Dr. Whyte Summer Exam 2 (FINAL EXAM PREP)

A. Swelling of the lower extremities

Which of the following best indicates right sided heart failure?

A. Swelling of the lower extremities

B. Shortness of Breath

C. Productive Cough

D. Liver Failure

A. Angiotensin II

Which of the following substances has the greatest effect on after-load

A. Angiotensin II

B. Epinephrine

C. Angiotension Converting Enzyme

D. Nerepinephrine

A. B1

Which of the following receptors has the most significant direct effect on cardiac output

A. B1

B. B2

C. Angiotensin II Receptor

D. A1

Preload

Which of the following factors manipulates cardiac output in a way consistent with Starling Law?

A. Preload

B. Systematic Vascular Resistance

C. Afterload

D. Stroke Volume

Aldosterone

Which of the following is responsible for sodium retention in people with hypertension driven primarily by sodium retention?

A. Aldosterone

B. Aldactone

C. Renin

D. Angiotensiogen

LDL Cholesterol

Which of the following comprises the majority of an atheroma?

A. LDL Cholesterol

B. HDL Cholesterol

C. Triglycerides

D. Fibrous Tissue

A. The Fatty Streak

Which of the following is the earliest development in atherosclerotic vascular disease?

A. The Fatty Streak

B. Accumulation of LDL

C. LDL encapsulated in leukocytes

D. Fibrous infiltration of the atheroma

A. Exercise

What is the best way to raise HDL cholesterol

A. Exercise

B. Diet

C. Medications

D. Alcohol Intake

A. Muscle Loss due to Myocardial Infarction

Which of the following is the most common cause of Congestive Heart Failure

A. Muscle Loss due to a Myocardial Infarction

B. Valvular Heart Disease caused by untreated hypertension

C. The accumulation of atheromatas Lesions

D. Hypertension induced ventricular hypertrophy

A. Triglycerides

Which of the following substances creates the pro-inflammatory environment conducive to the development of the fatty streak?

A. Triglycerides

B. LDL Cholesterol

C. HDL Cholesterol

D. Prastagladin

90- 139 mm Hg

* Normal ranges are typically below 140

What are the normal ranges of systolic blood pressure?

Broad Range of 50-89 mm Hg

* Normal ranges are typically below 90

What are the normal ranges of diastolic blood pressure?

High Blood Pressure is typically asymptomatic until it’s too late (you generally don’t feel symptoms)

IMPORTANT NOTE

Genetics, environment, and ways that your environment and genetics might interactPrimary Risk Factors is Obesity.

What predisposes a patient to high blood pressure?

Men Reason being when men gain weight the primary area they carry it is the abdomen

* When women gain weight they tend to carry it in their legs or bottom more

Which gender based patient is more likely to be diagnosed with hypertension due to obesity?

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* Main job in the human body is to establish osmotic pressure
* Most common extracellular Electrolyte
* Plays a role in both healthy and unhealthy blood pressure

People who take excessive salt in their diets tend to run higher blood pressure, Although, genetically some people retain sodium more aggressively than others. Individuals who are exposed to high temperatures for generations are more prone to retaining sodium quite readily which allows to to retain water for a longer period of time. A pre-domiant group that has a far higher rate amongst blood pressure is African-Americans

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What is the role of salt in Hypertension

A Diuretic (they work very well with on salt retainers)

An African- American patient comes to your clinic and has been diagnosed with hypertension. You want to get rid of any excess salt that could possibly prevent the patient from lowering their blood pressure? What would be the best treatment?

Nicotine Every time you take it reduces constriction of the blood vessels.

* It is a stimulant as well (so it gives you a burst of energy) but it is absolutely terrible for your blood pressure.

What is the most common vasoconstrictive substance that people abuse?

amphetamines such meth, cocaine, hydrochloride

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there are all huge risk factors. In fact a lot of patients with heart disease have a pattern of drug abuse

What are other types of vasoconstrictive substances that could possibly increase blood pressure?

One of the primary reasons of hypertension (high blood pressure) When a patient is stressed out they activate the sympathetic nervous system (fight or flight) which will then trigger the hormone epinephrine resulting in an increase in cardiac output driving your blood pressure up by attacking the B1 receptors in the heart.

What role does stress play in hypertension?

Stress Due to the over abundance of catecholamines

A patient comes to your clinic after being diagnosed with hypertension although wants to figure the cause. You see that the patient is both hypertensive and has a persistently high heart rate. What is the most likely cause of this patient hypertension?

Individuals who drink an excess of one to two normally sized drinks a day have a profound possibility of developing at least some hypertension in part to alcohol

What role does alcohol play in hypertension?

One of the primary ways that we regulate blood pressure using the sympathetic nervous system.

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* When catachlomines are released they innervate the beta-1 receptor causing an increase in heart rate. Getting an increase in the rate of squeeze of the heart muscle.

Define the catecholamine driven process seen in HTN

Causes a drop in blood pressure. When the JXA detects a drop in blood pressure, renin is releasedOne of the most important effects of renin is establishing vascular tone.Renin is also responsible for causing the reduction of aldosterone which causes us to hold on to salt. Which is responsible for increasing our volume.

What role does aldosterone play in hypertension?

* Angiotension One is a vasocontructive substance (responsible for making blood vessels constrict)

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* Angiotension Two- Is THE most vasoconstructive substance in the body.Responsible for establishing After-Load Peripheral Vascular Resistance (the more constricted the blood vessels are, the smaller the opening, the harder the blood has to work to force blood into them and that will raise the systematic blood pressure

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Ace Inhibitors typically have the last amount of side effects out of all drugs

What is the difference between Angiotensin One and Angiotensin two?

Angiotension Two

What is the most vasoconstructive substance in the body?

Pre-load (the pressure that is exerted into the right ventricle as it, initially, as it returns from the vena canva, and the systematic circulation

Volume that is returning to the heart is known as?

Avoiding processed foods, avoiding add salt to processed foods

Diuretic Medications (causes you to waste sodium in your kidneys which leads to lower volume which decreases pre-load)

How can we counteract a patient who is experiencing some time of pre-load to the heart?

Reducing high blood pressure by blocking beta 1 receptors

* Beta blockers have a really high rate of Erectile Dysfunction

What is the primary function of Beta-Blockers?

When patient has normal kidney function, normal cardiovascular function, nothing drastic can be identified but the patient still has high blood pressure

What is essential hypertension?

There is something wrong in another organ (most common would be the kidneys)

* Kidneys have a unique characteristics with allows them to perfuse themselves that can determine blood delivery to themselves which most organs can’t do.


* The most common cause of secondary hypertension is high blood pressure

What is secondary hypertension?

An interaction of mechanical force on the vascular endothelium (the blood vessel) and chemical processes Cholesterol serves a significant problem

What is atherosclerosis?

* LDL (Low Density Lipoprotein) recommended for LDL levels to be less than 100. Classified as the “bad” cholesterol. Has a direct correlation with patients who’s had big heart attacks due to LDL blocking blood vessels and coronary arteries LDL cholesterol comes from animal products such as meats, cheese, diary products, diary eggs, etc

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* HDL (High Density Lipoprotein) classified as the “good” protein created by a carrier molecule by the liver

What are the different types of cholesterol?

Exercise Moderate Alcohol use can raise HDL levels a little bit as well.

What is the primary way that we raise HDL cholesterol?

Triglycerides  Triglycerides are a fat, but there are a product of carbohydrate metabolism, so they're an intermediate. Our liver will take sugar and make it into triglycerides, and then those triglycerides will eventually be distributed to fat cells and stored, however, if we have too many. Triglycerides It's a real problem because triglycerides are extremely irritating to the vascular endothelium (vessel walls)

How does HDL get into the vessel walls?

Strokes due to decrease blood flow to the brain When coronary arteries block off, we see heat attacksWhen Renal Arteries are blocked off, we see renal vascular disease or kidney failure

What is the effect of when chrotic arteries or vertebral arteries start to block off?

Triglycerides, high blood pressure, and high LDL Metabolic Syndrome is common alone but most common in type II diabetes

What is the metabolic syndrome?

White Coat Hypertension

When a patient gets hypertension due to the setting where they are surrounded by individuals with white coats (most likely in a healthcare setting) it is classified as?

Hypothalamus and Adrenal Medulla

What two organs is responsible for the release of catacholamines?

(If patient is reliable) we can have them buy a cuff and have them keep a cuff and keep a log for healthcare providers. (a lot more reliable than blood pressure taken at the office)

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* Ambulatory Blood Pressure Monitoring- A machine that allows a healthcare provider to put a little cuff on somebody and the machine records all of their blood pressure at random times throughout the day to see if they are really suffering from hypertension

What are some alternative ways to measure a patients blood pressure?

Plaque broke from an artery. It released and just all at once blocked off a coronary artery

What happens during an Acute Myocardial Infarction?

Non-modifiable risk factors (factors we can’t control)

Family History (generally a focus on first degree relatives)

Advancing Age Gender

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Modifiable Risk Factors

Tabacco Smoking, Dyslipidemia, Hypertension, Obesity, Sedentary Lifestyle, Diabetes, Emerging Risk Factors

What are the different types of risk factors for Coronary Artery Disease

The presence of testosterone and thus run a higher hemoglobin and have slightly different clotting pictures as we see with women.

Men typically have a earlier life risk of Coronary Artery Disease due to?

Myocardial Infarction Treatment is typically mechanical (ex: removing it, pushing it to the side, or applying a stint) if it’s really bad then open heart surgery has to be done.

You examine a patient’s arteries and spot that all clotting factors have been activated. You also see platelets that have stuck to these coronary arteries causing a big blob of lipid that’s also clogging the arteries. What can the patient be diagnosed with?

Begins with some source of vascular injury due to untreated hypertension or the presence of high degrees of triglycerides causing vessel walls to inflame. Metaplasia causes tissue to thicken in response to chronic injury (chronic inflammation) causing fibroblasts to starting trying to reinforce the intima of the artery which produces a surface which LDL cholesterol (bad cholesterol) can stick

What is the progression of Artheroscolerosis?

Macrophages that become foamy due to the engulfment of liplids

Typically Waste

What are foam cells?

The presence of fibrous tissue and calcium in your bloodstream which causes things to slowly harden.The purpose of the deposition of fibrous tissue is to wall off the vessels to keep foreign stuff away from us.

What is Stable Chronic Atheroma?

Structural damage to the myocardium of the heart that alters the ability of the heart to perform adequately

What is Congestive Heart Failure?

* Ejectile problem- which means that the heart is no longer strong enough to squeeze the blood out adequately to the systemic circulation

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* Diastolic Failure- Which is a failure to relax because as the heart muscle scars after these events, the chambers become smaller because the the muscle no longer relaxes like it used to during diastole

What are the two general patterns of Congestive Heart Failure?

Catacolamine driven (ex: Eprepinephrine and norepinephrine) once that is released it will stimulate the beta-1 receptors in the heart because your body has detected a drop in blood pressure to increase cardiac output as well as oxygen demand.

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* Renin, which goes to the adrenal cortex and causes us to release aldosterone, which causes us to retain salt and causes us to retain volume also known as pre-load Patients who have hearts attacks and that are not treated will result in the heart eventually consuming itself leading to the patients death

What are the compensatory mechanisms for diminished cardiac output states

A situation where the body requires an increase of oxygen demand although the coronary arteries aren’t capable of delivering that oxygen. Lack of Oxygen

What is Ischemia

Beta Blockers (medications that block the Beta- 1 Receptors)

What are some of the first medicines that we give patients during compensatory mechanisms for heart failure?

The more fluid that is returning to the heart, it will stretch the myocardium and result in a higher cardiac output

What is Starling’s Law state?

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If the right side of the heart fails, fluid that comes in from the vena cava backs up into the vena cava venous system which is a low pressure system. Resulting in the blood to back up into the patients abdomen and legs. Causes a really protuberant abdomen called Ascites

* Ascites- Is when fluid collect inside of the abdominal cavity and then we get swelling of the legs

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* With left sided heart failure a patient will get pulmonary edema (a condition caused by fluid back-up in the lungs).
* Symptoms would be a patient who’s short of breath, maybe a little cyanotic, productive cough (typically coughing up a pink foam due to the air, blood, and gasses in the alveoli)
* They’ll have a “crackle” sound
* Most common type of heart failure would be left sided heart failure

Differentiate right versus left sided heart failure according to symptom patterns

Diuretics Thiazide Diuretic- is responsible for lowering blood pressure by helping get rid of a little bit of salt.

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Loop Diuretic (used primarily for heart failure)Causes patients to urine profoundly

What is the treatment for pre-load problems, and fulminate left or right sided heart failure is?

We have Angiotension 1 (A1) which converts to angiotension converting enzyme (ACE) to Angiotension 2 (A2)

* Your body does this to increase vascular resistance also known as After-Load Increases workload- O2 consumption

What is the process of Angiotension 1 and 2?

Opens up arteries, as well as decreases the workload of the heart

What is the primary function of Ace Inhibitors/ARBs?

Myocardial Infarction, Untreated Hypertension, Cardio Myopathy (Excessive Alcoholism)

Identify the main causes of congestive heart failure

* Comes from a vascular injury due to untreated hypertension and/or elevated triglycerides and hence an inflammatory state
* We begin to get those LDL cholesterols that start sticking to the vessels walls which results in a fatty streak. Macro sites Matt it, fiber blasts come in and cover it resulting in the formation of a atheroma

Differentiate the pathophysiologic basis for atheroma formation

A. It is High

Which of the following best describes the insulin level of someone with Type 2 Diabetes at the time that they are diagnosed?

A. It is High

B. It is normal

C. It is Low

D. It is undetectable

A. HgB A1C of 8.2%

Which of the following indicates that a patient has had elevated blood glucose for weeks-months?

A. HgB A1C of 8.2%

B. Random finger stick of 210

C. Fasting Blood Sugar of 120

D. Hgb A1C of 5.1%

A. TSH

Which of the following is the standard screening test for patients suspected of hypothyroidism?

A. TSH

B. Free T4

C. TRH

D. Total T4

A. Insulin resistance in type 2 Diabetes

Which factor most clearly differentiates the clincal response to Type 2 versus Type 1 Diabetes?

A. Insulin resistance in Type 2 Diabetes

B. Differences in insulin Levels

C. Insulin deficits in both diseases

D. The Vascular effects

A. Abrupt with Ketoacidosis

Which of the following best describes the onset of Type 1 Diabetes?

A. Abrupt with Ketoacidosis

B. Gradual with frequency of urination being the first sign

C. Abrupt with hypoglycemia

D. Gradual with slow increase in fasting blood sugars

A. Cold intolerance

Which of the following is not a symptom of hyperthyroidism?

A. Cold intolerance

B. Excessive hunger

C. Weight Loss

D. Insomnia

A. She has Cushing’s Syndrome

A patient has been taking prednisone for rheumaoid arthritis for several months. She gained 15 pounds, seen an elevated blood pressure. and is begging to have hyperglycemia. Which of the following best describes this?

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A. She has Cushing’s Syndrome

B. She has Addisions Disease

C. She has Cushing Disease

D. She has Pheochromocytoma

A. Large Blood Vessels

Which of the following structures are not generally effected by prolonged hyperglycemia in Type 1 Diabetics?

A. Large Blood vessels

B. Small blood vessels

C. Peripheral nerves

D. The Kidneys

A. Aldosterone

Which of the following hormones is not elevated in Pheochromycytoma?

A. Aldosterone

B. Epinephrine

C. Dopamine

D. Norepinephrine

A. Small Cell Cancer of the Lung

Which of the following diseases is most commonly associated with the Syndrome of Inappropriate ADH Secretion (SIADH)?

A. Small Cell Cancer of the Lung

B. Adenocarcinoma of the Lung

C. Adenocarcinoma of the large intestine

D. Chronic kidney disease

Acts to manage homeostasis Plays a very important role in detecting changes in hormonal levels in order to perpetuate important body processes.

What is the primary function of the hypothalamus?

Hypothalamus

Where do we detect low androgen levels?

Signals the anterior pituitary gland to release two hormones

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Lutinizing Hormone (LH) which is responsible for signaling the testes to produce more hormones

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Follice Simulating Hormone (FSH) which plays a greater role in women than men responsible for stimulating the ovaries to produce more eggs

What happens when GnRH is released from the hypothalmus?

Lutinizing Hormone (LH)

What has the most direct effect on androgen levels?

By releasing growth hormones from the anterior pituitary gland

If a child’s growth hormones are low, how would the hypothalamus respond to that?

The absence of sufficient levels of a particular hormone that signals the hypothalamus to begin releasing these hormones.

What is the negative feedback mechanism?

Releasing CRH (Corticotropin releasing hormone) which would signal the anterior pituitary gland ACTH (Adrenal Corticotropin Hormone) which signals the Adrenal Cortex to produce more cortisol.

If a patient had a decrease of cortisol levels, how would the hypothalamus respond?

Anterior Pituitary Gland

Thyroid Stimulating Hormone, Adrenocorticotropic Hormone, Prolactin Growth Hormone, Lutinzing Hormone, and Follice Stimulating Hormone all come from the?

The Anterior Pituitary Gland is responsible for making hormones The Posterior Pituary Gland is a little sack that serves as a storage

What is the difference between the Anterior vs Posterior Pituitary Gland?

It is classified as the “feel good” hormone that we get when we workout really hard.

* It also stimulates the letdown of milk in mothers after they have babies

What is the primary function of the hormone Oxytocin?

Is stimulating the re-absorption of water in the distal collecting duct of the nephrone giving us the ability to concentrate on urine Without the Antidiuretic Hormone an individual would not be able to preserve water.

What is the primary function of the Antidiuretic Hormone?

* Diabetes Incipidus (the primary one that is seen) normally due to head injury or swelling of the brain.- There is damage in both the anterior and posterior pituitary gland due to compression causing the lose of ability to release antidiuretic hormone causing Pyluria (the loss of lots of water in the neighborhood of a liter an hour)Urine looks very clear (just like water)

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* Inappropriate Antidiuretic Hormone secretion or Sidhu which a syndrome where there is an overproduction of antiduretic hormone in general due to a couple of reasons.Most common is hypersecretion of various cancers particularly small cell carcinoma of the lung is associated with this.
* When we make too much antiduretic hormone, we don’t release enough water ending up in our urine becoming extremely dark-colored due to concentration

What are the two disorders that are reflect upon the lose of anti-diuretic hormone?

1.015 to 1.025 In the case of a patient who has diabetes Incipidus their specific gravity of water will just be 1

What is the normal specific gravity of water?

A hormone must be administered called desmopressin, Once administered it basically “turns the facet off” allowing us to begin to reabsorb water again and we get a profound halt to excessive urine production

What is the treatment for diabetes Incipidus?

Treating the problem (the cancer)

What is the treatment for Inappropriate Antiduretic Hormone?

Pituitary Adenoma- Which is a mass in the pituitary gland generally either not cancerous or low grade cellular differentiation. Produces excessive growth hormone when this happens in childhood we call it giantism because these individual will grow very large in stature

Diseases that involve hypersecretion of growth hormone result from?

T4 does not have a drastic metabolic effects on human beings although T3 has the majority of metabolic effects

What is the difference between T3 and T4 in regards of the effect it has on individuals?

Typically associated with “Graves Disease” an autoimmune reaction which results in the rapid production of T4 to T3

* No TSH is being produced
* Not diagnosed quickly due to the fact that the results are desirable

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What also happens is a component of this reaction is a very rapid conversion of T4 to T3 causing an increase in metabolism (higher basal metabolic rate), begin to lose weight, an increase in pulse rate, increase in blood pressure, high anxiety and lack of sleep.

What is Hyperthyroidism?

TSH (Thryoid Stimulating Hormones) If a patient is making too much thyroid hormone then their TSH will be undetectable (meaning TSH would be very low)

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T3 is more indicative of hyperthyroidism than T4 in the case hyperthyroidism.

What is the screening test for all Thyroid diseases?

A patient ends up making no thyroid hormone due to thyroiditis

* The most primary kind of thyroiditis is Hashimoto’s thyroiditis. For a variety of reasons, the body attacks the follicular cells can no longer recognize the their major histocompatibility eventually consuming the cells. Majority of the cause is menopause in women.
* Very High TSH

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The majority of people suffering this are women.

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* Iodine plays a role in hypothyroidism as it is used to make thyroid hormone. (Most Iodine nowdays is recieve through salt)

What is hypothyroidism?

Hypothyroidism

A lady is undergoing menopause, she starts to gain a little weight, gets really depressed, crying fits, a lot of anxiety, and very moody. What is the most likely cause of this?

Free T4

What is the best indicator of hypothyroidism?

Abnormally Low PTH levels

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* Usually caused by parathyroid damage in thyroid surgery (most common way it’s damaged)

What is hypoparathyroidism?

Dangerously high Calcium Levels Less common (typically associated with some type of cancer)

What is hyperparathyroidism?

To produce two hormones primarily

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Cortisol- Metabolically active, needed to use glucose, use calories, store fat (very important to metabolism) Has a huge effect on circulating blood sugar and heavily influences the way that we use calories

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Aldosterone- Utilized to help the body retain sodium - Typically referred to as “mineral corticoid hormone because it manipulates minerals

What is the role of the Adrenal Cortex?

Begins with a tumor which is sometimes non-cancerous of the adrenal cortex begins to produce too many hormones causing a split between aldosterone and cortisol .

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* Typically becomes depressed over time

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On the aldosterone side, we begin to absorb too much salt causing a high blood pressure, swelling, causing them to be puffy (they are able to put on weight very quickly)

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On the cortisol side, we have a production of more glucose through gluconeogensis causing a crave of high calorie foods which will cause an access of fat storage in the body and putting on weight quickly.

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Most likely to receive type 2 diabetes due to the weight developing central obesity over time. They begin to lose muscle, they develop a hump in the back, skin rashes, apple shape etc

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What is Cushing’s Disease?

Charged with making catacolymines such as epinephrine, noepinephrine. Classified as the “centerpiece” of the fighter or flight reaction (an increase in vigilance, cardiac output, blood fota, and skeletal muscles

What is the function of the Adrenal Medulla

When the cells of the Adrenal Medulla become hyperproliferate and begin to produce too much catacholamines also known as “pheochromocytoma” Typically diagnosed through a biopsy

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Typically happens to younger people

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(people in their late teens to mid 30s)

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Secondary Causes of High Blood Pressure

What are disorders of the Adrenal Medulla?

Failure of a Organ itself (for instance the thyroid gland, or the testes

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Failure in signaling the hypothalamic pituitary gland

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Failure of the Receptor end

When looking at a patient with an endocrine problem what are the two typical failures that we deal with?

Parathyroid hormone is responsible for producing parathormone or parathyroid hormone which is meant to allow us to extract calcium from the bones so that we can use it in biological processes.

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* Calcitonin- Works by opposing the action of parathyroid hormone, which means it acts to reduce calcium levels in the blood

What is the role of parathyroid hormone and calcitonin?

Caused by taking too many steroids/medications

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Addision’s Disease-

* Results in Hypersecretion


* occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone causing us to waste away
* Relatively uncommon
* seen at birth in babies
* hormone replacement therapy for the rest of their life

What is the cause of Cushing’s Sydrome