Quiz 4 - Lung, Renal, Blood Flashcards
What is atelectasis?
inadequate expansion or collapse of the air spaces
What are the causes of atelectasis?
obstruction (aspiration), compression (pneumothorax), contraction (pleural fibrosis)
What is ARDS?
Acute respiratory distress syndrome
it is a progression of acute injury (either physical or chemical)
What causes the damage to the airway in ARDS?
the inflammatory response of neutrophils and fluid accumulation
What is COPD?
Chronic obstructive pulmonary disease
Examples include: emphysema, asthma, chronic bronchitis, bronchiectasis
What is the main cause of COPD?
smoking
What is emphysema?
type of COPD
destruction of elastic fibers in alveolar walls and permanent enlargement of the airspaces
What are the main causes of emphysema?
smoking, alpha-1 antitrypsin deficiency (imbalance of the protease and the anti-protease activity), and air pollution
What are some symptoms of emphysema?
barrel chested due to attempt at compensation and inability to fully exhale
dyspnea with cough and wheezing
What is pneumothorax?
air pockets into the pleural spaces causing collapse of the lungs
can result from ruptured bullous emphysema
What is chronic bronchitis?
type of COPD
persistent cough for 3+ months in 2 consecutive years
“blue bloaters”
Reid index = proportion of depth of mucosa that is composed of mucous glands…if >0.4, this suggests chronic bronchitis.
What are the main causes of chronic bronchitis?
smoking
air pollution
What is bronchiectasis?
obstruction of the bronchi
destruction of elastin and muscle in the bronchial walls
hypersecretion of mucus
What are some causes of bronchiectasis?
obstruction of the bronchi
persistent necrotizing infections (pneumonias)
microorganisms (staph, TB) that cause hypersecretion of mucus
cystic fibrosis
What are some symptoms of bronchiectasis?
persistent, foul-smelling cough
coughing up blood
hypoxemia
What is asthma and its symptoms?
Reactive airway disease narrowing of the airway hyperinflated lungs, thick mucus plugs in airways, smooth muscle hypertrophy shortness of breath with chest tightness wheezing precipitated by the vagal nerve occurs in younger populations
What is atopic vs. non-atopic asthma?
atopic - allergic reaction
non-atopic - not allergy related (may be familial) and the cause is unknown.
What is restrictive lung disease and what are some examples?
Diseases that make it difficult to inhale; results from pleural fibrosis or chest wall abnormalitis; gas exchange is imparied by thickened septal walls; air movement is impaired by an inability to inhale/expand the lungs.
Fibrosing lung diseases occupational lung diseases sarcoidosis hypersentivity peumonitis iatrogenic causes (chemotherapy, radiation exposure, contamination in iv solutions used by drug abusers)
What are fibrosing lung diseases?
type of restrictive lung disease
associated with collagen vascular diseases such as RA
can lead to left sided heart failure
What are occupational lung diseases?
type of restrictive lung disease
mineral-dust induced (coal workers)
silicosis, asbestosis (can lead to mesothelioma - cancer of the pleural)
What is sarcoidosis?
type restrictive lung disease abnormal connective tissue and reduced elastic properties multi-organ involvement immune-related disease lethal in ~10% of cases
What is hypersensitivity pneumonitis?
caused by mold or animal products (dander and feces)
What is hemoptosis?
coughing up blood
seen in most diseases that cause sever coughing
What is a pulmonary embolus?
clot that from deep veins in the leg that can cause occlusion of the main pulmonary artery
obstruction of blood flow can lead to right heart failure
What are some causes/predisposing factors of a pulmonary embolus?
prolonged bed rest, surgery, congestive heart failure, hypercoagulability state
What causes of pulmonary hypertension?
recurrent thromboemboli, heart disease, chronic lung disease
cor pulmonale - right ventricular failure as a result of pulmonary hypertension
What is a cause of diffuse alveolar hemorrhage?
autoimmune responses.
In vascular lung diseases, how is gas exchanged impaired?
obstructed or thickened vessels
alveolar hemorrhage
In obstructive lung diseases, is gas exchange through septal walls impaired?
NO
air movement is impaired by the inability to exhale.
T/F - For lung infections, the type of microorganism responsible is the same, independent of location.
False
Hospital acquired pulmonary infections…
are a nosocomial infection, usually in patients with severe underlying illness.
Walking or Community pneumonia symptoms include…
low-grade fever (acute onset with chills), productive cough, general malaise but still able to function at school or work
most are bacterial in nature
What is the cause of tuberculosis?
mycobacterium tuberculosis
acid fast mycobacterium associated with Ghon complexes.
What are some characteristics of Tb?
usually affects the lungs, but can affect other organs
flourishes in crowded, impoverished areas
non-contagious in periods of dormancy
problems with multi-drug abx resistance
forms necrotizing granulomas (caseating)
associated with HIV infections
Miliary Tb = organisms break off and spread throughout the body
Pulmonary fungal infections…
differ across the country and are usually seen in individuals that are immune-suppressed.
95% of primary lung cancers are…
carcinomas (as opposed to sarcomas, etc.)
What are the most common types of primary lung carcinomas?
adenocarcinoma
squamous cell carcinoma
What is the most aggressive type of lung carcinoma?
small cell (oat cell) carcinoma
Which risk factor puts a person at 55x the risk for developing lung cancer?
smoking
Lung cancers frequently spread to which site?
the brain
T/F - Carcinoma of the lungs is the 2nd leading cause of cancer death world-wide.
False - its THE leading cause of cancer death world wide.
What are the common triggers of asthma?
hyper-responsiveness to triggers fluid secretions increase infections allergens excessive exercise cold temperatures tobacco some drugs stress
Prevalence of asthma
F > M
children > adults
can progress to COPD in adults
What are some dental considerations for the asthmatic patient?
mouth breathers –> xerostomia
steroid inhalers –>irritate back of mouth
remind patients to bring inhaler and medicate before appointment.
Properties and uses of “relievers” for asthma medication
early treatments short-acting or rescuers rapid bronchodilators (within minutes) used for less severe cases of asthma (intermittent asthma) typically beta-2 agonists given at minimum doses and frequencies to avoid tolerance
albuterol
beta-2 agonist
“reliever”
rapid onset and 4-6 hr effects
MOA = directly relaxes airway smooth muscle and causes bronchodilation; also decreases microvascular leakage
salmeterol
beta-2 agonist
“reliever”
slower onset than albuterol, 12 hr effectiveness
MOA = directly relaxes airway smooth muscle and causes bronchodilation; also decreases microvascular leakage
Properties and uses of “controllers” for asthma.
taken regularly for long-term stable control
often have more side effects
inhaled corticosteroids are the drug of choice for moderate to severe asthma
often combined with beta-2 agonists
NOT for rescue
for routine use
fluticasone
inhaled steroid
MOA = anti-inflammatory effects reduce bronchial reactivity
side effects = nose bleeds; sores in nose, mouth, and tongue that don’t heal; increased oral infections (candidiasis)
[oral steroids such as prednisone are last resort]
Theophylline
methylxanthine drug (tablet or inhaler) MOA = phosphodiesterase inhibitor that increases cAMP and relaxes airway smooth muscle side effects = headaches, nausea, anxiety, sleep problems uses = add-on controller; monotherapy for mild asthma; combined with corticosteroids to reduce steroid doses and side effects.
Ipratropium
anti-muscarinic
MOA = reverses the contraction of smooth muscle and reduces mucous secretions from vagal activity
uses = back-up to beta-2 agonists
slow onset
Montelukast
“Singulair”
leukotriene modifier
MOA = block leukotriene-binding receptor
uses = for prophylaxis and for patients that have trouble with inhaled therpaies
Cromolyn
inhibits releases of inflammatory mediators such as histamine
for prophylactic use only
Omalizumab
monoclonal antibodies
inhibit IgE binding to mast cells preventing the release of inflammatory mediators
very expensive
only for severe non-responsive asthma
Tiotropium bromide
“Spireva”
Treatment of COPD
long-acting bronchodilator
Pharmacological treatments of COPD include
- tiotropium bromide - long-acting vasodilator
- salmeterol - longer acting beta-2 agonist
- Theophylline + glucocorticoids
Typically, responses are not as good as with asthma.
Oseltamivir
“Tamiflu”
MOA = prevents separation of virus particle from cell receptors –> stops viral spread; early treatment is essential
decreases duration by 1-2 days and reduces severity
effective for both influenza A & B.
Symptoms of allergic reactions include…
ithcing, hives, sneezing, wheezing, difficulty breathing
What causes an allergic reaction?
contact with allergens
release of histamine from mast cells and basophils leads to (1) contraction of pulmonary smooth muscles (2) dilate blood vessels –> lower blood pressure (3) increased permeability of vessels (4) increase gastric secretion
Pharmacologic treatment of allergic reaction includes…
anti-histamines (H1 blockers - these have anti-cholinergic/sedation side effects)
diphenhydramine
“Benadryl”
anti-histamine
chlorpheniramine
anti-histamine
epinephrine (for allergy)
potent reversal
vasoconstriction and reduces fluid in the lungs so breathing improves and swelling reduces.
Anti-smoking medications include…
nicotine replacement therapy
bupropion (Zyban; Wellbutrin) - antidepressants
varenicline (Chantix) - stimulates selective nicotine receptors to reduce craving
bupropion
“Zyban”
“Wellbutrin”
anti-depressants
anti-smoking
varenicline
“Chantix”
stimulates selective nicotine receptors to reduce craving
anti-smoking
What are the symptoms of urinary obstruction?
anuria, polyuria, bladder distention
can also be asymptomatic
What are the symptoms of renal/ureter stones?
renal colic, hematuria, pyelonephritis
can also be asymptomatic
What is pyelonephritis?
inflammation of the kidney, usually as the result of a urinary tract infection/bacterial infection.
What are the causes of pyelonephritis?
retrograde spread of cystitis
urinary obstruction; stenosis
diabetes
What are the symptoms/consequences of pyelonephritis?
flank pain, fever
10-20% develop chronic renal failure
kidney scarring
What are some properties of renal cell carcinomas?
comprise 80-90% of renal malignancies
more common in males >40yrs and in smokers
common in analgesic users (NSAIDs)
obesity is a risk factor
What are the symptoms of renal cell carcinomas?
often asymptomatic
hematuria, dull flank pain, fever, fatigue
clear cell type is the most common
Most likely site of renal cell carcinoma metastasis is…
lung or bones
What are some characteristics of Wilms tumor?
most common congenital malignant renal tumor
usually develops within the first 3 years of life
What are some contributing factors of bacterial cystitis?
stones, catheters, short female urethras, obstructions
usually caused by E. coli
What are some features of urothelial carcinomas?
males >50 yrs most common
associated with smoking and other carcinogens (dyes, paints, etc.)
most common urothelial malignancy
What are some features of prostatitis?
often cause by bacterial (cystitis)
enlarged and tender prostate can cause obstruction
most common in older men
What are some features of benign prostatic hypertrophy?
very common in older men (95% in men >75 yrs)
serious sequelae are less common
cause is unknown (possibly androgens or estrogens)
urinary obstruction is common
10% require surgery to relieve
What are some features of prostatic adenocarcinomas?
most common malignancy (except skin cancers) in older men (60% of men >80 yrs)
most often detected by rectal exams
many lesions are small and not clinically significant, but can be deadly in some patients
most common metastatic site is bone
What is prostate specific antigen?
abnormal levels are greater than 4-6mg/mL (usually higher with age)
rapidly increasing PSA = higher risk for cancer
more PSA bound to alpha-1-antichymotrypsin = greater risk for cancer
About how many american adults are on dialysis?
500,000
What are the main causes of Chronic Renal Disease?
diabetes, hypertension, chronic glomerulonephritis
What is the most common type of primary glomerulonephritis?
IgA nephropathy
triggered by a viral infection
What are common complications that chronic renal disease patients have?
platelet dysfunction (bleeding) gingival hyperplasia (due to immunosuppressant drugs following transplants) bone abnormalities (slow bone healing) premature bone loss (osteoporosis) infections (due to immunosuppression)
What are some dental considerations for patients with chronic renal disease?
uremia can result in halitosis
decreased bone density and cortical plate thickness
premature bone loss
gingival overgrowth
What are common symptoms of chronic renal disease?
heavy proteinuria
hematuria
inflammatory injury to the kidney (immune deposits in the glomeruli block normal blood filtration and reabsorption)
glomeruli scarring and damage functioning
Nephrotic syndrome
heavy proteinuria, edema, hyperlipidemia
Nephritic syndrome
associated with hypertension and kidney dysfunction
glomerulonephritis
inflammatory injury to the kidneys
immune deposits
glomerulosclerosis
chronic renal injury and renal scarring
Describe medullary sponge kidney.
enlarged, kidney stones, UTI, benign
Usual causes of hydronephrosis include…
blood clot, tumor, or pregnancy
Characteristics of kidney stones…
10% of US has kidney stones
Men > women
risk factors include anything that reduces hydration/body fluid
Treatments for small stones (< 1cm)
drink considerable amounts of water
dietary changes
OTC analgesics
Tamulosin (Flomax) - alpha-1 antagonist to relax the ureter muscle
Treatments of large stones
lithotripsy (shockwave treatment) to break up stones
surgical removal
opioid analgesics for pain
4 types of kidney stones
Calcium oxylate (due to excess in urine; 80%)
Struvite (10%, magnesium ammonium phosphate crystals, often associated with urinary infections; treatment is to acidify the urine)
Uric acid (associated with gout)
Cysteine
Treating most kidney stones…
alkalinize the urine (except for struvite stones)
Medications to treat kidney stones
hydrochlorothiazide - thiazide diuretic; reduces calcium in the urine
sodium bicarbonate - alkalinizes urine
allopurinol - reduces uric acid excretion; also used to gout
Features of urinary tract infections
F > M
often called by E. coli
Common treatments for UTIs
Trimethoprim-sulfamethoxazole
amoxicillin + clavulanic acid (resistant bacteria can be a problem)
ciprofloxacin (expensive)
Drugs commonly used for patients on hemodialysis
atenolol for HTN
captopril for HTN
Heparin to prevent clotting in blood passed through machine
Furosemide to reduce the amount of fluid that needs to be removed by dialysis
prophylactic antibiotics to decrease the rate of infection
Dental concerns for patients on hemodialysis
increased perio dx
increased oral infections due to weakened immune system
prophylactic abx for dental surgery
What is the difference between primary and secondary hemostasis?
primary - platelets
secondary - factors to cause adhesion of platelets (coagulation cascades, etc.)
Features of platelets
anucleate
life span = ~10 days
when circulating they don’t adhere; during stasis they start to adhere to each other
Features of primary hemostasis
initiated by injury
platelets adhere to subendothelium by interacting with vWF (which is a carrier for factor VIII)
release of granules to attract other platelets
aggregate with other platelets and form surface for coagulation cascade
Features of secondary hemostasis
coagulation cascade with most of the factors coming from the liver
series of activating enzymatic conversions that result in formation of thrombin and then fibrin
fibrin and platelet aggregates for a stable clot
Intrinsic pathway
factors = XII, XI, IX, VIII
measured by PTT clotting time
Extrinsic pathway
VII factors
measured by PT clotting time
Common factors in the coagulation cascade
Factors X, V, II and fibrin production
measured by both PT and PTT clotting times
Which factors of the coagulation cascade are Vit. K - dependent?
Factors II, VII, IX, and X
vitamin K is necessary for calcium binding sites and activation of the cascade.
What are some natural anti-coagulants?
protein C
antithrombin
these factors prevent the growth of a clot
What is fibrinolysis?
breaks down a clot and releases fibrin
How to assess hemostasis?
platelet count (part of the CBC) PTT (intrinsic and common pathway) PT (extrinsic and common pathway) prolonged bleeding time may indicate deficiency of certain factors or inhibition of certain factors
What are causes of thrombotic disorders?
Virchow’s triad: (1) endothelial injury, (2) abnormal blood flow, (3) hypercoagulability (acquired or inherited factors)
Acquired hypercoagulable sates include…
surgery/trauma limb immobilization bedridden long-distance air travel pregnancy oral contraceptives
What is factor V Leiden mutation
genetic thrombotic disorder
most common inherited thrombophilia (associated with increased fibrin formation)
increased clotting but not usually a major problem
found in 5% of adults (quite common)
What is Caisson Disease?
caused by air embolism blocking blood flow
T/F - Superficial venous thrombi in leg rarely embolize
True
emboli are usually from deep vein thrombosis and can dislodge, especially to the lung
What are some causes of bleeding disorders?
abnormal vessels
decreased platelets
platelet dysfunction
abnormal clotting factors
Features of platelet-type bleeding
mucocutaneous bleeding (petechiae on mucosal surfaces) causes - thrombocytopenia, von Willebrand disease (mutated VIII-related carrier protein)
What are some causes of thrombocytopenia?
decreased bone marrow production of platelets
hemodilution due to multiple transfusions
immune reaction due to platelet autoantibodies directed at platelet surface proteins
T/F - platelet counts below 10,000-20,000 generally do not result in spontaneous bleeding.
FALSE
anti-platelet drugs like aspirin will also increase bleeding tendency.
Thrombocytopenia purpura include…
fever
renal failure
transient neurological deficits
microangiopathetic hemolytic anemia
Features of von Willebrand disease
most common inherited blood-clotting disorder
altered vWF does not bind properly to Factor VIII and interferes with platelet adhesion to collagen
Features of Hemophilia A and B
A - deficient factor VIII; B - deficient XI
more likely in males less than 25 yrs
X-linked trait
prolonged PTT and PT times
Examples of acquired bleeding disorders
liver disease
vit. K deficiency (usually due to malabsorption of fat; increases both PT and PTT times
What is disseminated intravascular coagulation (DIC)?
generalized secondary activation of clotting due to disseminated factors such as toxins (rattle snake venom), inflammation, cancers, etc.
can cause organ ischemia because of increased clotting as well as bleeding due to increased activation of fibrolysis.
What are some things included in a CBC?
complete blood count
red and white blood cell counts
platelet counts
Factors that alter the CBC…
iron deficiency medications alcohol infections gender pregnancy
Importances of WBC
leukocyte count includes all nucleated hematopoietic cells (except of RBCs)
used to evaluate infections, drug effects, radiation therapy, etc.
Normal WBC
3500 - 10,000 cells/uL
normal count for neutrophils
1800 - 6700 cells/uL
55% of WBCs
normal count for eosinophils
0 - 570 cells/uL
3% of WBCs
normal count for lymphocytes
1400 - 3900 cells/uL
35% of WBCs
Leukocytosis
WBC > 10,000 combined
causes - chronic infection or inflammation, exercise, some leukemias
Gaisbock syndrome
relative polycythemia (increased RBCs) due to decreased plasma volume (the # of RBCs stays the same)
Polycythemia vera
genetic issue that causes increased RBCs
Microcytic anemia
smaller (<80 fl)
usually due to iron deficiency (b/c of hemorrhaging
often have glossitis
other causes include blood loss, poor diet, and lead poisoning
Macrocytic anemia
larger (>100 fl)
causes include liver disease, drugs
vitamin B12 or folate deficiency (associated with pregnancy) - often associated with neurological findings (paresthesia, weakness, dementia)
pernicious anemia or other autoimmune diseases.
Normocytic anemia
caused by aplastic anemia, blood loss, anemia of chronic diseases.
Sickle-cell anemia
globin of the molecule is abnormal due to an amino acid substitution
Definition of leukemia
systemically distributed neoplasm of white cells
Actue myeloid or lymphoblastic leukemias
no evidence of maturation in the blood or marrow
>20% blast form - immature cells, indicative of acute leukemia
skin and gum infiltration possible
more frequent in children
progresses rapidly, but more responsive to treatment
Chronic myeloid of lymphblastic leukemias
increased % of mature cells
presence of Philadelphia chromosome - transposition of chromosomes 9/22 that results in abnormal tyrosine kinase
more cells can function and patients have better prognosis
Definition of lymphomas
solid tumors of hematopoietic system
neoplasms of lymphoid tissue
lymphadenopathy (enlarged, painless)
clonal expansion at various developmental stages
Features of non-Hodgkin lymphomas
indolent (less curable) to aggressive (more treatable)
90% of lymphomas
survival is from weeks to years depending on type
Features of Hodgkins lymphoma
10% of lymphomas
most types are curable
Reed-Sternberg cells
Multiple myeloma
cancer of plasma cells that arises in bone marrow
presence of Bence-Jones proteins
