter, evolving 
* Diagnosis
* Biopsy 

Basal Cell Carcinoma

* Most common form of skin cancer
* 90% of skin cancer rarely metastasize 
* begins as small, dome shaped bump
* Skiny, translucent texture 
* Grow slowly and deeply 
* cured with surgery

Squamous Cell Carcinoma 

* Risk increases with age/UV exposure 
* Appears as red, crusted or scaly patch
* May appear as non-healing ulcer or firm, red nodule 
* May develop from actinic keratosis 
* Diagnosis is a biopsy 

Fungi 

* Candida albicans - yeast infection 
* Superficial fungi 
* Dermatophytes 
* Tinea (ringworm)
* Pruritus, lesions, and cosmetic changes to skin, hair, nails, may occur

Warts 

* HPV
* Benign lesions
* May occur in anywhere on the body
* Gential warts 
* Can increase risk for cervical, anal, or rectal cancers

molluscum contagiosum

* smooth, waxy, small bumps, central core filled with cheesecake substance
* can be transmitted through spas, baths, swimming pools

arachnoid bites - mites

* transmits scabies
* associated with poverty, malnutrition, sexual promiscuity
* usually spread skin to skin contact, sometimes objects
* female might burrow under skin

arachnoid bites - ticks

* bacteria some ticks carry
* causes lyme disease and may present a bullseye rash
* rocky mountain spotted fever

bed bugs

known as cimix. lectularius

* bite is painless
* saliva contains substance that may induce reaction of the skin
* vigorous sanitation of bedding needed to kill bed bugs

spider bites

* most spider bites are benign
* dangerous spiders are black widows and brown recluse

lice bites

* pediculosis
* can live on clothing for up to month
* bite skin and such blood
* nits '
* destruction of lice requires special soaps and shampoos

hymenoptera bites

* bees and wasps
* venom injected
* anaphylaxis may develop
* fleas
* bite is called pulicosis
* small, brown lesions
* can jump from person to person or from animal to person

pressure ulcers

* decubitus ulcers, bedsores
* due to diminished blood flow, especially over bony areas

stasis ulcers

* diminished circulation in lower extremities
* blood pooling in veins
* skin damage in veins
* slow healing

eczema - atopic dermatitis

* oozing vesicle begins on cheeks and spreads to scalp, arms, trunk
* dry, lichenified lesions in antecubital and popliteal areas
* interaction between genetics, environment, stress and immune factors

psoriasis

* genetic component
* t cell mediated autoimmune
* chronic thickening of epidermis with silver-white scales covering red plaques
* lesions frequency on extensor surface of knee and elbows
* lesions bleed when scales are removed

pityriasis rosea

* Oval rash surrounded by erythema
* Herald patch: first appearance, \n normally on neck or trunk
* Patch enlarges and begins to fade
* Additional patches may appear
* Usually clears within 6–8 weeks

lichen planus

* unknown cause
* name means tree moss
* small papule covered with shiny, lace like pattern

urticaria

* hives, wheals
* may be accompanied by angiodema
* swelling of eyes, face, lips, mucous membranes

disorders of skin blood and lymphatic vessels

* vascular lesions
* small tumors with dialted blood vessels
* senile angiomas
* small dome shaped red-colored papule
* telangiectasis
* single dilated capillary

systemic lupus erythematosus

* inflammatory condition
* may be limited to skin or be systemic

discoid lupus erythematosis

* red, butterfly-shaped pattern on found
* igM found in skin biopsies

erythema multiform

= acute, recurring inflammation

* allergic or toxic reaction to drugs or microorganisms
* can be mild or very serious
* mouth, airways, esophagus, urethra may be involved

stevens-johnsons syndrome

* rare, serious disorder of the skin and mucous membranes
* triggered by an infection or drug
* begins with flu-like symptoms followed by a painful red rash that involves into large blisters and bull with skin sloughing

dissipated intravascular coagulation

* excessive bleeding and clotting at the same time
* excessive thrombin and fibrin circulation
* rapid producing DIC causes severe bleeding problems
* cancer, trauma, chock

lab testing

* Platelets - a low count can increase the risk of bleeding (thrombocytopenia)
* D - dimer measures fibrin degradation - an elevation indicates recent clotting activity 
* aPTT - elevation indivates prolonged clotting time 
* PT - elevation indicates prolonged time 
* INR - elevation indicates prolonged clotting time 

clinical signs of heart failure

* elevated brian natriertic peptide
* low serum sodium level
* low serum potassium level
* enlarged heart
* ventricular ectopy

conduction facts

* Regulates the heart rhythm 
* Sinoatrial node - intrinsic rate of 60-100bpm 
* Internodal pathway - conducts the impulse from the SA node to the Av node
* Atrioventricular node - intrinsic rate of 50bpm; connects the atrial and ventricular conduction
* Bundle of His - transitional bath between AV node and purkinje fibers 
* Purkinje fibers - intrinsic rate 15-40bpm