Who’s at risk for pneumonia
young and old COPD Emphysema Asthma Immunocompromised
Pathogenesis of Type 2 Diabetes
Liver: Insulin resistance in the liver results in glucose overproduction despite elevation in fasting insulin
Pancreas alpha cells: Increased glucagon secretion from alpha cells stimulates an increased hepatic glucose production and decreased insulin secretion
Pancreas: decrease in beta cell fx leads to decreased insulin secretion
Pathogenesis of type 2 diabetes
Hormone Permissiveness
the hormone’s ability to increase the number of receptors for other hormones creates a chain of events
Normal V/Q ratio:
4-5L = 0.8
Diabetes Insipidus
Clinical Manifestations
Clinical manifestations
- Polyuria, polydipsia (hallmark)
- Low urine-specific gravity
- Nocturia
- Hypernatremia because of water deficit
- Normal glucose levels
- Dry mucous membranes, poor skin turgor, decreased saliva and sweat production
- Disorientation, lethargy, seizures
- Manifestations from cell shrinkage
Classification of Pulmonary Malignancies Non-small cell (85%)
Adenocarcinoma - most common, in lung periphery (doubles every 6 months) Squamous cell carcinoma - center (hilar) region (doubles every 100 days) Large cell carcinoma - develops in periphery (doubles every 100 days)
Pneumonia etiology
inflammatory reaction in the alveoli and interstitium cause by an infectious agent
A 35 yo presents with no history
of smoking, chest X-ray is clear. Lungs are hyperinflated with a severely depressed FEV1 @40%
Alpha 1 Anti Trypsin Deficiency
If you have a patient that presents as a severe COPDer who never smoked and is young <35. You have to consider Alpha 1 Anti Trypsin Deficiency which is what keeps surfactant and alveoli going
Perfusion
Movement of blood into and out of the capillary beds of the lungs to body organs and tissue
Honeycomb Lung
Restrictive vs Obstructive
Diseases
Classification of Asthma Severity
Intermittent
- Symptoms: <2 days a week
- Nighttime awakenings: <2x month
- Uses inhaler: <2 days/week
- Interference with normal activity: None
Bronchiolitis Clinical Manifestations
Can be mild to fatal Wheezing Decreased breath sounds Retractions Increased sputum Dyspnea Tachypnea low grade fever
What is untrue about asthma
You have a decreased airway reaction in asthma
In asthma, there is s an increased airway reaction which is why you see the bronchospasms
Obstructive Lung Disorders
Manifested by increased resistance to airflow
CAN’T GET AIR OUT
Primary
vs
Secondary
Hyper/Hypo Thyroidism
Primary - thyroid is the problem
Secondary - pituitary is the problem
Cystic Fibrosis
Diagnosis
Diagnosis
- ABG
- Hypoxemia and hypercapnia
- PFT
- Decreased VC, airflow, TV
- Increased airway resistance, functional residual capacity
- Chest x-ray
- Patchy atelectasis, bronchiectasis, cystic lung fields
- 72-hour stool collection
- Determine fat absorption and fecal fat excretion
- Sweat test (pilocarpine iontophoresis)
- Elevated Na, Cl levels
- Genetic testing
- Genetic marker AF-508 confirms diagnosis
Emphysema
Pathology
Pathogenesis
- Destruction of alveolar ducts (bronchials) and alveolar walls causing enlargement of distal air sacs due to release of proteolytic enzymes from neutrophils and macrophages
- Ineffective gas exchange (diffusion)
- Blebs and bullae form
- Elastin and surfactant are destroyed reducing lung recoil
- Small airways collapse restricting airflow and trap gas
- Smoking causes alveolar damage
- Inactivates α1-antitrypsin (normally protects lung parenchyma)
- Develop hypercapnia and hypoxia
- Damage is irreversible
Croup Clinical manifestations
URI sx for 1-2 days then: Hoarseness Seal-like barking cough No drooling Respiratory retractions and stridor NO DROOLING
What are 3 ways that a
Growth Hormone Deficiency can develop
Etiology
- Decreased GH secretion from pituitary or GHRH from hypothalmus
- Defective GH action (structurally abnormal GH or defective GH receptor)
- Defective IGF-1 (somatomedin) generation
Emphysema
Clinical Manifestations
PINK PUFFER
Clinical manifestations
- Type A COPD
- “Pink puffer”
- Progressive, exertional dyspnea
- Thin due to increased respiratory effort and decreased ability to consume adequate calories
- Use of accessory muscles
- Pursed-lip breathing
- Cough
- Inspiratory and expiratory wheezing - lack of crackles, breath sounds, hyper resonance
- Digital clubbing
- Fatigued
- Barrel chest
- Frequent URIs due to loss of cilia
Goiter vs Thyroid Nodules
Goiter
- Abnormal growth of the thyroid gland
- May cause hypothyroid, hyperthyroid, or a euthyroid state
- Usually painless
- Worldwide cause is Iodine deficiency resulting in decreased T3 and T4 production
- US cause is nodules or autoimmune response
Thyroid nodules
- Abnormal growths on the thyroid gland
- May occur without goiter
- 15% may be malignant
- May be present in hypothyroid, hyperthyroid, or a euthyroid state
- Both may cause obstructive trachea or esophageal symptoms
What is the biggest risk factor for DM
- Obesity strongest risk factor for DM
- Body mass index (BMI) >30 kg/m2
Clinical Manifestations
of
Adrenal Insufficiency
Clinical manifestations
- Early signs include anorexia, weight loss, salt-wasting, weakness, malaise, apathy, electrolyte disturbances, hyperpigmentation of skin, hypoglycemia, and hyperkalemia.
- Diminished vascular tone, reduced cardiac output, inadequate circulating blood volume, and low blood pressure can lead to cardiovascular collapse.
Clinical manifestations Hand-Foot-Mouth Disease
Pharyngitis - vesicles on buccal mucosa & tongue Odynophagia Vesicles on hand and feet Fever Fatique
J-Receptors
Juxtapulonary Capillary Receptors
Located in the alveolar capillaries
Sense increased pulmonary capillary pressure due to acidosis
Initiates rapid deep breathing to reduce CO2 and cause alkalosis with lowers pulmonary pressure
Explain
Thyroid storm
- Life-threatening thyrotoxicosis that occurs when excessive amounts of thyroid hormones are acutely released into circulation
- Clinical manifestations
- Elevated temperatures, tachycardia, arrhythmias, congestive heart failure
- Extreme restlessness, agitation, and psychosis
- Precipitating event: stress, gland manipulation
Epiglottitis Patho
Lift threatening condition Rapid cellulitis of epiglottis and surrounding soft tissue Air blockage into the trachea Children ages 2-4
Parathyroid
Gland
Disorders
- Regulates calcium absorption and resorption from bone
- Serum calcium levels provide the feedback to regulate parathyroid hormone (PTH) secretion.
- Decrease in calcium causes PTH release.
- Elevated calcium levels lead to suppression of PTH secretion.
Infective Mono - Epstein Barr Virus Pathology
Cytomegalovirus (CMV) Trans primarily saliva Viral - no abx Incubation is 4-6 weeks
Adrenal Gland
Located on top of each kidney
- Has inner medulla and outer cortex
- Hypothalamus regulates function
Obstructive Lung Disorders
Classifications
- Obstruction from conditions in the wall of the lumen (Asthma/Bronchitis)
- Obstruction resulting from increasing pressure around the outside of the airway lumen (Emphysema)
- Obstruction of the airway lumen
How to diagnosis Diabetes Mellitus
- DM: endocrine disorder diagnosed by the presence of chronic hyperglycemia
- Diagnosis: if any two of the following conditions occurs
- Random sampling of blood glucose above 200 mg/dL with classic signs and symptoms
- Fasting blood glucose level of greater than 126 mg/dL
- Blood glucose concentration greater than 200 mg/dL 2 hours after a 75-g oral glucose load
- HgbA1c : 6.5% or higher (normal <5.7%)
Virchow’s Triad
Venous stasis/sluggish blood flow Hypercoagulability Damage to the venous wall
Adrenocorticotropic Hormone (ACTH)
- Produced by corticotropes in the anterior pituitary in response to hypothalamic corticotropin-releasing hormone (CRH)
- Binds to G protein-coupled receptors on cells in the adrenal cortex and stimulates the production of cortisol and adrenal androgens
Restrictive Lung Disease
Cannot get air in
- Result from decreased lung expansion
- Alterations in lung parenchyma, pleura, chest wall, or neuromuscular function
- Represent acute or chronic patterns of lung dysfunctions (not a single disease)
- ALS, Guillaine-Barre Syndrome
- Fibrotic Interstitial Lung Disease
- Pulmonary Fibrosis, Sarcoidosis
What does the thyroid gland do
Controls growth and metabolism. Hypothalamus releases thyrotropin-releasing hormone (TRH) which stimulates anterior pituitary to release thyroid-stimulating hormone (TSH) which stimulates the thyroid to release T3 and T4
Only 10% of T3 is produced in the thyroid - T4 converts to T3 in body tissues
Iodine needed to synthesize the T3 and T4
Thyroid hormones are bound to thyroglobulin (protein) until they are released
How to diagnosis Sarcoidosis
Increased eosinophil count, elevated sedimentation rate (ESR), liver enzymes, angiotensin-converting enzyme in active disease
Transbronchial lung biopsy shows Noncaseating granulomas (definitive diagnosis)
Stages 0 to 4
Progressing from normal to advanced fibrosis with evidence of honeycombing, hilar retraction, bullae, cysts, and emphysema
Mechanisms of Lipid Hormone Action
Steroid (lipid) hormones diffuse easily through the lipid bilayer of the cell membrane; cell membrane carriers transport thyroid hormones
Thyroid and steroid receptors located in the cytoplasm or in the nucleus of the target cell
Once inside the cell lipid hormones have to go through gene expression to have the effect amplified.
Lipid acts slower than water-soluble bc of the multiple steps and gene expression that has to take place before amplification can take place.
What hormones
are released
fro the
Posterior Pituitary
•Posterior
ADH (vasopressin)
Oxytocin
Diagnostic tests for DM
- Glycosylated hemoglobin (HbgA1c) to determine long-term glycemic control and to evaluate therapeutic goals
- Glucose freely attaches to RBCs.
- Not useful for day-to-day management, reflects glucose average over the past 100 to 120 days
- Values of less than 7% without adverse effect are considered desirable.
- Capillary glucose testing (<120 mg/dL)
- For day-to-day management
- Testing for ketones through urine testing
- If glucose >300; pregnant; ill; suspect ketoacidosis
Glycolysis
Breakdown of glucose for energy
Pulmonary circulation
- Blood from right ventricle goes to pulmonary arteries (unoxygenated) and then to pulmonary arterioles to the capillary membrane for gas exchange.
- Pulmonary venous blood – oxygenated – flows back into the left atrium
COPD
Criteria
A - no symptoms or hospitalizations
B - mod symptoms no hospitalizations
C - have been hospitalizations
Hypoparathyroidism
Clinical Manifestations
- Paresthesias of the distal extremities, muscle cramps, spasms, fatigue, hyperirritability, anxiety, depression, prolonged Q-T intervals, increases in intracranial pressure
- Severe symptoms: carpopedal spasm, laryngospasm, and seizures
- Tetany: Chvostek or Trousseau sign
- Manifestations result from low serum calcium levels; increased neuromuscular excitability.
Acute Bronchitis Pathogenesis
Airways become inflamed and narrowed from capillary dilation Swelling from fluid exudation Infiltration with inflammatory cells Increased mucus production Loss of ciliary function
Common Physical Findings
Emphysema
Common physical findings
- Thin, wasted individual hunched forward
- Using accessory muscles
- Decreased breath sounds, lack of crackles and rhonchi
- Prolonged expiration
- Decreased heart sounds
- Hyperresonance - loud b/c of trapped air
- Decreased diaphragmatic excursion
- Chronic morning cough
Clinical Manifestations of Pulmonary Malignancies
Persistent cough that changes Dyspnea Hemoptysis Hoarseness Frequent URIs
Hyperthyroidism/Graves Disease
Etiology and Pathogenesis
- Most common: autoantibodies bind and stimulate TSH receptors leading to diffuse toxic goiter (Graves disease)
- Thyromegaly
- Exophthalmos (immune mediated so may not resolve with treatment)
- Widening of the palpebral fissure resulting in exposed sclera
- Lid lag, vision changes, photophobia
Elevated prolactin (from anterior pituitary) level
Galactorrhea
Amenorrhea
Headache
Hormones secreted by the
ANTERIOR PITUITARY
Somoatotropes secrete GH
Gonadotropes secrete LH/FSH
Thyrotropes secrete ACTH
Lactropes secrete prolactin (PRL)
Pituitary gland what does it do and where is it located
The pituitary gland is located at the base of the brain and controls hormones.
Anterior and Posterior pituitary gland
Posterior gland is connected to the hypothalamus by the pituitary stalk
When the hypothalamus wants to communicate with the Anterior pituitary it has to put hormones out into the system for pituitary gland to receive b/c there is not a direct connection
Functions as a intermediary between the hypothalamus and the target organs
What are some Diabetic Goals?
- Goals
- Achieving metabolic control of blood glucose levels
- Preprandial blood glucose level between 70 and 130 mg/dL
- Postprandial blood glucose level less than 180 mg/dL for adults (<160 2 hrs post prandial)
- Preventing acute and chronic complications
- Accomplished by diet, exercise, medication, and such hygiene practices as daily foot care and smoking cessation
CURB-65
CURB-65 Scores
- Confusion
- BUN>20
- Respiratory Rate >30
- BP:SBP <90mmHg or DBP <60mmHg
- Age>65
Total Points
0-2 outpatient (2 may have short-stay inpatient)
3 Inpatient
4 most likely ICU
5 Inpatient ICU
Lung Parenchyma Disorders
Fibrotic interstitial lung disease
Interstitial lung disease
Group of disorders (more than 180 disease entities)
Characterized by acute, subacute, or chronic infiltration of alveolar walls by cells, fluid, and connective tissue
If left untreated, may progress to irreversible fibrosis
Characterized by thickening of alveolar interstitium
Emphysema
Classifications
Classifications
- Centriacinar (centrilobular)
- Associated with smoking and chronic bronchitis
- Destroys respiratory bronchioles
- Panacinar (panlobular)
- Destroys the alveoli
- Paraseptal
- Affects the peripheral lobules
Type B Influenza
Generally milder Isloated primarily to humans
How to diagnose Pulmonary HTN
Measurement of pulmonary artery pressure during exercise Stress testing ECHO Big R wave or Inverted T wave
FEV1
How much air can be expelled in 1 sec
>80% Normal
<70% is obstructive
>70% is normal or restrictive
Etiology and Pathogenesis of
Hyperthyroidism
Etiology and pathogenesis
•Thyroid hyperfunction with increased secretion of T4 and T3 (Graves disease)
Thyroid follicular cell destruction with release of preformed T4 and T3 (Hashimoto thyroiditis)
Explain Somogyi phenomenon
Rise in AM glucose as a rebound effect of hypoglycemia
Best overall ventilation and perfusion occurs in the
Dependant lung fields
Laryngitis Clinical Manifestations
Throat is NOT red Hoarseness Weak voice Aphonia
Growth Hormone Excess
Etiology and pathogenesis
- Uncontrolled GH production by a benign tumor of the pituitary (adenoma)
- Stimulates liver to produce IGF-1
- Cause up-regulated growth of soft and bony tissues
Lipid Soluble Hormones
Carried in circulation by transport proteins (globulin) poorly soluble
Activate intracellular receptors
Thyroid hormones (T3, T4) with iodine attached
Steroids - derived from cholesterol
Hormone detaches at the site of the target cell
Exercise Induced Asthma
Intrinsic - Nonatopic
Common in children and adolescents
- Bronchospasm often occurs within 10-15 minutes after the end of exercise; usually resolves in 60 minutes.
- Heat loss, water loss, and increased osmolarity of the lower respiratory mucosa stimulate mediator release from basophils and tissue mast cells causing smooth muscle contraction.
Clinical manifestations Epiglottis
High fever Drooling Stridor
Asthma Pathogenesis
- Immunohistopathologic features
- Edema
•Mast cell activation starting reaction
- Inflammatory cell infiltration by neutrophils, eosinophils, and lymphocytes
- Inflammation of the airway
- Acute bronchospasm (bronchoconstriction)
- Normal respiratory epithelium replaced by goblet cells, resulting in mucosal edema, mucus plug formation - like a callus in respiratory system
- Airway wall remodeling: thickening of basement membrane
Insulin actions:
- Enhance protein synthesis and prevent muscle breakdown
- Inhibit gluconeogenesis
- Enhance fat deposition by preventing fat breakdown (lipolysis) and inducing lipid formation
- Stimulate growth by enhancing secretion of IGF-1 (somatomedin)
Residual Volume
amount of gas left in the lungs after expiration – 1.2 L
can’t breathe everything out
Peritonsillar Abscess
Emergency Abscess of one tonsil can displace uvula Caused by staph or strep Clinical manifestations: drooling, dysphasia
Lower Airway Structures
Parasympathetic Stimulation
•Parasympathetic stimulation (mediated by acetylcholine) via the vagus nerve leads to constriction of muscle.
Diabetic Ketoacidosis
Etiology and Pathogenesis
- Continued insulin deficiency leads to lipolysis of body tissues—metabolism of fats leads to free fatty acids (FFA).
- FFAs are transformed into ketones, leading to ketoacidosis.
Diagnosis of Asthma
- Pulmonary function tests
- Forced expiratory volumes decrease
- Peak expiratory flow rate (PEFR) determines index of airway function ratio of FEV1/FVC before and after administration of short-acting bronchodilator
- Skin testing
- Young patients with extrinsic asthma
- Elevated WBCs and eosinophils
Obstructive defect for spirometry alone as rated by FEV%
>70% = Mild
60-69% = Moderate
50-59% = Moderate severe
35-49% = Severe
<35% = Very severe
Adrenocorticotropic Hormone (ACTH)
Produced by corticotropes in the anterior pituitary in response to hypothalamic corticotropin-releasing hormone (CRH)
Binds to receptors on cells in the adrenal cortex and stimulates the production of cortisol and adrenal androgens
CRH and ACTH have a significant diurnal pattern, with a peak on wakening in the morning and a valley in the evening.
Determining Hypothyroidism
Anterior pituitary gland hormones are regulated
by the hypothalamus
Explain Glucose Metabolism
Glucose is stimulus for insulin release from vesicles. Insulin then binds to its receptor on insulin-sensitive cells (not all cells do this) and it triggers glucose uptake
Insulin needs access to insulin receptor cells to allow it to function
Pathogenesis of Growth Hormone Deficiency
Pathogenesis
- May be idiopathic or related to tumors, radiation, or trauma
- Resection of pituitary tumors or head injuries
Asthma
Etiology
Airway obstruction that is reversible
Airway inflammation
Leukotriene reaction of bronchoconstriction
Increase in bronchial responsiveness to a variety of stimuli
Hormone Synthesis - Lipid Soluble
Steroid (Lipid) Hormones are formed on-demand from cholesterol that is stored in the cell or retrieved from the circulating lipoproteins.
Central Chemoreceptors
- Located in the medullary center
- Responds to changes in CO2 and pH
- Normal stimulus to breathe is small increase in arterial carbon dioxide tension.
- Alveolar ventilation can increase tenfold with acute rise in PaCO2.
Hypothyroidism
vs
Hyperthyroidism
Clinical Manifestations
CHRONIC BRONCHITIS
Type B COPD “blue bloater”
Overweight
Dyspnea on exertion
Excess sputum
Chronic cough - WORSE IN AM
Cyanosis - late sign
Explain Hyposecretion
HYPOSECRETION
- Too little secretion of hormone
- Primary hyposecretion occurs when an endocrine gland releases an inadequate amount of hormone to meet physiologic needs.
- Secondary hyposecretion occurs when secretion of a tropic hormone is inadequate to cause the target gland to secrete adequate amounts of hormone.
Secondary Hypercortisolism
Means the anterior pituitary is telling the adrenals to put out a high level of cortisol level and they do this by stimulating it with a
High level of ACTH
Cause and clinical manifestations of
Hyperpituitarism
•Benign pituitary adenomas as most common cause
- Manifestations
- usually headache and visual field loss
- Hormonal manifestations
- Diagnosis
- History and physical exam with vision testing
- MRI of the brain , CT of the brain, hormone levels
GOLD Criteria
Classification for COPD
IN PATIENTS WITH FEV1/FVC RATIO < 0.70 - This is the guide BASE ON PREDICTED LEVEL
GOLD 1 MILD - >80%
GOLD 2 MOD - FEV1 is between 50% and 79% predicted
GOLD 3 SEVERE - FEV1 is between 30% and 49% predicted
GOLD 4 VERY SEVERE - FEV1 <30% predicted
Ventilation
Movement of air in and out of the lungs
Up regulation
low level of hormone then we need more of it so the body increases the # of receptors to it
Ex: Oxytocin (labor and delivery)
Chronic Bronchitis - Blue Bloater
Emphysema - Pink Puffer
Chronic Obstructive Pulmonary Diseases
Antidiuretic Hormone Disorder
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE
SIADH
Etiology & Pathogenesis
Etiology and pathogenesis
- Excessive ADH from ectopic production from tumors, notably primary lung malignancies
- Excess ADH stimulates renal tubules to reabsorb water despite decreased blood osmolality.
- Adrenal insufficiency and hypothyroidism can cause increased ADH secretion and hyponatremia.
Antidiuretic Hormone Disorder
DIABETES INSIPIDUS
Etiology and Pathogenesis
Etiology and pathogenesis
Insufficient ADH activity; excessive loss of water in urine
Damage to hypothalamus ADH-producing cells
Brain injury, tumors, or procedures
Some pharmacologic agents
Means large diuresis of inappropriately dilute urine
Central: involves hypothalamus or pituitary gland
Nephrogenic: involves kidneys
Clinical manifestations Pulmonary Embolus
Restlessness Pain on inspiration Tachycardia Hemoptysis Anxiety
Grade of COPD Symptoms
COPD Assessment Test (CAT)
Impact Level
CAT score-Impact level
< 10 Low
10 – 20Medium
21 – 30 High
> 30 Very high
Hyperparathyroidism
Etiology
and
Pathogenesis
- Idiopathic, genetic, parathyroid adenoma, hyperplasia of parathyroid glands, chronic renal failure (reduced vitamin D)
- Bone resorption and formation rates are increased.
- Malignant cells can release PTH-like hormones; are a more frequent cause of hypercalcemic crisis.
- Despite an elevated calcium level, PTH continues to be secreted.
- During pregnancy it can lead to perinatal and neonatal complications.
- Newborn’s PTH production will be suppressed by maternal hypercalcemia, leading to neonatal hypocalcemia and tetany.
- Some drugs such as lithium and thiazides can increase calcium levels.
Central Diabetes Insipidus
vs
Nephrogenic Diabetes Insipidus
Central: involves hypothalamus or pituitary gland
Nephrogenic: involves kidneys
A patient has secondary adrenal insufficiency (not putting out enough cortisol)
Decreased secretion of ACTH
Pituitary is not telling the adrenals what to do and the adrenal does not know what to do
Secondary - lose weight anorexic pigmented skin
Diagnosis
CT of chest with contrast to light up vessels Pulse OX
Type 2 Diabetes Mellitus
Etiology and Pathogenesis
- Most common form of DM
- Non-Caucasian and elderly disproportionately affected
- Insulin resistance and β cell dysfunction lead to a relative lack of insulin.
- Suspect decreased number of insulin receptors or abnormal translocation of glucose transporters
- As disease progresses, insulin production may be impaired.
Explain IGF-1
Growth hormone
- Insulin-like growth factor-1 (IGF-1) also called Somatomedin is stimulated by hypoglycemia, starvation, and exercise to stimulate GH secretion
- Affected by estrogen, testosterone, thyroid hormone
Distribution of pulmonary blood flow
Gravity affects lung:
- Upright position – blood flow is decreased in the apices and increased in the bases.
- Supine position - blood flow is decreased anteriorly and increased posteriorly perfusion
Clinical manifestations Influenza
Sudden onset Significant fatigue Significant myalgia (muscle pain) Headache Fever >100 Chest congestion and non-productive cough Clear nasal secretions
Glycogenesis
Excess circulating glucose is converted into glycogen and stored in the liver and muscle cells
Hypoxia
Decrease in tissue oxygenation
Clinical Manifestations
Asthma
- •Wheezing - Dyspnea
- •Feeling of tightness of chest
- •Cough (dry or productive)
- •Increased sputum
- •Decreased breath sounds
- •Prolonged expiration
- •Use of accessory muscles of respiration
- •Intercostal retractions
- •Distant breath sounds with inspiratory or expiratory wheezing
- •Orthopnea, tachypnea
- •Tachycardia
Primary causes of Pulmonary Malignancies Secondary - metastasize from another source
Bronchial epithelial cell origin Smoking (85%) Asbestosis Radon gas Pollutant Bronchoalveolar (5%) in peripherals metastasize from lymphatics - no correlation to smoking
Chronic Bronchitis
Pathogenesis
Chronic inflammation and swelling of the LARGE bronchial airway mucosa causing bronchial wall thickness and scarring
Goblet cell hypertrophy of bronchial mucous r/i increased prod of mucus w/formation of mucus plugs
Increased bronchial wall thickness - increases work of breathing and O2 demands
Ventilation-perfusion mismatch w/hypoxemia and hypercarbia increases pulmonary artery resistance
Pulmonary hypertension leads to R sided heart failure
The Ominous Octect
What is not true about your bodies response to causing high sugar
You have a decreased glucagon secretion
(Glucagon comes from the pancreas to raise our sugar. Insulin comes from the pancreas to lower our sugar. So when our body is having an issue with to high of sugar it is because the pancreas puts out too much glucagon)
Deep labored respirations that are fruity in odor
Kussmaul respirations and they occur in diabetic ketoacidosis
Etiology
Chronic Bronchitis
BLUE BLOATERS
Cigarette smoking (90%)
Repeated airway infections
Genetic predisposition
Inhalation of physical or chemical irritants
Cystic Fibrosis
Clinical Manifestations
•Clinical manifestations
- Pancreatic insufficiency, cirrhosis of the liver, diabetes mellitus, gallstones, nasal polyps, and failure of development of the vas deferens in males
- Nutritional assessment
- Depleted fat stores
- Steatorrhea (fatty stools)
- Anorexia
- Decreased growth rate in children (wt, ht, head circ)
Causes of Croup
Flu
Viruses
RSV
Adenovirus
Influenza
Viral infection of the upper and lower respiratory tract Common Oct - March
What 4 things enhance the development of neuropathy?
•Hypertriglyceridemia, obesity, smoking, and hypertension enhance development of neuropathy.
Clinical Manifestations
of
Hypothyroidism in
Adults
Clinical manifestations in adults
- Decreased basal metabolic rate
- Weakness, lethargy, cold intolerance, decreased appetite
- Bradycardia, narrowed pulse pressure, and mild/moderate weight gain
- Elevated serum cholesterol and triglycerides
- Enlarged thyroid, dry skin, constipation
- Depression, difficulties with concentration/memory
- Menstrual irregularity - amenorrhea
- Myxedema - generalized facial puffiness
Microvascular Diabetic Complications
Microvascular: retinopathy and nephropathy from abnormal thickening of the basement membrane in capillaries; may lead to blindness and renal failure
- Hyperglycemia disrupts platelet function and growth of the basement membrane.
- Thickening of basement membrane may improve with glycemic control.
- Urine protein loss occurs in nephropathy.
- Preventive: control blood glucose and hypertension
CURB 65
1 POINT 68 YO
1 POINT HYPOTENSIVE
1 POINT BUN ELEVATED
CUT OFF FOR RESPIRATORY IS 30 TO GET A POINT
Classification of Pulmonary Malignancies Small cell carcinoma
Oat cell (Extremely aggressive) Central bronchial region Doubles every 30 days Poor prognosis usually found incidentally
Pheochromocytoma
Clinical Manifestations
- Hypertension (persistent or intermittent)
- Headache, tachycardia, diaphoresis (classic triad)
- Tremor, nervousness, emotional lability, pallor, fatigue, orthostatic hypotension
- Hypermetabolic state with fever, weight loss
Diagnosis
- Abdominal CT/MRI
- 24 hour urine for catecholamines
Glycogenesis
Producing and storing glycogen from the breakdown of excess glucose
When do sinuses fully develop
7 years old
Restrictive Pulmonary Disorders
Characteristics
- Decrease in vital capacity (VC), total lung capacity (TLC), functional residual capacity (FRC), residual volume (RV)
- The greater the decrease in lung volume, the greater the severity of disease.
Hypothalamic-Pituitary Axis
Hypothalamus secretes releasing and inhibiting hormones and it regulates what the pituitary gland does. It connects the nervous and endocrine systems
Chronic Geriatric Complications of DM
Chronic complications
- Heart and blood vessel disease
- Foot disease
- Avoiding foot problems can be challenging from the frequent presence of orthopedic deformity and other common aging-related changes, as well as the decreased ability to perform appropriate foot care.
- Eye disease
- Kidney disease
Ventilation
Movement of air into the lungs and distributing air to the alveoli for maintenance of oxygenation and removal of carbon dioxide
Intrinsic (Nonatopic) Asthma
- Develops in middle age with less favorable prognosis
- No history of allergies
•High eosinophil reaction –not allergic
- Repeated respiratory infections
- Aspirin exacerbated asthma reaction
- Occupational exposure
- Exercise induced
SIADH
vs
DI
Growth Hormone Excess
Diagnosis
Diagnosis: High IGF-1 and an elevated GH level that is not suppressed by administration of oral glucose
Alpha cells produce…
Glucagon
Hyperthyroidism
Diagnosis
•Diagnosis
- TSH levels are low
- Elevated serum T4 and T3 (confirm)
- 24-hour radioactive iodine uptake study can confirm diagnosis of Graves disease and exclude presence of thyroid neoplasms.
Hering-Breuer Reflex
Stretch receptors in the alveolar septa, bronchi, and bronchioles keep you from taking too deep of a breath that cold rupture your lung
Primary (idiopathetic) Pulmonary HTN
HTN progresses rapidly (women>men) Long term prognosis poor as med trmt is ineffective
Tuberculosis
Diagnosis
- Tuberculin skin test – Mantoux test (PPD)
- Local reaction typical to a small amount of bacilli
5mm compromised immunity
10mm at risk
15mm no risk factors
based on risk
- Not used in prior BCG immunization or prior + test
- Interferon gamma release assays (Interferon Gold)
Sarcoidosis
Etiology and Pathogenesis
Acute or chronic systemic disease of unknown cause
Immunologic basis
First degree relative increases risk 5 fold
Development of multiple noncaseating epithelioid granulomas
Abnormal T-cell fx
Glycolysis
Breakdown of glucose for energy
Clinical Manifestations of Acute Bronchitis
Distinct hallmark is recent onset of acute cough Usually mild and self limiting (7-10 days) Cough (productive or nonproductive) Wheezing Low-grade fever Sore throat Postnasal drip Fatigue
Complications of Gestational Diabetes
Complications
- Infant: metabolic abnormalities, stillbirth, macrosomia, and neonatal hypoglycemia
- Mother: development of type 2 diabetes mellitus or impairment in glucose tolerance later in life
- All pregnant women older than 25 years should be screened during the 24th to 28th weeks.
Secondary Pulmonary HTN
Stems from a known disease Mitral stenosis Mitral regurgitation LV heart failure Chronic lung diseases Vasculitis
Adrenal insufficiency
Congenital adrenal hyperplasia
Congenital adrenal hyperplasia: rare cause in pediatric populations, because of specific enzymatic defects in the biosynthesis of cortisol by the adrenals
Causes severe and life-threatening symptoms
Overproduction of ACTH leads to hyperplasia of the adrenal glands and excessive androgen secretion.
Restrictive lung disease
Cannot get air in
Cannot perfuse if there is no oxygen to transfer first
Breathing first - alveolar ventilation
Perfusion is the second process of respiration
Diffusion is third
Normal level of TSH
0.5 - 4.5
Hypoituitarism
Causes and General Manifestations
Causes: Primary Pituitary Secondary Hypothalamus
General Manifestations:
- GH deficiency
- FSH/LH deficiency
- TSH deficiency
- ACTH deficiency
- ADH deficiency
Pathogenesis
Cystic Fibrosis
Pathogenesis
- Recurrent infection of bronchial walls leads to persistent dilation.
- Bronchial wall thickening
- Inflammation results in the destruction of walls.
- Destructive process leads to loss of ciliated epithelium.
- Transforms to squamous cell and pus formation
- Leads to bronchial obstruction
Cause of hypertension that is NOT from a cardiac source
Hyperthyroidism
Explain Dawn phenomenon
Rise in glucose in early morning hours from growth hormone, cortisol, glucagon, and epinephrine release
Examples of low alveolar ventilation but normal perfusion = low V/Q ratio (<0.8)
Atelectasis Pneumonia ARDS example: 3L/5L = 0.6VQ
How to diagnosis
Adrenal Insufficiency
Diagnosis
- Decreased plasma cortisol levels
- ACTH provocation test (chronic AI)
- Serum cortisol levels increase following this stimulus if adrenal cortex is normal; failure to produce cortisol indicates primary adrenal insufficiency.
- Abdominal CT/MRI to evaluate adrenal gland size
Manifestations Pneumonia
Crackles and decreased breath sounds over affected area Dull to percussion over infilitrate Chills and fever Cough, purulent sputum Dyspnea and tachypnea
Secondary Hyperthyroidism
•Secondary—stimulation of TSH receptors by TSH (hypersecretion of TSH)
Explain the properties of T3 and T4
- Approximately 90% of the thyroid hormone is in the form of T4, whereas 10% is T3.
- Remain attached to thyroglobulin until stimulated by TSH
- Released T4 and T3 are lipid soluble and diffuse from the follicle into circulation.
- Once in the cell, T3 binds to its receptor and exerts its actions.
Cushing’s Syndrome
Hormone Metabolism/Excretion
Water Soluble
vs
Lipid Soluble
Water-soluble hormones - Finds their way out in urine
Lipid- soluble hormones are bound to plasma proteins and stored in adipose tissue so they remain in circulation for longer periods of time
Metabolized by kidney and liver; degraded by target cell after binding to receptors
What does the epiglottis do
Closes the airway to prevent food from going into trachea
Hypoglycemia Complications
Causes
&
Clinical Manifestations
- Causes
- Insufficient food intake, unplanned activity, or an inappropriate insulin or sulfonylurea dose
- Manifestations:
- Pallor, tremor, diaphoresis, palpitations, and anxiety
- Hunger, visual disturbance, weakness, paresthesias, confusion, agitation, coma, death
Addisonian Crisis
Acute Adrenocortical Insufficiency
Acute adrenocortical Insufficiency
- Life-threatening condition caused by inadequate levels of glucocorticoids and mineralocorticoids, leading to circulatory collapse
- May occur with acute withdrawal of corticosteroids or may be caused by periods of stress/trauma
Chronic Hyperglycemia can lead to…
Chronic Hyperglycemia
- May lead to systemic changes over time and increase the risk of other diseases, including metabolic syndrome, hypertension, cardiovascular disease, and stroke
- Complications are categorized as vascular and neuropathic.
How to diagnosis
Hypercortisolism
Diagnosis
- ACTH measurement
- Primary = low ACTH
- Secondary = high ACTH
- Plasma cortisol increased
- 24-hour urinary free cortisol levels
- Renal US/CT ABD can detect adrenal tumor
- Dexamethasone suppression test
- Differentiate between pituitary causes and ectopic causes
Half life of a hormone
Duration of hormone activity in circulation expressed in minutes, hours, or days
its the time for a hormone to reach one half of its original concentration in the blood and is influenced by the rate uptake by cells, degradation, and excretion
Lipids usually have a longer half life
Heavier people with more adipose tissue may hold onto hormones a lot longer than someone with no adipose tissue
Explain Myxedema and when you would see it in Hypothyroidism
- Myxedema occurs in severe or prolonged hypothyroidism.
- Generalized, non-pitting edema
- Decreased level of consciousness, hypotension, hypothermia, history of precipitating event (trauma, sepsis, certain drugs)
- May progress to myxedema coma, a life-threatening condition if treatment not received
Factors affecting hormone secretions
Feeding-fasting cycle
Light dark cycle
Sleep-wake cycle
24 hour (circadian cycle)
Longer cycles (28-day menstrual cycle)
Pathology of Pulmonary HTN
Pulmonary vessels become thickened from an increase in the muscle. Pulmonary artery wall becomes fibrotic. Sustained PHTN results in the formation of a network of blood vessels that impedes blood flow
Chronic Obstructive Pulmonary Disease
COPD
IRREVERSIBLE
Irreversible airway or alveolar abnormalities
Chronic Bronchitis
Emphysema
OBSTRUCTIVE
- Damage from prolonged inflammation
- Smoking history or secondhand smoke exposure
- Pollution and chemical irritants
- Symptomatic around 60 years of age
- Equal presentation in men and women
- Alpha 1 Antitrypsin presentation – 30 to 40 years of age
What are Incretins and what is their function?
Incretins are released after a meal to stimulate insulin release and inhibit glucagon release
Incretins slow gastric emptying and decrease appetite
Dipeptidyl Peptidase 4 (DPP-4) causes breakdown of the Incretins
There is a new diabetic med that inhibits the breakdown of DPP-4 allowing the incretins to work and natural glucose metabolism
Primary Hyperthyroidism
- Primary—Graves disease, autoimmune, tumor related, inflammatory; also malignancy
- Autoimmune—related to TSH receptor antibodies
Laryngotracheobronchitis - CROUP - Patho
Subglottic (under epiglottis) area edema leading to airway narrowing and obstruction Children 3 month - 3 years Occurs autumn and early winter
Hypoparathyroidism
Etiology and Pathogenesis
- Primary: may be idiopathic, autoimmune
- Secondary: parathyroid or thyroid surgery; may be temporary or permanent
- Can occur with removal of parathyroid gland
- Congenital lack of parathyroid tissue and idiopathic hypoparathyroidism are causes of hypoparathyroidism in children and infants.
Two types of Asthma
Intrinsic: non-allergic, adult-onset
Extrinsic: allergic, pediatric-onset
Down regulation
Cells have been exposed to a high concentration of a hormone so the body to protect itself decreased the # of receptor sites available, so it doesn’t have excessive activity
example: insulin receptors
Chronic high glucose levels so the body is putting out a lot of insulin trying to fix the level so the body shuts down insulin receptor cells. This is how insulin resistance occurs
Explain
INCRETIN EFFECT
- Glucose ingested food causes a brief rise in insulin release (first phase).
- Continued glucose causes the second phase: insulin secretion.
- Ingestion of nutrients stimulates release of glucose–dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) from cells in the gut.
- Effect on blood glucose known as incretin effect
Hormonal regulation of insulin
Insulin is synthesized in the pancreas by the β cells of the islets of Langerhans. (beta)
Diffusion (Respiration)
Movement of gas between air spaces in the lungs and bloodstream
Secondary Pulmonary HTN causes
Has to come from something after the lungs so it would be the left side of the heart that would cause secondary pulmonary HTN
Diagnosis of Diabetes Type 1
C peptide level is low along with low insulin levels
What happens with insulin in the fasting state?
In the fasting state, glucose is produced by glycogenolysis, gluconeogenesis, and insulin falls to basal level.
Glucagon is responsible for most glucose production in fasting state
Peripheral chemoreceptors
- Located in the aortic arch and carotid bodies
- Respond to decrease in arterial O2
- Also respond to increases in:
- Increased Hydrogen ion concentration (decreased pH)
- Arterial carbon dioxide level (PaCO2)
Hormones
Blood-borne chemical messengers that affect target cells anatomically distant from the secreting cell
- Regulates: Growth and development
- Metabolism
- Sexual function
- Reproduction
- Mood stability
Explain GIP and GLP-1
GIP and GLP-1 stimulate the production of insulin and GLP-1 inhibits glucagon
Insulin stimulates diffusion of glucose into adipose and muscle tissue; inhibits production of glucose by liver.
Type A Influenza
Most common type Sicker presentation Responsible for epidemics and pandemics Found in humans and animals Went to bed fine woke up very ill Transmission through airborne droplets Incubation 1-4 days Continual antigen changes with gene mutations dev new strains
Tuberculosis
Clinical manifestations
Clinical manifestations – active primary
- Gradual onset
- Productive cough
- Night sweats, fever, chills
- Fatigue
- Unexplained weight loss, anorexia
Pheochromocytoma
(Adrenal Gland Disorder)
Etiology and Pathogenesis
Etiology and pathogenesis
- Adrenal medulla secretes catecholamines, norepinephrine, and epinephrine, in response to SNS stimulation.
- Catecholamines increase heart rate, blood pressure, and glucose release from the liver.
- Pheochromocytoma: adrenal medulla tumor resulting in excessive production and release of catecholamines
What causes Hypercortisolism
- Microadenomas or adenomas causing excessive production of pituitary ACTH
- Nonpituitary tumors can cause ectopic ACTH production (malignancies)
- Exogenous steroid use is the most common cause of Cushing syndrome in the US related to use with allergic and autoimmune diseases
Expiratory Reserve Volume
gas that can be expired with a maximal expiration – 1.2 L
DEEP expiration beyond normal TV
Lower airway structures
Autonomic nervous system
•Autonomic nervous system: control bronchi and bronchiole musculature
Acute Bronchitis Etiology
Acute inflammation of the trachea and bronchi Viral 90% of the time Not infectious Sx will improve 7-10 days Cough will linger 3-4 weeks
Acute Bronchitis Causes
Viral - RSV, Adenovirus, Influenza, Rhinovirus Bacterial not common is usually a secondary infection Inhalation of chemical irritants - bleach Allergic reactions
Types of pneumonia
Community acquired (gram positive - strep pneumonia) Hospital acquired Atypical pneumonia (mycoplasma, legionella-breeds in water) Ventilator associated
What can trigger Asthma?
Aspirin
NSAIDS
Beta Blockers
Tartrazine (yellow #5)
MSG
Sodium or K
Hops in beer
Obesity (fat stores of cytokines)
Classification of Asthma Severity
Moderate
Symptoms: Daily
Nighttime awakenings: 1x week but not nightly
Uses inhaler: Daily
Interference with normal activity: Some limitation
Glycogenesis
Excess circulating glucose is converted into glycogen and
stored in the liver and muscle cells
Opposite of Glycogenolysis
Inspiratory Reserve Volume
gas that can be inspired with maximal inspiration - 2.5 - 3 L
Deep inspiration beyond normal TV 2.5 - 3L
Fluid balance in the lungs
- Hydrostatic pressure
- Colloid osmotic pressure
- Capillary permeability
- When capillary hydrostatic pressure exceeds colloid osmotic pressure, fluid moves from capillaries into the interstitial space.
- If fluid shift is not controlled, fluid will move into the alveoli causing alveolar edema leading to poor gas exchange.
What effect does excessive glucose have on myoinositol in neurons?
Excessive glucose is thought to interfere with myoinositol in neurons and reduced myoinositol in peripheral nerves.
Hand-Foot-Mouth Disease
Enteroviruses, particularly Coxsackievirus Incubation 4-6 weeks (respiratory, contaminated hands, fecal matter)
Chronic complications of DM
Chronic complications
- Rarely manifested before adolescence
- Screening for neuropathy/nephropathy ongoing
- Counseling on metabolic control before initiation of pregnancy
COPD Categories
Group A-D
Based on symptoms and Risk of exacerbation
Whether exacerbation landed them in the hospital or not
Exacerbation is acute worsening of resp sx/ URI usually
- Group A: low risk (0-1 exacerbation per year, not requiring hospitalization) and fewer symptoms (mMRC 0-1 or CAT <10)
- Group B: low risk (0-1 exacerbation per year, not requiring hospitalization) and more symptoms (mMRC≥ 2 or CAT≥ 10)
- Group C: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and fewer symptoms (mMRC 0-1 or CAT <10)
- Group D: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and more symptoms (mMRC≥ 2 or CAT≥ 10).
How does the hypothalamus function in relation to the thyroid
- Hypothalamus releases thyrotropin-releasing hormone (TRH) which stimulates anterior pituitary to release thyroid-stimulating hormone (TSH) which stimulates the thyroid to release T3 and T4
- Only 10% of T3 is produced in thyroid – T4 converts to T3 in body tissues
- Iodine needed to synthesize the T3 and T4
- Thyroid hormones are bound to thyroglobulin (protein) until they are released
Growth Hormone Excess
Pituitary gigantism vs acromegaly
Pituitary gigantism: occurs in childhood before the skeletal epiphyses close
- Accelerated growth velocity (>95 percentile on pediatric growth chart)
- Left untreated, may grow >8 feet tall with increased risk of cardiomegaly and heart failure
Acromegaly: growth hormone excess in adults; progressive over several years
Adrenal Gland
Cortex Produces
Salt sugar and sex tells you what comes out of the
Adrenal Cortex
- Mineralocorticoids - Aldosterone (salt and water)
- Glucocorticoids – Cortisol (sugar)
- Gnadocorticoids - Androgens and Estrogens (sex)
Classification of Asthma
Severe
Symptoms: Throughout the day
Nighttime awakenings: Often 7x week
Uses inhaler: Several times a day
Interference with normal activity: Extremely limited
Islet of Langerhans
Types of cells
- Alpha cells – secrete glucagon
- Glucagon (opposite of insulin) tells the liver to break down glycogen stores into glucose - raises sugar
- Beta cells – secrete insulin and amylin
- Insulin works with amylin to control glucose
- Delta cells – secrete somatostatin and gastrin
- Somatostatin inhibits growth hormone
- Gastrin stimulates the stomach to release gastric acid
You can have hypoxemia at tissue level but not hypoxemia
Yes example is a crushing injury
Hyperparathyroidism
Diagnosis
- Primary hyperparathyroidism:
- Serum calcium levels elevated with low to normal phosphorus
- Urinary excretion of calcium and phosphorus are elevated; serum PTH levels are elevated
- Intact PTH and Ionized calcium
- Thyroid US and parathyroid nuclear scan
Clinical Manifestations Mono
Sever pharyngitis; exudate (mimics strep) Fever - high Tonsillar and cervical lymphadenopathy Hepatosplenomegaly and elevated LFTs Thrombocytopenia (spleen), elevated WBCs
GOLD Criteria - COPD
IN PATIENTS WITH FEV1/FVC RATIO < 0.70 - This is the guide BASE ON PREDICTED LEVEL
GOLD 1 MILD - >80%
GOLD 2 MOD - FEV1 is between 50% and 79% predicted
GOLD 3 SEVERE - FEV1 is between 30% and 49% predicted
GOLD 4 VERY SEVERE - FEV1 <30% predicted
Hormones secreted by the
POSTERIOR PITUITARY
ADH (vasopressin)
Oxytocin
Urine Specific Gravity
low number means diluted urine
high number means concentrated urine
Specificity
The “fit” of a hormone into a receptor binding pocket
Functions of the Pancreas
- Exocrine secretions for digestion
- Endocrine functions
Explain Pulmonary Circulation
High flow LOW pressure Coming from the Right Ventricle should be low pressure <25mm/Hg
Glycogenolysis
Breakdown of glycogen into glucose for energy
Pharyngitis (Tonsillitis)
Fever >100.4 Bacterial - Strep A Viral - RSV
Peritonsillar Abscess
Emergency Absess of one tonsil, can displace uvula Caused by staph or strep Clinical manifestations: drooling, dysphasia
Pulmonary HTN Clinical Manifestations
Activity intolerance Fatigue Hemoptysis (excess pressure leaks back into alveoli) Syncope Chest pain on exertion When sx appear cannot be reversed focus on prevention
Hormone Synthesis - Thyroid Hormone
Thyroid hormones (lipid-soluble) are formed on demand but are trapped attached to thyroglobulin and sit and wait until they are told its time to be released by the hypothalamus or anterior pituitary
Diagnosis of Hypoparathyroidism
- Serum calcium (low); phosphorus (high)
- Antibodies to parathyroid gland present if autoimmune mechanism involved
Hypercortisolism
Etiology and Pathogenesis
- Primary: disease of the adrenal cortex
- Secondary: hyperfunction of anterior pituitary ACTH-secreting cells
- Tertiary: hypothalamic dysfunction or injury
- Iatrogenic - long term steroid use
- Ectopic ACTH producing tumor – small cell lung cancer
Screening for Diabetes
Screening for Diabetes -USPSTF
- All adults older than age 40 should be screened at least every 3 years for type 2.
- Individuals with risk factors should be screened earlier or more frequently.
No screening requirements for type 1
What would you see in relation to insulin in
a person with Growth Hormone Excess
May cause persistent hyperglycemia and increased insulin production (GH called a diabetogenic hormone)
Explain the
Primary Classification of
Endocrine Disorders
Primary: intrinsic malfunction of the hormone-producing gland
In primary, gland fails; an inadequate hormone produced, low levels of circulating hormone, but blood levels of the corresponding trophic pituitary hormone levels very elevated.
When do you measure cortisol for testing
First thing in the morning when its at the highest
Risk factors for Diabetes Mellitus
Type 2 Diabetes Mellitus
- Risk factors: female sex, obesity, aging, and sedentary lifestyle
- Polyuria, polydipsia, and polyphagia may be more subtle
Clinical Manifestations of Hypothyroidism in Infants
•Clinical manifestations in infants
Routine screening in newborns has resulted in increased treatment for congenital hypothyroidism.
- Dull appearance, thick, protuberant tongue, and thick lips
- Prolonged neonatal jaundice
- Poor muscle tone, umbilical hernia
- Bradycardia, mottled extremities
- Hoarse cry
- Mental retardation unless treated early
Geriatric Complications
Increased prevalence of type 2 DM
Increased adiposity, decreased lean body mass, decreased activity levels, decreased insulin secretion, hyperglycemic effect of certain medications
How does exercise affect insuln levels
Initially insulin levels drop and glucagon and catecholamine levels rise, increasing production of free fatty acids (FFAs) and stimulating glycogenolysis.
Glucose from liver meets energy demands. (Glycogenolysis)
Muscle contractions increase insulin sensitivity, maintaining normal blood glucose levels in the presence of lower insulin levels.
Emphysema
Etiology
- Smoking >70 packs/year (2pk/dayX30years)
- Air pollution
- Certain occupations (mining, welding, working with or near asbestos)
- α1-Antitrypsin deficiency
- Expanded “floppy” lungs
Hypercortisolism
Cushings Syndrome
•Cushing syndrome—term used to describe any other reason for hypercortisolism
STEROID HORMONES
GLUCOCORTICOIDS
Primary effect on glucose metabolism
Oppose the effects of insulin and raise blood glucose levels by decreasing glucose uptake by many body cells (decreased glycogenesis) and increasing glucose synthesis in the liver from glycogen and amino acid and glycerol substrates in fat stores (glycogenolysis, gluconeogenesis)
Clinical Manifestations of
Growth Hormone Deficiency
Most clinically relevant in children
Associated with:
Birth history of prolonged labor or breech delivery, congenital chromosomal anomaly; nystagmus, retinal abnormalities, midline or midfacial abnormalities (cleft lip or palate)
Clinical manifestations in children:
Hypoglycemia
Growth below the third percentile
Dental eruption delayed
Irregular setting of permanent teeth
Thin hair, poor nail growth
Greater fat mass, decreased muscle mass and delayed bone formation
Delayed puberty
Clinical manifestations in adults:
Diminished lean body mass
Hypercholesterolemia
Decreased bone density
Diagnosis
Confirmed by decreased serum GH
Diffuse Interstitial Lung Disease
Clinical manifestations
Clinical manifestations
- Progressive dyspnea with irritating, nonproductive cough
- Rapid-shallow breathing
- Clubbing of nail beds
- Bibasilar end-expiratory crackles
- Cyanosis (late finding)
- Anorexia, weight loss
- Inability to increase cardiac output with exercise
Secondary Pulmonary HTN
Stems from a known disease Mitral stenosis Mitral regurgitation LV heart failure Chronic lung diseases Vasculitis
Growth Hormone Disorders
- Growth hormone (GH) produced in anterior pituitary gland
- Regulated by hypothalamic:
- Release of growth hormone-releasing hormone (GHRH)
- Inhibited by Somatostatin
- Primary target organ is the liver.
- Increases lean body mass, reduces fat mass, and induces liver to release glucose under conditions of hypoglycemia
- GH acts opposite of insulin and raises glucose
FEV 1
amount of forced air exhaled over 1 second
Normal – generally 80% of Forced Vital Capacity
Normal range for Hemaglobin A1c - HgbA1
Normal range 4 - 5.7%
1% reduction decreases microvascular risks by 10%
What happens after you eat in relation to glucose metabolism
- Glucose ingested food causes a brief rise in insulin release (first phase).
- Continued glucose causes increased insulin secretion (second phase)
- Ingestion of nutrients stimulates release of glucose–dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) from cells in the gut.(Incretins stimulates insulin release and inhibits glucagon to lower sugar)
- Effect on blood glucose known as incretin effect
Antidiuretic Hormone Disorders
Syndrome of Inappropriate Antidiuretic Hormone
SIADH
Clinical Manifestations
Clinical manifestations
- Hyponatremia < 135 mEq/L (135-145)
- High urine osmolality
- Low serum osmolality
- Weakness, muscle cramps, N/V, postural BP changes, poor skin turgor, fatigue, anorexia, lethargy
- Confusion, hemiparesis, seizures, coma
Pharmacologic Hormone Concentrations
vs
Physiologic hormone concentrations
Physiologic hormones are extremely low due to amplification
Pharmacologic levels are much higher
Tissue response to pharmacologic hormone concentrations may be significantly different from physiologic levels
Describe Type 1 Diabetes Mellitus
- Characterized by destruction of the β cells of the pancreas
- Usually diagnosed between 5 and 20 years of age
- Etiology may be immune-mediated or idiopathic (without autoimmune markers or HLA association).
- Autoimmune markers: chromosome 6
- HLA: MHC genes
Hypothyroidism
Etiology
and
Pathologenesis
- May be congenital or acquired
- Majority are primary, because of intrinsic thyroid gland dysfunction
- Congenital hypothyroidism (cretinism) typically caused by thyroid dysgenesis (lack of development)
•Secondary, as a result of defects in TSH production (hyposecretion)
Bronchiolitis eitilogoy
Widespread inflammation of the bronchioles (smaller bronchioles) RSV most common cause Winter to spring Common in children Adults for smoking, toxic fumes
Pre-diabetes classes:
- Impaired glucose tolerance
- 2-hour post-glucose value of 140 to 200 mg/dL
- Impaired fasting glucose tolerance
- Fasting plasma glucose value of 100 to 125 mg/dL
Etiologies
of
Endorine Disorders
Functional disorders - Caused by nonendocrine disease such as chronic renal failure, liver disease, or heart failure
Tissue resistance - Occurs when target tissue fails to respond to a hormone (hormone resistance or target tissue resistance)
Iatrongenic - Induced by medical treatments such as chemotherapy, radiation therapy, or surgical removal of glands
Mechanism of Water Hormones with Cell Membrane Receptors
Hormones exert their action by binding to target cell receptor proteins
Water-soluble hormones have a hormone-binding site located on the external portion of a specific cell surface receptor
Once binding takes place, receptor protein conveys a signal to the interior of the cell to produce a response
Clinical Manifestations of
Prolactinemia
Clinical manifestations
- Hypogonadism
- Premenopausal female infertility, oligomenorrhea, and galactorrhea
- Male decreased libido, impotence, infertility, gynecomastia, and galactorrhea
Hormones are categorized by chemical composition
Steroids - androgens glucocorticoids, thyroid (lipids)
Proteins/polypeptides - Insulin, growth hormone (water)
Amines/amino acids - epinephrine (water)
Fatty acid derivatives - prostaglandins
Three mechanisms involved in Secondary HTN
Increased pulmonary blood flow Increased resistance to blood flow Increased left atrial pressures
Acute Geriatric Complications
- Acute complications
- Hyperglycemia: often asymptomatic; dehydration; increased risk of infection;
- Non-ketotic hyperglycemic hyperosmolar coma
Glucose >500-600, dehydrated, electrolyte
imbalances; arrhythmias, seizures, coma
- Hypoglycemia may be atypical and can lead to injury.
- Lethargy or focal neurologic dysfunction
- Age-related decreases in counter-regulatory function or an inability to report hypoglycemic symptoms
Lower airway structures
Sympathetic stimulation
•Sympathetic stimulation (mediated by β2-adrenergic receptors); leads to relaxation of the smooth muscle
Amplification of Hormone Activity
Why you can have a very small amount of circulating protein and it can cause a tremendous effect on the body.
Progressively larger numbers of chemical reactions occur at each step, resulting in the activation of numerous G proteins
Cross specificity
One receptor site will respond to two or more different hormones.
May occur between hormones
Example is growth hormone and prolactin both can bind to a prolactin receptor so if growth hormone take up all the receptors their won’t be any for prolactin
What may prevent or improve symptoms of diabetic neuropathy?
Glycemic control may prevent or improve symptoms of diabetic neuropathy.
Spermatocele
Lump on testicle that is painless and moveable
What influences resistance in the airway
Resistance influenced by airway radius and the pattern of gas flow
Ventilation
Movement of air in and out of the lungs
FEV1/FVC RATIO
> 70% Normal
Ratio of how much you exhaled in the first second divided by how much you exhale
Less than 70% is obstructive
Greater than 70% is either normal or restrictive (FVC <80%)
What does Calcitonin do?
- Calcitonin produced by thyroid parafollicular cells; also influences the processing of calcium by bone cells
- Calcitonin increases bone formation by osteoblasts and inhibits bone breakdown by osteoclasts.
- Calcitonin decreases blood calcium levels and promotes conservation of hard bone matrix.
Hypoxemia
Low oxygen in bloodstream
Parathyroid Gland
- 4 glands
- Located behind the thyroid glands
- Secrete parathyroid hormone (PTH)
<strong>•PTH – regulates calcium</strong>
- Can cause calcium release from bones when serum calcium levels are low (makes bones weak)
- Can increase calcium absorption from the GI tract and in the renal system
- PTH stimulates Vitamin D which is needed for calcium GI absorption
Gestational Diabetes Mellitus
Risk Factors
Most likely precipitated by placental hormones and weight gain
Risk factors
Severe obesity, history of gestational diabetes, previous offspring weighing more than 9 lbs at birth, presence of glycosuria, or a strong family history of type 2 diabetes
Hyperparathyroidism
Clinical Manifestations
•Clinical manifestations
- Kidney stones
- Bone demineralization (osteoporosis)
- Polyuria and dehydration
- Anorexia, nausea, vomiting, constipation
- Bradycardia, heart block, and cardiac arrest
- Manifestations result from high serum calcium levels and bone demineralization.
- High serum calcium levels decrease neuromuscular excitability.
Pneumonia causes
Bacterial, viral, fungi Aspiration of secretions or gastric contents Inhalation of smoke or chemicals
Water soluble hormones
Bind to cell surface receptors
Peptides (small proteins) majority of endocrine hormones
Easily transported in the bloodstream
ACTH FSH LH, Growth Hormone, TSH PTH
FVC
Total expiration of air
Epiglottis Causes
Haemophilus influenzae type b (HIB) GABHS bacteria Throat trauma Hot liquids Foreign objects
Adrenal Insufficiency
Etiology & Pathogenesis
Etiology and pathogenesis
- Primary: hyposecretion caused by disease of adrenal cortex; idiopathic or autoimmune (Addison disease), surgical removal
- Secondary: inadequate secretion of ACTH from anterior pituitary; usually iatrogenic, related to corticosteroid therapy (suppresses ACTH) followed by sudden withdrawal of steroids
- Tertiary: lack of secretion of CRH from hypothalmus
- Cortisol insufficiency is most clinically relevant
Flu Vaccine information
Quadrivalent (2 strains both A and B) Intranasal for ages 2-49 its a live vaccine (no for pregnant, immunocompromised or chronic resp prob) If over 65 4 dose series of not live vaccine
Negative Feedback for Thyroid System
Clinical Manifestations
Graves Disease
- Clinical manifestations
- Insomnia, restlessness, tremor, irritability, palpitations, heat intolerance, diaphoresis, diarrhea, inability to concentrate that interferes with work performance; enlarged thyroid gland
- Increased basal metabolic rate leads to weight loss, although appetite and dietary intake increase.
- Amenorrhea/scant menses
Pathogenesis
Cystic Fibrosis
CTFR Gene
Pathogenesis
- Dysfunction of CFTR gene
- Normally CFTR encodes a membrane chloride channel and is in sweat glands, lungs, and pancreas
- CFTR gene mutations result in alteration in chloride and water transport across epithelial cells.
- Primarily affects the pancreas, intestinal tract, sweat glands, and lungs, and in males causes infertility
- High concentrations of sodium and chloride in sweat, salivary, and lacrimal secretions
Comparison of Type 1 and Type 2 Diabetes
Normal level of
T3 & T4
T3 (75 - 195 ng/ml)
T4 (5-12 mcg/dL)
Classifications of Rhinosinusitis
Most infections are viral Acute sx <4 weeks Chronic sx =12 weeks Recurrent >4 year
The Adrenal Glands
Medulla Produces
Epinephrine
Norepinephrine
Diabetes
Mellitus
- Hyperglycemia from insulin production and/or action defects
- Type 1 diabetes - autoimmune
- Destruction of pancreatic beta cells
- Type 2 diabetes - herideratary
- Insulin resistance and loss of insulin production
- Gestational diabetes
- Glucose intolerance during pregnancy
- Ineffective pancreatic function to overcome insulin resistant state
Types of ventilation - perfusion imbalances
High (under perfused) Ventilation > perfusion - Alveolar unit is ventilated, but not perfused. Happens with PE (lack of blood flow)
Low (underventilated) Ventilation
Grade of COPD Symptoms
Modified British Medical Research Council
mMRC
Questionnaire on breathlessness
0 minimal sx
1-2 slowing down
3 -4 - symptomatic to very symptomatic
Proprioceptors
- Located in muscles and tendons of movable joints
- Respond to body movement (exercise) and increase rate and depth of respiration
Muscle movement stimulates you to take a breath
HTN slows down respiration
Hypotension increases respiration - venous return
Cystic Fibrosis
Pathogenesis
- Mucous-producing glands in the GI tract enlarge
- Generates excessive secretions
- Thick eosinophilic mucus secretions plud the glands and ducts of the GI tract, causing dilation and fibrosis
- Leads to decreased production of pancreatic enzymes, causing increased FAT and PROTEIN IN THE STOOL
Steroid Hormones
MINERALCORTICOIDS
ALDOSTERONE
- Maintain normal salt and water balance by promoting sodium retention and potassium excretion at the distal renal tubules
- Aldosterone secretion regulated primarily by the renin-angiotensin system associated with the juxtaglomerular cells of the kidney
- Released in response to low blood pressure, reduced renal perfusion and a high serum potassium level
Diagnosis
of
Chronic Bronchitis
Diagnosis
- Chest x-ray
- Increased bronchial vascular markings
- Congested lung fields
- Evidence of previous pulmonary infection
- Pulmonary function tests
- Normal total lung capacity (TLC)
- Increased residual volume (RV)
- Decreased FEV1
- ECG - right ventricular hypertrophy
- CBC – polycythemia due to hypoxia
- Chronic or recurrent productive cough >3 months >2+ successive years
- Persistent, irreversible when paired with emphysema
Diagnosis for Hypothyroidism
Diagnosis
•Primary: elevated TSH
(0.5-4.5 normal levels)
May have elevated TPO/Thyroglobulin
- Secondary: decreased TSH (Pituitary failure)
- Low levels of T3 and T4 may not occur until later in the disease course.
- T3 (75-195 ng/ml) T4 (5 -12 mcg/dL)
Sarcoidosis
Clinical Manifestations
- Malaise, fatigue
- Weight loss
- Fever
- Dyspnea of insidious onset
- Dry, nonproductive cough
- Erythema nodosum
- Macules, papules, hyperpigmentation, and subcutaneous nodules
- Hepatosplenomegaly, lymphadenopathy
Tuberculosis
Caused by Mycobacterium tuberculosis
Transmission via aerosol droplets with active TB patient
Can survive weeks in dry sputum
Florida 4th state for positive cases
Diagnosis Pneumonia
CURB - 65 WBC >15,000 (bacterial) Chest Xray shows white shadows (Parenchymal infiltrates)
Risk factors for Pulmonary Embolus
Immobility Trauma Pregnancy Cancer Heart Failure Estrogen Use Smoking
Causes of Restrictive Lung Diseases
- Stiff lungs (can’t inflate) 2. Stiff chest wall (kyphosis, obesity, rigidity) 3. Elasticity of lungs (can’t snap back) -Decreased (COPD) Increased - (Pulmonary fibrosis, Sarcoidosis, SLE, Asbestos)
What hormones are released
from the
Anterior Pituitary
•Anterior
Somoatotropes secrete GH
Gonadotropes secrete LH/FSH
Thyrotropes secrete TSH
Corticotropes secrete ACTH
Lactropes secrete prolactin (PRL)
Extrinsic (Atopic) Asthma
(E)xtrinsic = IgE
(A)topic = allergy
1/3 to 1/2 of asthma cases
A genetic IgE-mediated exaggerated response in many cases
Allergic rhinitis, atopic dermatitis and eczema
Prolactinemia
Cause Primary vs Secondary
Primary is a disorder of the anterior pituitary
Secondary is a disorder of the hypothalamus
Normal range = Men 10-20
Women 10-25
Diffusion
Respiration
Movement of gas between air spaces in the lungs and the bloodstream
Hormone Synthesis - Water soluble
Peptide hormones are contained within the bilayer of the vesicles and stored until a trigger results in the exocytosis of the hormone into the extracellular space
Hormones are classified by
Action - the effect they have (insulin lowers glucose)
Source - Anterior or posterior pituitary
Chemical structure
What is the most common cause of acquired hypothyroidism:
Lymphocytic thyroiditis (Hashimoto or autoimmune thyroiditis); may result in a goiter
Irradiation of the thyroid gland
Surgical removal of thyroid tissue
Iodine deficiency
Where do we get energy how is it metabolized
Energy requirements are met by glucose and fats
Glucose is produced from glucose stores or glycogen in liver primarily it is coming from the bloodstream from the GI tract and liver
Tidal Volume
amount of gas entering or leaving in a normal breath – 500 ml
Increases with exercise
Hypercortisolism
Clinical Manifestations
Clinical manifestations
- Round face with flushed cheeks, “moon face”
- Weight gain with excess total body fat, particularly in the abdomen, thin extremities
- Cervical fat pad, capillary friability, thin skin with formation of purple striae and ecchymosis over the abdomen, arms, and thighs
- Decreased muscle mass, muscle weakness
- Glucose intolerance, hyperglycemia
- Hypertension (salt-retaining activity of cortisol)
- Demineralization of bone (osteoporosis)
- Increased androgen production causing excessive hair production, acne, menstrual irregularities
- Emotional lability, anxiety, irritability, depression
What are secondary complications of the flu
Secondary pneumonia Reye Syndrome in children
Pleural Effusion
Etiology & Pathogenesis
Collection of fluid or pus in pleural cavity as a result of another disease process
Changes in pleural capillary hydrostatic pressure, colloid oncotic pressure, or intrapleural pressure
Imbalance in pressure associated with fluid formation exceeding fluid removal
Perfusion
Movement of blood into and out of the capillary beds of the lungs to body organs and tissues
Glycolysis
Body is breaking down sugar so the cells can use it
Acute Pediatric Complications of DM
- Dehydration: diabetic ketoacidosis
- When blood glucose is >240 mg/dL or during illness, test for ketones.
- Hypoglycemia may be difficult to detect; subtle behavioral changes.
- Lethargy, pallor, and sleep disturbances
Causes of impaired diffusion
Thickening of alveolar cap membrane - pneumonia, pulm edema; also aging
Surface – Emphysema – areas destroyed
Activity - less blood flow time in the lungs
Elderly – decreased lung capacity, blood flow
Newborn - thick alveolar membrane
Explain Hypersecretion of the Thyroid Disease
HYPERSECRETION
- Excess secretion of hormone
- Primary hypersecretion occurs when there is a dysfunction of the endocrine gland that results in abnormally high secretion of hormone.
- Secondary hypersecretion occurs when there is an elevation in the tropic level of one hormone that results in an increased plasma concentration of another hormone.
Gluconeogenesis
No sugar in system and glycogen used up so the body gets sugar from other non sugar substances
Cystic Fibrosis
Etiology
Autosomal recessive disorder of exocrine glands
Most common genetic lung disease in the US
Classified as airflow or suppurative (pus-forming)
Hypersecretion of abnormal, thick mucus that obstructs exocrine glands and ducts
Median survival age: 31 years
Diabetic Neuropathy
Patho and Etiology
Diabetic neuropathy
- Autonomic dysfunction: GI disturbances, bladder dysfunction, tachycardia, postural hypotension, and sexual dysfunction
- Sensory dysfunction includes carpal tunnel syndrome, paresthesias in extremities, especially feet.
- Amputation 15 to 40 times higher than in nondiabetic individuals
Growth Hormone Excess
Clinical Manifestations
Clinical manifestations of acromegaly
- Increased ring or shoe size
- Enlargement of frontal sinus causes prominent brow.
- Growth of mandible leads to progressive underbite (prognathism).
- Coarse facial features and skin tags
- Increased size of internal organs
- Deepening of the voice and enlarged tongue
How to diagnosis
Diabetes Insipidus
Diagnosis
- Dilute urine, hypernatremia along with abnormally low serum ADH levels (diagnostic of central DI)
- Renal US or MRI Brain
Affinity
The degree of “tightness” or the hormone receptor bond or the inclination of the hormone to remain bound to the receptor
i.e. Old key locks you put key in a jiggle it around present-day locks have a high affinity with tight locks only fitting the intended key
When you have a high affinity you don’t need as much of the hormone you can use a very small amount
Acidosis can result in
Hyperkalemia
Examples of normal ventilation but low perfusion = high V/Q ratio (>0.8)
Pulmonary emboli SLE Sarcoidosis Alveolar carcinoma example: 4L/3L = 1.3VQ
Normal range for HgbA1c
5.7%
Gluconeogenesis
Generation of glucose from
non-sugars
Sleep Apnea
Etiology
Obstructive (OSA) or Central (CSA)
OSA - associated with obesity oral or pharyngeal obstruction
CSA - associated with heart or brain abnormalities (rare)
Risk factors - neck circumference 17” in men 16” in women
What are etiologies of Endocrine Disorders
Congenital
Inborn genetic defect that causes excessive production of hormone precursors
Autoimmune
Involves genetic predisposition and environmental trigger; antibodies made against antigens on self-tissue cells
Neoplastic
Hormones may be produced by abnormal tissue sites (ectopic) such as malignancies.
Explain Negative feedback control
The body says it need so much of a hormone the body reacts to it and it sends a signal back to the anterior pituitary and hypothalamus that fx at a good level.
If we don’t need as much hormones it will send a message back that to the anterior pituitary to slow down production
If deficient in hormone sends signal to anterior pituitary and hypothalamus that we need more
How we keep hormone level fx and at level we want
Beta cells produce…
β cells produce proinsulin.
- Stored in granules, where it is cleaved into insulin and C-peptide
- 1:1 RATIO OF INSULIN AND C-PEPTIDE
Diffuse Interstitial
Lung Disease
Pathogenesis
Begins with injury to alveolar epithelial or capillary endothelial cells
Persistent alveolitis leads to obliteration of alveolar capillaries, reorganization of lung parenchyma, irreversible fibrosis
Leads to large air-filled sacs (cysts) with dilated terminal and respiratory bronchioles (honey-comb lung)
Diagnosis
Emphysema
Diagnosis
- Pulmonary function tests (PFTs) -BIG LUNGS-
- Increased functional residual capacity
- Increased RV, TLC
- Decreased FEV1, FVC
- Chest x-ray
- Hyperventilation
- Low, flat diaphragm
- Presence of blebs or bullae
- Narrow mediastinum
- ECG
- Normal, show tall P waves
- Sinus tachycardia: first sign of decreased oxygenation
- Supraventricular and ventricular arrhythmias
Disorders/Diseases
of the
Thyroid Gland
Hyposecretion
Hypersecretion
Target cell hypo-responsiveness
Delta cells produce…
Somatostatin (counteracts growth hormone)
Hypercortisolism
Cushing’s Disease
•Cushing disease—term only used for pituitary hyperstimulation of adrenal cortex; secretes excess cortisol
Glycogenolysis
Breakdown of glycogen into glucose for energy
Opposite of Glycogenesis
Regulation of Receptor Responses
What determines the ability of a cell to respond to a particular hormone
Cell response to a hormone depends on the presence of specific receptors on very specific cells
for that hormone on the cell called the target cells
A cell can change how it wants to respond to a hormone by changing the # of receptors or an affinity for the hormones
What happens when glucose levels rise?
Glucose levels rise, leading to polyuria (increased urination), polydipsia (thirst), and polyphagia (hunger): classic signs.
Laryngitis
Inflammation of the larynx - vocal cord Noninfectious - screaming, singing, vomiting Infectious form - Rhinovirus, Strep
Macrovascular damage r/t Diabetic Vascular Complications with DM
Macrovascular: damage to large blood vessels; leads to cardiovascular disease, peripheral vascular disease, and stroke
- Preventive: caloric restriction, exercise, possibly drugs, control dyslipidemia, and hypertension
- DM is an independent risk factor for coronary artery disease (CAD).
- Dyslipidemia, hypertension, and impaired fibrinolysis are present in uncontrolled DM; improve with blood glucose control.
What does an overproduction of glucagon stimulate?
Glycogenolysis
and
Gluconeogenesis
Metabolic
Syndrome
- Cluster of risk factors
- Hyperglycemia, hypertension, hypercholesterolemia, increased waist circumference
- Chronic complications
- Directly result from long-term excessive glucose levels
- Thickening and hardening of vessel walls
- Causing diffuse ischemia and necrosis
- Macrovascular complications
- Microvascular complications
- Miscellaneous complications
Tuberculosis
Pathogenesis
- Lymphocytes and macrophages form a granuloma around bacilli to contain it
- Caseating granuloma
- Intact immune system inhibits granuloma formation and develop Ghon complexes that calcify
- Latent TB – infected but asymptomatic and not contagious
When are CRH and ACTH at their peak and lowest point?
CRH and ACTH have a significant diurnal pattern, with a peak on wakening in the morning and a valley in the evening.
Hydrocele
Excess fluid
What is the ideal Ventilation to Perfusion ratio
Ventilation 4L/min
Perfusion 5L/min
4/5-0.8
Thyroid Gland follicles
- Thyroxine – T4
- Triiodothyronine – T3
- Thyrocalcitonin – Calcitonin (regulates calcium levels)
Persistent Asthma Classification
Mild X2 week
Moderate X1 day
Severe multiple X a day
Pre-Diabetes — Impaired Glucose
Impaired glucose tolerance and impaired fasting glucose tolerance
Intermediate stages between normal glucose metabolism and diabetes
•HgbA1c : 5.7 – 6.4%
Explain the
Secondary Classification of
Endocrine Disorders
- Secondary: malfunction of the hypothalamus/pituitary cells that control the target gland
- In secondary, pituitary gland fails to release trophic hormone, secondarily reducing primary gland production, so both levels are abnormally low.
- Since clinical manifestations are similar, laboratory results can help distinguish between primary and secondary.
Classification of Asthma Severity
Mild
Symptoms: >2 days a week, but not daily
Nighttime awakenings: 3-4x month
Uses inhaler: >2 days/week but not daily, and not more than 1x day
Interference with normal activity: Minor limitation
Diffuse Interstitial Lung Disease
Diagnosis
Diagnosis
- Chest x-ray
- PFTs (decreased VC, TLC; normal FEV1/FVC ratio
- Open lung or transbronchial biopsy
- Gallium-67 scan lung scan
- High-resolution computed tomography (HRCT) and bronchoalveolar lavage
Cystic Fibrosis
Clinical Manifestations
Clinical manifestations
- Persistent, daily, chronic, productive cough
- Purulent, foul-smelling, green, or yellow sputum
- Hemoptysis
- Fever, night sweats
- Moist crackles, rhonchi
- Halitosis (bad breath)
- Skin pallor