Patho Exam 2

Ferrous Sulfate and Phantom Limb Pain

  • Phantom Limb Pain: A condition where a person feels sensations such as itching, burning, or stabbing pain in a limb that has been amputated.

    • Mechanism: The end of regenerating nerves in the absence of the limb gets trapped in scar tissue, leading to these sensations.

Migraines

  • Definition: Migraines do not occur without a trigger.

  • Trigger Identification: To find out what triggers an individual's migraines, it is recommended to maintain a headache notebook to log all relevant information.

  • Physiological Mechanism:

    • Triggers cause the release of serotonin, leading to vasodilation (widening of blood vessels) and the subsequent delivery of more blood to the affected area.

    • This dilation of cranial arteries activates prostaglandins, which stimulate inflammation.

Pathophysiology in Disorders of Red Blood Cells

Erythropoiesis

  • Definition: The process by which the body produces red blood cells.

  • Location Dynamics:

    • In the fetus, red blood cells are produced in the red bone marrow.

    • After 5 years of age, activity starts declining, and by 20 years, red blood cell production mainly occurs in membranous bones, including:

    • Vertebrae

    • Sternum

    • Pelvis

    • Ribs

  • Heme Breakdown: The heme component breaks down in the spleen to form bilirubin and iron, while the globin is recycled back into the bloodstream.

  • Iron Retention: The majority of the body’s iron is retained from recycled red blood cells.

Anemia

  • Symptoms: Fatigue, chest pain.

  • Assessment: Determined by evaluating red blood cell size using Wintrobe’s classification based on Mean Corpuscular Volume (MCV).

    • Microcytic:

    • Definition: Small red blood cells with MCV less than 80

    • Treatment: Needs vitamin B

    • Normocytic:

    • Definition: Normal cell size with MCV between 80-96

    • Macrocytic:

    • Definition: Abnormally large cells with MCV greater than 96

Blood Transfusion Therapies

  • Function: Phototherapy may be employed for certain blood transfusion situations.

Neuro Function and Pain Evaluation

Cranial Nerves

  • Dysfunction of cranial nerves 9 and 10 can lead to aspiration and death.

Pain Assessment

  • Importance of direct patient feedback on pain experience before imposing descriptive terminology.

  • For children, graphic and visual aids are used to express pain feelings.

  • Physical Indicators of Pain:

    • Elevated blood pressure

    • Groaning

    • Grimacing

    • High heart rate

Pain Management Strategies

Non-pharmacological

  • RICE Protocol: Rest, Ice, Compression, Elevation.

  • Physical Activities: Swimming, stretching, walking, acupuncture.

Pharmacological

  • NSAIDs: Non-steroidal anti-inflammatory drugs that block prostaglandins. Recommended to take with food or milk.

  • Antiseizure Medications and Antidepressants: These can modify pain pathways.

  • Opioids: Morphine is commonly used.

Headache Classifications

Primary Headaches

  • Definition: No underlying organic cause.

  • Types:

    • Migraine: Characterized by periodic attacks.

    • Tension: Common, persistent.

    • Cluster: Episodic, with distinct cycles.

  • Patient may recognize the onset of headaches.

Secondary Headaches

  • Definition: Cause attributed to an underlying organic condition.

  • Use of SNOOP mnemonic to assess signs of secondary headaches:

    • S: Systemic symptoms

    • N: Neurological symptoms

    • O: Onset pattern, particularly sudden

    • O: Older than 50 years

    • P: Previous headache differing from usual patterns

Genetic and Chronic Factors

  • 70-90% of headaches have a genetic component.

  • Chronic versus episodic headache classifications; unilateral pulsating sensations reported by patients.

Migraine Triggers

  • Common triggers include:

    • Menstrual cycle

    • Bright light exposure

    • Stress and depression

    • Fatigue

    • Specific food and beverages (cheese, chocolate, fruits, nuts, processed foods containing nitrates, alcohol, red wine, caffeine)

    • Drugs and poor sleep patterns

    • Strong odors and motion sickness

    • Hypoglycemia (low blood sugar)

Medications for Migraines

Sumatriptan (Imitrex)

  • Indicated for acute treatment of migraines and cluster headaches.

  • Contraindications: Patients with hypertension or cardiac history due to potential constrictive effects.

Cluster Headaches

  • Characteristics: Unilateral, 1-8 occurrences per day, sudden and severe, sharp pain, often in the orbital area, increased sensitivity to light and noise, and seasonal occurrence (spring and fall).

Myasthenia Gravis

  • Definition: A chronic autoimmune neuromuscular disorder characterized by the destruction of acetylcholine receptors at the neuromuscular junction.

  • Pathophysiology: Acetylcholine is broken down by acetylcholinesterase before it can attach fully to receptors and stimulate muscle contraction, leading to muscle weakness that worsens with activity.

Diagnostic Testing

  • Tensilon Test: Injection of edrophonium, which temporarily blocks the action of acetylcholinesterase and improves muscle strength.

  • Donepezil (Aricept): Cholinesterase inhibitor used to decrease breakdown of acetylcholine, increasing neuromuscular impulse transmission. Side effects may include nausea and vomiting.

  • Demographics: Primarily affects females.

Chronic Headache

  • Defined as occurring 15 days per month, lasting 4 hours or more per episode.

  • Treatment options: Include beta-blockers (propranolol), calcium channel blockers (Norvasc), anticonvulsants (e.g., lamictal, neurontin, depakote, valproic acid), and antidepressants (SSRIs such as celexa, prozac, paxil).

Tension Headache

  • Description: A common type of chronic headache, typically lasts 30 minutes to 7 days. Characterized by dull, pressing, non-pulsating pain that is bilateral and predominantly seen in males.

  • Treatment: 100% oxygen for 15-20 minutes via mask for vasoconstriction.

Temporomandibular Joint Disorder (TMJ)

  • Symptoms: Pain and tenderness in jaw joints, may include teeth grinding, jaw injuries, arthritis, and wear and tear.

  • Treatment options: May involve medication, physical therapy, custom mouth guards, and possibly jaw surgery.

Pain Assessment in Infants and Children

  • FLACC Scale: Face, Legs, Activity, Cry, Consolability as a method of evaluating pain.

Disorders of Motor Function

Muscular Atrophy

  • Definition: A normally innervated muscle that is not used over extended periods decreases in diameter and loses much of its contractile protein, leading to weakness.

Muscular Dystrophy

  • Description: A group of genetic disorders resulting in progressive deterioration of skeletal muscles due to a mix of muscle cell hypertrophy, atrophy, and necrosis.

Peripheral Neuropathies

Mononeuropathies

  • Caused by trauma or infection affecting a single nerve, plexus, or nerve trunk.

Polyneuropathy

  • Condition involving demyelination affecting multiple peripheral nerves.

Parkinson’s Disease

  • Symptoms: Muscle weakness, tremors, and postural changes.

  • Mechanism: Involves the loss of dopamine-producing brain cells and an imbalance with acetylcholine. The condition is more prevalent in men than women; exact causes remain unclear but may include genetics, infections, atherosclerosis, head trauma, chronic antipsychotic use, or environmental exposure.

Treatment

  • Levodopa/Carbidopa (Sinemet): Reduces symptoms of bradykinesia (slowness of movement), crosses the blood-brain barrier, converts to dopamine. Effectiveness lasts for 2-5 years. Medications must be administered on schedule.

  • Therapies: Physical and occupational therapy, speech therapy are recommended.

Multiple Sclerosis (MS)

  • Description: A neuroimmunologic and autoimmune disease that attacks the myelin sheath, resulting in inflammation and the formation of plaques in the CNS. No cure is currently available.

Treatment Options

  • Avonex (Interferon): A disease-modifying therapy that reduces relapses and prevents the formation of new plaques and lesions in the brain and spinal cord.

  • Corticosteroids: Can quickly reduce inflammation.

  • Management: Anti-seizure medications such as Dilantin may also be utilized.

Increased Cranial Pressure

  • Causes: Bleeding and inflammation can increase pressure, limiting blood flow to brain tissue.

  • Management: Use of medications such as Tylenol and cooling blankets.

Posture and Positioning

Decorticate Posturing

  • Hands on the chest.

Decerebrate Posturing

  • Arms down and hands extended outward.

Treatment

  • Mannitol: An osmotic diuretic used to pull fluid out of the brain.

Diagnostic Tests

  • Test for Cranial Fluid: Positive glucose indicates presence of glucose in clear nasal drainage; performed only when drainage is clear.

Basal Ganglia

  • Role: A group of nuclei critical for the regulation of movement. Disorders affecting these areas can inhibit involuntary movements, body posture, and muscle tone.

Four Cardinal Signs of Parkinson's Disease (TRAP):

  • Tremors

  • Rigidity

  • Akinesia: Slowness in movement (bradykinesia)

  • Postural Inability

Amyotrophic Lateral Sclerosis (ALS)

  • Description: A degenerative disease affecting motor neurons in the spinal cord, brainstem, and cerebral cortex, leading to muscle weakness and atrophy while sensory and vision functions remain intact.

  • Management: High fiber intake is important due to constipation risks, as patients may experience reduced mobility, fatigue, numbness, and issues such as neurogenic bladder.

Spinal Cord Injury (SCI)

  • Definition: Refers to damage to neural elements of the spinal cord caused by various types of trauma (e.g., automobile accidents, sports injuries, violence).

Disorders of Brain Function

Skull Fractures

Linear Skull Fracture

  • Characteristics: Simple fracture with the bone bending inward and surrounding areas bending outward. Typically resulting from low-velocity impact.

  • Management: No sports for 2-3 weeks, follow-up in a week with monitoring for potential headaches (risk of bleeding).

Depressed Skull Fracture

  • Description: The bone is pressed into the brain, may require cosmetic surgery.

Open Laceration

  • Definition: Direct opening to brain tissue, must be washed thoroughly; prophylactic antibiotics are necessary.

Comminuted Fracture

  • Fragmented bones are embedded in brain tissue, associated with significant blood loss.

Basilar Skull Fracture

  • Characteristics: CSF leaks; occurs at the base of the skull. Symptoms include nasal drainage and potential affects on internal carotid artery.

Positive Halo Test

  • Test Method: Wipe fluid on white paper; blood pools in the center while CSF remains on the outer edges.

  • Treatment: Mannitol can be utilized to remove excess fluid.

Seizures

  • Definition: A seizure is a single event of abnormal cerebral function; occurrence of more than one indicates epilepsy.

  • Phases:

    • Pre-ictal: Presence of an aura before seizure onset.

    • Ictal Phase: Actual seizure activity.

    • Post-ictal Phase: Recovery phase, often associated with amnesia about the event.

Medications for Seizures

  • Phenytoin (Dilantin): Used for seizure management; can cause gingival hyperplasia.

  • Phenobarbital: Intended for long-term treatment of focal seizures; may lead to hallucinations and nightmares, often deterring patients from continuation.

Meningitis

  • Definition: Inflammation of the pia mater, arachnoid, and the subarachnoid space filled with CSF.

    • Symptoms: Headache and stiff neck.

  • Bacterial Meningitis: Caused by

    • Meningococcus: Highly lethal.

    • Pneumococcus: Also severe and spreads through respiratory droplets (coughing, sneezing), kissing, and shared utensils.

  • Complications: Change in urinary output, which can lead to diabetes insipidus.

Primary vs Secondary Brain Tumors

  • Primary Brain Tumors: Rarely metastasize outside the brain.

  • Secondary Brain Tumors: Arise from metastatic sites external to the brain.

Phases of Seizures

  • Types:

    • Partial/Focal Seizures: Involve only one part of the brain.

    • Generalized Seizures: Affect the entire brain.

Seizure Triggers

  • Common triggers include fever (especially in children), hypoxemia, genetics, drugs, alcohol, allergies, and severe hypertension.

  • It is essential to observe and document the occurrence of seizures, utilizing lab tests such as EEG, CT, PET, and MRI for diagnosis.

Stroke (Cerebrovascular Accident, CVA)

  • Definition: Occurs when a blood clot disrupts blood flow to the brain.

  • Types:

    • Ischemic Stroke: Most prevalent type, resulting from blood flow interruption.

    • Hemorrhagic Stroke: Caused by bleeding into brain tissue, commonly associated with hypertension or aneurysms.

  • Atrial Fibrillation (Afib): Can lead to the formation of blood clots resulting in stroke.

  • Management: Fever reduction with medications like Tylenol and cooling blankets.

Disorders of Hepatobiliary and Exocrine Pancreas Function

Kupffer Cells

  • Function: Responsible for phagocytizing old and defective blood cells.

  • Bile Duct Role: Vital in fat metabolism. Blockage can lead to major symptoms, including itching.

Liver Failure

  • Causes: Acute trauma, viral infections (hepatitis types B and C), and excessive drug use (tylenol, antidepressants, antiseizure medications) can lead to liver failure.

Manifestations of Liver Failure

  • Patients may present with bleeding due to the liver's failure to synthesize fibrinogen (a clotting factor) and altered mental status due to elevated ammonia levels from protein metabolism; often necessitating a low-protein diet.

  • Lactulose: Used to flush out ammonia toxins from the body.

Cholestasis

  • Definition: Slowing or stalling of bile flow from the liver; can result in the accumulation of bile in the blood leading to jaundice, illness, itching, malabsorption, and deficiencies in fat-soluble vitamins (E, D, K, A).

Jaundice

  • Description: A condition characterized by yellowing of the skin, sclera, and mucous membranes, often due to high levels of bilirubin.

Management of Liver Issues

  • Correct fluid and electrolyte imbalances, blood transfusion support, and liver transplantation may be necessary. Dietary management includes increasing carbohydrates and calories to mitigate toxic ammonia levels.

Hepatitis Types

Hepatitis A

  • Characteristics: A small enveloped RNA virus, preventable by vaccination. Transmission via contaminated shellfish or water.

Hepatitis B

  • Description: Caused by a DNA virus; can be transmitted through blood, sexual contact, or from mother to child at birth; vaccination available.

Hepatitis C

  • Description: Inflammation caused by the hepatitis C virus, typically blood-borne. Antivirals can cure over 95% of infections.

Hepatitis D & E

  • Hepatitis D: Occurs only in those with hepatitis B.

  • Hepatitis E: Transmitted via fecal-oral route, common in certain regions of Asia.

Cirrhosis

Primary Biliary Cirrhosis

  • Description: An autoimmune condition that causes the destruction of bile ducts leading to cholestasis.

Secondary Biliary Cirrhosis

  • Causes: Resulting from prolonged obstruction of the extra-biliary tree, primarily due to gallstones or other neoplasms.

Portal Hypertension

  • Definition: Increased resistance to flow in the portal venous system leads to sustained pressure in the portal vein.

  • Causes: May be prehepatic (portal vein thrombosis, external compression), intrahepatic, or posthepatic.

  • Pathophysiology: Obstruction in the portal vein elevates hydrostatic pressure within peritoneal capillaries, potentially leading to ascites, splenic engorgement, and complications like slow white blood cell production and easy bleeding from esophageal varices.

Gallstones

  • Description: Formed from cholesterol or bilirubin which solidify in the gallbladder.

Treatment with Ursodiol

  • Function: Prevents and treats certain types of gallstones by reducing liver cholesterol production and breaking down existing gallstones.

  • Administration Considerations: Takes months for desired action; patients should be informed that it is not quick relief. Avoid antacids that can hamper absorption and monitor for side effects like hair loss and liver function tests (LFTs).

Pancreatic Function

Acute Pancreatitis

  • Commonly associated with alcoholism and gallstones; presents with abdominal pain.

Pancreatic Cancer

  • Description: Cause is unknown, but risk factors include smoking, obesity, and diabetes, particularly in individuals under 50.

  • Symptoms: Manifestations may be site-dependent, with tumors leading to increased pain during food consumption or when lying down, particularly in the body's pancreatic region.

Disorders of Endocrine Function

Diabetes Mellitus

  • Definition: Characterized by high serum glucose levels due to inadequate insulin production.

  • Mechanism: High glucose levels excite beta cells to release insulin, facilitating glucose entry into muscle, fat, and liver cells.

Insulin and Glucagon

  • Insulin Function: Essential for glucose and potassium transport into cells.

  • Glucagon: Released from alpha cells in response to low glucose, prompting the mobilization of glycogen from the liver to raise blood glucose levels.

Symptoms of Diabetes

  • Increased thirst, slow healing, fatigue, blurred vision, frequent urination, and unexplained weight loss.

A1C Test

  • Definition: A test measuring average blood sugar levels over the previous 3 months, reflecting red blood cells that are sugar-coated.

  • A1C Levels:

    • Diabetes: 6.5% or higher

    • Prediabetes: 5.7% - 6.4%

    • Normal: Below 5.6%

Prediabetes

  • Characteristics: Elevated blood glucose that does not meet criteria for diabetes.

    • A1C: 5.7% - 6.4%

    • Fasting Blood Sugar (FBS): 100-125 mg/dl

Management of Diabetes

  • Metformin: Prescribed for type 2 diabetes in those older than 10; functions to enhance glucose usage and reduce hepatic glucose production.

  • Wegovy: Recently noted for weight loss but associated with possible concerns in patients with a history of pancreatic or thyroid cancer.

  • Emergency Treatment: Consider fruit juice for conscious patients; IV dextrose or glucagon for unconscious patients.

Insulin Types

  • Exogenous Insulin: Includes various options, such as injectables, pumps, and inhalable forms.

Type 1 Diabetes

  • Definition: Characterized by the complete lack of insulin due to autoimmune destruction of pancreatic beta cells. Rapid symptom onset.

  • Liver Dynamics: The liver releases glucose, while adipose tissue breaks down leading to free fatty acid production.

Ketoacidosis

  • Significant complication, leading to increased fatty acid production and resultant ketone bodies, causing fruity-smelling breath in afflicted patients.

  • Kussmaul’s Respirations: Rapid, deep respirations as a compensatory mechanism against high acid levels.

Type 2 Diabetes

  • Definition: Accounts for 90-95% of diabetes cases, characterized by a slow, progressive onset.

  • Mechanism: Insulin is produced, but cellular response is diminished, leading to retained glucose in the bloodstream. Eventually, pancreatic function may decline, leading to increased insulin resistance.

Hyperosmolar Hyperglycemic State (HHS)

  • A life-threatening condition associated with prolonged hyperglycemia and resultant dehydration and confusion.

Gestational Diabetes

  • A form of diabetes arising during pregnancy when placental hormones block insulin utilization.

  • Complications: Associated with increased risks of perinatal complications such as macrosomia, preeclampsia, and future type 2 development.

  • Diagnosis: Glucose screening tests or one-hour glucose tolerance tests.

Hyperglycemia and Hypoglycemia

Hyperglycemia Symptoms

  • Characterized by fatigue, mood swings, increased appetite, and dry, itchy skin.

Hypoglycemia Symptoms

  • Include shaking, sweating, rapid heart rate, anxiety, and numbness; caution is required in treating during pregnancy and for patients on drugs lowering glucose levels.

Medication Impacts

  • Patients on steroids may require more insulin due to elevated blood glucose levels associated with the medication.

Sulfonylureas

  • Action: Stimulate insulin release from pancreatic beta cells and enhance binding to insulin receptors.

  • Types:

    • First Generation: Chlorpropamide (Diabinese)

    • Second Generation: Glipizide (Glucotrol), Glyburide (DiaBeta, Micronase)

Metformin

  • Use: Specifically for treating type 2 diabetes in patients older than 10.

  • Mechanism: Increases peripheral glucose usage, insulin production, and decreases hepatic glucose output; not suitable for patients with liver issues as it may lead to lactic acidosis.

Microvascular and Macrovascular Complications

  • Microvascular Complications:

    • Retinopathy: Can occur leading to vision loss as blood vessels in the eyes narrow and close.

    • Neuropathy: Causing sensory and motor changes in the feet and legs, with progressive nerve involvement due to oxygen deprivation.

    • Nephropathy: Resulting in renal dysfunction from alterations in the glomerular basement membrane.

  • Macrovascular Complications: Associated with heightened cardiovascular disease risks, including conditions impacting coronary, cerebral, and peripheral vascular health.

  • Diabetic Foot Ulcers: May go unnoticed due to diminished sensation in the feet, increasing the risk of infection.

  • Infection Risk: Elevated glucose levels enhance the proliferation of microorganisms in patients with diabetes.