human pathology exam 3 content

vascular and pulmonary

hypertension (definition + level)

high blood pressure, 130/80 mm Hg and higher signifies high blood pressure

hypertension shorthand

htn

how many cases of primary hypertension are idiopathic?

95%

what are the causes of primary hypertension?

obesity

stress

lack of activity

high sodium diet

age

race

what is secondary hypertension caused by?

• renal artery stenosis (renovascular hypertension) (stenosis = narrowing). stenosis decreases blood to the kidney, stimulating the renin-angiotensin system, further increasing B.

• fibromuscular dysplasia of blood vessels is a defect in the blood vessel wall, causing arteries to thicken (renal and carotid artery), “string of pearls sign”

• atherosclerosis in the elderly

what is the string of pearls sign caused by?

fibromuscular dysplasia of blood vessels that causes arteries to thicken

arteriosclerosis

hardening of arteries

what are the three forms of arterioscleoris?

1. atherosclerosis

2. arteriolosclerosis

3. Monckeberg’s medial calcific sclerosis

atherosclerosis definition/process

1. fatty plaque develops in the intimal layer of large and medium arteries

2. excess lipids leak into intimal layer

3. lipids are oxidized and are attacked by macrophages causing an inflammatory response

fatty plaque structure

fatty plaque has a necrotic lipid core made of cholesterol surrounded by a calcified fibrous capsule

what arteries are most commonly affected by atherosclerosis?

abdominal aorta, coronary arteries, internal carotid artery, and popliteal

causes of atherosclerosis

elevated LDL (hypercholesterolemia), low HDL, smoking, and diabetes

complications of plaque formation lead to (regarding atherosclerosis)

• stenosis of blood vessel and ischemia

• plaque will rupture with thrombosis (myocardial infarction)

• plaque ruptures with embolization (atherosclerotic emboli)

• weakens vessel wall causing aneurysm

atherosclerotic emboli

plaque ruptures with embolization

arteriolosclerosis (the subtype)

narrowing of small arteries

two types: hyaline and hyperplastic

hyaline arteriosclerosis

formed when proteins leak into vessel wall causing thickening of vessel wall

hyperplastic arteriosclerosis definition

it is hyperplasia (increase # of cells) of the tunica media of the blood vessel, “onion skin” appearance.

what can hyperplastic arteriosclerosis cause?

malignant hypertension

end organ ischemia

kidney necrosis with hemorrhage

Monckeberg’s medial calcified necrosis

calcification of the tunic media; not clinically significant as it’s an incidental finding on a plain film xray.

thoracic aortic aneurysm (TAA)

the aortic wall weakens and balloons out.

can cause aortic root dilation and aortic valve insufficiency, can push on other mediastinal structures

seen in tertiary syphilis, aortic trauma, Marfan’s syndrome, and age

abdominal aortic aneurysm (AAA) definition

fatty plaque buildup and blood clotting will cause pressure against the vessel wall, weakening it and causing its dilation.

dilation of of the abdominal aorta inferior to renal arteries, but superior aortic bifurcation (into common iliacs).

risk for rupturing (>5cm) increases overtime.

what is primary cause of abdominal aortic aneurysm?

atherosclerosis typically seen in hypertensive males over the age of 60; smokers.

is abdominal aortic aneurysm primary asymptomatic or symptomatic?

asymptomatic

how does abdominal aortic aneurysm present?

presents as pulsating abdominal mass when aorta is palpated. pulsation will come up to meet your fingers from deep to superficial.

how to palpate abdominal aorta

go 1 inch up and 1 inch to the left of the umbilicus and push down on that spot.

what is width once abdominal aorta ruptures and what does it immediately cause?

>5cm

hypotension, pulsating mass, flank pain

fusiform aneurysm

spindle-shaped aneurysm

saccular aneurysm

looks like sac

remember this picture for thoracic vs abdominal aortic aneurysm

aortic dissection definition

tear located in the tunic initima with blood surging between the intimal and medial layers.

occurs in the proximal 10cm of the aorta (highest stress point).

pain presents with searing, tearing chest pain that radiates to the back

complications of rupture are death

causes of aortic dissection

in older patients: hypertension

in younger patients: defect in connective tissue (Marfan’s Syndrome)

what are the upper respiratory tract disorders?

1. rhinitis

2. nasal polyps

3. singer’s nodule

4. croup

5. laryngeal carcinoma

rhinitis

caused by inflammation of the nasal mucosa typically seen by an adenovirus.

seen with common cold and allergies. seen in patients with asthma and eczema.

symptoms: rhinorrhea (nose discharge), sneezing, and congestion

nasal polyps

inflamed and edematous nasal mucosa (swelling of inner nose lining).

seen in patients with cystic fibrosis, aspirin-intolerant asthma, and aspirin induced bronchospasms and nasal polyps.

nasal polyps are seen in 10% of asthmatic adults

Singer’s nodule

arises on the true vocal cords and are non-neoplastic. occurs bilateral (on both sides) and is an overuse injury.

presents with hoarseness of the voice, 50% of cases require surgery

anatomical space where Singer’s nodules arise

Reinke’s space

the tighter the vocal cords the _____ the pitch

higher

croup (laryngotracheobronchitis)

caused by parainfluenza virus.

patient presents with a barking cough, hoarse voice, and inspiratory stridor (high-pitched sound made upon inspiration)

worse at night

stridor is primarily _____?

inspiratory

if stridor is heard both during inspiration and expiration, it is called ____?

biphasic

laryngeal carcinoma

squamous cell carcinoma that arises from the epithelial lining of the vocal cords.

can be caused by alcohol and tobacco use

presents with hoarseness, stridor, and cough

use the bell of the stethoscope to hear what?

blood flow through artieries

low frequencies

use the diaphragm of stethoscope to hear?

breathing sounds

high pitch

where is the apex of the lung?

supraclavicular fossa

what are the auscultation points for lungs?

apices, superior lobes, middle lobes, inferior lobes

triangle of auscultation on back borders

superior border: trapezius

inferior border: latissimus dorsi

lateral border: scapula/medial border

which bronchi is larger?

right primary bronchi

abnormal lung sounds are:

1. rhonci

2. rales (crackles)

3. wheezes

4. stridor

rhonci definition

low-pitched rattling noises, like snoring

caused by inflammatory secretions or obstructions in the large airways (trachea + bronchus). occurs when air leves trachea and hits secretion or mucus.

in what disorders is rhonci seen in?

pneumonia and COPD

fine rales (crackles)

higher-pitched popping noise heard upon inspiration like crackling cellophane.

these sounds are discontinuous, individual sounds

caused by fluid in smaller airways like bronchioles or alveoli

course rales (crackles)

lower-pitched popping noise heard upon inspiration. located in large airways like bronchi

occurs when patients try to breathe but large airways are partially blocked by mucus

sounds like gurgling.

conditions where fine rales are heard

CHF, atelectasis, pneumonia

conditions where course rales are heard

heart failure due to pulmonary edema, pneumonia, bronchiectasis, infections that result in mucus secretions.

wheezes

high-pitched whistling sounds resulting in narrowing of the bronchial tree as seen in asthma.

mainly heard on expiration, located throughout respiratory system. sound occurs because of narrow airways

conditions where wheezes can be heard

asthma, COPD, lung infections that can narrow airways

stridor

high-pitched wheeze dependent on if it occurs during inspiration or expiration. occurs in upper respiratory tract. occurs due to narrowing of larynx and trachea bc of swelling or blockage

conditions where stridor occurs

epiglottis, croup, anaphylaxis, obstruction

pleural friction rub

low pitch, found in pleura layers. harsh grating sound + pain during breathing or cough.

occurs when pleura layers get inflamed and rub up on each other (usually there’s a space between pleura)

in what conditions can pleural friction rub be found in?

pleurisy, pneumonia, tuberculosis

bronchophony

patient told to say 99 when stethoscope touches them.

it’ll sound muffled NORMALLY. If there’s an area of consolidation (like pneumonia), the 99 will sound clearer

egophony

patient told to say “E".” Normally you’ll hear eeeee. If there’s areas of consolidation (abnormal), it’ll sound like ahhhh or ehhhh

whispered pectorilaquy

tell patient to whisper 99. areas of consolidation will make the whisper louder

tactile fremitus

use your hand, put palm to patient, have them say 99. touch their back to feel vibrations, should be equal or symmetrical. different vibration is abnormal

lower respiratory disorders

1. pneumonia

2. tuberculosis

3. mesothelioma

4. emphysema

pneumonia (definition)

infection found in the lung parenchyma, occurs when normal pulmonary defenses are weakened.

pneumonia symptoms

fever, chills, cough producing thick yellow/green (pus) sputum, rusty colored sputum indicates blood (hemoptysis), fast breathing rate (tachypnea), chest pain, SOB, elevated WBC, dullness to percuss and decreased breath sounds

hemoptysis

coughing off blood, associated with pneumonia

tachypnea

fast breathing rate, occurs in pneumonia because body is trying to get more oxygen in

how to diagnose pneumonia?

chest x-ray, sputum culture with gram stain, and blood culture

three forms of pneumonia (found by x-ray)

1. lobar pneumonia

2. bronchopneumonia (bacterial)

3. interstitial pneumonia (viral)

lobar pneumonia

consolidation (fills with fluid or dense stuff) of an entire lobe of lung.

occurs in the intra-alveolar space.

caused by two main bacteria: Streptococcus pneumoniae (95%) and Klebsiella pneumoniae)

gross changes/phases of lobar pneumonia

1. congestions due to edema and inflammation in the first 24 hrs

2. red hepatization: alveolar air space fills with neutrophils, bloody exudate, and fibrin. red cells extravasate intra-alveolar space

3. gray hepatization: red cells hemolyze (RBCs rupture) within exudate

4. resolution

what does grey hepatization look like?

lung tissue becomes firm, airless, and liver-like. caused by alveoli filling with fluid and cells. starts “red” early and then “grey” later.

S. pneumoniae (hint: s for senior citizen)

community-acquired pneumonia, seen in middle age and elderly population

K. pneumoniae

individuals who are malnourished and debilitated (elder care homes), caused by alcoholism and diabetes. presents with “currant jelly” sputum

bronchopneumonia

characterized by scattered and patchy consolidations around the bronchioles. multifocal and bilateral, this pneumonia can cross multiple lobes

bacteria that can cause bronchopneumonia

Staphylococcus aureus - typically superimposed on a viral upper respiratory tract infection

Haemophilus influenza - COPD

Pseudomonas aeruginosa - cystic fibrosis

pulmonic exams for pneumonia

1. Tactile Fremitus
2. Bronchophony/Egophony
3. Whispered Pectroliquy

interstitial (atypical) pneumonia definition

Scarring in tissues around alveoli

interstitial (atypical) pneumonia causes

etiological agents:

• influenza virus: high risk for immunocompromised elderly

• mycoplasma pneumoniae: most common type of atypical pneumonia, found in college students (from dorms); “walking pneumonia”

• respiratory syncytial virus (RSV) - most common atypical pneumonia in infants

MRSA - methicillin resistant staphylocuccus aulcus definition

can decrease macrophage ability in air sacs. virus suppresses immune system by suppressing macrophages

to get full chest x-ray, which way does it go?

posterior to anterior

what are the forms of tuberculosis and what causes tb?

two forms: primary and secondary

caused by the inhalation of aerosolized mycobacterium tuberculosis

primary tb process

1. M. tuberculosis is inhaled deep into lungs. immune response initiated and alveolar macrophages begin to engulf the bacteria

2. M. tuberculosis secretes a protein SapM that prevents the lysosome in the macrophage from fusing with the phagosome containing the bacteria. the bacteria begin to multiply and produce a mild infection.

3. at this point, patient is asymptomatic or exhibits mild flu-like symptoms.

4. 3 weeks post-infection, cell-mediated immunity will wall off the infection producing a granuloma (tuberculoma), which will hide the bacteria from the immune system. the center of the granuloma dies and appears as caseous necrosis (Ghon’s focus)

5. bacteria get transported to nearby lymph nodes. these lymph nodes undergo fibrosis and calcification. the lung granulomas (Ghon’s focus) and fibrotic lymph nodes combines are called a Ghon’s complex.

6. The Ghon’s complex produces calcified scar tissue that can be seen on plain-film xray. this scar tissue is called Ranke’s complex

7. immune system can destroy tb or it can become dormant

granuloma

a small, localized cluster of immune cells (macrophages) that forms to wall off foreign substances, infections (ex: TB)

Ghon’s focus

when the center of the granuloma (tuberculoma) dies and appears as caseous necrosis

process to Ranke complex (simplified)

granuloma (tubercolumo) → Ghon’s focus → Ghon’s complex → Ranke complex

Ranke complex

when Ghon’s complex becomes calcified scar tissue that can be seen on xray and becomes this new complex

Ghon’s complex

when the lung granuloma (Ghon’s focus) and fibrotic lymph nodes combine.

how many tb cases are primary?

90%

how long can tb be dormant for?

2 years

how many tb cases are secondary tb?

5-10%

secondary tb process

1. if immunocompromised (AIDS, organ transplant, IVDU - IV drug use, or aging), the tb reactivates and travels to upper lobes of the lung where there os greater oxygenation bc bacteria wants the oxygen

2. memory T-Cells release cytokines causing more infectious caseous necrosis.

3. tissue cavitates (bubbles form) and bacteria spread through lymphatic drainage and airways causing bronchopneumonia. the patient is infectious as they cough.

4. tb can enter the vascular system and become system (systemic miliary TB)

systemic miliary tb

when TB enters the vascular system and becomes systemic

structures affected by systemic miliary tb

• kidneys - sterile pyuria (pus) with high WBC count

• cervical lymph nodes - lymphadenitis (inflamed lymph nodes - scrofula)

• adrenal glands: Addison’s disease (adrenal hypofunction)

• lumbar vertebrae - Pott’s disease

• meninges - meningitis

• liver - hepatitis

scrofula

inflamed lymph nodes

signs and symptoms of tb

• hemoptysis

• coughing that lasts three or more weeks

• chest pain or pain w/ breathing or coughing

• SOB

• fatigue

• night sweats

• unintentional weight loss

• fever

• chills

• scrofula

Pott’s disease

causes severe back pain + vertebral deformity

how to test for TB?

• PPD (purified protein derivative) - Mantoux test. inject stuff into the skin, if it becomes firm, it’s a positive result. results interpreted based on firmness

• tine test

• IGRA - blood test that detects TB protein, very efficient, does not give false positive even if patient has the BCG vaccine to prevent tb. patient doesn’t need to return to get results