Final Exam Information

• The final exam is scheduled for Friday, April 25th at 10am.
• Room information is to be announced; check for updates next week.
• Blank scrap paper will be provided during the exam.
• Review the syllabus and student handbook for exam policies and information.
• If you are unable to take the exam as scheduled, an incomplete grade will be required.
• All incomplete grades must be resolved before the start of the next semester.
• Make-up exams will be conducted in person.

Exam Components

• Consists of 60 questions.
• Approximately 1/3 of the questions will relate to shock.
• Approximately 1/3 of the questions will relate to endocrine 7, neuro 9, and Gl 8.
• The remaining questions cover other modules with some crossover.
• Expect case studies similar to the midterm, and the question types may include matching, "select all that apply," select "n", multiple dropdowns, and multiple choice.
• The exam has a 90-minute time limit.
• Leaving the room is not permitted for any reason once the exam begins.
• At the 60-minute mark, those who have finished can leave.
• Individuals who are fast test-takers should sit at the back or ends of rows for easier exit.
• Final grades will be released at the end of the exam day.
• One-on-one exam reviews will be available in the summer semester if requested.

Review Content

• Shock is not included in this review; use the shock module, class slides, and Shock Synthesis Assignment to prepare.
• Content other than shock in this review is inclusive of concepts and conditions you will be responsible for during the final exam.
• Be sure to review Synthesis Assignment 1, pre- and post-module worksheets, class slides with answers, and exam prep sections in modules to develop study materials.

Importance of ATP and Oxidative Phosphorylation

• Oxidative metabolism (oxphos) produces 95% of ATP.
• Oxphos generates 20 times more ATP compared to anaerobic metabolism.
• A lack of oxygen results in less energy and more lactic acid production.

Acid/Base Balance

• Includes interpretation.
• Common conditions associated with imbalances.
• Effects of imbalances on the oxygen-hemoglobin dissociation curve.

Metabolic Acidosis

• Marked by excessive acid build-up OR excessive bicarb loss.
• The anion gap can help determine the underlying cause.
• pH is low.
• CO2 is OK.
• HCO3 is low.

Anion Gap and Metabolic Acidosis

• The anion gap represents the difference in cation and anion ratios in plasma.
• Tells whether metabolic acidosis is due to acid build-up or bicarb loss.
• The normal anion gap is approximately 12 mmol/L.
• Normal anion gap indicates too little or loss of bicarb from chronic diarrhea, pancreatic issues, or renal tube acidosis.
• Elevated anion gap signifies excessive build-up of acid from lactic acidosis, ketoacidosis, other renal failures, medications, or inherited metabolic disorders.

Metabolic Alkalosis

• Involves loss of acid from blood, causing excess bicarb.
• Common causes include excessive vomiting, hyperaldosteronism, and diuretic medications.
• pH is high.
• CO2 is OK.
• HCO3 is high.

Respiratory Acidosis

• Caused by excessive carbon dioxide build-up.
• Hypoventilation results from medications, drugs, or CNS depression.
• Diffusion issues and obstructive diseases are contributing factors.
• pH is low.
• CO2 is high.
• HCO3 is OK.

Respiratory Alkalosis

• Caused by excessive loss of CO2.
• Hyperventilation due to altitude sickness or panic attacks.
• pH is high.
• CO2 is low.
• HCO3 is OK.

Understanding Oxygen Carrying: Key Vocabulary

• PaO2 represents the partial pressure of oxygen.
• The oxygen content dissolved in arterial blood measures O2 movement from the lungs to the bloodstream.
• Oxygen saturation (O2 sat, SPO2) represents the percentage of hemoglobin sites carrying oxygen relative to total hemoglobin.
• With an SPO2 of 99%, 99% of available hemoglobin sites are saturated with O2.
• O2 Affinity is how much hemoglobin binds oxygen.
• Higher affinity means more oxygen binding and less release into tissues.

Oxygen-Hgb Dissociation Curve – Right Shift (Decreased Affinity)

• Oxygen leaves hemoglobin and goes to the tissues in acidosis, including lactic acid production, other acid production, or loss of bicarb.
• This also occurs when CO is retained or produced in excess and in high temperature.
• Hemoglobin has a decreased affinity for oxygen under these circumstances.
• Hemoglobin wants oxygen to leave and go to the tissues.
• Makes it less likely to pick up O2 in the lungs, which results in hypoxia.

Oxygen-Hgb Dissociation Curve – Left Shift (Increased Affinity)

• Oxygen will stay with or go to hemoglobin in alkalosis, such as vomiting.
• Also found when the temperature is low.
• Occurs in low partial pressure of CO2.
• Hemoglobin has an increased affinity for oxygen under these circumstances.
• Hemoglobin wants oxygen to go to it and stay with it.
• Makes it difficult for oxygen to leave and go to the tissues, resulting in hypoxia.

Fluid Filtration and Reabsorption at Capillaries

• Fluid filtration is the movement of fluid moving OUT OF vascular space.
• A major force includes capillary hydrostatic pressure pushing fluid out of the capillary.
• Fluid reabsorption is the movement of fluid moving BACK INTO the vascular space.
• Capillary oncotic pressure pulls fluid back into the capillary.
• Albumin is the protein for this force and is made in the liver.
• Net filtrate, the left-over fluid in the interstitial space, is drained by the lymph system.

RAAS

• In healthy people, the RAAS is an important mechanism to maintain balance BP and tissue perfusion.
• In people with HTN, the RAAS can be overactive, leading to salt and water retention and increased blood vessel tone.

RBC's and Anemia

• Red blood cells are made in the bone marrow.
• Erythropoietin (EPO) stimulates red blood cell production and is made in the kidneys.
• Anemia can develop from various reasons, including iron deficiency, B-12 deficiency, hemolysis, cancers, SCD, bleeds, renal disease, and liver disease.
• Signs and symptoms are explained when you know the RBC's function: fatigue, tachycardia, DOE, diaphoresis, leg cramps, and insomnia.
• Diagnosis: CBC, Hemoglobin, Hct (Hematocrit), MCH, MCV, RBC count, and iron levels.

Anemia Classification

• Microcytic hypochromic anemias are characterized by small cell size and low color and include iron deficiencies and small, chronic bleeds.
• Macrocytic normochromic anemias are characterized by large cell size and normal color and include other nutritional deficiencies such as B12.
• Normocytic normochromic anemias include normal cell size and color and causes include blood loss.

Plasma Protein System: Clotting

• Prevents spread of infection to other tissues.
• Traps microorganisms and foreign bodies at the inflammation site.
• Fibrin is the end product that provides a framework for future repair.

Clotting Factors

• All factors are made in the liver EXCEPT factor 8.
• Factor 8 is produced by endothelium.
• Low or missing clotting factors = increased risk for bleeding.
• Measure with PT/INR and PTT
• PT/INR measures the extrinsic pathway
• Helpful for effectiveness of warfarin, an anticoagulant
• PTT measures an intrinsic pathway.
• Helpful for effectiveness of heparin, an anticoagulant.
• Each test measures specific clotting factors to help determine any missing clotting factors.

Sickle Cell Disease

• Autosomal recessive disease (inherited).
• Proteins undergo polymerization, resulting in sickling of RBCs.
• Signs and symptoms: bilateral pain, extremity edema, acute chest syndrome, glomerular disease, and infection.

Inflammatory Response

• 2nd line of defense
• Neutrophils, macrophages, dendritic cells, mast cells, etc. showing up to a threat.
• Histamine, Pro-inflammatory cytokines, and other chemical messengers
• Vascular dilation and increased capillary permeability
• Clotting cascade and complement.
• Bradykinin
• Causes pain, swelling, redness, and heat.

Functions of Antibodies

• Direct protection; neutralize by secreting into blood and mucosa or binding with pathogens and inactivating them.
• Agglutinate; causes pathogens to clump together, which increases removal by phagocytosis.
• Precipitation makes a soluble antigen into an insoluble precipitate.
• Indirect and include complement activation, which results in bacterial destruction by lysis.
• Opsonization: help phagocytes recognize what needs to be eaten.

Endotoxic Shock

• A specific form of Septic Shock is caused by LPS endotoxins from gram-negative bacterial infection.
• Results in inflammatory tissue injuries, multi-organ failure, and massive production of cytokines.

Viral Infections

• Need host cell DNA to replicate and must invade the cell.
• HIV infects CD4+ lymphocytes and results in AIDS diagnosis at CD4+ count < 200 cells/mm3.
• The condition includes anorexia, weight loss, Kaposi sarcoma, herpes lesions, cytomegalovirus retinitis, and thrush.

Hypersensitivity Reactions

• Auto-immune conditions.
• Antibody-mediated (humoral).
• Type I: allergies, anaphylactic reactions.
• Type II: tissue-specific reactions of antigens binding to antibodies.
• Type III: antigen-antibody complexes deposit in vessel walls or extravascular tissues.
• Type IV: cell-mediated reactions.

Type I Hypersensitivity Reaction: Anaphylaxis

• Mediated by IgE
• An allergy reaction is an Anaphylactic reaction
• The antigen from allergen causes either Mast cell or eosinophil “de-granulation”, resulting in.
• Immediate response: 5-30 minutes after exposure:
• IgE relased by B cells
• Release of histamine from mast cells
• Eosinophil recruitment, release of granules/mediator, and epithelial damage.
• Delayed response: 2-8 hours after exposure: a. Leukocyte infiltration, edema, mucus secretion, and epithelial damage b. Prostaglandin
• Results in decreased blood pressure (vasodilation), increased heart rate, redness, itching, rash (mast cells and other inflammatory responses.
• Also bronchospasms (bronchoconstriction) and upper airway swelling

Other Hypersensitivity Reactions

• Myasthenia gravis(Type II) targets acetylcholine receptors. resulting in muscle weakness.

• Goodpasture's (Type II) targets the basement membranes of the lungs and the kidney, which results in dyspnea and blood in the urine.

• Reynaud's (Type III) is a lack of blood flow to the hands from cold.

  • Usually resolves.

• Systemic Lupus Erythematosus(SLE) (Type III) , antibody/antigen complex in health tissue, esp. face and kidneys

• causes Butterfly rash

• Can get really sick because complexes can attack and invade various locations within body

• Type IV HSR, Cell-Mediated and DO NOT use antibody interactions

• Delayed response and IS Cell-mediated

Cardiac Terms

• Preload represents the filling pressure during diastole (filling); affected by blood volume and blood pressure, which helps them stretch.
• Contractility describes how well the heart can contract.
• Afterload is the pressure the heart needs to push against to get blood out of the heart during systole such as SVR.
• Cardiac output = Stroke volume x heart rate (CO = SV x HR).
• Stroke volume is impacted by preload, contractility, and afterload.

Coronary Artery Disease

• Vascular disorder that narrows or occludes coronary arteries.
• A reversible myocardial ischemia or irreversible infarction may result.
• Results from an imbalance between coronary supply of blood and myocardial demand for oxygen and nutrients.
• Atherosclerosis is the most common cause.
• Form cholesterol engulfed by macrophages causing plaque formation in blood vessel walls.
• Can form in any blood vessel in the body leading to ischemia, obstruction and/or infarction.

RAAS and Hypertension

• In healthy people, the RAAS is an important mechanism to maintain balance BP and tissue perfusion.
• In people with HTN, the RAAS can be overactive, leading to salt and water retention and increased blood vessel tone.

Atelectasis

• Collapse of alveoli.
• Involves reduced alveolar ventilation when air inside a plugged alveolus is absorbed.
• Risk factors include confinement to bed, infections, disease, and foreign body.
• Leads to hypoxia, pneumonia, and respiratory failure.
• Presents with dyspnea, tachycardia, cough, pain, cyanosis, and wheezing.

Pulmonary Embolism Risk: Virchow's Triad

• Three risk factors cause a blood clot or thrombus formation

1. Hypercoagulable State

• Maliginancy
• Pregnancy
• Oral birthcontrol pills
• Inflammatory bowel disease ( IBD)
• nephrotic syndrome

2. Circulatory Stasis (stasis) : -Arrythmia like Atrial Fibillation -Obesity with excess abodminal weight

• immobility or paralysis

3. Vascular Wall injuries: _ Trauma for surgery

• indwelling catherters
• Chemicla irritation

Pneumonia

• Infection of the lungs are viral, bacterial, and fungal, and causes purulent fluid in alveoli.
• The purulent fluid causes the lung disease that presents through symptoms such as cyanosis, cough, fever, sweating, fatigue, and tachypnea is dyspnea

ALI/ARDS

• Respiratory distress which causes the lungs to inflame from trauma
• Damage to cells lining the alveoli

Asthma

• Bronchospasms causing inflammation and airway narrowing causing reduced oxygen -wheezing Dyspnea anxiety

COPD: Chronic Obstructive Pulmonary Disease

• Includes Chronic Bronchitis causing Bronchial Imparment

Emphysema "Pink Puffer"

Increase Co2 Retention causes minimal cyanosis, and purse lip breathing.

Blue Bloater

Airway Low, dusky cyanotic, recurrent cough, Hyerpoxia, Respiratory acidosis and increase hgb

Renal/Urinary Tract Functions

• Includes filtering out Water , glucose, creating urine, filtering, and secreting hormones.

Acute Kidney injuries

• Lower GFR
• Measure kidney function with BUN
• kidneys not working properly if there are obstructions

Chronic Kidney Disease

• Loss to the kidney due to the bodies systemic systems
• High salt and water imbalance occurs because reserves are exhausted.

Clincial manifestations of CKD

• High levels of seium or creatine

Types of Jaundice

• Liver unable to process due to many factors

Cerebral Vascular Disease

• Most common neurologic issue that effects blood vessels

TlAS VS strokes

• Transient Ischemic Attack (TIA), episode of neurologic dysfunction lasting no more than 1 hour. There can be stroke within 90 days

Seizures

Generalized vs focal , triggers parkinsons- lack of dopamine/ tremor