exam 3 Flashcards
atelectasis
definition
incomplete expansion of lung, a collapse of a part of the lung
pneumothorax
definition
two types
accumulation of air in the pleural space
open or closed
tension pneumothorax
defintion
pathogenesis
progressive build up of air within the pleural space due to lung laceration (allow air to escape into pleural space but not to return)
pressure build up will compress lung
spontaneous pneumothorax
definition
risks
symptoms
treatment
in absence of blunt or penetrating trauma
smoking, tall stature
rapid onset, sharp chest and shoulder pain, coughing or lifting, dec. or absent breath sounds, tachypnea, diaphoresis
maintain airway, monitor for tension pneumo, pleural decompression if pt becomes cyanotic, hypoxic, and difficult to ventilate
lung cancer: lung carcinoma
definition
mortality
causes
smoking related neoplasm, common malignant tumor, mortality in women exceeds breast cancer
genetic, EGFR, industrial exposure to nickel and chromates (4 types)
lung cancer: squamous cell carcinoma
definition
tumor placement
progression
most common, metaplastic squamous epithelium to line main bronchi from agents such as cigarette smoke
tumors are central and cause bronchial obstruction
slow growing, possible resection
lung cancer: adenocarcinoma
kind of cells
growth
cause/risk
glandular cells (mucous goblet cell, clara cells, type II pneumocytes)
slowest rate of growth
common in women
passive cigarette smoke, common in non smokers, EGFR mutation
small cell carcinoma
AKA
tumor characteristics
cell characteristics
(oat)
highly malignant central rapidly growing tumor from bronchial endocrine
dense secretory granules that are also seen increased in bronchial carcinoid tumors (neuroendocrine)
rough, little cytoplasm, nuclei = oat grains
metastasis usually present at dx
lung cancer: large cell anaplastic carcinoma
types
lesion location
cell characteristics
prognosis
squamous or adenocarcinoma
lesions are central or peripheral
large cells with nuclear pleomorphism and frequent giant cell forms
poor prognosis and frequently widely disseminated at dx
lung cancer: metastases
brain
liver
heart
bone
adrenal/kidney
pleura
hilar and mediastinal lymph nodes
lung cancer: treatment
chemo
radiation
surgery
tyrosine kinase inhibitors
genetic bone disorders: achondroplasia
definition
causes
dwarfism caused by impaired cartilage proliferation in growth plate
mutation of gene for fibroblast growth factor receptor 3 (FGFR3) - sporadic
increased paternal age
genetic bone disorders: osteogenesis imperfecta
cause
signs
mutated gene for collagen #1
multiple fractures, blue sclera, hearing loss
genetic bone disorders: osteopetrosis
definition
causes
treatment
thick bones from defected osteoclasts
bone fractures, anemia, cranial nerve plasties
need bone marrow transplant
osteomyelitis
definition
causes
signs
diagnosis
treatment
infection of bone marrow and bone
staph aureus (90%), N. gonorrhocae (sexually active young adults), salmonella (sickle cell), pseudomonas (diabetic or IV drug user), mycobacterium tuberculosis (Potts disease)
bone pain with signs of infection (fever, leukocytosis), lytic focus (abscess) of bone on xray
dx by blood culture or bone aspiration
treat with antibiotics
osteoporosis
definition
causes
types
symptoms
diagnosis
treatment
reduced bone mass
genetic, diet, decreased estrogen, lack of exercise
primary and secondary
bone pain, fractures in weight bearing areas (vertebrae, hip, distal radius)
DEXA scan, lab test PTH
treat with exercise, vitamin D calcium, biphosphonates (Boniva, induce apoptosis of osteoclasts), SERM (selective estrogen receptor modulator)
RIckets
definition
signs
low vitamin D in children under 10
bowlegs, flawed teeth, pigeon breast deformity
osteomalacia
definition
cause
symptoms
treatment
activation
low vitamin D in adults
back pain, muscle weakness, fractures
treat with vitamin D and underlying cause
softening of bone due to inadequate mineralization of osteoid
activation: 25-hydroxylationn by liver —> 2-alpha-hydroxylation by kidney
Paget’s disease
definition
age, cause
phases
symptoms
treatment
imbalance between osteoclasts and osetoblasts function
late adulthood (>60), idiopathic
3 phases: destructive, mixed, osteosclerotic
bone pain (micro-fx), inc. hate size, hearing loss, lion-like face, isolated elevated alkaline phosphatase
treat with calcitonin and bisphosphonates - goal is to inhibit osteoclasts
compartment syndrome
definition
pathogenesis
increased pressure in a muscle compartment of arm or leg
swelling or bleeding within a compartment —> fascia does not stretch = increased pressure on capillaries, nerves, and muscles
crush injury
acute compartment syndrome
definition
causes
symptoms
treatment
complication of injury, radius/ulna or tib/fib fx causes significant bleeding in 1 or more compartments
badly bruised muscle, crush injury, sports, MVA, tight casts,
pain, tingling/burning, far gone if numbness and paralysis, reperfusion swelling possible
treat with emergency surgery, stabilize first with IV meds, fasciotomy, skin graft after if needed
chronic compartment syndrome
definition
area
symptoms
treatment
pain or cramping with exercise, subsides when activity ends
in leg
numbness, difficulty moving foot, visible muscle bulging
treat with PT, orthotics, anti-inflammatories, fasciotomy (elective surgery)
bone tumors: benign versus malignant
benign (not common): osteoma (genetic), chondroma, giant cell tumor
malignant (common): osteosarcoma, chondrosarcoma, Ewing’s sarcoma
often invade long bone and mimic osteomyelitis, lytic tumor with onion skin appearance
bone tumors: treatment
radiation, chemo, surgery
bone tumors: chondrosarcoma
area
prognosis
treatment
cartilage, pelvis
5 years with surgery
chemo
bone tumors: osteosarcoma
cells involved
risks
area
test results
treatment
osetoblasts (bone forming)
men 10-20 years old, Paget’s disease = increased risk
60% by knee
xray shows elevation of periosteum (Codman triangle or sunburst growth pattern)
treat with surgery and chemo
bone tumors: Ewing sarcoma
who is affected
sign
children under 20 years old
blue due to sheets of primitive cells which store a large amount of glycogen
osetoarthritis
aka
definition
risk
cause
area
symptom
types
treatment
degenerative joint disease or “wear and tear disease”
most common joint disease, joint space narrowing with osteophytes and floating cartilage
60+
trauma, obesity
weight bearing joints and small joints of the hands and feet
morning stiffness that gets worse
primary and secondary
treat with NSAIDs, cox 2 inhibitors, surgery
SHORT ANSWER: rheumatoid arthritis
definition
pathogenesis
chronic systemic disease of unknown etiology with symmetric inflammation of joints
- chronic inflammation by autoantibodies and thickening of synovial membrane which leads to pannus formation (inflammatory granulation tissue)
- increasing degrees of inflammation destroys cartilage and ankylosis (fusion) of joint
- autoimmune, IgM in blood (rheumatoid factor), women, HLA-DR4 gene
rheumatoid arthritis
symptoms
diagnosis
morning stiffness resolved with activity, PIP joints, wrist, elbow, ankle, knee, rheumatoid nodules present
joint space narrowing, loss of cartilage, osteopenia on xray
lab IgM against FC portion of IgG, neutrophils, high protein in synovial fluid
rheumatoid arthritis: treatments
DMARD (disease-modifying antirheumatic drugs)
shown to alter the disease course and improve radiographic outcomes
rheumatoid arthritis: treatments
methotrexate (MTX)
now considered the first line DMARD agent for most patients with RA. the anti-inflammatory effects of MTX in RA appear to be related at least in part to interruption of adenosine and possible effects on TNF pathways (tumor necrosis factor alpha; mediate joint damage)
rheumatoid arthritis: treatments
Enbrel (Ethanercept)
binds TNF in the circulation and in the joint, preventing interaction with cell surface TNF receptors thereby reducing TNF activity
rheumatoid arthritis: treatments
Remicade (Infliximab)
mono-therapy or in combo with MTX, binds to TNF in joint and in circulation, preventing its interaction with TNF receptors on surface of inflammatory cells, and eventually clearing TNF from the circulation
rheumatoid arthritis: treatments
Humira (adalimumab)
fully human anti-TNF monoclonal antibody with high specificity for TNF
rheumatoid arthritis: treatments
Orencia (abatacept)
class of agents known as T-cell costimulatory blockers (antigen-presenting cells and T lymphocytes)
rheumatoid arthritis: treatments
Rituxan (rituximab)
monoclonal antibody that binds to CD20 molecule (marker) on B cell surface leading to removal of B cells from circulation
rheumatoid arthritis: treatments
depletion of B cells
has reduced signs and symptoms and slowed radiographic progress
rheumatoid arthritis: treatments
Anakinra (Kineret)
human recombinant IL-1 receptor antagonist (hu rIL-1 ra) is approved for RA, used alone or in combo with DMARDs other than TNF blocker
JAK-STAT pathway
sends signals involving bone marrow and immune system activation
rheumatoid arthritis: treatments
Xeljanz (tofacitinib)
small new molecule that enters a cell and binds to ATP binding site on enzyme Janus Kinase (JAK), which prevents JAK from activating STAT and sending important messages to the nucleus of immune system cells
rheumatoid arthritis: treatments
kevzara (sarilumab)
injectable interleukin-6 (IL) receptor blocker. it stops the IL-6 signal mediated pathways. IL-6 mediated signaling through these receptors. IL-6 is a pro-inflammatory cytokine produced by a variety of cell types including T and B cells, lymphocytes, monocytes, fibroblasts
scoliosis
definition
who does it affect
signs
abnormal lateral curvature of the spine; large curves cause pronounced disabilities
4% of people, idiopathic in adolescent girls
one shoulder higher than the other and tilted pelvis
gout
definition
diagnosis
treatment for acute
treatment for chronic
colchicine
probalan
deposit of uric acid crystals (monosodium urate) in small joints of hands and feet causing inflammation
joint fluid test, urate crystals, blood uric acid levels
NSAIDS, corticosteroid (prednisone)
block uric acid production = xanthine oxidase inhibitor including allopurinol (zyloprim, aloprim) and febuxostat (uloric)
pain relieves by preventing polymerization of tubulin
improves kidneys abilities to remove uric acid
gout: primary
pathogenesis
most common, idiopathic pathogenesis for hyperuricemia
gout: secondary
secondary to…
signs
leukemia, Lesch-Nyhan syndrome
presents with mental retardation and self-mutilation, renal insufficiency
diagnosis of muscle disease
toxin, drug, autoimmune, destruction characterized by release of CK
dermatomyositis
definition
symptoms
lab findings
treatment
inflammatory disorder of skin and skeletal muscle, idiopathic
rash on upper eyelids, red papules on elbows, knuckles, knees
increased CK and anti-Jo-1 antibody
treat with corticosteroid
polymyositis
definition
symptoms
inflammatory disorder of skeletal muscle
proximal muscle weakness, endomysial inflammation (CD8+ T cells) with necrotic muscle fibers
types of open soft injuries
amputation
avulsion
crush injury
puncture
abrasion
laceration
myasthenia gravis: pathogenesis
autoantibodies against acetylcholine receptors
hypersensitivity-II
antibodies block neuron transmission, antibodies synthesized by thymus gland
myasthenia gravis: treatment
anti-cholinerterase to prevent acetylcholine breakdown at NMJ, blood transfusion, immunosuppressive drug, surgery on thymus gland
myasthenia gravis: diagnosis
tensilon test, presence of autoantibodies
myasthenia gravis: symptoms
muscular weakness (especially extraocular and facial muscles), ptosis, easily fatigues, inability to chew
Lambert-Eaton syndrome
pathogenesis
treatment
secondary to small cell carcinoma, antibodies against presynaptic calcium channel of NMJ, impaired acetylcholine release
treat the cancer
muscular dystrophy
cause
symptom
sign
genetic defect (autosomal or sex linked), heterogeneous
progressive muscle wasting
elevated CK level
duchenne muscular dystrophy
who does it affect
pathogenesis
mild form
most common, sex-linked - boys, death in late teens of early 20s
deficiency of dystrophin, holds together other structural proteins, degeneration of skeletal muscle cells
Becker’s dystophy - mutated dystrophin, better prognosis, death around 40
botulism
cause
pathogenesis
symptom
treatment
food poisoning from old canned food
toxin binds to acetylcholine nerve endings at presynaptic terminal and blocks release
muscle paralysis
treat with anti-toxins but must be administered quickly
congenital skin disorder: birth mark or nevus greater than 1 cm
definition
benign neoplasm of melanocytes
congenital skin disorder: melasma
who does it affect
signs
treatment
women who are pregnant or taking oral contraceptives or HRT, worsened by sun
well circumscribed, hyperpigmented patches (cheek and forehead) (“mask of pregnancy”)
treat with sunscreen
congenital skin disorder: ichthyosis congenita (fish skin)
definition
heterogeneous group of diseases with striking thickening of the stratum corneum
congenital skin disorder: albinism
definition
physiological cause
cure
congenital lack of pigmentation
enzyme defect impairs melanin production from tyrosine (usually) and phenylalanine
no cure
congenital skin disorder: vitiligo
definition
treatment
localized loss of skin pigmentation due to autoimmune destruction of melanocytes
treat with cortisol
burns: 3 factors for burn extent
temperature of agent
concentration of heat
duration of contact
burns: Jackson’s theory
3 zones
zone of coagulation: nearest the heat source, suffers the most damage (clotted blood and thrombosed blood vessels)
zone of stasis: surrounding zone of coagulation, decreased blood flow
zone of hypermia: area around burn with increased blood flow
burns: electrical burn
wound
resistance
contact
entrance/exit wound
dry skin= inc. resistance (bone, muscle)
wet skin= decreased resistance (vessels, nerves)
inc. contact = inc. injury
dec. point of contact = inc. concentrated energy = inc. injury
burns: chemical burns
acid and base
acid: thick, insoluble mass, coagulation necrosis (limit burn damage)
alkalis (base): destroy cell membrane through liquefaction necrosis (deeper tissue penetration and burn)
burns: classification
degrees
rule of palms/nines
1st degree: superficial, red, painful, dry (no blisters), erythema, swelling
2nd degree: partial thickness, red or white, painful, wet (blisters), involving epidermis
3rd degree: leathery skin (charred, white, dark brown), minimal pain, dry, full thickness with massive necrosis of epidermis and parts of dermis
rule of nines: large area
ant/post head - 9%, ant/post trunk - 36%, ant/post UE - 18%, perineum - 1%, ant/post LE - 36%
rule of palms: irregular or splash burns, <10% BSA, hand = 1% BSA
bacterial infections: impetigo
definition
who does it affect
infectious bacteria
superficial infection, macules to pustules in face, honeycomb scab
staph. aureus or strep pyogenes
children
bacterial infection: carbuncle
definition
treatment
red, swollen, painful cluster of boils (infected hair follicle with pus) connected under skin
treat with antibiotics and drainage
bacterial infection: staph. scalded skin syndrome
definition
infectious bacteria
treatment
sloughing of skin with erythematous rash and fever, significant skin loss
staph. aureus
treat with oral or cream antibiotic
bacterial infection: acne
definition
pathogenesis
treatment
chronic inflammation of hair follicles
propiobacterium acnes produces lipases that break down sebum, releasing pro-inflammatory fatty acids, pustule or nodule formation
treat with benzoyl peroxide (antimicrobial) and vitamin A derivatives (Accutane)
viral infections
mesels
chicken pox
herpes zoster (vesicles)
human papillomavirus (HPV, wart)
psoriasis
definition
signs
classification
treatment
papules and plaque with silvery scaling
lesions involve extensors surfaces of elbows and knees, scalp and sacrum, most often non-pruritic (no itch), psoriatic arthritis (RA like lesions on fingers)
HLA-C, may be autoimmune
treat with corticosteroids, MTX, or other immuno-modulators
scleroderma
definition
who does it affect
classification
symptoms and signs
treatment
vasculopathy and excessive collagen deposition in skin and internal organs (lung, heart, GI, kidney)
4x more likely in women, familial incidence
HLA-DQB1 and autoantibodies = autoimmune
skin edema then induration (hardening), inc. collagen fibers in dermis, thinning of epidermis, atrophy of dermal appendages, hyalinization and destruction of arterioles, and variable mononuclear infiltrates (T cells)
treat with anti-inflammatories, immunosuppressants, anti-fibrotic agents
skin cancer: basal cell carcinoma
definition
prognosis
risks
area
sign
treatment
most common malignant, basal cells
good prognosis
UVB induced DNA damage and prolonged exposure to sunlight, albinism, xeroderma pigmentosum
upper lip
elevated nodule with central dome shapes, “pink-pearl like papule”
treat with surgery, metastasis is rare
skin cancer: squamous cell carcinoma
definition
sign
risks
treatment
malignant proliferation of squamous cells
keratin pearls, bleeds, small, red, firm, ulcerating nodule on face
UVB induced DNA damage and prolonged exposure to sunlight, albinism and xeroderma pigmentosum, arsenic exposure
treat with surgery, metastasis is rare
malignant melanoma
definition
risks
malignant neoplasm of melanocytes (most common cause of death from skin cancer)
UVB DNA damage, sunlight, albinism, xeroderma pigmentosum
malignant melanoma: radial growth
definition
metastasis
discolored macule, horizontal growth of atypical cells in epidermis, does NOT metastasize
malignant melanoma: vertical growth
definition
metastasis
nodular, into dermis
does metastasize and probability is directly proportional to depth of invasion
malignant melanoma: lab finding and prognosis
presence of S-100 tumor marker
metastatic and modular = prognosis
malignant melanoma: treatment
surgical excision and sentinel lymph node biopsy for stage 1B and higher, chemo, consider IL-2 for metastatic
malignant melanoma: abcs
asymmetry of pigmented lesion
borders are irregular
color varies from dark brown to dark black to red
diameter of lesion, worry when it is bigger than 6 mm
hair diseases: hirsutism
cause
definition
signs
treatment
hormonal or idiopathic
soft, fine, unpigmented hair into coarse and pigmented hair by androgen
inc. bulk, dec. voice from inc. sensitivity to high androgen and low estrogen
treat with oral contraceptives
hair diseases: alopecia
who does if affect
cause
treatment
males
from increased dihydrotestosterone (DHT)
treat with finasteride
stomatitis
definition
causes
who does it affect
inflammation of oral cavity
alcohol (moonshine, whiskey), tobacco, stress; infectious agents:
herpes virus (HSV-1) - vesicles in oral mucosa with shallow, painful, red ulcers, virus remains dormant in ganglia of trigeminal nerve, stress/hormones reactivate, lead to vesicles on the lips (cold sores)
oral candidiasis (thrush) - local white membranous lesion caused by Candida albicans
infants, children, immuno-compromised, diabetes
oral cancer
type
cause
area
leukoplakia
erythroplakia
squamous cell carcinoma
tobacco
floor of mouth
white plaque which cannot be scraped away
red plaque, vascularized
atresia
definition
with fistula
sign
treatment
esophagus ends in blind pouch
tapers at proximal end
fluids come out via nose, mouth causing respiratory distress
treat with surgery
achalasia
definition
pathogenesis
cause
inability to relax the lower esophageal sphincter (LES)
loss of ganglion cells —> progressive dilation of esophagus
South American parasite Trypanosoma cruzi infection in Chagas disease
hiatal hernia
definition
protrusion of abdominal contents through abdominal wall to thoracic cavity
GERD
definition
symptom
cause
reflux of gastric juice into esophagus, incompetent LES and hiatal hernia
burning relieved by antacids
excessive alcohol, tobacco
Barrett’s esopahgus
pathogenesis
treatment
late complication of GERD, lower portion, squamous cell lining replaced by columnar epithelium, glandular metaplasia due to GERD
treat with antacids, H-2 blocker, acid pump reducer drugs
acute gastritis
definition
cause
treatment
acidic damage to stomach, short duration
NSAIDs, heavy alcohol, burn patients, increase intracranial pressure, increased stimulation of vagus nerve
treat with H-2 blocker or acid pump reducer
chronic gastritis
definition
chronic mucosal inflammation and mucosal gland atrophy
chronic gastritis: type A
classification
cause
autoimmune = anitbodies to parietal cells, lack of gastric acid secretion
thyroiditis/Addison’s disease, aging, gastric ulcer, gastric carcinoma
chronic gastritis: type B
cause
pathogenesis
treatment
helicobacter pylori bacteria and common form
aid in development of adenocarcinoma of stomach and gastric lymphoma
treat with triple antibiotic to treat H pylori
peptic ulcer
area
cause
symptom
complications
lesser curvature
H pylori (95%)
not dependent on increased gastric acid secretion
epigastric pain resolves with meals
complications: hemorrhage, hematemesis, melena, iron deficiency anemia
gastric carcinoma
definition
risks
malignant proliferation of surface epithelial cells
50+ years old, men, blood group A, japan, finland, iceland, decreased in US
gastric carcinoma: intestinal
definition
area
more common
large, irregular ulcer with heaped up margins
lesser curvature of antrum
gastric carcinoma: diffuse
definition
treatment
signet ring cells that diffusely infiltrate gastric wall (leather bottle stomach)
treat with surgical resection with or without chemo
hirschsprungs disease
definition
cause
symptoms
treatment
megacolon proximal to rectal narrowing
congenital failure of ganglion cells
failure to pass meconium, chronic constipation, acute enterocolitis, rupture of colon
treat with resection of involved bowel
diverticulosis
definition
area
risks
symptoms
outpouching of colonic mucosa through weak area in wall
sigmoid, multiple
older persons, constipation and low fiber
asymptomatic
diverticulitis
definition
signs
treatment
fecal matter trapped in pouches and incite inflammation
inflammation, perforation, bright red rectal bleeding
treatment with resection of involved bowel
hemorrhoids
definition
cause
symptoms
treatment
swollen veins in anus or rectum
idiopathic
bright red bleeding and painful stool
treat with stool softener, high fiber, rectal ointment
angiodysplasia
definition
who does it affect
localized vascular lesion in colon and unexplained bleeding in old people
ischemic bowel disease
definiton
cause
decreased blood flow in intestine due to atherosclerotic occlusion of at least 2 of the major mesenteric vessels
SHORT ANSWER
inflammatory bowel disorder: pathogenesis of Crohn’s disease
inflammation of the distal ileum (s. intestine) which affects the right side of abdomen
Crohn’s disease
symptoms and signs
scans
treatment
patchy, inflammation may skip areas
ulceration of mucosal layer and scarring of the s. intestine
string signs on barium xray (granuloma, fistula, stenosis)
treat with cortisol, humira, remicade (DMARDs)
SHORT ANSWER
inflammatory bowel disorder: pathogenesis of ulcerative colitis
recurrent chronic inflammation of large intestine and affects left side
ulcerative colitis
signs and symptoms
treatment
risks
involves whole area, megacolon and pseudopolyps, deep linear ulceration and mucosal layer is red
treat with anti-diarrheals, cortisol, immunosuppressants
higher risk of colorectal adenocarcinoma
large intestinal infection - Shigella, Norwalk virus
AKA
cruise ship fever
appendicitis
definition
who does it affect
symptoms
treatment
inflammation of appendix
older children/young adults
nausea, vomiting, low-grade fever, rebound tenderness, pain in McBurney’s point (RLQ)
treat with surgery
intestinal obstructions: adhesions
tumor
intestinal obstructions: volvulus
twisting of a portion of GI tract about itself
intestinal obstructions: intussusception
proximal segment of bowel forward into distal segment, pulled forward by peristalsis, caused by tumor
celiac sprue
classification
tests
risk
symptoms
hypersensitivity to dietary grain, HLA-B8 and HLA-DW3, antibodies against gliaden
antibody test, biopsy, presence IgA and anti-tissue transglutaminase
T1D
steatorrhea (fat in stool), chronic diarrhea, bloating
colon cancer polyps: hyperplastic
anywhere along length of bowel and no significance
colon cancer polyps: inflammatory
granulation tissue, caused by inflammation that occurs with IBD
colon cancer polyps: hamartomatus - juvenile
children, s. and l. bowel, most commonly rectum
more = inc. risk of progression to carcinoma
colon cancer polyps: hamartomatus - Peutz-Jeghers
autosomal dominant, s. and l. bowel, GI tract, hands, mouth, lips, genitals
inc. risk of colorectal, breast, gynecologic cancer
colon cancer polyps: adenomatous - tubular adenoma
malignancy potential
most common, small and peduncular
slight increased risk of developing malignancy, but malignant potential is low
colon cancer polyps: adenomatous - tubulovillous adenoma
malignancy potential
5-10%, similar to tubular
surface covered with finger-like projections
intermediate malignancy potential
colon cancer polyps: adenomatous - villous adenoma
malignancy potential
1%, somewhat flattened surface
highest associated malignant potential with 30% becoming malignant
colon cancer
tissues affected
commonality among cancers
age
genetic cause
signs
testing
goal
area of colon
colonic or rectal mucosa
3rd most common cancer site
peak at 60-70 years old
p53 gene, mismatch repair genes in DNA
de novo at a relatively young age, right sided
colonoscopy beginning at 50, fecal test, blood test
goal is to remove polyps before carcinoma develops
entire colon
left sided colon cancer
“napkin-ring” lesion, LLQ pain, blood streaked stool
right sided colon cancer
raised lesion, iron deficiency anemia, vague pain
colon cancer: staging
T - depth of invasion; tumors limited to mucosa
N - spread to regional lymph nodes
M - distant spread; most commonly involves liver
colon cancer: treatment
chemo and surgery
jaundice
definition
three types
yellow discoloration of skin, sclarae, tissues by hyperbilirubinemia
pre-hepatic (unconjugated), hepatic (mixed), post-hepatic (conjugated)
hepatitis A
type of virus
method of transmission
antigen-antibody test results
complications
prevention of disease after exposure
immunization
RNA
fecal-oral, contaminated food or water
anti-HAV
no carriers or chronic liver disease
gamma globulin
yes
hepatitis B
type of virus
method of transmission
antigen-antibody test results
complications
prevention of disease after exposure
immunization
particles
DNA
blood or body fluids
HbsAg + (infected) and lack anti-HBs, lack HbsAg (immune) and have anti-HBs
10% become chronic carriers and may develop chronic liver disease
Hep B immunoglobulin
yes
dane particles: HBsAg (surface antigen), HBcAg (core antigen), HBeAg (extra antigen)
hepatitis C
type of virus
method of transmission
antigen-antibody test results
complications
prevention of disease after exposure
immunization
RNA
blood or body fluids
HCV RNA (active infection) and anti-HCV denotes infection
75% become carriers and many develop chronic liver disease
new drugs
no
hepatitis D
who does it infect
cause
pathogenesis
only infects those with acute or chronic HBV infection
needle sharing
delta virus cannot produce its own coat and uses HBsAg produced by HBV
hepatitis E
transmission
prevention
immunization
oral fecal
no prevention after exposure
no immunization
hepatitis G
does not lead to chronic hepatitis and no known relationship with hepatocellular carcinoma
alcoholic liver disease: alcoholic fatty liver
definition
treatment
accumulation of fat in hepatocytes
treat with abistinence
alcoholic liver disease: alcoholic hepatitis
definition
signs
acetaldehyde mediates damage, swelling of hepatocytes with formation of Mallory vodies
necrosis, hepatomegaly, inc. liver enzymes
alcoholic liver disease: alcoholic cirrhosis
most advanced, fatty liver may become brown, shrunken, irregular nodularity with hobnail appearance and fibrosis of liver with loss of hepatic architecture
cirrhosis
definition
classification
risks
causes
disorganization of hepatic architecture with scarring and nodule formation
micro-, macro-, or mixed macro-micronodules forms
inc. risk of hepatocellular carcinoma
prolonged alcohol intake, drugs, chemical agents
viral hepatitis, biliary obstruction, and hemachromotosis
Wilson’s disrease
biliary cirrhosis: primary
classification
risks
cause
autoimmune
female, 40+
unknown cause, anti-mitochondrial antibody present
biliary cirrhosis: secondary
cause
duct obstruction by gallstone, yellow green liver
hemochromatosis
pathogenesis
classification
excess iron —> deposit in tissue and organ damage
autosomal recessive (Hfe, chr. 6)
hemochromatosis: primary
cause
symptoms
lab test finding
defect in Fe absorption
triad of cirrhosis, diabetes, inc. skin pigmentation
inc. serum iron, reduction ion total iron binding capacity
hemochromatosis: secondary
cause
treatment
chronic transfusions, ineffective erythropoeisis and multiple transfusions (thalassemia major)
treat with weekly phlebotomy and low iron diet
Wilson’s disease
definition
symptoms
treatment
autosomal recessive of copper metabolism, deposits in tissues, free radicals lead to tissue damage
anemia, dementia, Kayser-Fleischer ring, copper in urine
treat with copper chelater, low copper diet
portal hypertension
definition
portal vein obstruction —> varices in esophagus and developing ascites
portal hypertension: pre-hepatic
portal and splenic vein obstruction by thrombosis
portal hypertension: intrahepatic
intrahepatic vascular obstruction by cirrhosis or tumor
portal hypertension: post-hepatic
venous congestion in distal hepatic venous circulation or thrombolytic hepatic vein occlusion (Budd-Chiari syndrome)
Reye’s syndrome
pathogenesis
symptoms
rare childhood disease with small fat vacuoles in liver, after influenza or varicella, aspirin makes it worse
hypoglycemia, elevated liver enzymes, nausea, coma, death
primary sclerosing cholangitis
due to…?
symptoms
ulcerative colitis
inflammation, fibrosis (onion skin), biliary cirrhosis
cholelithiasis
definition
symptoms
risks
stones in gallbladder (cholesterol or pigment), usually mixed with cholesterol and calcium salts (seen on xray)
asymptomatic, may present with biliary colic
fat forty fair female febrile
acute cholecystitis
definition
symptoms
inflammation of gallbladder
pyogenic
nausea, vomiting, fever, leukocytosis, RUQ and epigastric pain
chronic cholecystitis
definition
treatment
thickening of gallbladder wall as a result of extensive fibrosis
treat with antibiotics and ERCP
benign liver tumors: hemangioma
definition
benign tumor of the liver
benign liver tumors: hepatocellular adenoma
cause
caused by oral contraceptives
malignant liver tumors: hepatocellular carcinoma
definition
cause
most common primary malignancy of liver
preexisting HBV, contamination of nuts and grains (aflatoxin B1, causes point mutations of p53)
malignant liver tumors: cholangrocellular carcinoma
where in the world
cause
tissue affected
far East, river fluke infection (rice fields), intrahepatic biliary epithelium
malignant liver tumors: angiosarcoma
definition
cause
rare malignant vascular tumor
PVC and arsenic exposure
63 year old man with left eyelid droopiness, shortness of breath over last 2 months, 40 year heavy smoker, ptosis and miosis of left eye, dry skin of left face. CXR shows irreg. mass in apex of left lung. need biopsy, prognosis not good
bronchogenic carcinoma
71 year old man with water retention. well hydrated, intake does not match output. shortness of breath, down 15 lbs over 3 months. 2.5 packs per day for 50 years. CXR shows central coin lesion. small round cells on biopsy
bronchogenic carcinoma
22 year old man in ER with severe chest pain and shortness of breath. Tall and thin. dec breath sounds, dec tactile fremitus, hyperresonance to percussion over right chest. normal ECG. CXR shows deep sulcus sign over right costophrenic angle and tracheal deviation. put on O2 and place chest tube
pneumothorax
2 month old male in ER by adoptive parents. fussy and cries with touch to the L arm, which is hypoactive. multiple fx, no bruising (no child abuse), blue sclerae
osteogenesis imperfecta
32 year old woman with intermittent double vision in afternoons and evenings. ptosis of both eyes that worsens when asked to keep eyelids open. symptoms improve after edrophonium administration. may have a thymoma
myasthenia gravis
15 year old boy in ER with tib/fib fx after a fall. broken several bones before, mother has bone disease, hearing loss, facial asymmetry, hepatosplenomegaly. labs show anemia and xrays show fx and erlenmeyer flask deformity
osteopetrosis
68 year old woman with aching LBP. feels she is getting shorter and slightly hunched forward. xray shows compression fx of L4, dec. bone mass
osteoporosis
74 year old with bone pain in L thigh, hearing loss over 6 months. labs show inc. serum alkaline phosphate with normal CA2+, phosporus, PTH. xray shows thickening and lucency of bone
Paget’s disease
5 year old boy with skeletak deformities. short pale boy with sternal protrusion, thinning of occipital and parietal bones with square head, rachitic rosary. well nourished and no prior medical issues. suggest vitamins and exposure to sunlight
Rickets and osteomalacia
19 year old man in ER with R lower thigh pain after fall. xray shows fx in a stalk of bone growth protruding from end of femur. autosomal dominant. biopsy to show endochondral ossification over medullary cavity, no atypical cells
osteochondroma
13 year old boy with pain and swelling in left knee. no trauma and no fever. labs show inc. serum alkaline phosphate, xray shows a mass with sunburst growth pattern and periosteal elevation by mass, aka codman triangle. will need chemo, sx, oncologist
osteosarcoma
11 year old boy in ER with painful swollen mass in right leg, no trauma. xray shows lytic tumor with onion skin appearance in medullary cavity of R femur. admit to oncology
Ewing sarcoma
44 year old woman with chronically swollen finger joints over 6 months. most severe in morning, but resolves in a few hours. swollen PIP and MCP joints of hands and subcutaneous nodules over both elbows. labs show IgM directed against Fc of IgG. refer to rheumo
RA
74byear old woman with stiffness and paon on both knees, worse later in day after walking. bilateral swollen knees with mild joint effusion and crepitus with flexion. bony nodules on DIP and PIP joints
osteoarthritis
45 year old obese man in ER with swollen, tender big toe on R foot. no trauma. lots of alcohol night before. aspirate of synovial fluid from metatarsophalangeal joint of R big toe demonstrates neutrophils along with needle shapes, negatively birefringent crystals. prescribe indomethacin
gout
6 year old boy with severe muscle weakness, esp. of thighs. maternal uncle died of muscle disease as a kid. enlarged calves and dec strength in proximal muscles of LE. uses arms to get up. Labs show inc. serum CK
Duchenne MD
28 year old man with generalized muscle stiffness. mother suffers from disease with similar symptoms. delayed relaxation of hand muscles after prolonged grip, weakness of distal muscles in limn. testicular atrophy and frontal baldness. prescribe phenytoin
myotonic dystrophy
55 year old woman with muscle weakness andrash. inc difficulty rising from chairs and climbing stairs over 3 months. malar rash on face. erythema on neck ans shoulders, periorbital edema and purplish eyelids. hands has scaly patches over dorsum of proximal interphalangeal abd metacarpophalangeal joints bilaterally. look at serum and aldolase, muscle biopsy
myositides (polymyositis and dermatomyositis)
24 year old african american with irreg depigmented patches on hands and mouth. hashimotos. biospy shows no melanin pigment and absence of melanocytes. recommend sunscreen, inc risk of skin cancer
albinism and vitiligo
10 year old boy with pruritic, vesicular rash. was in woods yesterday during summer camp. topical corticosteroid cream and avoid certain plants
allergic contact dermatitis
1 year old female with rash. 3 episodes over 6 months. itchy, red, patchy, on face, wrists, elbows, knees. father has seasonal allergies and asthma. crusty scaly erythematous plaques on skin. topical corticosteroids and moisturizer
atopic dermatitis (eczema)
34 year old woman with chronic skin rash of well-demarcated coral-colored plaques with silvery scales over scalp, elbows, and knees. removing scales results in pinpoint bleeding. arthritic symptoms. biopsy shows acanthosis with Munro microabscesses, parakeratosis, and elongation of rete ridges
psoriasis
67 year old man with hard, red, ulcerated nodule on back of L hand. biopsy shows cellular atypia and anaplasia in epidermis and dermis, hyperkeratosis with keratin pearls. has cancer but simple excision will cure
squamous cell carcinoma of skin
62 year old woman with raised ulcerated lesion on R cheek. used to be a gardener and does as a hobby now. pearly, ulcerated papule with overlying telangiectasias. biopsy shows clusters of cells with dark blue nuclei surrounded by palisading basal cells. cured with sx excision
basal cell carcinoma
48 year old man with irreg. shaped lesion on extensor surface of L forearm. changed from light brown to dark reddish purple and is more raised. poorly defined, hyperpigmented, multicolored nodule. L axillary lymphadenopathy. biopsy shows nests of atypical pigmented cells in dermis. refer to oncology
malignant melanoma
newborn boy choking and coughing up breast milk on first attempt to feed. excessive salivation and is slightly blue. look for fluid and electrolyte imbalance and gastric air bubble
tracheoesophageal fistula
45 year old man with 3 year hx of gastroesophageal reflux with inc heartburn and regurgitation. antacids and proton pump used to help. endoscopy shows orange gastric type epithelium extending upward from stomach into distal esophagus
Barrett esophagus
55 year old white man at Gi with difficulty keeping down both solids and liquids over last several months. regurgitated small amounts of undigested food after almost every meal for three weeks. substernal pain even hours after small meals. barium esophagography shows bird beak at LES. botulinium toxin can be injected for relief
achalasia
42 year old african american man with heartburn 30 mins after most meals, worse with lying down after eating. tx with baking soda with good results. no regurgitation or dysphagia. prescribe omeprazole (proton pump inhibitor)
GERD
56 year old man with dec ability to swallow solid foods. avoiding large meals and lost 30 lbs over 6 months. smoked two packs a day for 20 years and heavy alcohol use. pain in throat when swallowing and coughing up small amounts of blood sometimes. cervical lymphadenopathy and hepatomegaly, hoarse voice
esophageal carcinoma
66 year old woman in ER with several bouts of bloody vomit. hx shows epigastric pain. osteoarthritis, high dose motrin daily
acute and chronic gastritis
65 year old man with epigastric pain after meals. hx shows heavy smoker and lost 10 lbs in 4 months due to dec appetite connected with pain with meals. no frank blood in stool, but has been darker. upper endoscopy and proton pump inhibitor
peptic ulcer disease
54 year old japanese american man with gnawing epigastric pain. lost 20 lbs over 2 months and been vomiting after meals. not relieved by OTC antacids. supracalvicular lymph node swelling and darkened, thickened skin in flexural area of arms and legs. upper endoscopy and biopsy
gastric carcinoma
25 year old woman with intermittent bouts of diarrhea and RLQ pain not associated with meals. constipated for several days. temp of 100, several oral ulcers, palpable RLQ mass. episodes of migrating joint pain and periodic burning sensation in eyes with blurred vision, but eye exam is normal. perianal region is normal, but guaiac test is positive. upper GI series needed
Crohn disease
23 year old Irish immigrant with diarrhea with 4 weeks. 10+ bowel movements a day, stool is soft, pale, large, floating, greasy, and foul smelling. lost 7 lbs over last month with inc appetite. loss of muscle mass and marked pallor, distended abdomen and hyperactive bowel sounds. serum shows antigliadin antibodies
Celiac Sprue
2 day old baby with Downs has failed to pass meconium, distended bowel consistent with obstruction. possible bowel perforation with peritonitis
Hirschsprung disease
65 year old man with mild aching LLQ pain. constipated, loose stools every other day of 5 days. vomited three times, low grade fever, palpable LLQ mass with tenderness, positive stool guaiac test. no free abdominal air. start antibiotics, need high fiber diet
diverticulosis and diverticulitis
32 year old woman with blood tinged diarrhea. four episodes of loose stool per dat with intermittent rectal bleeding over two weeks. frequently sits on toilet with urge to defecate but has no movement. LLQ tenderness and red blood visible on digital rectal exam. need sigmoidoscopy
ulcerative colitis
55 year old man with family hx of colon cancer for annual screening. fecal test is positive. sigmoidoscopy shows several pedunculated polyps are seen and biopsied
adenomatous polyps of the colon
55 year old white man with weakness and fatigue. intermittent rectal bleeding and loose stools, lost 15 lbs over two months, family hx of colon cancer. marked pallow and + stool guaiac test. Labs show iron deficiency anemia and elevated CEA levels. need colonoscopy and biopsy
colorectal adenocarcinoma
13 year old girl in ER with RLQ pain, nausea, vomiting. 12 hours ago has vague colicky periumbilical pain. low grade fever and tenderness in RLQ on palpation. labs show mild leukocytosis
acute appendicitis
50 year old man in ER with abdominal discomfort. dull RUQ ache for a week and low grade fever, malaise. urine become darker even with good hydration. yellow discoloration of skin and yellowing of whites of eyes. liver is tender and enlarged, appreciable ascites and asterixis. labs show conjugated and unconjugated bilirubin, inc urine bilirubin, and inc AST and ALT
jaundice
30 year old man with abdominal pain and dark urine. RUQ pain over 6 months. jaundice, hepatomegaly. not safely sexually active. IV drug use. serum shows inc ALT and AST
viral hepatitis
52 year old man with fatigue, bloating, loss of sex drive. come on slowly over last year and is a recovering alcoholic. painful swelling of bilateral breasts, ascites, scleral icterus, jaundice, several capillary telangiectasias on face, 3+ ankle edema bilaterally. start diuretic therapy and encourage to not drink alcohol
hepatic cirrhosis
48 year old woman with nausea and abdominal pain after a weekend of binge drinking. fairly regularly over 15 years. lost appetite, jaundiced, mild hepatomegaly with palpation. serum shows AST:ALT of 2.5 with leukocytosis. elevated serum ALP. liver biopsy to show macrovesicular fat, neutrophil infiltration with hepatic necrosis, Mallory bodies, and micronodular cirrhosis. recommend to stop drinking alcohol
alcoholic liver disease
55 year old man with weakness, fatiguability, weight loss, anorexia. thirstier and urinating more frequently than usual. scleral icterus, jaundice, hyperpigmentation of skin on trunk and extremities. serum shows elevated LFTs, iron, dec TIBC, transferrin sat of 85%, ferritin level of 1500 ug/L. need weekly phlebotomy and deferoxamine and family members should get tested.
hemochromatosis
8 year old boy with strange, jerky movements and drastic behavior and personality changes. more emotionally liable and out of context statements that are incomprehensible. brownish ring around sup and inf poles of cornea. tremor in both arms and hands. labs show dec serum ceruloplasmin and elevated copper, amino acids, and glycogen in urine. start on penicillamine to inc urinary excretion of chelated copper
Wilson disease
45 year old woman with spitting up red blood. recent hemorrhoids with red blood found on toilet paper after bowel movements. no sig. alcohol use, hx of hepatitis, or drug use. BP 100/5-. has pallor, ascites, marked splenomegaly. varices around navel and visible external rectal hemorrhoids. labs show normal LFTs but hypersplenism
portal hypertension
48 year old woman with gallstones with 1 day hx of nausea, vomiting, abdominal pain (severe, epigastric and RUQ). temp of 101.1, inspiratory arrest on RUQ palpation. serum shows inc ALP, leukocytosis, mild hyperbilirubinemia. start on antibiotics, will need sx
acute and chronic cholecystitis
60 year old native american woman with 3 month hx of severe RUQ pain. birthed five children, is post menopausal, taking HRT. pain exacerbated after she has greasy food. drinks a bit on weekends and feels abdominal pain shortly afterwards. mild tenderness in RUQ. need ultrasound
cholelithiasis (gallstones)
