GOLDFARB SCHOOL OF NURSING AT BARNES-JEWISH COLLEGE PATHOPHYSIOLOGY STUDY QUIDE FOR TEST V - THE LAST ONE!! 1. Discuss !

" #$%&!'($s #$% (s)&!'($s *+#, # &!+( i$ #c$(. Skin - mucous membranes Acne - an inflammatory reaction that involves sebaceous glands. The problem is that sebaceous glands increase their activity, so an increase in the amount of secretions in sebaceous glands. those secretions become infected which subsequently causes an inflammatory reaction in the sebaceous gland. Androgens tend to increase sebaceous gland activity which is why you tend to see more of a problem with acne in males than females. estrogens decrease sebaceous gland activity. So, those with higher estrogen levels tend to have less of a problem with acne. Also why the commercials of the birth control pill say it will give you lighter periods, you won't get pregnant, and it will make your skin nice and clear. That's true because of the estrogens in the pills. It's the estrogens when you were pregnant that makes your skin glow. -. W ic #$)i.i!)ics #&( ),*ic#++, us(% )! )&(#) #c$(/ tetracycline (don't worry about it)

0. Discuss ) ( %i11(&($c(s .()"(($ #)!*ic #$% c!$)#c) (c2(3#. Ec ema - a generic term that refers to red! blistering! scaly! wee"y! itchy! thick lesions (it's a generic term that refers to a variety of lesions that can occur on the skin) #)!*ic (c2(3# is hereditary tends to a""ear (well! can a""ear at any age) ec ema develo"s at fle#ure "oints$ elbow knee wrist neck it's hereditary! nothing we can do about it e#ce"t treat it when the ec ema occurs it will occur! then get better! the go away "retty much! then come back a chronic condition (won't kill you) c!$)#c) (c2(3# "retty common

 locali ed antigen-antibody reaction e#am"le$ "oison ivy "oison oak that you got on the skin metal in %ewelry that "eo"le are allergic to (nickel! silver) 4. Discuss ) ( %i11(&($c(s .()"(($ $(u&!%(&3#)i)is #$% i5(s. $(u&!%(&3#)i)is ty"ically see in the cold months of the year. gets started because of dry skin. when skin gets dry! it itches and you scratch the skin! gets infected! which dries it out more so scratch more...you're in this vicious circle treated by kee"ing skin moist! lubricated! so it doesn't dry out - then it's not much of a "roblem. i5(s also common characteri ed by edema and erythema edema - swelling erythema - redness almost always (&&.&')! hives are the result of allergic reactions often times! "articularly if the hives are all over the body! it's not from contact! but from something the "erson ingested orally. E#$ as"irins antibiotics 6. I%($)i1, " (&( *s!&i#sis usu#++, !ccu&s. "soriasis is$ thick! silvery white! scaly a""earance looks a little bit like fish scales. usually also occurs at fle#ure "oints (classically - fle#ure "oints)$ elbow! knees! will see "eo"le with it on the scal" runs in the family! also. very correlated with osteoarthritis arthritis. (not unusual for a "erson with arthritis to also have "soriasis) occurs in about the same fre(uency as arthritis ()-*' of the "o"ulation) +ust like arthritis fluctuates with severity! "soriasis fluctuates with severity ,hat really seems to be going on with "soriasis is the "roblem is at the basal layer of the e"idermis (skin). Their cell "roduction is too ra"id so they're "roducing a lot of thick! e"idermal layer and that's what gives it this fish scaly a""earance it will e#acerbate for awhile! then slows down! and e#acerbate - cycle they'll have it the rest of their life and there's really not much we can do about it.

 7.

a chronic condition

Discuss " (&( 1+#) #$% *+#$)(&s "#&)s usu#++, #**(#&. warts on the skin are a result of -.A viruses (viral infections) these are contagious (because caused by a virus) /n a way! warts are contagious flat warts a""ear anywhere 01T the bottom of your foot. grow flat "lanters warts warts on the bottom of the foot can be "ainful and may re(uire some attention. on the bottom of the foot! these -.A viruses tend to grow down in a triangle (not flat like the rest of the body). /f they continue to grow dee" in the tissue of the foot they can hit a nerve. .ow! the nerve becomes inflamed because of the virus growing there and really becomes "ainful some "eo"le may have to have the "lanter's warts e#cised out (cut out) because they can't walk - that's how "ainful it is. on the foot! ty"ically it's been "icked u" walking barefoot on the floor! in the gym! in the shower. /t's a virus you've "icked u" on the bottom of your foot it's contagious. Discuss ) ( %i11(&($c( .()"(($ H(&*(s si3*+(9 I #$% II. These are viruses that affect the skin! mucous membranes (double-check this) 2er"es sim"le# / - cold sores or fever blisters 2er"es Sim"le# // - se#ually transmitted disease! her"es rule of thumb$ get her"es sim"le# / above the waist and her"es sim"le# // below the waist can you get these on the o""osite side of the waist3 4es. these are obviously contagious and communicable cold sores can be communicated with kissing someone who has a cold sore! drinking after someone her"es // transmitted through se#ual activity from someone who is infected to someone who is not infected. with her"es // (and kind of true with her"es / - more true with her"es //)! when "eo"le have outbreaks of their her"es // and they're a""lying to"ical meds. 4ou have to caution "eo"le to be very careful about washing hands after a""lying medication to their her"es outbreak. because what can ha""en is they a""ly the meds! don't wash hands! then touch their eyes and now they've got her"es // in the eye! which is an e#tension of your brain. So! now you've got her"es // in the brain and that you don't want to do. so always caution "eo"le about washing hands and being careful around their eyes when they have a 2er"es // outbreak. with "regnant females and her"es //! the consideration is at delivery time with an

8.

outbreak of her"es. 4ou don't want to do a vaginal delivery. This virus is growing in this warm! moist mucous membraie environment in the mother the skin of the newborn is nice and warm and moist! floating around in the amniotic fluid for & months the newborn will "ick u" the virus on the skin as it "asses through the vaginal o"ening and will develo"$ %iss(3i$#)(% (&*(s (which means her"es from head to toe) mortality rate is 56' if mom is having an outbreak of her"es and ready to deliver! you really don't want to do a vaginal delivery - do a c-section will occasionally see this if mom delivers at home and is having an outbreak of her"es (that she wasn't aware of). A week later! child is covered in her"es sores. :. Discuss ) ( &(+#)i!$s i* .()"(($ c ic;($ *!9 #$% s i$'+(s. ,e talk about these together because they're really caused the the same virus$ the 78 virus. highest "revalence of chicken "o# (assuming kid was not vaccinated) is between 9 and ): yr. old you really do want your kids to get immuni ed for chicken "o# because$ chicken "o# infections in 9 - ): yr old is$ res"onsible for 6:' of strokes in that age grou". strokes are not real common! but still half are from com"lications of chicken "o# infection. 78 virus )st introduction of virus in body causes chicken "o# immune system res"onds by "roducing an antibody! but the immune system really only "roduces an antibody to a "ortion of the virus. it's communicable! but not highly. /f someone has an outbreak! wash clothes se"arately! etc. when the virus is introduced again! the only manifestation of this virus is now going to be the other "art. The other "art is what causes shingles. in other words! shingles re"resents the reinfection of a "artially immune host. it also means that if you had chicken "o# as a child! then your child gets chicken "o#! your child could give you shingles. and you with shingles could give your child the chicken "o#. 0ody recogni es a "ortion of the chn "o# virus. The other "ortion can cause shingles later in life because we didn;t build u" antibiodies to the other "ortion of the chn "o# virus. .ew borns are highly succe"tible to her"es and shingles. when virus is reintroduced with shingles! it's infecting nerve endings close to the surface of the skin (so they infect the dermaton - an area of skin su""lied

by a single s"inal nerve. Each nerve relays sensation! including "ain! from a region of the skin to the brain.) it won't look like such a big deal$ a rash across the forward a rash down one side of the chest a rash around the waist a rash about the si e of the "encil it definitely looks like a rash and it's im"ressive! but but it's very! very "ainful <when / had shingles! it was the worst "ain /'ve ever had in my entire life< it's not the kind of "ain where you can take a cou"le of Tylenol! it's more like "ercocet! vicodin! heroine! whatever you can find... because it's the actual nerve itself that's inflamed and this will last a few weeks Ty"ically! in "eo"le with recurrent shingles! what "recedes shingles (es"ecially reoccurance) is something that com"romises the immune system (stre"! "neumonia! dog died) - and usually occurs in the same "lace. vaccine$ different than vaccines like ==> chicken "o# vaccine decreases the "robability of being infected by 9:6:' or if your child is infected! it will be milder it does not mean your child will be infected! maybe a few s"ots. most likely scenario where you would see shingles in children is when they're immunocom"romised. not likely unless immunocom"romised. unusual to see adults with chicken "o#. So it seems as you age you're less likely to get chicken "o#. There seems to be some inherent resistance. "regnancy and virus "o# can cross "lacenta don't want to get any virus when the baby's fetal cells are %ust develo"ing (it can cross the "lacenta) because virus becomes "art of cell causing! by definition! mutation! toes! urinary bladder etc. <. I%($)i1, ) ( ,(#s) !1)($ c#usi$' ) &us #$% 5#'i$#+ ,(#s) i$1(c)i!$s. C#$%i%i#sis is yeast candida infections yeast is a normal flora organism so if you u"set normal flora relationshi"s (at least with bacteria)! you may allow yeast to overgrow. so that's often times how you get vaginal yeast infections kill bacteria in the lining of the vagina and allow yeast to overgrow in

vagina ) &us other "lace you see this is in newborns - they "ick u" yeast infection in mouth "assing down through vaginal canal. /f you're seeing candida as a "resenting infection in kids or adults (not vaginal or in the mouth)! always think about immune com"romise because to get a "rimary yeast infection it's most likely the "erson is com"romised in some way$ A/-S "atients! for e#am"le! do get candida immune-su""ressed S;i$ Tu3!&s =3!s) c!33!$ )! +(#s) c!33!$>? basal cell carcinoma s(uamous cell carcinoma melanoma 1@. C!3*#&( #$% c!$)&#s) .#s#+ c(++ c#&ci$!3# #$% sAu#3!us c(++ c#&ci$!3#. B#s#+ c(++ c#&ci$!3#? =ost common malignant growth on the skin. carcinoma's - e"ithelial tissue occuring at the base (basal) cell layer of e"idermis this is directly "ro"ortional to age (so the older - more likely you are to get this) and inversely related to "igmentation. (and less "igmented - more likely to get this) about ?:' of these carcinoma's occur on routinely sun-e#"osed areas face neck hands if you're going to get skin cancer and get a choice$ take this one. it's really not a big deal if you get it removed right away rarely metastasi es early easy to deal with - go in office and get it taken off. SAu#3!us c(++ c#&ci$!3# ty"e of e"ithelial cell involved is s(uamous cell rarely metastasi es IF it occurs on routinely sun-e#"osed area on your hand (rarely metastasi e) face neck removed and kind of like basal cell carcinoma - no big deal on your butt! more likely to metastasi e S(uaomous and 0asal cell carcinoma account for &5' of all skin cancers 11. B(+#$!3# 'i5i$' C !5(&#++ s;i$ CAD #'( #$% c!&&(+#)i!$ "i) su$ (9*!su&(.

Strong family line @' of all skin cancers are from the one we hear the most about - melanoma accounts for A B:' of all deaths from skin cancer. so that says that these fre(uently metastasi e usually occur in 9:-5: yr. usually occur on sun-e#"osed areas can start in the "igmented "art of the eyes these are very correlated with sun e#"osure this is why you constantly hear! <wear sun screen< the language doesn't fit (<oma< usually means benign! but not here - it's malignant) <melana< is from latin that means <black< or <dark< melanoma a black or dark growth the one that the cancer society guidelines for growth of skin$ A - assymetry (if half the sha"e doesn't match the other half) 0 - border (if the growth is not smooth! it's %agged! notched! blurry) C - color (if color looks uneven! if half darker than other half! or shades of color) - - diameter (if it's getting bigger) E - can mean elevated but all melanomas might not be elevated.

A mole can be any of these! but /f you check your mole and it has these A!0!C!characteristics! it's more likely to be melanoma! but could be basal or s(uamous cell growths. N(u&!+!'ic#+ %is!&%(&s 1-. I%($)i), ) ( 4 3#E!& c#us(s !1 CVA #$% %iscuss (#c . Cerebrovascular Accident$ stroke - sudden death of brain cells due to lack of o#ygen when the blood flow to the brain is i m"aired by blockage or ru"ture of an artery to the vein. means that we're dealing with a disru"tion in cerebral circulation these are "retty common C7A's are the @rd leading cause of death in this country 9 mechanisms by which "eo"le can have C7A's (most common to least common)$ ) &!3.!sis most common cause of a C7A about 9:' of C7A's are from thrombosis this is the result of "la(ue! hardening of the arteries - "la(ue forming in the cerebral vessels. "eak age for this to occur is B:-B& yr. ho"efully these "eo"le have some T/A's (transient ischemic attacks)

transient e"isodes of neuro dysfunction because of "la(ue a T/A is to the brain what angina is to the heart angina is a transitory e"isode due to lack of o#ygen telling you something is going on. a C7A is transitory telling you something is going on with the cerebral vessels these "eo"le are most likely to have "roblems in the early morning hours or shortly after awakening (most thrombosis strokes occur at these times) - as do most =/'s. ,hy3 strokes and an =/ are being caused by "la(ue and the "latelets stick to that and you begin the clotting formation. your "latelets are stickier in the morning than in the afternoon so in the early morning your "latelets are more likely to stick to the "la(ue and start the clotting "rocess in the morning changes in stickiness due to circadian rhythms evolutionary - need to be stickier in the morning when out foraging for food and more likely to get in%ured. /n the evening! if you're out foraging for food! you will be food. "eo"le with strokes will tell you when they describe their sym"toms$ analogy is like walking down an incline < noticed left shoulder numb! then in a little while my whole left arm! then my fingers were numb! then my chest was numb. they're describing the gradual ascent of sym"toms don't "lace diagnosis on that - it's sub%ective. c(&(.&#+ (3.!+is3s *nd most common reason for a stroke tends to effect a younger "o"ulation than thrombosis this is reflective of their heart "roblem. they've got a thrombosis that is in the heart and has broken away and has ended u" in their middle cerebral artery - (location where it's most likely to enter). And! its' "lugged u" the middle cerebral artery (it could have ended u" in the "ulmonary system as a "ulmonary embolis). nothing going on with brain tissue! it's %ust the luck of the draw for this embolis. i$)&#c&#$i#+ .+((%s !& (3!&& #'( @rd most likely reason - a bleed "roblem with a bleed in the brain is #+"#,s - com"ression and dis"lacement of the brain tissue. That's AD,A4S the "roblem with a bleed in the brain. Com"ression$ e#ists because the brain tissue is enclosed in an immovable skull. if we do anything to cause brain tissue to e#"and (like "utting blood in

the tissue)! then the tissue has no where to e#"and to e#ce"t "ress against this immovable skull. the harder you "ress against the immovable skull! the more s(uishing of blood vessels in the brain which means no blood su""ly for tissue (less cerebral circulation) the more blood accumulates in the tissue and "ushes against the skull! the less cerebral circulation we have -is"lacement dis"lacement may not be a big "roblem u" in the cerebral hemis"here it is a big "roblem down in the brain stem if a bleed ha""ens down in the brain stem and the brain stem is dis"laced (scooted over a little)! then we're "ressing the brain stem against "art of the skull which means you may not breath the im"ortant thing is " (&( the bleed occur$ in the cerebral hemis"here! if we do it slowly! we could dribble through )::mD of blood in here and you're "robably going to be EF because you have a big cerebral hemis"here if / "ut 6mD of blood in the brainstem! /'ll kill you. That 6mD will be enough to dis"lace the brain stem and "ress it against the base of the skull and we're interfering with all those nerves that control breathing! res"iration! heart rate. what else does brain stem control3 #$(u&is3s most unlikely reason we talked about aortic aneurisms this is basically the same thing! but in the brain! not the aorta most likely "lace for this to occur is arteries of the Circle of ,illis. we could be sitting here with an aneurism in our head and the )st sym"tom will be our funeral. There are no sym"toms. /t ru"tures! you bleed into the brain and we're back dealing with a bleed and there's nothing we can do about it. these usually occur in the youngest of the "o"ulations of strokes they usually ru"ture during some activity when 0G is elevated. %ogging "laying tennis something strenuous they'll say! it felt like something sna""ed! or broke in my head. They felt (andHor heard) the aneurism "o" and they'll grab their head as they fall to the floor. de"ending on where it is and how much blood we're talking about! they may be dead in * minutes or we may do EF because now we're dealing with blood accumulating in the brain. these also can run in the family$ there are some inherent! "robably genetic! structural deformaties that can occur in the vessels in the brain.

if mom's had an aneurism (and "articularly at a young age)! should "robably look at your cerebral circulatory system! es"ecially if we determine that mom's is an inherit deficiency in the walls of the vessel.

2eadaches can be caused by a variety of things$ head in%uries brain tumors intracranial hemorrhage sinusitis eye strains ... 10. C!3*#&( ) ( ()i!+!', #$% s,3*)!3s !1 5#scu+#&D c+#ssic #$% c!33!$ 3i'&#i$(s. @ categories of headaches$ V#scu+#&? Bi'&#i$(s the big one in this category is 3i'&#i$(s migraines are more common in females under the age of 9: than males migraines most common in females between *6 and @6 (about ):' of female "o"ulation in this age range has migraines) overall! about @-6' of "o"ulation has migraines 5:' of "eo"le who have migraines have a "ositive family history for migraines (runs in the family to a great degree) in females! migraines are very correlated with the menstrual cycle because of this reason! "eo"le who don't know about migraines try to "ut "atients on the birth control "ill! but it will make them worse. migraines involve ()) vasoconstriction and (*) vasodilation and (@) locali ed vessel inflammation before the onset of the headache! cerebral blood flow is decreased (vasoconstriction) during the ("ain of the) headache! cerebral blood flow is increased (vasodilation) Two "resentations of migraine headache$ c+#ssic 3i'&#i$( often have a "rodormal (early sym"tom indicating the onset of an attackHdisease) "hase you have some (often neurological) cue that you're about to get a migraine lose "eri"heral vision smell something feel tingling in your fingers c!33!$ 3i'&#i$(s no "rodormal or "re-headache "hase

 you're sitting there! fine! then all of a sudden you reali e you have a migraine /n both "resentations of headaches! "eo"le will tell you$ ty"ically! their "ain starts unilaterally (one side of head) initially! a dull "ain that starts then (uickly becomes unilateral and it's throbbing (because it's a vascular "ain) "oint to where it hurts3 they can't. </t %ust hurts across 'here' - they're "ointing from tem"le to tem"le (all across forehead)< it's a "ain that you want to be left alone - don't talk to me! don't touch me! turn out the lights! go away! leave me alone. / want to "ull the covers over my head and be alone why3 Ene of the things that will relieve my "ain often times is slee". The "roblem is it's hard to go to slee" when you have a throbbing "ain. *: years ago! the only thing we could do! if you couldn't get to slee"! is bring you in! give you mor"hine! and knock you out. 2o"e that "ut you to slee" and ? hours later when you woke u"! ho"e the migraine was gone. or we could give you a drug called ergot! which vasoconstricts. but it's got some side-effects (DS--like). about )6 years ago! the drug imitre#! originally came out as nasal s"ray first! then a self-in%ection! and now we have a "ill of imitre# it does the same as ergot! it vasoconstricts. almost all of the migraine drugs vasoconstrict. often works fine! but if you've got known cardiovascular disease and migraines! we really don't want to give you a drug that vasoconstricts your blood vessels becaues we'll kill you. so migraines in "eo"le with known C- "resents a whole other set of "roblems in terms of how to control their "ain. migraines in "eo"le often times have triggers$ </ drink red wine and / have a migraine< </ drink white wine H bourbon H caffeine and /'m going to get a migraine< it's hel"ful to identify triggers so you can avoid them for some "eo"le! we'll "ut them on beta blockers (we don't know why it works) 00's work in terms of controlling their migraine for some "eo"le! Tri-cyclic Antide"ressants (TCA) work ("ut you on antide"ressants "ermanently! not %ust during the headache) for some "eo"le it significantly decreases the incidence of their migraine. for some "eo"le! CC0 will work. often times! we %ust run through the list and see if we can find something that works migraines in females tend to go away after meno"ause.

/f we can't find any of these drugs that work! for some "eo"le! these migraines really inca"acitates them. They're not at work a day or two once or twice a month. sometimes there's migraines in children! unusual in 9-B year old tend to be really e#treme "ain head feels like it's going to burst. very difficult to control and diagnose.

14. C!3*#&( #$% c!$)&#s) ()i!+!', #$% s,3*)!3s !1 c+us)(&D )($si!$ #$% )&#c)i!$ (#%#c (s. Cluster headaches may be migraines these occur in a cluster of time may occur for a few weeks or few months! then they go away! and may by B months or 6 years before they reoccur for a few weeks and then go away. much more common in males than females different "resentation of "ain$ not the kind of "ain where you go to bed and "ull the cover over your head "eo"le move with this "ain they get u"! sit down! "ace the floor! get u"! sit down - they can't sit still they'll describe it not a throbbing "ain! but a constant "ain if you say! "oint to where it hurts3 usually on one side of the face around the orbital (eye) tissue. it feels like someone's got my eye and they're holding it really tight and / can't shake it off. with their constant movement! somebody's really gri""ing hard and they're trying to loosen the gri" this headache most likely woke them u" - they were aslee" when this started very correlated with >E= slee" "atterns woke u" with this "ain in their head! and took something and finally relieved "ain! went back to slee" woke u" * hours later and the ne#t night the same thing thinking is that this is a different "resentation of a migraine! but right now not classified as a migraine. thinking too is - you say! / have a sinus headache3 about half the time! the sinus "ain is actually a migraine "ain if all this comes to be! migraines are a lot more common. if <sinus "ain< came on all of a sudden and you don't have a cold or anything else going on! it could be a migraine in a real sinus headache! you have ? sinusesHholes in your head ("art of the reason is so head's not too heavy) they're lined with mucous membranes that normally drain ) (uart of water down the back of your throat and you never even feel it. if the drainage tubes become inflamed! and they can't drain then the fluid accumulates in the sinus and the "ressure builds u" and fluid can't get

out. it's a non-sterile area! then fluid gets infected and you've got a sinus infection. if you thought you had a sinus infection and took an ab# for a week and it went away3 it wasn't really a sinus infection - at least not bacterial you will need ab# for a month to clear this. if it's truly a sinus infection and you have bacteria growing there you want to be careful - so close to the brain. Geo"le die from sinus infections the bacteria can move from the sinus tissue to the brain and then the mortality rate goes through the roof. Buscu+#& c!$)&#c)i!$F 3usc+( )($si!$ (#%#c (s these are really muscle contractions feels like my head is in a vice and feel like a band around my head and it's being tightened nothing to do with vascular "roblems! it has to do with the muscles. that's why you take ibu"rofin! aleve! and Advil it's due to muscle tension! nothing neurologically going on. if you're taking acetomeno"hin and it's working! fine. 0ut! if you're taking it every * hours sto". /f it's not working or you're taking it fre(uently! switch to ibu"rofin ibu"rofin - it's an anti-"rostiglandin. Ene of the things that makes smooth muscle constrict is "rostaglandins. that's why Tylenol doesn't work for cram"s - use motrin! ibu"rofin (they're anti"rostiglandin). "rostaglandins are making your uterus contract. so we're inhibiting that. And! "rostaglandins could be what's making the muscles around your head contract. don't continue to take Tylenol of it doesn't work very long! switch to something else. I$1+#33#)!&, (#%#c (s F )&#c)i!$ i$1+#33#)!&, (#%#c (s these are secondary headaches they're headaches that are involved with the region we're in$ if someone has meningitis (s"inal column) if someone has a broken nose if / have a truly infected sinus (sinus) abscessed wisdom tooth. (infected tooth) it's %ust because these things are in the area of my head that it causes a headache. /t's %ust referred "ain! nothing going on neurologically with the head. 16. Discuss ) ( %i11(&($c(s .()"(($ J#c;s!$i#$D '($(&#+ s(i2u&(s #$% 1(.&i+( )!$ic s(i2u&(s.

E*i+(*s, is the most chronic sei ure disorder. )st described by hi""ocrates over *::: years ago the highest incidence of "rimary e"ile"sy is in children I *: years old it would be very unusual to see a @:-year old suddenly develo" e"ile"sy do @:-year olds have sei ures -yes. 56' of the time! "rimary e"ile"sy develo"s in younger individuals E"ile"sy is divided into two categories$ *#&)i#+F1!c#+ s(i2u&( %is!&%(&s there is one s"ecific s"ot in the cerebral corte# that is causing the "roblem. classically! there are two "resentations$ J#c;s!$i#$ s(i2u&(s 0@ s(c G -F0 3i$s "eo"le start with one finger twitching! then the hand twitches then the arm twitches then the shoulder then the right side of body twitches then right leg twitches it's always on one side of the body reflective of the fact that the region that's firing like this is on the other side. conscious during this Ps,c !3!)!& s(i2u&(s classically! how "eo"le "resent is doing re"eated! "ur"oseless movements$ cla""ing one hand blinking their eyes smacking their li"s they're conscious during this! don't lose u"right "osition often times! after the attack! even though they were conscious! they don't recall what's been going on for the "ast @: seconds. They're oblivious to the "ast @: seconds when they've had this focal sei ure. Juge state- state of hy"eractivity lasting 6-): mins after a "sychomotor sei ure a concern several years ago when "eo"le thought video games were causing kids to have sei ures$ it's not a "roblem in causing "sychomotor sei urew can video games induce "sychomotor sei ures3 yes as can strobe lights at rock concerts as can the rhythm of drums "sychomotor sei ures can be induced in "eo"le who already have them with$ blinking strobe lights

sto" lights music staring at a blinking light and it's set at a "articular rhythm and you have "sychomotor sei ures! it can induce a sei ure if you're not under control. video games don't cause it! but they can induce a sei ure in someone who already has them - it's %ust the activity on the screen at a "articular rhythm

'($(&#+i2(% s(i2u&( %is!&%(&s we're not talking about locali ed! isolated firings in the cerebral corte# talking about the whole cerebral corte# suddenly firing like cra y A cou"le of "resentations$ #.s($c(F*()i) 3#+ <absent< describes this this "erson "resents - you're sitting there carrying on a conversation with the "erson and they're %ust not there for a few seconds you've been carrying on a conversation with someone and they're not listening. They could be having a "etit mal sei ure it may only last a few seconds that they're not there. usually don't give any outward signs that they're having a sei ure! other than a blank stare which! in a way! seems like it might not be a big "roblem! but if you're 5 years old! riding a bike and suddenly absent for 6 seconds! you could get killed. almost e#clusively in children! but will most likely continue into adulthood (although could sto" in adulthood) really unusual to see it develo" in an adult )!$icFc+!$icH'&#$% 3#+ '($(&#+i2(% s(i2u&( one we think of the most when thinking of sei ures you have a loss of u"right "ositioning tonic-clonic movements (o""osing movements of muscles) because of the firing in the cerebral corte# gives you this %erking motion. some "eo"le have an aura before their grand mal sei ure aura is kind of like a T/A - it's some indication that you're going to have a grand mal$ your vision changes your ears start ringing you smell something some cue that you're about to have a sei ure - and not an hour before! it's usually seconds before the sei ure. /t gives you some time! if you're on a ladder! to get down.

the sei ure may last @-6 minutes they're unconscious after sei ure is over! the last thing they remember is the aura (if they had one) - or what they were doing 6 minutes ago. if you look at EEK activity! it looks like an earth(uake (many s"ikes u" and down). The neurons are firing like cra y. it looks like 7-fib in the brain - it's %ust as random. sei ure dogs - dogs for "eo"le with grand mal sei ures ty"ically the dogs are for uncontrolled grand mal sei ures when they don't have an aura. the dog is laying aslee"! %um"s u"! grabs "erson by sleeve and "ulls them to the ground and they're going to have a sei ure - every single time. the dog knows when they're about ready to have a sei ure and they do it every single time. big dog - trained to "ull "erson to ground before sei ure starts. no one knows why! but the thinking is the dog "icks u" an odor (because they smell ):: times better than we do). 9-6 years ago! an editorial "iece about this guy's dog (dermatologist) his shnou er was obsessed with one foot. After a few weeks! he noticed there was a growth on his foot and it turned out to be melanoma. he started brining dog into office and let the dog smell the lesions every single time! the e#act same reaction when the "ath re"ort came back as melanoma a few weeks after that! a study in England! in which they had sealed %ars with tissue sam"les - some malignant! some weren't brought dogs in and this one dog <diagnosed< malignancy in every sam"le that was there - e#ce"t one. he had a reaction saying a kidney tissue was malignant! but it wasn't. E#ce"t! B months later! it was. a cou"le of studies around the country with dogs smelling malignancies "robably will see animals in the doctor's office in <our< lifetime. febrile tonic sei ures grand mal-like sei ures ha""ens in children I 6 year due to ra"id onsets of hy"erthermia

 so the kid suddenly s"ikes a fever. scares the "arents with the first child$ *-year old s"ikes a tem" and they're having a sei ure call &)) bring tem" down and the kid is fine - never has another sei ure it does run in the family! no one knows why it ha""ens H what the cause in the vast ma%ority of kids this goes away over time small "ercentage where it does not go away$ so at @:-year old with stre" throat and they s"ike a tem" ():*)! they'll have a sei ure. even when they're ?:! s"ike a fever and they'll have a sei ure. the *nd time it ha""ens (first time since a kid) s"end thousands of dollars with a sei ure work-u" once we know they've had febrile sei ures! it "oints in the right direction. D('($(&#)i5( !& C &!$ic C($)&#+ N(&5!us s,s)(3 %is!&%(&s? 17. Discuss ) ( ()i!+!', !1 ALSD Hu$)i$')!$Is #$% P#&;i$s!$is3.

A3,!)&!* ic L#)(&#+ Sc+(&!sis =ALS>? J (&(K Dou Kehrig's disease baseball "layer )st "erson who died with this very correlated with getting closed head in%uries Dou Kherig had 5 concussions who else gets head in%uries (and who has the highest incidence of ADS)3 football "layers (tackling somebody with your head and bouncing the brain against the skull because the brain has nowhere to go) studies - .JD statistically for the L of "eo"le who have "layed in the .JD and you look at the ' who should have ADS3 E.E - that's all how many e#-.JD "layers have ADS3 )9 bo#ers "ast year you've been hearing about head in%uries from football in high school and colleges - ADS incidence is where this is coming from. higher incidence of ADS has been one of the reasons Classic ADS starts between 9th and 5th decade of life (so 9:-5:) it's correlated with head in%uries classics for etiology are genetic! viral! auto immune what ha""ens in ADS - awful disease$

we see changes in their s"inal cord we see changes in their lower brain stem we see changes in the motor neurons of the cerebral corte# what ha""ens is they lose motor neurons! the motor neurons are deteriorating e#ce"t sensory neurons are com"letely intact! not affected what that means is this "erson is com"letely aware that they can't move they can't walk they can't move their arm or leg that's cruel to be totally aware sensory-wise and intellectually-wise that you can't move or move muscles! is cruel average "erson survives about @ years after diagnosis they usually die of "neumonnia they can't breath they can't cough their lungs get infected as they lose res"iratory ca"acity! do we "ut them on a res"irator3 in which case they'll be on it from now on (never weaned off) or do you let them die of "neumonia at age 9@.

Hu$)i$')!$Is is genetic! not very common! and we know where the gene is. the gene on chromosome L9 a very slow disease average age of onset is @? these "eo"le live ): - @: years after diagnosis! with good care what ha""ens$ a deterioration of neurons in the basal ganglia and cerebral corte# over time! gradually you're losing cells in the basal ganglia and cerebral corte# /ndiana e#it for a town called 2untington! /ndia named after the 2untington family where the disease was first identified a huge L in this family had the disease we can test for this genetically if we test you and you've got the gene3 are we going to do anything for you3 no but! you might want to know if you have the gene before you re"roduce. this is everything - motor! sensory (starts with motor) causes certain nerve cells in your brain to waste away

 e#"erience uncontrolled movements! emotional disturbances and mental deterioration. basal ganglia regulate movement cerebral corte# - res"onsible for higher-order functions like language and information "rocessing! including tactile! sensory! visual! auditory! s"eech! ... P#&;i$s!$is3 Ru$s i$ ) ( 1#3i+, syndrome that's characteri ed by rhythmic tremors and bradykinesia (which means slow movement) this movement disorder is a result of a decrease in do"amine "roduction and do"amine "athways in Garkinson's "atients - the tremors are rhythmic and early on - actually! throughout the disease - they're resting tremors (usually in both arms - more so than %ust one) later in the disease! as these resting tumors occur! will have "ill-rollling tremors their movements are really slow take 6 minutes to get through the doorway take ): minutes to cross the street if you're early in the disease and you're moving this slow when crossing the street! if you come u" behind them and hit a siren and scare them! they'll run across the street! get on the other side! and start the rhythmic tremors again. because if they've still got enough do"amine-"roducing cells that if you scare them enough! you get a surge of do"amine. Jor a minute or two! they look like normal. instead of siren scaring them! you can use a cou"le trials going on dee" vein stimulation "ut electrodes in the do"amine-"roducing "arts of the brain run the electrode down the neck! down the neck! down the chest then connect the electrodes to a little "ager-ty"e device! "lug them in the "ager then sends electrical im"ulses u" to the do"amine-"roducing area to increase the amount of do"amine. if we need to ad%ust the "ager! most of these you can ad%ust over the "hone. it's not curing the disease! we're increasing the amount of do"amine. because later as the do"amine "athways deteriorate! it doesn't matter how much do"amine we crank out! there's nothing to carry it. but! for awhile! this is buying time and increasing the (uality time. 18. Discuss BS "i) &(1(&($c( )! #'( !ccu&&($c(D ()i!+!',D %is)(3*(& #$%

+!c#)i!$ !1 +(si!$s. most common neurological "roblem that affects a young "o"ulation more common in females than in males the mean age of occurrence is about @:. this is one of those that we don't really know what causes this current thinking is - it's an autoimmune disease in almost all =S "atients you can find antibodies to a "rotein in the myelin sheath which suggests autoimmune interesting "henomena about =S it is much more common in tem"erate climates than in tro"ical climates - not clear why if you go to +amaica - you will never see an =S case in indengenous "eo"le of +amaica (and other tro"ical areas) - it doesn't ha""en that doesn't mean if you have =S and move to +amaica! you will not get better what ha""ens$ lesions occur only in the white matter of the C.S - so in the$ s"inal cord o"tic nerves brain stem inner layer of the corte# in the brain white matter contains nerve fibers. =any of the nerve fibers are surrounded by myelin! which gives the white a""earance of the white matter. - it insulates and increases the s"eed of transmission of nerve signals and these individuals start gradually demyelinating their nerve cells the myelin sheath is the insulation of the nerve cells so the charge doesn't leak out as the charge is sent down the nerve the =S "atients lose this myelin sheath so as we send and im"ulse down! it may be really slow getting there because we're losing the charge or it may not get there at all. with =S "atients you notice$ they're having trouble with their right hand being numb a month or so down the road! right hand gets better! and now having trouble with vision in my left eye a month or so later! left eye gets better and we have trouble with right foot. it %um"s around what we used to teach "eo"le was that once you lost your myelin sheath! it was gone. =S taught us differently "atient had sym"toms in one "lace one month! then somewhere else they remyelinatined - which is why sym"toms are %um"ing around treatments <not cures) for =S$

 in%ecting with cow (bovine) myelin (works for some and not for others) - this is assuming it's an autoimmune disease. the thinking is if we in%ect them with bovine myelin! that's more of an attractive antigen to the antibody than their own myelin. the bovine antigen and "rotein antibody interact So their antibodies leave their own myelin alone. therefore! they don't have sym"toms (in those it works for) for those it doesn't work! it's very un"redictable some! with minimum treatment! live nice and long others are dead at @?. 1:. Discuss P#) !* ,si!+!', !1 BS "i) &(1(&($c( )! i$ci%($c(D #'( *(#; #$% #c(),+c !+i$( &(c(*)!&s. / think this is =K - see )?b. 1:.. Discuss B,#s) (3i# G&#5is a condition of neuromuscular im"airment affects ) in ):!::: "eo"le "eak age of incidence is *: yr. what ha""ens with =K is that these "eo"le lose acetylcholine (a neurotransmitter) rece"tors on the receiving cells. current thinking is this is "robably an autoimmune disease because in most "eo"le with =K! you can find an antibody to a "rotein that is in the ACh rece"tor. So! they're develo"ing an anitbody to an e#isting "rotein (i.e.! an autoimmune disease). so! when the antibody interacts with the antigen ("rotein on the ACh rece"tor)! the rece"tor can no longer acce"t ACh. about &:' of =K "eo"le! their first com"laint is "roblems with ocular muscles then a "roblem with facial muscles langeal (laryngeal) muscle "roblems (elevates laryn# for breathing and for vocali ation) "haryngeal muscle "roblems ("haryngeal muscles initiate swallowing) res"iratory muscle "roblems then they get "neumonias and die of their "neumonias a small ' of these "eo"le that "resent with ocular muscle "roblems never "rogress. /t sto"s at the ocular muscle "roblem stage. if that is the case! then having =K in no way decreases life e#"ectancy 1<. Discuss A+2 (i3(&Ls "i) &(1(&($c( )! #'( !ccu&&($c(D i**!c#3*#+ #$% c!&)ic#+ $(u&!$sD #c(),+c !+i$( #$% *!ssi.+( ()i!+!',. G($( !$ c &!3!s!3( -1D 14D 1< disabling disease that affects about ):' of the "o"ulation over age B6. they lose$ hi""ocam"al neurons

cortical neurons and ACh "roduction the degree of dementia is very correlated with the decreases in their ACh levels Classics for etiology$ it's a virus it's autoimmune aluminum to#icity uni(ue to al heimer;s! but in no way causes the disease came about a few years ago when it was observed during "ost-mortems on Al heimer;s "atients that there was a lot of aluminum in the brain. the thought was that it was drinking soda out of aluminum cans and wra""ing leftovers in aluminum foil that was causing Al heimer;s --A no! absolutely not e#cessive amount of aluminum in the brain is a factor that you see in this disease! but aluminum in no way causes it. it's a correlation at "ost-mortem Geo"le with Al yheimer's Sym"toms - "resent with recent or short-term memory$ "resent with "roblems with short-term memory$ forget to turn off the iron forget to take their =ed's forget to turn the light off in the closet when they walk out later! "roblems understanding what they read "roblems with "aying the bills "roblems organi ing daily activity finally become disoriented confused can't remember where they live not sure about their name some long-term memory they never lose but they can still "lay the "iano but what about their name - "retty long-term3 average course of disease from diagnosis to death is about B-? years de"ending on$ acuity of it s"eed of "rogression ty"e of care they receive. >onald >eagan lived )6 years ("robably even had for 9: years) - de"ends on ty"e of care. sym"toms turning out lights3 off iron3 normal forgetfulness

if you forget where you "arked your car - not Al heimer;s - normal forgetfulness if you get to your car and look at your care keys and wonder what they are for - "roblem with Al heimer;s normal forgetfulness is one of life -iagnosis one of e#clusion$ we don't have any definitive way to diagnose Al heimer;s if you haven't had a stroke! don't have sy"hillus or )6 other diseases! it's "robably Al heimer;s but no clear way yet to diagnose Al heimer;s And! even if we did! will it change the treatment3 no! there is no treatment. coming down the road! in the ne#t few years! a test to diagnose Al heimer;s there's a "rotein found in the s"inal fluid! called A-AG (Al heimer;s -isease Associated Grotein) it is very correlated with Al heimer;s! but it means doing a s"inal ta"! which is invasive EF! done the s"inal ta"! you've got the "rotein and you've "robably got Al heimer;s! now what do we do3 nothing. A cou"le of drug com"anies looking at a blood test for this A-AG to see if it crosses the 000 maybe we could "ick it u" with a blood test until that ha""ens! there's no clear way of diagnosing Al heimer;s >uns in the family if you've had a )st degree relative with Al heimer;s! you're about ):-*:' more likely to develo" Al heimer;s it's going to be an enormous "roblem as baby boomers get into that age grou" there's an enormous L of baby boomers hitting the mid-B:'s and as they tend to live longer we're going to see more Al heimer;s friend a few years ago with mom who had Al heimer;s she had gone to the grocery store came out and couldn't find her car told K.S. her car had been stolen "olice couldn't find her car either and they fill out stolen car "a"erwork "olice take her home (* blocks away) and the car in her garage she says! <,ell! / guess they brought it back.<

CNS i$Eu&i(s? -@. I%($)i1, $!&3#+ ICP #$% (9*+#i$ !" I$c&(#s(% ICP &(%uc(s .+!!% 1+!". .ormal /ntracranial "ressure (/CG) is about 6:-*:: mm 2*E (water! not mercury) if you e(uated it to mercury (like blood "ressure)! we'd be looking at about 6 )6 mm2g - not an enormous amount of /CG

a little or even substantial increase in /CG for a short "eriod of time is EF. your /CG increases and decreases throughout the day and it's no big deal when we've got a sustained increase in /CG that's for @B - 9? hours! then it's "otentially a "roblem because there's nowhere for this brain to e#"and to. because the brain is tra""ed in this immovable skull whatever is causing the /CG "ressure (fluids! bleeding! whatever)! it's causing this brain to begin to "ress against this immovable skull with the more "ressure! hence the more force that is "ressing against the skull! the blood vessels between the tissue and the area of the skull gets s(uished together and we occlude the blood su""ly! then we've got dead! or certainly ischemic brain tissue. most of this "henomena of /CG occurs with$ closed head traumas big time concussions didn't s"lit your head o"en! %ust bounced your brain around for a little bit inside your skull.

-1. E9*+#i$ ) ( &(+#)i!$s i* .()"(($ .&#i$ )issu( %#3#'(D I$c&(#s(% ICP #$% %(c&(#s(% c(&(.&#+ .+!!% 1+!" #$% %(c&(#s( .+!!% P . Schematic way to say this$ c+!s(% (#% )&#u3# --A .&#i$ )issu( %#3#'( (done something to the brain tissue as we bounced it around in the skull) --A .&(#;%!"$ !1 .+!!% .&#i$ .#&&i(& ("roblem begins when we've broken down the blood-brain barrier which now means we can get fluids out of the vessels) C(&(.&#+ E%(3# (and into the brain tissue which means the tissue will begin to swell) --A as tissues swells! we i$c&(#s( i$ ICP --K so in the area the swell is ha""ening! we're %(c&(#si$' c(&(.&#+ .+!!% 1+!" --A de"ending on the degree of decrease! we either have isc (3i# or )&u( ,*!9i# (because we've com"letely occluded the blood su""ly) --A when you get hy"o#ia! you i$c&(#s( PCO- levels! %(c&(#s( P levels and the *!)#ssiu3 '!(s u* and the hy"o#ia can certainly result in the death of the tissue. you will see sometimes if we've got significant edema of the brain from closed head traumas if we can't control the swelling with drugs! we'll take out a "iece of the skull (saw off a chunk) and "ut in the free er sometimes if we know we're going to have to have the "iece of skull off for a long time and want to make sure it ho"efully stays healthy! we'll "ut it back in

the abdomen or thigh so it has some blood e#"osure @ months from now take it out of abdomen or leg and sew it back on their head. as medieval as this sounds! taking a "iece of skull out and letting the brain have a "lace to e#"and out to without the counter-"ressure that comes from the skull! can save their life. --. E9*+#i$ G+#s'!" C!3# Sc#+(. 7ariations on this scale (scale is sometimes )-9! sometimes )-B! even )-):) used to assessH(uantify C.S function H consciousness Eye o"ening$ does the "atient s"ontaneously o"en their eyes when you a""roach them3 can they follow you with their eyes3 (6 or 9) do they not o"en their eyes at all when you're talking to them! even with stimulation their eyes never o"en (:) 7erbal res"onses can they give you a""ro"riate verbal res"onses do they know where they are3 are they oriented3 know month3 year3 are they not able verbali e anything even with "ainful stimulation =otor res"onses3 hold u" one hand3 hold u" two fingers! "ut down ) finger can they have control over motor function or can they not do anything3 so no res"onse at all

-0. E9*+#i$ ) ( *#) !+!', !1 (*i%u&#+ (3#)!3#. 2ematoma - collection of blood in soft tissues or an enclosed s"ace E"idural hematoma collection of blood between the inner surface of the skull and the dura. caused by a torn artery and is almost always associated with a skull fracture. torn artery has higher /CG than a vein so there's more bleeding how does the blood get into this area - it's not a s"ace. =y AMG book says it consists of outer and inner fibrous layers. /t leaks out with the fracture. where they are3 what the "roblem is3 e"idurals - tend to be arterial in nature more bleeding and more /CG with arterial than with venous subdurals - tend to be venous -4. E9*+#i$ ) ( *#) !+!', !1 su.%u&#+ (3#)!3#. Subdural hematoma collection of blood between the inner surface of the dura mater and the surface of the brain

 resulting from the shearing of small 5(i$s that bridge the subdural s"ace veins of the brain o"en into these sinuses! which deliver the venous blood to the internal %ugular veins of the neck result from blows! falls! or sudden accelerationHdeceleration of the head! as occurs in shaken baby syndrome. -6. D(1i$( #3($!&& (# #$% %iscuss ) ( c!33!$ c#us(s. amenorrhea - the absence of menstruation Two ways to get there$ "rimary amenorrhea the absence of menstruation (never had a "eriod) by the age of )5 secondary amenorrhea the absence of menstruation for a @- to B-month "eriod of time after already establishing a normal menstrual cycle. amenorrhea ("rimary or secondary) is a sym"tom (like anemia is always a sym"tom) you don't wake u" one day with amenorrhea may be something's going on with the "ituitary may be something's going on with the hy"othalamus it may be the ovaries it may be the uterus it may be the endometrial lining of the uterus it may be weight in females! your ' of body fat is very tied into your re"roductive system when you get below about 6'-5' body fat! you're re"roductive system turns off you don't ovulate or menstruate biologically! it's too risky you don't have enough fat reserves to sustain yourself! much less sustain a fetus so shut your re"roductive system down bulemics tri-athletes when you "ut your body fat back on! the re"roductive system turns right back on because you can now su""ort a "regnancy. only works at the low body fat end. it doesn't mean that if you have *?' body fat! you ovulate like hell only in females it doesn't matter what body fat ' in males - it has nothing to do with s"erm "roduction. -7. Discuss ) ( cu&&($) i%(#s #.!u) PBS =*&(-3($s)&u#+ s,$%&!3(> call things syndromes - because multi"le sym"toms to it (u" to about )@: sym"toms associated with G=S)

some "eo"le think G=S doesn't e#ist or in your head - it's not. it's in your uterus it e#ists we know that$ if you never interru"ted your cycle in any way (never "regnant or on birth control)! G=S is very unusual G=S only seems to ha""en in women who have interru"ted their menstrual cycle in some fashion when you do interru"t menstrual cycle! like with a "regnancy! G=S tends to get worse with each "regnancy. in some women! certain things e#acerbate the G=S$ sugar caffeine alcohol in the "ast year! there were two legal cases in which two women got off with a defense of G=S and their crime was )st degree murder (shot husbands) - in England. The defense star witness (7irginia -ol"hin)! who e#"lained G=S. (never used in a murder case in 1.S.) for a long time! we e(uated G=S to "ost-"artum blues! "ost-"artumm de"ression! or even "ost-"artum "sychosis for a long time we thought that it was due to a "reci"itous dro" in "rogesterone that occurred 5 - ): days before menstruation so what we did was we gave women "rogesterone in%ections starting about 5): days out it didn't do any good! didn't seem to hel"! but for some reason we ke"t doing it for along time vitamins a cou"le of studies showed that calcium seemed to really hel" control the mood swings with G=S right now! about the best thing out there. some anti-de"ressants ("ro ac) - hel"s a lot of women with G=S that's about all we have to offer at this "oint. Discuss ) ( &!+( !1 *&!s)#'+#$%i$ i$ %,s3($!&& (#. is "ainful menstruation correlated with an increase of "rostaglandins in the endometrial lining of the uterus the endometrium is the inner most lining of the uterus that you lose during menstruation in some women that endometrial tissue "roduces lots of "rostaglandins and "rostaglandins cause muscles to contract. so when you lose your endometrium! you're s"illing out a lot of "rostaglandins in the uterus and it causes the myometrium (muscle layer of the uterus) to contract and you've got cram"s. /bu"rofin's! midol (are anti-"rostaglandins) - that's why they hel" with cram"s

-8.

tylenol! acetomeni"hin - doesn't hel"! not an anti-"rostaglandin birth control "ill for G=S! "utting you on birth control "ills doesn't hel" for dysmenorrhea! birth control "ill hel"s because on the combination birth control "ill! you build u" less endometrium (that's why "eriods are lighter) so less "rostaglandins! so less cram"ing assuming with "ainful menstruation we're not talking about women having endometriosis (similar! but a whole other "henomena)

-8.. P(+5ic I$1+#33#)!&, Dis(#s( =PID> it's a generali ed infection of the "elvic area. the "roblem is that since re"roductive organs are sitting in "elvic area they can become infected also. one of the things we worry about (with G/-)$ if you have a generali ed infection in "elvic area! we're concerned about the fallo"ian tubes (which are about the width of a s"aghetti) if it becomes infected! we'll leave scar tissue which makes tube narrower. conce"tion takes "lace in the fallo"ian tube s"erm gets "ast scar tissue! fertili es the egg! then the egg divides! becomes larger! and can't get "ast scar tissue and gets stuck. the egg continues to divide! e#"and the fallo"ian tube and we've got a tubal! or ecto"ic "regnancy. eventually! it will ru"ture the fallo"ian tube which means emergency surgery! try to "iece back your fallo"ian tube! leaving behind scar tissue. /1- increases the risk /1-'s are on the comeback (they were gone in 5:'s through early &:'s) there are two /1-'s back on the market now irritates the endometrial lining and "revents the ygote from im"lanting /1-'s slightly increase the risk of G/-. commercials will say there's a slight risk of G/-'s with the /1 some G/-'s are from ST-'s gonnarhea chalamydia these women are sick fevers increased ,0C we're in a vascular area so we're concerned about organisms getting into blood stream develo"ing se"ticemia they can be sickN don't %ust give them a cou"le of antibiotics and send them home. -:. E9*+#i$ ) ( &(+#)i!$s i* .()"(($ )!9ic s !c; s,$%&!3( #$% S. #u&(us.

there's a lot of concern (starting *6 years ago) that tam"ons were contaminated with S. aureus and that was the reason for to#ic shock syndrome. .ever ha""ened. this is what ha""ens - a small "ercentage of women (about 6-5') of women! carry S. aureus in the lining of the vagina side note$ small "ercentage of "eo"le carry S. aureus in noes and nasal "haryn# - of no conse(uence. /n a nursery (G/C1's! etc.) - once a year infection control will come stick a swab u" your nose to see if you're a carrier of sta"h. because as you're coughing! breathing! snee ing you can dis"el organism onto newborns and they're very susce"tible to sta"h. Sta"h loves sugarN (sugar to sta"h is like fertili er) most tam"ons! "articularly su"er absorbent! the ma%or fiber in there is cotton. as cotton breaks down! one of the "roducts you get is sugar. you're carrying sta"h! sugar is fertili er! so sta"h starts growing like cra y as it grows! it "roduces an e#oto#in we're in a very mucous membrane area! so e#oto#in gets absorbed through the mucous lining of the vagina and circulates throughout the body. the e#oto#in causes$ the fever (not low grade! but ):)-):@) a rash that resembles a sunburn most im"ortantly - diarrhea on the bo# of tam"ons tells you if you have these sym"toms! discontinue and seek medical attention scenario$ this "erson had ):* and significant diarrhea for ?-): hours! maybe a little vomiting by the time they get to the E> (after ?-): hours)$ their fluid and electrolytes are so shot they are in res"iratory arrest C7 arrest doesn't have enough veins to get an /7 in to "ut fluids in it's the fluid and electrolyte disturbance from the e#oto#in that kills them. rather than trying to "ick u" all the carriers! we said be concerned about "articularly su"erabsorbant tam"ons that are used for an e#tended "eriod of time.

-<. I%($)i1, ) ( .#sic *#) !+!', #ss!ci#)(% "i) c#$c(& !1 ) ( c(&5i9D ($%!3()&iu3D !5#&, #$% 1#++!*i#$ )u.(s. C#$c(& !1 ) ( c(&5i9 often times is a uni(ue kind of cancer it's called <carcinoma in situ< (in situ O inside) is a non-invasive ty"e of cancer

it's actually a cancer that's really more like benign growths the cancer cells on the inside are surrounded by "erfectly normal cells the truly malignant cells are %ust nudging the tissue aside! not invading it only a cou"le "laces where we ty"ically find in situ malignancies is found (cervi# is a classic) if the growth has invaded the full thickness of the cervi#! then you've got c#$c(& of the cervi# if less than full thickness of cervi#! then it's %,s*+#si# ("re-cancerous and watch it) there's considerable evidence that 56'-?6' is really the result of * se#ually transmitted diseases$ 2G7 virus 2er"es virus so males are giving you 2G7 and 2er"es - which is giving you cancer of the cervi#. who has the highest incidence of cancer of the cervi#3 "rostitutes (more "artners and the more often you have them) - the more likely you will get 2G7 and 2er"es they also have the lowest incidence of breast cancer (why3 - assume more births) lowest incidence of cervical cancer3 nuns nuns also have the highest incidence of breast cancer this is why you need to give daughters 2G7 vaccine also! it kind of makes sense to vaccinate the males (and will hear about soon) recommendation is about )*-)@ yr! start vaccinating males for 2G7 2er"es - no vaccine yet cancer of the cervi# is why you're getting a "a" smear "a" smear started back in the 9:'s by an italian "hysician it has significantly reduced the incidence of cancer of the cervi# but you've got to get a "a" smear regularly

E$%!3()&i#+ C#$c(& cancer is most common after meno"ause after meno"ause! nothing is going on with endometrial lining so this is a ty"e of cancer that doesn't get diagnosed early because there aren't any signs it metastasi es classically to the ovaries and to the myometrium (muscle lining of uterus) sym"toms come after it's metastasi ed commercials on birth control "ills decreases some forms of cancer - this is one of them

 on the other hand! endometrial cancer is most common after meno"ause so why are you on the "ill3 you're not. there is some endometrial cancer before meno"ause! but incidence is very! very small. C#$c(& !1 ) ( !5#&i(s accounts for about *B' of cancers in females involving the re"roductive system most common in women after meno"ause what's going on with ovaries after meno"ause3 not much usually! these malignancies in the ovaries have grown to a si e where you're getting some abdominal discomfort or they're "alatable on a "elvic e#am. by that time! they've metastasi ed. there aren't any clear! early warning signs "ost-meno"ausal of ovarian cancers. can run in the family ("resented with breast cancer info below) P&i3#&, F#++!*i#$ )u.( c#$c(& "robably never see this - really rare. 4ou %ust don't see it. it's good because these have a really! really "oor "rognosis 6 year survival rate is around ero. 0@. Discuss 1i.&!c,s)+c %is(#s( !1 ) ( .&(#s) #$% &(+#)( (s)&!'($ #$% *&!'(s)(&!$( +(5(+s )! ) is %is(#s(. 1i.&!c,s)ic .&(#s) %is(#s( =$#3(% c #$'(% )! M1i.&!c,s)ic c #$'(sM includes cyst formation! ductal e"ithelial "roliferation! and ductal adenosis with the formation of fibrous tissue (glandular disease of the breast in which the ducts are enlarged.) all this means is that there are "alatable nodulesHcysts in the breast sometimes! es"ecially if there is a lot of ductal stuff going on! there will also be discharge from the ni""le tissue of the breast caused by$ an increase in estrogen and a deficiency in "rogesterone during the luteal "hase of menstrual cycle (before ovulation) cycle$ folliculary "hase ovulation luteal "hase - right after ovulation this usually occurs bilaterally about 6:' of females have this. on "ost-mortem we find it in 6:' of females

if 6:' of a "o"ulation has something! it's "robably not a disease so fibrocystic breast disease was renamed$ <fibrocystic changes M some of these changes can be correlated with an increase incidence in breast cancer! but some are not. if you've got a lot of e"ithelial "roliferation! then we need to watch that "retty closely if what you've got is reoccuring cysts in the breast tissue! its' not "articularly correlated with breast cancer ti"off is that cysts a""ear and disa""ear (de"ending on time of the month) but this scares women - and it should a mass "icked u" on breast e#am! should have someone look at it. what "eo"le think of is breast cancer.

@).

E9*+#i$ c#$c(& !1 ) ( .&(#s) i$ )(&3s !1 ),*( !1 )issu( i$5!+5(% #$% &#)( #$% 1&(Au($c,. breast cancer is the second most common form of cancer in females )st is lung cancer e"idemiology$ very common in .. America! western euro"e very rare in +a"an increase risk of breast cancer$ if you've never given birth (nulli"arte) you started menstruating early ():) and went through meno"ause late (5:) slightly increase your risk if your first "regnancy is after age of @: yr. but counteract that (decrease risk) if you breastfeed genetics (gene that gives you 56' "robability of breast cancer) a slight variation of this gene for breast cancer that increases risk by 56' of develo"ing ovarian cancer (ovarian cancer runs in the family! too! because of this gene that "redis"oses you) broken down into @ categories LCIS (lobular carcinoma in situ) in the lobular e"ithelial tissue in situ - noninvasive ty"ically! a lum"ectomy is done cut out cells watch from now on! but this is not an invasive cancer DCIS (ductal carcinoma in situ) same thing as DC/S! but in ductal system DC/S and -C/S only account for *:' of breast cancer I$5#si5( %uc)#+ c#&ci$!3# =IDC> ?:' of breast cancers it's kind of a classic cancer

start with a little hy"er"lasia a little bit of weird looking cells then they look more weird then they starts re"roducing like cra y - a real classic cancer. it's also a real slow-growing cancer time from if we took one malignant cell of /-C to ) cm mass in breast (about the smallest you can "al"ate)$ takes about 5 years by the time we've gotten to )cm mass! *6' of these cancers have metastasi ed. ,e're in the ductal system. by the time you've "icked it u" in the breast! *6' have already metastasi ed to the lym"h nodes! liver! lungs! whatever we're talking about. women are better at breast e#ams than males are at testicular e#ams we've done a lot in teaching females on how to do breast e#ams a degree of breast tissue masses and testicular masses are "icked u" by significant others by accident. teach everyone how to do both ty"es of e#ams we thought mammograms would be the key (*: years ago) they aren't really "anning out to what we thought they would do we still have to inter"ret the mammogram and make some decisions need a sim"le blood test (like GSA for "rostate)! but we don't have that with *6' of these cancers metastasi e! that's going to mean deaths from breast cancer. They're going to stay high until we can diagnose early. mammograms can "ick u" slightly less than )cm incidence slightly higher in African Americans

0-. Dis)i$'uis .()"(($ P#'() %is(#s( #$% i$1+#33#)!&, c#$c(&. P#'() %is(#s(? it's a variation on a theme this is breast cancer but the malignancy follows s"ecifically the ni""le ducts it will invade eventually the e"idermis of the ni""le tissue but it is %ust in the ni""le ducts and glands (not in the lobular initially - although will invade at some "oint) I$1+#33#)!&, B&(#s) c#$c(& ho"e you never get it or see it this is an e#tremely fast-growing cancer - "henomenal awful mortality rate see this more in a younger$ 9:-6: year old "resentation =onday - breast looks fine! nothing

by Jriday! this breast is swollen red! looks likely it's acutely infected tissue! breast looks like the skin of an orange! dim"led this is an acute infection this is how (uickly this malignancy has begun to grow. bio"sied on Jriday night Saturday! remove breast =onday! start radiation and chemo this is very (uick growing this has a very (uick metastasi ing time and a very "oor "rognosis but not nearly as common as ordinary breast cancer

B#+( R(*&!%uc)i5( s,s)(3 @@. E9*+#i$ ,*!'!$#%is3 #$% ) ( &(+#)i!$s i* !1 )(s)!s)(&!$( )! ) ( c!$%i)i!$. Konads - generic term that refers to the "rimary re"roductive structures (ovaries and tests) hy"ogonadism means hy"o functioning testes in males testesHgonads are res"onsible for testosterone "roduction what "resents sym"tom-wise is a function of the age of male "re-born male$ if you've got an P4 male there's a grou" of cells that are going to be the male re"roductive structures! since we have an P4 male! we have a cou"le of other cells that start "roducing testosterone about ?-& weeks in. when the grou" of cells start receiving testosterone! that's the signal for them to start differentiating into male anatomy seminiferous tubule is where s"erm "roduction takes "lace interstitial cell "roduces testosterone PP fetus the same grou" of cells are in the PP fetus! but they don't have the other cells that "roduce testosterone at ):-)) weeks without testosterone! the grou" of cells start "roducing female anatomy "ro"ecia - for growing hair if "regnant or might be "regnant! don't take these "ills if you were early in "regnancy and you take these (and a cou"le other meds like this too)!

 the grou" of cells will think you have testosterone and start develo"ing into male se#ual characteristics (no big deal in a male! but an obvious "roblem with a female fetus) before males are born! the low amount of testosterone can affect male anatomy (low s"erm count) interesting...a cou"le of studies have shown that in P4 males who got a little e#tra estrogen in their develo"ment! they are more likely to be gay. <4ou are born gay< At least it's correlated with it in males later in life! testosterone "roduction is involved in s"erm "roduction - (uality and (uantity and libido males with hy"o-functionaing gonads (like males who have been on growth hormones and steroids - which also su""ress gonad activity) steroidal males - big muscles! great bodies! but can't do anything with them because they've lost their testosterone$ im"otent and s"erm "roduction is almost gone. after they've taken steroids! they still have this "roblem (no erection! no s"erm "roduction) - "ermanent damage "uberty - hy"o-functioning gonads a lot to do with bone develo"ment and e"i"hyseal closing in long bones 04. I%($)i1, ) ( c!33!$ ),*( !1 c#$c(& #11(c)i$' ) ( *&!s)#)(. )&' of all cancers in males (head to toe) &6' of these cancers are adenocarcinomas (glandular e"ithelial) no genetic correlation yet but it is highly correlated. we've also said that "rostate cancer is something you will get if you live long enough and have a "rostate *H@ of ?6 year olds have "rostate cancer 0G2 (benign "rostatic hy"er"lasia - big "rostate) it is not correlated with cancer of the "rostate ty"ically! hy"er"lasia indicates cancerous! but not in the "rostate treatment is a function of who you ask surgeon$ cut it out radiologist$ "ut radioactive beams in it and radiate it endocrinologist$ treat it with hormones does work sometimes the "rostate in males is a gland that is very sensitive to testosterone levels and very sensitive to estrogen levels so give estrogen and it can decrease "rostate activity! decrease hy"er"lasia! decrease malignant growth but you have to deal with the side effect of estrogen in males$

 breast develo"ment develo"ed at ,1! a decade ago! GSA ("rostate s"ecific antigen) - a blood test a "rotein that seems to be correlated with "rostate cancer this is coming under some scrutiny right now because we ty"ically said u" until a cou"le years ago that elevated GSA and we've seen it a cou"le times! at least do a bio"sy some elevations in GSA's not really correlated with "rostate cancer! they're %ust elevations that seem to ha""en as males age current recommendation (won't ask on test) assuming no "rostate cancer in family and a white male GSA at 6:! 66! at B: (Q B: GSA and "rostate e#am annually) ): years earlier if there is a h# of "rostate cancer if African American male first GSA at 9:! 96! then annually from 6: on (no h#) start at @: if there is a h# of "rostate cancer for some reason they get "rostate cancer ): years before white males and we don't know why if family history! if you have a )st degree relative everything gets moved ): years earlier because there is a genetic link! we think! in "rostate cancer you have to ste" back and use logic do we want to take out "rostate3 at ?@! they've had elevated GSA a few times! you will "robably die of something else so do you want to me incontinent and im"otent if @?! we should consider some surgery and some nerve s"aring surgeries (remove "rostate! but cut around nerves) are starting to ha""en so incidence of incontinence and im"otent is better used to be ?:' "robability of incontinence and im"otence now "robability around im"otency and inconstancy is *:' C#$c(& !1 ) ( )(s)(s accounts for about )' of all cancer in males tends to occur in young males ("eak age$ *:-@6 yr) more familiar of it because Dance Armstrong had it if a male has a growth in the testes! it will be malignant (&&.&') there are no benign growths in the testes they can have hematomas! but not growths tests (and males) are "retty sim"le testes made u" of a coiled tube$ seminiferous tubule in this tube is where s"erm "roduction takes "lace

in between the coils are interstitial cells! those cells "roduce testosterone if you uncoiled semi-niferous tubule - 9: yards long$ each testes so you com"ress the 9:-yd tube into a * # )< s"ace so these are "retty small tubes you've got long tubes and s"erm "roduction ha""ening all through here that's why males "roduce a lot of s"erm. males "roduce )6:: s"ermHminutes *9hr H day - a lot of s"erm when a males e%aculates! he e%aculates about 6:: million s"erm why do you need 6:: million s"erm - they're not that bright$ lose s"erm try to fertili e vagina! uterus! cervi# only one fallo"ian tube has an egg so a bunch head u" the wrong tube only have about half the s"erm (*6: million s"erm) left on the correct tube it takes hundreds u"on thousands s"erm to beat u" against the egg before a s"erm can fertili e it. an en yme reaction is going on because the egg has a very thick shell around it. The en yme reaction is loosening the shell and takes hundreds and thousands of s"erm to do this. one of times! one of these s"erm makes it into the egg and then instantly all the other s"erm are re"elled and they immediately start swimming in the other direction otherwise serious chromosome "roblems could ha""en @6. E9*+#i$ ) ( &(#s!$s 1!& ) ( s,3*)!3s !1 GC i$ .!) 3#+(s #$% 1(3#+(s. Konorrhea - caused by the bacteria! .eisseria gonorrhea. (KC is shorthand for gonorrhea) @-9 million new cases re"orted! actual cases are "robably *# this. this is a very delicate bacteria it's a bacteria that if it's on the tableto" you're writing on will live there about a minute or less it can't live outside the body for any length of time at all <can you get gonorrhea from a toilet seat3< - yes! if you have se# there. you don't get this organism from the environment it's "assed on from "erson to "erson. =ales (a""lies to &&.&' of males) incubation "eriod is @ to 6 days at end of incubation "eriod$ they have "ain and burning on urination and a discharge from the "enis the reason they have the sym"toms is that gonarrhea in males is a locali ed infection of the urethra - an infected urethra urine "asses through the urethra$ "ain and burning discharge coming from the urethra is "us it's nice that males have these sym"toms - they are motivating to get them into the clinicHE> because they're uncomfortable.

Jemales about 6:' have same sym"toms as males in @ to 6 days$ "ain and burning u"on urination discharge from vagina other 6:' don't have the same sym"toms in @ to 6 days$ it may be * weeks! @ weeks! B - ? weeks before she has any sym"toms so if they remain se#ually active! they will s"read the disease this is the grou" that's res"onsible for (transmits) most of the cases of gonarrhea she's not going to know until a male se#ual "artner comes back and says that she's the cause of his gonarrhea. There's something you can do! well the lab can do this$ they'll do a direct gram stain of discharge material ("us) discharge is "us and "us is segmented neutro"hil looking for intracellular gram negative cocci a gram negative cocci inside of a segmented neutro"hil diagnosis$ ?6' chance of being right if you say gonarrhea if they have$ "ain and burning u"on urination discharge from vaginaH"enis observation of intracellular gram negative cocci (inside a seg) high enough "robability to start treatment if we did not see the gram negative cocci inside their seg! we're going to say these "eo"le have$ .K1 (non-gynococcal urethritis) an infected! inflamed urethra! but not gonarrhea "robably going to use the same RtreatementRRRRR =ulti"le scars in the urethera "uts "ressure on the bladder! "ressure on the ureters and "ressure on the kidneys Fidneys aren;t; designed for back "ressure and can lead to loss of renal f#n in E0! you'll come across KC every child that is born has antibiotics "ut in their eyes %ust in case mom had gonarrhea because the child can "ick u" the organism in the con%unctiva lining of the eye and results in gynococcal blindness standard "ractice is to get child's eye irrigated with antibiotic. conse(uently we don't see gonarrhea in the eyes if you do see this! the child was not delivered in a hos"ital

07. E9*+#i$ ) ( &(#s!$s 1!& c!3*+ic#)i!$s suc #s NNNNNNNs)(&i+i), #$% )u.#+ *&('$#$c, 1!++!"i$' GC i$1(c)i!$s. due to increased risk of G/-

08. I%($)i), ) ( s)#'(s !1 s,* i+is #$% (9*+#i$ ) ( s,3*)!3s !1 (#c s)#'(. "robably been around since day * a lot of famous Al Ca"one Scott +o"lin Christo"her Columbus Edgar Alan Goe Jlorence .ightingale this is a very hardy organism Tre"onema Gallidum it's s"iral sha"ed very hardy organism will live on table to" )*-)9 hours and still be infective sy"hilis is very un"redictable could get sy"hilis today and die in @ months could get sy"hilis today and live another 9: years how (uickly "eo"le "roceed through this is un"redictable stages stage )$ i$cu.#)i!$ *(&i!% all diseases have this lasts about * to 9 weeks stage *$ *&i3#&, s)#'( what characteri es this stage is a""earance of a chancer (aka canker) a chanker is a little soft ulcer it looks the same as an ulcer on inside of cheek (called a chankloid) <oid< means <like< which stays around for a week or so and then goes away it's caused by a virus chancer with sy"hilis stays around for * to 9 weeks and then goes away "eo"le will say! </ had this growth on my "enis and it went away< !$+, time sy"hilis is transmitted through se#ual activity is when the chancer is "resent! assuming the chancer is on the e#ternal genitalia (can't be transmitted before or after that) stage @$ S(c!$%#&, s)#'( get a lot of flu-like sym"toms sore throat swollen lym"h nodes rashes goes on for a year or so sym"toms "resent! then go away! then come back! stage 9$ +#)($) s)#'(

latent means <no sym"toms< no rash! no chancre! no nothing "eo"le can stay here for @: years stage 6$ )(&)i#&, s)#'( eventually! if they live long enough! stage 9 will end u" here and affect the C.S (brain) andHor affect the Cardiovascular system because that's where the organism is headed. incidence of sy"hilis is small com"ared to gonorrhea most sy"hilis is transmitted through blood. Can test the blood in the secondary! latent and tertiary stage only about @:!::: cases of sy"hilis "er year for * years in a row St. Douis led the nation for years we controlled sy"hilis by "remarital blood work. /t knocked down the cases of sy"hilis$ every state in the country did this$ "remarital blood work testing for sy"hilis if you have sy"hilis! state won't issue marriage license until you're treated most states have sto""ed doing this! but B or ? states still do this blood testing wait for @ days$ draw blood! test blood! get results some "eo"le have said that we should reinstate "re-marital blood tests but testing for A/-S - ridiculous now you need to give consent for "artner to see results be sus"icious if you didn't let them see it. we don't have a cure for 2/7 S so you don't get married. we'd rather have you married! less likely to transmit. it won't work. sy"hilis in children$ mom had sy"hilis in secondary latent stage! gets "regnant child was born with tertiary sy"hilis or child was born! looked fine and develo"ed sy"hilis at @ months! B months! * years or occasionally child was born to mom with sy"hilis! kid looks fine and is fine. )st clue isn't until the "ermanent teeth start to come in. they develo" <hutchinson's teeth< involve the two central front incisers (front big teeth) those * teeth have a very "ronounced notch out of the center of the tooth very obvious! see it clearly across the room. it also ha""ens in molars! but you can't see those hutchinson's teeth is a red flag the child has sy"hilis and may be your first indication

 as chancre begins to disa""ear! from that "oint on it's transmitted by blood if mom was in latent stage and got "regnant kid e#"osed during 9: months of "regnancy and they certainly would be born with tertiary. child could be in any of those @ stages (secondary! latent! tertiary)! so could we from needle sticks if we %ust knick the skin$ we'd get an incubation! chancre! ...and get sy"hilis that way and nobody will believe you but if you hit a vessel and in%ect some blood right into your vein$ ski" )st two stages and go to the @rd! 9th and 6th 0:. I%($)i1, ) ( s*(ci1ic !&'#$is3 c#usi$' s,* i+isD GCD H(&*(sD #$% 5#'i$#+ ,(#s) i$1(c)i!$s. Sy"hilis - Tre"onema Gallidum KCHKonnarhea - .eisseria gonorrhea 2er"es - 2er"es Sim"le# / and // virus 7aginal yeast infections - Candida albicans F+ui% V!+u3( #$% E+(c)&!+,)( Dis!&%(&s Three categories of "roblems with disorders of fluid volume and electrolytes$ 7olume imbalances "rimarily will deal with e#tracellular fluids generally we'll be talking about the e(ual loss or the e(ual gain of water and sodium. .ot dehydrationT dehydration is only the loss of h*: which leads to hy"ernatremia Esmotic imbalances this one's "rimarily going to deal with intracellular fluids generally talking about the une(ual loss or une(ual gain of sodium and water concentrating sodium or diluting sodium (so hy"er- or hy"onatremias) Com"osition changes first two (volume imbalances M osmotic imbalances) deal with sodium com"osition changes deals with ions other than sodium! and s"ecifically dealing with "otassium it is a change in an ion! like "otassium! without altering osmotic activity. 7ED1=E /=0ADA.CES /. ,e'll deal with ECJ deficits first 0<. E9*+#i$ H,*!5!+(3i#. hy"ovolemia means the loss of e(ual amounts of water and sodium. this is not dehydration dehydration is$ only the loss of water

but not a loss of sodium if you lose water! but not sodium! sodium is concentrated. these "eo"le who are dehydratead will be hy"ernatremic hy"ovolemia deals with the e(ual loss of water and sodium almost always this is going to be related to renal "roblems or e#trarenal "roblems (so the kidney or something else besides the kidneys) E#trarenal$ vomiting bleedings diarrhea >enalHkidneys would be things like$ renal failure basically anything that can cause "olyuria with the kidneys will "ossibly result in a volume "roblem. if we looked at all the "ossible reasons! renal and e#trarenal! the to" @ causes are$ "rolonged vomiting .K (nasogastric) suctions massive! big-time diarrhea's all @ causes involve K/ fluid K/ fluid is fluid (water) that's very high in sodium E#cluding vomiting! .K suctions! diarrhea and so forth (adults only) if "atient has a tem" of ):) - ):@ for a *9-hour "eriod! they have lost a""ro#imately 6:: mD of fluid (so they're 6::mD in the hole) if the "atient has a tem" above ):@ for *9 hours! they've lost a""ro#imately )::: mD of fluid (they're ):::mD in the hole) if you throw in a tem" of ):@ and /'ve also got vomiting and diarrhea and that kind of thing! then we're looking at big-time fluid losses$ *:::-*6:: range "roblem with hy"ovolemias! to some degree - on a continuum is always going to be that we run the "otential of interfering with cardiac out"ut because if you're going to e%ect 5:mD out of the left side of the heart and that is the stroke volume! you've got to get back that volume in the > side of the heart. if volume going into the right side of the heart is decreased then we're decreasing blood going out of the left side of the heart so 0G is down! tissue is not being "erfused! e#ce"t 2> goes u" to com"ensate what will ha""en when there is a little bit of fluid deficit! like 6::mD! then sym"athetic changes will usually take care of this$ increase 2> increase force of contraction generally that will maintain the fluid volume if we're over 6::mD! so closer to ):::mD! then we also kick in the >AAS

 which increases 07 and increases 0G (review >AAS system) generally! if /'m *:::mD low in fluid! then the >AAS will work e#ce"t when / stand u". /f / really have a fluid deficit of *:::mD and / stand u"! / will faint (which is your body's way of telling you to lay back down). if we get to the e#treme (B:::mD in the hole fluid-wise) low! there's nothing we can do to give you enough fluid to maintain cardiac out"ut. but as you get closer to that far e#treme! we start trying to shunt blood from! for e#am"le! your skin skin is cold and clammy take all fluid from skin and "ut in vital organs trying to do everything we can to retain "erfusion in vital organs - we're not concerned with your skin being "erfused at this "oint. 0<. E9*+#i$ H,*(&5!+(3i# means that we've retained sodium and water in the same "ro"ortion so as this fluid accumulates! it shifts into the interstitial s"aces! which is the definition of edema (fluid in interstitial s"aces is edema) this can be locali ed or very generali ed edema generali ed edema always indicates there's some "roblem going on with ECJ. +ust the fact of life. Things like$ renal failure cirrhosis of the liver C2J - those are things that can cause hy"ervolemia's if you're hy"ervolemic! 0G is u" (%ust like if you're hy"ovolemic! 0G is down)

4@. C!3*#&( H,*!5!+(3i# "i) %( ,%&#)i!$. see details in 2y"ovolemia descri"tion OSBOTIC IBBALANCES this one involves the concentration of solutes in body fluids sodium has the ma%or osmotic activity in ECJ's so talking about hy"o- and hy"er-osmotic situations which are really hy"o- and hy"er-natremia's 41. D(1i$( ,*! #$% ,*(&$#)&(3i#. H,*!!s3!)ic i3.#+#$c(s F H,*!$#)&(3i#Is defined as a serum sodium below )@6mE(HD There are two ways to get here$ the loss of sodium in e#cess of water - could be things like vomiting (how long and how much) are we at the "oint where we've em"tied your stomach! we've em"tied

your u""er "art of your duodenum and now we're at the "oint of dry heaves and throwing u" %ust fluid and there's nothing there to throw u". E#treme end of vomiting is ty"ically fluid imbalances otherwise! we're dealing with hy"onatremia diarrhea's Addison's disease any scenario where we're retaining "ro"ortionally a large amount of water over sodium. the gain of water in e#cess of sodium C2J could be renal failure there's also a "sychiatric condition called$ "sychogenic"olydy"sia com"ulsive drinking of water. they'll drink B-? gallons of water a day. if you're drinking ? gallons of water a day! you will be hy"oosmotic. H,*(&$#)&(3i# F ,*(&!s3!)ic defined as a serum sodium above )96mE(H$ so we now know the norms for serum sodium$ )9: SH- 6 an increase in sodium will cause water to shift from the intracellular fluids to the e#tracellular fluids because of the osmotic activity of sodium so therefore the cell shrinks H or the cell dehydrates (hy"ertonic draws intracellular fluid out into e#tracellular fluid) "oor salt on a slug on the concrete - it shriveled u" because we created a hy"erosmotic situation how do we get here$ the loss of water in e#cess of sodium can be things like fevers burn "atients have a tremendous "roblem with this our "rotection against hy"erosmotic scenarios is being thirsty if we eat a whole bag of "otato chi"s! you feel thirsty that's why they serve beer and salty snacks served at bars anytime you eat something salty! we're increasing salts so you need increased water or li(uid to balance that. or the gain of sodium in e#cess of water this can ha""en! unfortunately! more often than we'd like we have a "atient with a sodium level of )@: so we're giving him sodium salt /7's! but nobody's watching his labs so we shift this "erson from a sodium of )@: to a sodium of )66. %ust because nobody has the res"onsibility of watching the labs. Always watch lab values when we're talking about giving electrolytes another e#am"le of this increase of sodium over water is near-drownings

in sea water sea water has a lot of salt "atients in near drownings in sea water usually have hy"erosmotic situation 4-. Gi5( c!33!$ &(#s!$s 1!& 1+ui% 5!+u3( %(1ici). See above. 40. E9*+#i$ ) ( (11(c)s !1 ,*!5!+(3i# !1 &($#+ 1u$c)i!$ #$% ) ( &($#+ c!3*($s#)i!$ " ic usu#++, !ccu&s. See above 44. E9*+#i$ ,*(&5!+(3i# #$% 'i5( ) ( 3!s) c!33!$ c#us(s. see above 46. D(1i$( ,*!!s3!)ic i3.#+#$c(s i$ )(&3s !1 N#O5#+u(s. see above 47. E9*+#i$ ) ( )"! *&i3#&, &(#s!$s 1!& ,*!!s3!)ic i3.#+#$c(s. see above 48. D(1i$( ,*(&!s!3!)ic i3.#+#$c(s i$ )(&3s !1 N#O 5#+u(s. see above COBPOSITION CHANGES the other two dealt with sodium - sodium is the ma%or cation e#tracellularly Gotassium is the ma%or cation intracellularly the amount of "otassium in the serum is "retty low$ @.6-6.6 mE(HD as com"ared to the amount of "otassium inside cells (like nerve cells! >0C! cardiac cells) is )B: to *:: mE(HD that's fine because if you look at areas where intracellular and e#tracellular "otassium levels dramatically differences looking at to e#citable tissues cardiac muscle nerves sodium-"otassium "um"-kind of stuff you need the "otassiums to be different 4:. D(1i$( ,*!;#+(3i# i$ )(&3s !1 PO 5#+u(s. a serum "otassium below @.6 mE(HD how do we get there - hy"okalemia3 starvation vomiting diarrhea's .K suctions "atient on diarrhetic drugs

 most common causes for hy"okalemia's are going to be (for what we'll run into)$ vomiting diarrhea .K suction 4<. E9*+#i$ ) ( i$1+u($c( !1 PO !$ *H. "otassium levels are always correlated with blood "2 correlation is very "redictable for about every .) unit fall in "2! "otassium levels increase about .6 mE( for about every .) unit increase in "2! "otassium decreases .6mE(. so "otassium and blood "2 is always inversely related (one goes u"! the other goes down) 6@. E9*+#i$ " , ,*!;#+(3i# 1&!3 5!3i)i$' is $!) &(+#)(% )! ) ( +!ss !1 '#s)&ic c!$)($)s. those were the same @ things (vomiting! diarrhea! and .K suction) that got us hy"oosmotic because K/ fluid has a lot of sodium the K/ fluid (your stomach) does not have a lot of "otassium the amount of "otassium in your stomach is around 6-): mE(HD your "otassium level is not that high how do they become hy"okalemic because they're not losing much "otassium! then$ throwing u" for @ days or .K suction (you're sucking everying out of my stomach) for @ days my stomach is acidic and if /'m throwing u" the acidity then / don't have the acid to kick into the vascular system so my blood "2 is going to go u" when "2 goes u"! "otassium is shifted into the tubular "art of your kidneys and you "ee it out. you're not losing "otassium from the stomach! u""er K/ tract! or anywhere in the K/ tract! but constant loss of fluid from the K/ tract means the "atient will become alkalotic and alkalotic means hy"okalemia's because of the inverse relationshi". 61. D(1i$( ,*(&;#+(3i# i$ )(&3s !1 PO 5#+u(s. defined as serum "otassium above 6.6 how far we are above 6.6 tells you how much of a "roblem this is 6.B - not concerned ):.B - ma%or concern E9*+#i$ ) ( &(+#)i!$s i* !1 PO +(5(+s )! c#&%i#c 1u$c)i!$i$'. because hy"erkalemia mean tissue is less e#citable

6-.

so what ha""ens to your heart if "atient has ):.B "otassium level slows down and is less e#citable - will sto" heart e#$ as you e(uate "otassium levels! cardiac cells are less e#citable "otassium is @.) giving them "otassium /7's and no one is watching the labs "otassium goes from @.) to ?.) because no-one is watching the labs watch labs - "articularly when we're dealing with electrolytes most common scenario that you'll see with hy"erkalemia$ "eo"le who are in renal failure because they can't "ee out their "otassium (and can't "ee out their sodium)

B#c;'&!u$% - Aci% B#s( B#+#$c( ,hat makes something acid or alkaline is 2ydrogen ion concentration the more hydrogen ion something has! the more acid it is the less hydrogen ions something has! the less acid it is ,e same that if something has a$ "2 I 5! it's acid "2 A 5! it's alkaline "2 O 5! it's neutral The "2 range in the bloodstream is very narrow$ 5.@6 - 5.96 if someone has a "2 of 5.*! we say they're acidotic. ,ell! no they're not. "2 has to be below 5 to be acidotic and 5.* is not below 5. if you have a "2 of 5.B! you're alkaline. <4ou're always alkaline! it's %ust that you're more alkaline than usual. ,hen we say somebody is acidotic or alkalotic! we're actually aying it wrong. ,e %ust agree to say it wrong. /t's actually relative to normal. ,e're saying that if you've got a "2 of 5.*! you're acidotic. ,ell! you're really not acidotic! but in a way you are - relative to the norms. /t's something we all say wrong and you agree to say it wrong too. it's a very narrow range. There are lots of things going on to change this range so we have to have a way to maintain this very narrow range. ,e have @ ways$ .u11(& s,s)(3 &(s*i&#)!&, s,s)(3 i$1+u($c( !$ ) ( .u11(& &($#+ s,s)(3Is i$1+u($c( !$ ) ( .u11(& BUFFER SYSTEB 0,e have 9 buffer systems that o"erate in the vascular system to maintain 5.@6 - 5.96 /'m only going to talk about one of those because the one ) /'m going to talk about contributes 56' of our buffering ability. the other @ collectively contribute the other *6'.

called the S!%iu3 Bic#&. - c#&.!$ic #ci% s,s)(3$ Bu11(& O a solution of * or more com"ounds that "revents drastic changes in "2 when an acid or a base is added to that solution. look at things without a buffer first 2*E S 2Cl O 2S S Cl Start with 2*E (assume a "2 of 5) to that we add 2Cl (hydrochloric acid) - very strong acid ,hat ha""ens is this acid disassociates into 2ydrogen ions (2S) and Chloride ions (CD-) this water now becomes very acidic. "2 goes down 2*E S .aE2 O .aS S E2 Start with 2*E (assume a "2 of 5) to that we add sodium hydro#ide (a very strong base) it disassociates into .aS (sodium ions) and E2 (hydro#ide) ions there is no 2S ions this water becomes very alkaline the ma%or buffering systems that we're going to deal with are going to be$ c#&.!$ic #ci%$ 2*CE@ S!%iu3 Bic#&.!$#)($ .a2CE@ 2*E S 2Cl S .a2CE@ --A 2*CE@ S .aCl ,e've got our water (2*E) that has 2CD (hydrochloride acid) in it and to that water we then add sodium bicarb (.a2CE@) which means we will get carbonic acid (2*CE@) and salt (neutral$ .aCl) if you %ust let carbonic acid sit there for awhile! you will get ,ater and CE* but this disassociation of carbonic acid is slow so what we have ion the >0C's is an en yme called Carbonic anhydrase (an en yme s"eeds u" a reaction without being consumed) so in the vascular system! when we get carbonic acid! it's very (uickly disassociated by the en yme in the red cells into into water (no big deal) and CE* (e#"ire it and it's gone) H-O O N#OH O H-CO0 --K N#HCO0 O H-O if we have our water that we had sodium hydro#ide in! and to that we add carbonic acid (2*CE@! the buffer)! we get a slightly basic salt (.a2CE@! sodium bicarb) and water. in other words! what /'m saying to you in these formulas is this$ what carbonic acid (2*CE@) does for is is it soaks u"Hneutrali esHdissolves any e#cess base that's in the vascular system and what sodium bicarb (.a2CE@) does is soaks u"Hneutrali es any e#cess acid that's in the vascular system. so these are the two buffers (2*CE@ and .a2CE@) the acid neutrali es the base and the base neutrali es the acid. these two e#ist in a relationshi" of ) to *:

we have ) "art carbonic acid (2*CE@) to *: "arts sodium bicarb (.a2CE@) that's the normal relationshi" of the buffer if something were to ha""en to increase the amount of carbonic acid in the buffer! then your "2 will decrease because we increased the acid "ortion if something ha""ens to increase the base! the "2 will go u" because we increased the base or alkaline "ortion this )$*: relationshi" we have to maintain. which now brings us to the res"iratory and the renal system and their influence on this )$*: relationshi"

RESPIRATORY REGULATION the !$+, way the res"iratory system has of influencing the buffer is by CE* we said that if you left carbonic acid (2*CE@) %ust sit there for awhile! it will give you water and CE*. it also works in reverse. /f you mi# 2*E and CE* you get carbonic acid (2*CE@) if you increase the amount of CE* in the vascular system --A that means we have more carbonic acid2*CE@ which means the "2 of our buffer is more acid so blood "2 is acid if we have less CE* that means we have less carbonic acid 2*CE@ which means the "2 of our buffer is less acid! which means it is more alkaline. only way we have to influence our CE* levels is by the de"th and rate of breathing so if / increase the de"th and rate of res"iration --A /'m blowing off CE* less CE* means less carbonic acid (2*CE@) less carbonic acid (2*CE@) means my blood "2 is becoming more alkaline if / decrease the de"th and rate of res"iration (so breath @ times a minute instead of )*) --A increase CE* more CE* means more carbonic acid (2*CE@) more carbonic acid (2*CE@) means the "2 of the buffer is more acid so my blood "2 is going down RENAL REGULATION kidneys have two ways to e#ert an influence on the buffer if something were to cause an increase in carbonic acid (2*CE@) level or a decrease in sodium bicarb (.a2CE@)! what would you want the kidneys to do to hel" restore the )$*: relationshi"3 these mean the buffer is too acidic so you want the kidneys to$ "ee out 2S ion (get rid of what's causing things to be acid) reabsorb the base (2CE@-)

so that we can get back to the )$*: relationshi" Jactor causes --A increase in 2*CE@ or decrease in .a2CE@ --A kidney increase 2S e#cretion and reabsorb 2CE@-) --A normal ratio restored what about if for some reason the amount of carbonic acid (2*CE@) in the buffer is decreased or the amount of sodium bicarb (.a2CE@) is increased! so now we've screwed u" the )$*: relationshi". what do we want the kidneys to do to get back to the )$*: relationshi" "ee out the base (2CE@-) reabsorb 2S so kidneys can either "ee out 2S or "ee out base (2CE@-)

,hich regulation system (Fidney or res"iratory) has the (uickest influence on the buffer3 res"iratory what do you do the most of3 breathe or "ee3 if you "eed )* times a minute! then your kidneys would have more influence. ACID BASE DISORDERS when we say res"iratory acidosis or alkalosis - what we're telling you is the reason for the condition is the lungs when we say metabolic acidosis or alkalosis - what we're telling you is the reason for that condition is .ET the lungs! we're not saying what it is! but it's not the lungs. 60. D(1i$( 3()#.!+ic #ci%!sis i$ )(&3s !1 H-C@0- #$% *H. means for some reason! don't' know why! we are losing bicarb andHor increasing 2S ions! which is making the buffer more acid.

64.

Gi5( ) ( c!33!$ c#us(s !1 3()#.!+ic #ci%!sis. most common reason for losing a lot of bicarb is %i#&& (# other reasons for losing bicarb includes things like$ renal tubular acidosis (>TA)- defect in absor"tion of bicarb hy"oaldosteronism ketoacidosis starvation (if you're starving you also have ketoacidosis) some drug overdoses like as"irins. not breathing! which is increasing my lactic acid levels (although this would not be metabolic acidosis) anything that would ha""en that would increase lactic acid levels will give me metabolic acidosis kids that ingest antifree e (ASA) - antifree e is very acidic so kids will develo" metabolic acidosis. 66. E9*+#i$ ) ( c!3*($s#)i!$ 3(c #$is3s 1!& 3()#.!+ic #ci%!sis.

what will the lungs try to do com"ensate for this3 the only thing we can deal with with the lungs is CE* - that's it. we've either got to increase or decrease CE* so what the lungs are going to try to blow off as much CE* as they can it's like we talked about with the diabetic that's got a blood sugar through the roof and who has acidosis and they come into the E> they're breathing long e#hale! short inhales (Fusamal's res"iration) ,ill it work3 no what do you want the kidneys to do3 want the kidneys to "ee out the 2S ions and reabsorb the base because we're dealing with acid. the way you know the kidneys are com"ensating is if the "2 of the urine reflects the condition$ if the "atient's acidotic and the urine is acid! the kidneys are trying to com"ensate if the "atient's alkalotic and the urine is alkaline! we know the kidneys are trying to com"ensate you want the kidneys to reflect the condition - then you know there's com"ensation it will take @B hours before the kidneys can start doing this. They're not going to be real fast in terms of correcting what's going on.

67.

D(1i$( 3()#.!+ic #+;#+!sis i$ )(&3s !1 H-C@0- #$% *H. we've got an increase in bicarb or maybe a decrease in 2S ions for some reason things that will cause this$ vomiting .K suctions if you look at these two in "articular! because we're losing a lot of u""er K/ fluid which is very acidic so we're decreasing the acid "art of the buffer Cushings hy"eraldosteronism antacids / don't mean the =ilanta and stuff that we take - no big deal home remedy for heart burn$ baking soda - it's absorbed systemically and baking soda is alkaline the "atient who's been taking baking soda for @ days and he's in the E> and his blood "2 is through the roof because they've been absorbing all this baking soda. with alkalosis! there are two minor little com"ensations that kick in here

 hel" a little! but not dramatically with alkalosis we do get some 2S ions that e#it the cells out into the vascular system to hel" counteract the alkaline we get the 2S ions because cells ty"ically increase their "roduction of lactic acid not a huge deal! but a little contribution 68. E9*+#i$ ) ( c!3*($s#)i!$ 3(c #$is3s 1!& 3()#.!+ic #+;#+!sis. ,hat do you want the lungs to do to hel" com"ensate3 (>es"iratory com"ensation) (uit breathing - that's one way! but that has its limits decrease in res"iration is about the only thing the lungs can do what do you want the kidneys to do3 reflect the condition. (kidneys com"ensations) "ee out the base reabsorb 2S ions D(1i$( &(s*i&#)!&, #ci%!sis i$ )(&3s !1 PC@- #$% *H. now we know the reason for the acidosis is the lungs res"iratory acidosis is defined as a GCE* A 96 and "2 I 5.@6 E9*+#i$ ) ( &(+#)i!$s i* .()"(($ ,*!5($)i+#)i!$ #$% &(s*i&#)!&, #ci%!sis. lots of "ossible causes$ CEG anemias (3) severe "neumonia "neumothora# cardiac arrest slee" a"nea drugs everything we could list falls under the heading of hy"oventilation. /f you're hy"oventilating! then you're not blowing off enough CE* then "atients have res"iratory acidosis so no matter what we "ut! it's always going to be because of hy"oventilation. D(1i$( &(s*i&#)!&, #+;#+!sis i$ )(&3s !1 PC@- #$% *H. defined as a GCE* I @6mm2g and a blood "2 A 5.96 cb hy"erventilation! fevers! thyroto#icosis! "neumonia! asthma! C2J. E9*+#i$ ) ( &(+#)i!$s i* .()"(($ ,*(&5($)i+#)i!$ #$% &(s*i&#)!&, #+;#+!sis. ,ith res"iratory acidosis it was because of hy"oventilation! doesn't it make sense that res"iratory alkalosis is because of hy"erventilation due to hy"erventilation - anything that causes you to the "oint of hy"erventilating

6:.

6<.

7@.

71.

can causes this! but it's always going to be hy"erventilating because less CE* means less carbonic acid! which means the buffer is more alkaline C!3*($s#)i!$$ ,ith this one only! the lungs can sometimes be the "roblem and actually they can sometimes be the solution if the "atient has res"iratory alkalosis! how do we increase the CE*3 (uit breathing! but there's another way we can do that. "ut a "a"erback over your face and breath into the "a"er bag re-breathing your CE* this is one where the lungs can be the "roblem A.- the solution instead of saying don't breath for ): minutes! we %ust "ut a bag over your face and re-breathe your CE* what do you want the Fidneys to do3 reflect the condition urine is alkaline! reabsorb the 2S kidneys won't have an influence here because it will take a day and a half for that to ha""en.