CLO 1 (2)_merged Urinary System Disorders PDF

CLO1 Urinary System Disorders I. Define selected urinary system disorders: Urinary tract infections, Glomerulonephritis, Nephrotic syndrome, Urinary tract obstructions, Urolithiasis and Renal failure II. For each urinary disorder: Briefly de...

CLO1 Urinary System Disorders I. Define selected urinary system disorders: Urinary tract infections, Glomerulonephritis, Nephrotic syndrome, Urinary tract obstructions, Urolithiasis and Renal failure II. For each urinary disorder: Briefly describe the pathophysiology · Identify the etiology · Identify signs and symptoms · Define the most performed investigations · State the most common forms of management · III. Apply knowledge in analyzing given case studies · IV. Identify other relevant examples to illustrate disease categories Practice Questions Provide an outline of the renal system from the two kidneys, the ureters, bladder and into the urethra. Describe the anatomy of the kidney and nephron. Compare the male urethra with the female urethra. List the functions of the kidney. Explain UTI, Renal Failure, Urolithiasis and glomerulonephritis Urinary system: 2 kidneys, 2ureter, 1bladder,1urethra Cortex Each kidney is divided into Medulla 1. cortex -- (contain thousands of filtering units called – Nephrons -) 2. medulla – The Nephron Proximal convoluted tubule Each of our kidneys contains over a 1-3 million nephrons. Bowman’s capsule They are the functioning unit of the kidneys. Distal Glomerulus convoluted Nephron’s functions -- tubule 1. They remove waste from the body and produces urine. 2. Selective reabsorption and secretion of ions 3. Mechanical filtration of fluids, wastes, electrolytes, and acids and bases The Glomerulus Collecting Loop of henle duct Is surrounded by the Bowman’s capsule. The glomerulus is like a network of twistedcapillaries Acts as a filter: Blood is filtered across the glomerular capillaries into Bowman’s space. This is the first step in the formation of urine. Passes protein-free and red blood cell-free filtrate to Bowman’s capsule Filtrates then exits the Bowman’s space into the renal tubules Bowman’s Capsule Contains the glomerulus Glomerulus Collects the glomerular filtrate Bowman’s capsule Proximal Convoluted Tubule Is the first part of the renal tubule and it lies in the cortex of the kidney, close to the renal corpuscle. Fluid that is filtered from the Bowman’s Capsule enters the proximal tubule. Site of reabsorption : Glucose -Amino acids -Metabolites -Electrolytes Reabsorbed substances return to circulation Loop of Henle U-shaped nephron tubule Located in medulla of kidney Extends from proximal convoluted tubule to distal convoluted tubule Concentrates filtrate by re-absorption Page 2 of 9 Functions of kidney 1. To regulate: Body fluid volume The composition of urine Electrolyte balance – calcium, sodium, and potassium levels (To maintain acid base balance) Metabolism of vitamin D 2. To excrete other waste products e.g., urea and creatinine 3. To produce and secrete: The hormone erythropoietin (that regulates RBC production) Renin that maintains blood pressure and glomerular filtration rate (GFR) Prostaglandins – involved in the inflammatory immune system and maintains GFR. KIDNEY PHYSIOLOGY Mechanisms of urine formation The kidneys filter the entire plasma volume more than 60 times/day The kidneys account for about 1% of body weight, but consume 20–25% of all oxygen used by the body The kidneys process 180 L of blood derived fluid daily; only 1% of this amount (1.5 L) leaves the body as urine Urine formation and the adjustment of blood composition involves tubular filtration, reabsorption, and secretion Urological Terms Haematuria : The appearance of blood in the urine. Urinalysis : Analysis of urine by physical, chemical, and microscopical means to test for the presence of disease, drugs, etc. Intravenous pyelogram : (IVP) is an x-ray exam that uses an injection of contrast material to evaluate kidneys, ureters, and bladder. Cystoscopy : Is a procedure to examine the lining of bladder and the urethra , A hollow tube (cystoscope) equipped with a lens is inserted into urethra and slowly advanced into bladder. Urinary Tract Infections Terminology Classification 1. Kidney = pyelonephritis 1. Kidney = upper infection 2. Bladder = cystitis 2. Bladder = lower infection 3. Urethra = urethritis Page 3 of 9 Etiology 1. Inflammation of the urinary epithelium 2. Usually caused by bacteria from gut flora from retrograde movement into urethra and bladder. Pathology Most common site: bladder = cystitis More common in women Common organisms: 1. Escherichia coli 80–90% 2. Klebsiella, proteus and Enterobacter cloacae 5% 3. Pseudomonas ∎Staphylococcus saprophyticus – remaining 10–5% Types of Urinary Tract Infection need to be identified to determine appropriate treatments Asymptomatic bacteria – the absence of symptoms Symptomatic bacteria – gives symptoms of UTI Uncomplicated UTI – infection without structural or functional abnormality of the urinary tract, can occur in healthy individuals Complicated UTI – is an infection in the presence of one or more of the conditions of acute kidney injury (AKI) Signs and symptoms Dysuria Frequency of micturition Loin pain (is the combination of unilateral or bilateral flank pain) Urgency of micturition Pyrexia (fever) Blood in the urine (Hematuria) Abdominal pain Offensive smelling urine Cloudy urine (increased amount of discharge in the form of blood or pus) Diagnosis 1. urinalysis RBCs and WBCs in urine 2. Urine culture shows growth of bacteria 3. Intravenous pyelogram IVP detect abnormalities in renal system Treatment If asymptomatic no treatment required If symptomatic treatment with micro-organism specific antibiotics. Patients should be encouraged to drink fluids; an increase in urine output will serve to excrete the bacteria from the system. Page 4 of 9  Glomerulonephritis Inflammation of the capillaries of the renal glomeruli two types of glomerulonephritis: acute and chronic Acute Glomerulonephritis: is immune- mediated inflammatory disease that occurs 1-2 weeks after an acute infection (streptococcal upper respiratory disease). Pathology Kidney’s filters become inflamed and scarred. Lose ability to remove waste and excess water from blood. Etiology Results from the entrapment and collection of antigen(antibody) in the glomerular capillary membranes, inducing inflammatory damage and impeding glomerular function. Signs and symptoms for AGN Fatigue as toxins build up in the body Tea Colour urine Oliguria (less than 400ml/24 hrs) Proteinuria Loss of proteins into urine Hypoproteinemia =lead to water retention & causing edema Edema Swelling of face, hands, feet, and ankles High blood pressure due to edema Blood and protein in urine (proteinuria and Haematuria) Kidney often badly damaged before signs and symptoms appear. Diagnosis Acute Glomerulonephritis Patient History and assessment Urinalysis: Proteinuria, hematuria, RBCs, WBCs. Blood Analysis ( High serum urea - High serum creatinine ) Creatinine Clearance Test (LOW) :Creatinine is a product of body metabolism-Normally excreted by kidneys. Clearance compares amount of creatinine in blood with that appearing in the urine. Measures efficiency of glomeruli A throat cultures Renal Ultrasound (large kidney) Renal biopsy Page 5 of 9  Chronic Glomerulonephritis: - is inflammation of the glomeruli which results in sclerosis, scarring, and renal failure. - It is a slow progressive disease and irreversible. Pathology - Kidney’s filters become inflamed and scarred. - Lose ability to remove waste and excess water from blood. Etiology - Primary renal disorders, ex: Membranous glomerulopathy - Systemic disorders like lupus erythematosus. Signs and symptoms for CGN - Any time become progressive producing Nephrotic syndrome, hypertension, proteinuria, and Haematuria. - - In late stage it accelerate uremic symptoms (Uremia) : like - Azotemia: Urea and other nitrogenous bodies in greater concentration than normal in blood. - Nausea ,Vomiting - Pruritus: Generalised itching. - Dyspnea: Difficulty breathing caused by edema. - Malaise ,Fatigue - Edema Diagnosis for CGN 1. Patient History and assessment 2. Urinalysis: Proteinuria, hematuria, cylinderuria, RBCs, 3. Blood test :Urea nitrogen (BUN) ,Creatinine ,hypoalbuminemia > 3.5 g protein excreted / 24 hr - Albumin leaking out of blood into urine eventually exceeds liver’s ability to replace the losses 4. X- ray and ultrasound (small kidneys) 5. Kidney biopsy Treatment Try to slow progress of disease and prevent further problems 1. Angiotensin Converting Enzyme Inhibitor (Angiotensin II) Lowers blood pressure. 2. Limit protein intake to reduce build-up of waste products. 3. Limit electrolyte levels in blood. 4. In cases of renal failure – dialysis or renal transplant. 5. Antibiotics to treat underlying infections. Page 6 of 9  Creatinine Clearance Test Creatinine clearance = U.V Units = ml/min p.1440 U = urine creatinine (mml/L) V = urine volume (ml) p = plasma creatinine (mmol/L) 1440 = number of min in 24hr Normal = 80 – 120 ml/min Severe glomerulonephritis = c. 30 ml/min Nephrotic Syndrome Is a condition characterized by: 1. Marked proteinuria, hypoalbuminemia, hyperlipidaemia and edema. 2. Not a disease itself – caused by other primary problems. 3. Primary cause is leakage of albumin out of blood into urine through the glomerulus. Etiology 1. Primary glomerulonephritis (75% cases) 2. Diabetes mellitus 3. Systemic lupus erythematosus (SLE) 4. Circulatory diseases e.g. sickle cell anemia, heart failure. Pathophysiology 1. Increased permeability of glomeruli to protein. 2. Increased loss of protein in urine. 3. Resultant hypoalbuminaemia. Diagnosis - Blood tests : Proteinuria ,Increased cholesterol and triglycerides ,Reduced serum albumin. Treatment 1. Underlying cause. 2. Replace protein that has been lost. 3. Lower sodium intake. 4. Diuretics to increase water loss. 5. Antibiotic therapy. 6. Corticosteroids. Page 7 of 9  Urolithiasis - Stone formation in urinary tract. Etiology 1. Effect of pH - Low pH precipitates calcium and phosphate - High pH precipitates uric acid and cystine 2. Dietary influence 3. Stasis 4. Dehydration Pathophysiology 1. Costovertebral (CVA) tenderness 2. Infection and fever 3. Decreased urine output 4. Urgency, burning and frequency 5. Bladder distension - hydronephrosis Diagnosis 1. kidney, ureter, and bladder (KUB) X-ray 2. Excretory or Intravenous urography is a type of contrast study used to verify and localize upper urinary tract disease 3. Kidney ultrasonography Treatment 1. Increased fluid intake to promote natural passage of smaller stones. 2. Analgesics 3. Surgery 4. Lithotripsy Page 8 of 9  Renal Failure Renal function can be affected by = infection most commonly urinary tract can be obstructed by kidney stones or by a tumor Renal function can also be impaired by: disorders of the kidney itself or other systemic diseases. Because the kidney filters the blood, and is directly linked to every other system (e.g., cardiac), conditions that lead to renal failure can be life threatening Generalized causes of renal failure Infection usually bacterial - Obstruction from kidney stones - Tumors. Chronic Renal Failure 1. Progressive loss of renal function. 2. Accumulation of uremic toxins.(urea and phenols) 3. Potentially fatal physiological changes. Signs and symptoms 1. Renal and urological : hypotension, dry mouth, fatigue, nausea. 2. Cardiovascular: hypertension, arrhythmias, heart failure, pericardial effusion. 3. Respiratory: infection, edema, dyspnoea. 4. Haematopoietic: anemia, RBCs. Diagnosis 1. Clinical assessment 2. Blood tests : Increased serum urea and creatinine, Low Hb and haematocrit 3. Urinalysis : Proteinuria ,Glycosuria 4. X-rays :KUB ,Excretory urography 5. Kidney biopsy : Histology Treatment 1. Low protein diet 2. High calorie diet 3. Maintain fluid and electrolyte balance 4. Epo to increase RBC production Erythropoietin (EPO) is a hormone produced by the kidney promotes the formation of red blood cells by the bone marrow. 5. Dialysis 6. Renal transplantation Page 9 of 9 CLO2 Disorders of Musculoskeletal System I. Define selected musculoskeletal system disorders: Fractures, Dislocations, Osteoporosis, muscular dystrophy, Rheumatoid arthritis, Osteoarthritis, disc prolapse II. For each musculoskeletal system disorders: Briefly describe the pathophysiology · Identify the etiology · Identify signs and symptoms · Define the most performed investigations · State the most common forms of management · III. Apply knowledge in analyzing given case studies · IV. Identify other relevant examples to illustrate disease categories  Musculo-skeletal System Consists of: Skeletal system: (bones and joints) Skeletal Muscle system: (Voluntary and Striated) muscles. These two systems work together to provide basic functions that are essential to life, including: ❖ Protection ❖ Support ❖ Blood cell formation ❖ Mineral homeostasis ❖ Storage ❖ Leverage Tissues There are 5 basic tissues comprising the musculoskeletal system: Bones (206) ligaments (attaching bone to bone) cartilage (protective gel-like substance lining the joints and intervertebral discs), skeletal muscles tendons (attaching muscle to bone). Classifying Bones, there are 5 types of bones: 1. Long bones: -Long and narrow shaft (diaphysis) -A broad end (epiphysis) 2. Short (cuboidal) bones are found where only a limited range of movement is needed such as the carpal and tarsal bones 3. Flat bones have a protective function and are thin to allow attachment of muscles such as the ribs or scapulae 4. Irregular bones include vertebrae, hipbones, and mandible 5. Sesamoid bones are small, protective, and found where a tendon passes over the joint of a long bone such as the patella. Definitions: - Fracture: Any disruption in the continuity of bone. - Dislocation : Occurs when there is complete displacement of the bone from its normal position at the surface of the joint. - Subluxation : Partial dislocation of the joint from its normal position. - Fracture dislocation: Displacement of the joint from its normal position, as well as disruption in the continuity of the bone involving the joint. Page 2 of 9  Fractures - Simple (single fracture line) - Closed (the skin is not broken) Complete or incomplete - Open or Compound (the skin is broken) - Comminuted (many fractures and fragments) Signs and Symptoms: ▪ Paresthesia (sensation) ▪ Pain ▪ Pulselessness ▪ Pallor (color) ▪ Paralysis (movement) Cyanosis- Pale -Blanching ▪ Polar (temperature) Bone healing and repairer A. Hematoma formation occurs B. Osteoblasts fill the area of the fracture C. Hematoma is replaced with granulation tissue: A callus forms D. The callus becomes bone Fracture Treatment Open Treatment: Open Reduction Internal Fixation ORIF Closed Treatment: Closed Reduction Follows by x-ray and then Immobilization, Immobilization help in : ▪ relieve pain ▪ Prevents further damage ▪ Maintains position ▪ Allows uninvolved joints to move Page 3 of 9 The purpose of reduction and immobilization is to: ▪ promote bony union. ▪ promote bone healing ▪ restore function and appearance ▪ anatomic alignment returns the patient to their activities of daily living Treatment after reduction o Elevate the limb o Lift cast carefully o Expose the cast to air o Monitor cast drainage o Outline draining areas in black ink o Routine neurovascular checks o Exercises of unaffected limbs o Check cast for soft spots and for “fit.” o Skin Care o Itching Page 4 of 9  Articulations Synarthroses = Immovable joints Amphiarthroses = Slightly movable ▪ Vertebral joints ▪ Symphysis pubis Diarthroses = Freely movable ▪ Ball and socket (hip, shoulder) ▪ Hinge (elbow, knee) ▪ Pivot (radius and ulna) Dislocations: Bones in the joint are displaced and their articular surfaces are not in contact Can be_ - Congenital - Traumatic - Pathological Signs and Symptoms: - Deformity - Impaired mobility - Tenderness at the point - Pain - Damage to the surrounding tissues Treatment: Immediate reduction: Open or closed Pain killers Immobilization: Splint or traction Page 5 of 9  Osteoporosis is the most common metabolic bone disease – progressive decrease in bone mass with age, which decreases bone strength, predisposing women to an increased risk of fracture. Etiology 2 types of osteoporosis: o Type 1 or primary osteoporosis Post-menopausal type occurs in middle age and older women and estrogen levels fall too low to stimulate endometrial growth, bleeding stops - Senile type occurs after the age of 70 o Type 2 or secondary osteoporosis - Caused by diseases or drugs - Can temporarily develop in patients receiving large doses of heparin - The 3rd trimester of pregnancy Pathology ▪ Old bone is being reabsorbed faster than new bone is being made, causing compact and spongy bone to lose density Damage to the femoral neck, dorsal vertebrae, and distal radius the are common ▪ With ageing bone reabsorption occurs, bone becomes more thinner ▪ Bone density can be used to define osteoporosis Normal bone is greater than 833 mg/cm2 WHILE Osteoporosis is less than 648 mg/cm2. Clinical features distal radius ▪ Osteoporosis may be Asymptomatic ▪ Backache ▪ Bone deformity ▪ vertebrae may collapse due to typical crush fractures Treatment and prevention ▪ loss of height due to Collapse of vertebrae Prophylaxis: ▪ Bone fractures may occur - Good diet, with calcium, magnesium and vitamin D Investigations - Additional calcium intake ▪ X-ray will demonstrate decreased bone density - Low alcohol intake ▪ Measurements of bone mineral density - Moderate weight-bearing exercise ▪ Quantitative ultrasound (QUS) of heals Treatment ▪ Lumbar and thoracic vertebrae become biconcave in shape - can be unsatisfactory if loss of bone mass ▪ Blood levels of Ca, P, and ALP are normal has already occurred ▪ fracture risk assessment tool (FRAX) - Fractures caused by osteoporosis should be treated Page 6 of 9 MUSCLES There are more than 350 named muscles Muscular dystrophy pathology a group of inherited genetic conditions that gradually cause the muscles to weaken, leading to an increasing level of disability. a progressive condition, means it gets worse over time. Some types of MD eventually affect the heart, or the muscles used for breathing, make it life-threatening Etiology caused by mutations in the genes (often inherited) responsible for the structure and functioning of a person's muscles. Some Types of muscular dystrophy 1. Duchenne muscular dystrophy: – one of the most common and severe forms, with the onset in childhood 2. Myotonic dystrophy – a type of MD that can develop at any age 3. Acquired myopathies - These are secondary to other diseases especially metabolic or endocrine disease - Causes include thyroid disease, parathyroid disease 4. Drug-induced myopathy Diagnostic Tests investigating any symptoms discussing any family history of MD physical examination blood tests electrical tests on the nerves and muscles a muscle biopsy Treatment There's no cure for MD, but a range of treatments can help with the physical disabilities : mobility assistance – including exercise, physiotherapy and physical aids support groups – to deal with the practical and emotional impact of MD surgery – to correct postural deformities, such as scoliosis medication – such as steroids to improve muscle strength, or ACE inhibitors and beta-blockers to treat heart problems Page 7 of 9  Rheumatoid Arthritis an autoimmune condition, is inflammation of a joints connective tissues, such as the synovial membranes, which leads to the destruction of the articular cartilage. Etiology The trigger factor is unknown Genetic susceptibility to the disease Hormonal factors may have an influence in autoimmune disorders the body starts to make antibodies to body proteins Rheumatoid factor present in serum can lead to changes in the synovial fluid Pathology - The synovial membrane tissue become, warm, swollen and tender - As the condition progresses there is joint cartilage and capsule deformity, May lead to the progressive destruction - Usually affects more than one joint at the same time, commonly small joints of the hands and feet Clinical Features Pain and swelling in small joints Treatment and prevention Morning stiffness in affected joints NO cure May be tired, irritable, fever, weight loss and excessive fatigue Supportive treatment: joints take on a deformed appearance treat the symptoms patient can become depressed and anxious Rest Periods of exacerbation and remission Occupational therapies : Splints Diagnostic Tests: Physiotherapy X-rays Application of heat Blood tests, evaluated: RhF and ESR level Drug treatment (Rheumatoid factor, Erythrocyte sedimentation rate) CBC done for anemia Page 8 of 9  Osteoarthritis Osteoarthritis is a deterioration of cartilage and overgrowth of bone often due to "wear and tear". Etiology, factors include: Obesity Postural defect Malformed joint Long-term occupational or athletic stress on a joint Pathology A common degenerative disease, where there is a progressive breakdown of the joint surface resulting in a loss of articular cartilage and exposure to underlying bone o Inflammation of the joints is an important feature o Affects the weight-bearing joints: 1. The knees, 2. Inter-phalangeal joints of the hands, 3.hip joint Could be: ❖ Primary – a degenerative disease and the result of wear and tear on the joint ❖ Secondary – attributable to other causes, e.g. joint injury in athletics or trauma. Clinical features Joint aches and stiffness, increase with activity and decrease with rest No systemic signs or symptoms By time Pain becomes more persistent, and stiffness increases and degeneration progresses Limitation of movement in the affected joint Loss of mobility is from hip and knee involvement. Investigations Diagnosis is confirmed by X-ray Treatment and drug therapy o No prevention or arrest of the process o Analgesia is helpful, NSAIDs o Physiotherapy and the use of activities that reduce strain can help o Joint replacement often becomes necessary Page 9 of 9 CLO3 Disorders of Nervous System I. Define selected musculoskeletal system disorders: Transient ischemic attacks, cerebrovascular accidents, meningitis, encephalitis, Epilepsy, Alzheimer's disease, Head injuries and Spinal cord injuries. II. III. For each musculoskeletal system disorders: Briefly describe the pathophysiology · Identify the etiology · Identify signs and symptoms · Define the most performed investigations · State the most common forms of management · IV. Apply knowledge in analyzing given case studies · V. Identify other relevant examples to illustrate disease categories  Vascular Disorders Transient Ischemic Attacks (TIAs) a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Pathophysiology o Obstruction of a blood vessel o Temporarily interrupt Cerebral blood flow most commonly in the carotid arteries. o From second to 1 hr. event without evidence of infarction. Etiology o A buildup of cholesterol-containing fatty deposits called plaques (atherosclerosis), or small embolus, and vascular spasm in an artery or one of its branches that supplies oxygen and nutrients to brain o Caused temporary, localized reduction in blood flow o can be an important predictor of CVA Symptoms ▪ Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body ▪ garbled speech or difficulty understanding others ▪ double vision ▪ Dizziness or loss of balance ▪ Sudden, severe headache with no known cause. Diagnosis and performed investigations: Treatment: ▪ Physical examination and tests ▪ Anti-platelet drugs (aspirin). ▪ Carotid ultrasonography ▪ Anticoagulants. (heparin and warfarin). ▪ CT Computerized tomography ▪ Thrombolytic agents (Activas) ▪ CTA Computerized tomography angiography ▪ Carotid Endarterectomy Surgery ▪ MRI Magnetic resonance imaging ▪ Angioplasty : using a balloon-like device to open a clogged artery and placing a small wire tube ▪ MRA Magnetic resonance angiography (stent) into the artery to keep it open. ▪ Arteriography. Page 2 of 9 Cerebrovascular Accident (CVA) A stroke (CVA) is a medical emergency that happen when blood flow to your brain stops.(Complete block) o is a sudden impairment of cerebral circulation in one or more of the brain blood vessels o Oxygen supply will be interrupted that cause serious damage or necrosis in brain tissues = brain cells die. Pathophysiology When the blood supply to your brain is interrupted or reduced. This deprives brain of oxygen and nutrients, which can cause brain cells to die Etiology A stroke results from obstruction of a blood vessels (intracranial vessels). Factors that increase the risk for CVA are history of: o History of TIAs o High triglyceride o Atherosclerosis o No exercise o Hypertension o Smoking o Kidney disease o Oral contraceptive o Diabetes Mellitus o Arrhythmias (atrial fibrillation) There are two kinds of stroke 1. The more common kind, called ischemic stroke, is caused by: o (Thrombosis): a blood clot that blocks a blood vessel in the brain. o (Embolism) plugs or fragmented clot, a tumor, fat, bacteria, or air. 2. The other kind, called hemorrhagic stroke, is caused by leaking or bursting of one or more brain blood vessel that bleeds into the brain. Signs and Symptoms: same of TIV Treatment: Diagnosis and performed investigations: ▪ rehabilitation treatment: Physical therapy - o Physical examination and Blood tests. Occupational therapy -Speech therapy o CT Computerized tomography Ischemic stroke o MRI Magnetic resonance imaging. + Given Medications as: o Electrocardiogram. - Anti-platelet drugs (Aspirin) o Carotid duplex to detect stenosis. - Potent Clot-Busting drug Tissue plasminogen activator (TPA). o Angiography + Surgeries like Carotid endarterectomy Angioplasty and stents. o EEG helps localize damaged area. Haemorrhagic stroke + Given Medications to: - control bleeding - reduce brain pressure. + Surgical blood vessel repair Page 3 of 9  Infections of CNS Meningitis an illness in which there is inflammation of the tissues that cover the brain and spinal cord What are the causes of meningitis? by (bacteria more serious, viruses) Pathophysiology meningitis commonly begins as inflammation of the pia- arachnoid, which may progress to congestion of adjacent tissues and destruction of some nerve cells. Etiology ▪ Bacterial Meningitis is a complication of another bacterial infection- bacteremia (pneumonia, osteomyelitis, or endocarditis) otitis media, sinusitis, encephalitis, or brain abscess caused by: Neisseria meningitidis Haemophilus influenza Streptococcus pneumoniae ▪ Virus Meningitis Follow skull fracture, penetrating head wound, lumber puncture, or ventricular shunting procedure. Meningitis can also result from noninfectious causes, such as chemical reactions, drug allergies, some types of cancer. Signs and Symptoms: o Sensitivity to light o Sudden high fever o Seizures o Stiff neck o Drowsiness and Confusion o Severe headache o Skin rash o nausea and Vomiting o Rapid progression of small haemorrhages under the skin Diagnosis and performed investigations: o Patient history and physical examination - Blood cultures. o Diagnostic tests, such as x-rays, CT scan of the chest, skull, or sinuses. o Spinal tap (lumbar puncture): showing CSF findings that makes the definitive diagnosis of meningitis. Treatment: viral meningitis: bacterial meningitis: ▪ Bed rest and Plenty of fluids ▪ intravenous antibiotics helps ensure recovery and reduce the risk ▪ pain medications to reduce fever and relieve body aches of complications. ▪ corticosteroids to reduce swelling in the brain ▪ an anticonvulsant medication to control seizures. ▪ an antiviral medication for herpes virus meningitis Page 4 of 9 Encephalitis Is a sever inflammation of the brain. Pathophysiology ❖ In acute encephalitis, inflammation and edema occur in infected areas throughout the cerebral hemispheres, brain stem, cerebellum, and, occasionally, spinal cord. ❖ Petechial hemorrhages may be present in severe infections. Etiology ▪ Encephalitis is usually a primary manifestation or a secondary (post infectious) immunologic complication of viral infection ▪ Viruses causing primary encephalitis directly invade the brain. These infections may be: - Sporadic (eg herpes virus, or rabies ) - Mosquito-borne viral infect people during the spring, summer, and early fall when the weather is warm. - Ingestion of infected goat’s milk. - Air born virus (measles or mumps) Signs and Symptoms: ▪ Seizures ▪ Sudden fever ▪ Muscle weakness ▪ Headache ▪ Problems with speech or hearing ▪ Vomiting ▪ Loss of consciousness ▪ Confusion, agitation or hallucinations ▪ Loss of sensation or paralysis in certain areas of the face or body Diagnosis and performed investigations: ▪ Brain imaging. MRI or CT images ▪ Spinal tap (lumbar puncture). ▪ lab tests. blood, urine, throat culture ▪ Electroencephalogram (EEG). ▪ Brain biopsy. Rarely. Treatment: ▪ Bed rest ▪ Plenty of fluids ▪ Anti-inflammatory drugs to relieve headaches and fever ▪ Antiviral drugs , commonly used to treat encephalitis include: ▪ Acyclovir (Zovirax) ▪ Ganciclovir (Cytovene) ▪ Foscarnet (Foscavir) Page 5 of 9 Epilepsy is a brain disorder marked by recurrent seizures. happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. Pathophysiology ▪ Disturbance in the electrical activity of the brain causing recurrent seizures, which can be classified as: 1. Partial seizures arise from specific area of the brain - Simple Partial seizures: involuntary jerking of a body part, such as an arm or leg - Complex Partial seizures: repetitive movements, such as hand rubbing, chewing, swallowing, or walking in circles. 2. Generalized seizures involve all areas of the brain: - Absence (petit mal) seizures: subtle body movements such as eye blinking or lip smacking. - Tonic – Clonic (grand mal) seizures: most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting tongue - Myoclonic seizures; sudden brief jerks or twitches of your arms and legs - Tonic seizures: affect muscles in your back, arms, and legs - Clonic seizures: affect the neck, face, and arms Etiology - Epilepsy has many possible causes, including illness, brain injury, and abnormal brain development. 70% Unknown cause - Birth trauma. (During birth) of LOW O2 - Stroke - Perinatal Infection (before birth) - Head trauma (injury) - Anoxia (After Respiratory or Cardiac arrest) - Poisoning (mercury, lead, or carbon monoxide) Symptoms vary depending on the type of seizure: - Infectious diseases (meningitis, encephalitis, or brain abscess). - Temporary confusion ▪ - A staring spell - Uncontrollable jerking movements of the arms and legs - Loss of consciousness or awareness - Psychic symptoms such as fear, anxiety or déjà vu Diagnosis and performed investigations: Treatment: - A neurological exam. ▪ Anti-epileptic (Convulsant) medication - Blood tests. ▪ Surgical removal of a demonstrated focal lesion. - EEG Electroencephalogram ▪ Emergency treatment is Valium - CT Computerized tomography scan. - MRI Magnetic resonance imaging Page 6 of 9  Alzheimer’s Disease ▪ Alzheimer's disease (primary degenerative dementia) Pathophysiology ▪ Alzheimer's disease is the most common form of dementia among older people. ▪ begins slowly , First involves the parts of the brain that control thought, memory and language. ▪ People may have trouble remembering things that happened recently or names of people they know. ▪ Once-healthy nerve cells lose their ability to function and communicate with each other, and eventually they die. Etiology ▪ The cause is unknown. ▪ Characterized by atrophy of the frontal and temporal cortex of the brain and weight loss. ▪ Neurochemical factors (acetylcholine deficiency) and Genetic immunologic factors (family history) could cause it. Signs and Symptoms: ▪ Memory loss ▪ Poor judgment leading to bad decisions ▪ Loss of spontaneity and sense of initiative ▪ Taking longer to complete normal daily tasks ▪ Repeating questions ▪ Trouble handling money and paying bills ▪ Wandering and getting lost ▪ Losing things or misplacing them in odd places ▪ Mood and personality changes ▪ Increased anxiety and/or aggression ▪ Difficulty with language and problems with reading, writing, and working with numbers Diagnosis and performed investigations: Treatment: ▪ Patient history / exam and Blood/urine tests o Slow disease progression ▪ Cognitive and neuropsychological tests. o Manage behavioral problems (Measure memory, problem solving, attention, counting, o Modify the home environment language skills, and other abilities related to mental functioning) o Medication to treat memory deficit (Tacrine) ▪ CT Computed tomography o Effective communication system ▪ MRI Magnetic resonance imaging o Family support. ▪ Psychiatric evaluation. Page 7 of 9  CENTRAL NERVOUS SYSTEM TRAUMA Head Injury ▪ any trauma to the scalp, skull, or brain. ▪ Bone fragments from skull fracture can cause severe damage ▪ fractures may be linear, comminuted, compound, depressed, basilar (at base of skull) Pathophysiology, Brain injuries vary in severity and are classified as : 1. Concussions: transient loss of consciousness following blunt head trauma usually full recovery in 24 hrs. 2. Contusion (bruise); disruption of cerebral or meningeal blood vessels. 3. Laceration: caused by open trauma that disrupt the integrity of the brain Etiology ▪ Majority of accidents in young adults Automobile, motorcycle, diving accidents ▪ Alcohol frequently contributing factor ▪ Falls frequent cause, particularly in elderly ▪ Boxers, other contact sports ▪ Infants (from violent shaking) Signs and Symptoms Common symptoms of a minor head injury include: The symptoms of a severe head injury include: ▪ headache - lightheadedness ▪ loss of consciousness - Seizures AND vomiting ▪ spinning sensation - mild confusion ▪ balance or coordination problems ▪ nausea - temporary ringing in the ears ▪ serious disorientation - abnormal eye movements ▪ leaking of clear fluid from the ear or the nose ▪ loss of muscle control - worsening headache ▪ memory loss AND changes in mood Diagnosis and performed investigations: ▪ Glasgow Coma Scale (GCS). ▪ neurological examination ▪ Computed tomography (CT) ▪ Magnetic resonance imaging (MRI) Treatment: ▪ Acetaminophen (Tylenol) for minor injuries. ▪ Medication for sever cases ▪ ant seizure medication and diuretics ▪ Surgery ▪ Rehabilitation Page 8 of 9 Spinal Cord Injury damage to any part of the spinal cord or nerves at the end of the spinal canal often causes permanent changes in strength, sensation and other body functions below the site of the injury. Etiology ▪ result from damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself. A traumatic spinal cord injury: ✓ sudden, traumatic blow spine that fractures, dislocates, crushes or compresses one or more vertebrae. Motor vehicle, sport injuries, falls, act of violence a gunshot or knife wound that penetrates and cuts spinal cord. A nontraumatic spinal cord injury: ▪ arthritis, cancer, inflammation, infections or disk degeneration of the spine. Signs and Symptoms ▪ Complete when all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury ▪ Incomplete when some motor or sensory function below the affected area. paralysis from a spinal cord injury may be referred to as: ▪ Tetraplegia (quadriplegia): arms, hands, trunk, legs, and Treatment: pelvic organs are all affected by spinal cord injury. Medications: (IV) methylprednisolone. ▪ Paraplegia. This paralysis affects all or part of the trunk, Immobilization: traction to stabilize / bring the legs, and pelvic organs. spine into proper alignment or both. A rigid neck collar or special bed. Surgery: is necessary to remove fragments of Diagnosis and performed investigations: bones, foreign objects, herniated disks, or ▪ X-rays. fractured vertebrae that appear to be compressing the spine. Or to stabilize the spine ▪ Computerized tomography (CT) scan. to prevent future pain or deformity. ▪ Magnetic resonance imaging (MRI). Rehabilitation Page 9 of 9  Skin Disorders Integumentary System : ▪ The skin is the external covering of the body, and its primary function is : 1. To protect the body from outside influences. 2. Maintaining homeostasis and protecting underlying tissue and organs. ▪ The skin is known as the largest organ of the body ▪ The subspecialty of medicine concerned with skin diseases is called dermatology. ▪ The skin is an organ that consists of three layers: epidermis, dermis, and subcutaneous ▪ The dermis consists of connective tissue. ▪ It also contains blood vessels, nerves, hair follicles, and skin glands ▪ (skin-associated structures that serve a particular function including sensation, contractility, lubrication and heat loss). The skin : o The hypodermis, or subcutaneous, is made of fat tissue. o The surface of the skin is constantly abraded (wear away by friction) and the epidermis is constantly regenerated from the proliferating cells in the basal layer. o This is essential for maintaining the integrity of the skin and its primary function— protection against external injury. The most important diseases involving the skin are as follows: - Traumatic lesions caused by mechanical, chemical, or thermal injury - Infectious disease - Immune diseases and diseases of presumptive immune etiology - Metabolic diseases and those secondary to diseases of internal organs - Tumors  Common skin disease in UAE : 1) Cold sores (fever blisters) Small, painful, fluid-filled blisters on the mouth or nose, cold sores are caused by the herpes simplex virus. 2) Shingles (herpes zoster) Shingles starts with burning, tingling, or very sensitive skin. A rash of raised dots develops into painful blisters that last about two weeks. Shingles often occurs on the trunk and buttocks. Caused by varicella-zoster 3) Hives (urticaria) Hives, a common allergic reaction that looks like welts (bumps), are often itchy, stinging, or burning. They may appear anywhere and last minutes or days. 4) Psoriasis (2.8%) A non-contagious rash of thick red plaques covered with silvery scales, psoriasis usually affects the scalp, elbows, knees, and lower back. 5) Eczema Consists of several non-contagious conditions where skin is inflamed, red, dry, and itchy. Stress, irritants, allergens, and climate can trigger flare-ups 6) Rosacea Often beginning as a tendency to flush easily, rosacea causes redness on the nose, chin, cheeks, forehead, even in the eyes. 7) Rash from poisonous plants Contact with secretion from poison ivy, oak, and sumac (allergic skin rashes/ Rhus dermatitis) causes a rash in most people. 8) Skin tags A skin tag is a small flap of flesh-colored or slightly darker tissue that hangs off the skin. (Benign lesion) 9) Acne At the heart of acne lies the pimple (a plug of fat, skin, and keratin). Often seen on the face, chest, and back, acne is caused by many things, including hormones. 10) Melasma (pregnancy mask) Melasma (or chloasma) is characterized by tan or brown patches on the cheeks, nose, forehead, and chin.  11) Moles Usually brown or black, moles can be anywhere on the body, alone or in groups, and generally appear before age 20. 12) Warts Caused by contact with the contagious human papillomavirus, warts can spread from person to person or via contact with something used by a person with the virus. 13) Athlete’s foot (tinea pedis) A fungal infection that can cause peeling, redness, itching, burning, and sometimes blisters and sores, athlete's foot is mildly contagious, passed by direct contact Understanding Skin Disease : 1. The skin protects the body primarily by maintaining its own integrity. - Intact dry skin is the best barrier against infection. - Wounds caused by mechanical trauma or minor cuts provide entry sites for bacteria. - Moist skin, caused by sweating ( as during a hot, wet summer), also facilitates the entry of bacteria. - This explains why skin infections are more common among manual laborers whose skin is easily traumatized. 2. Skin can be traumatized mechanically, thermally, or chemically or by various forms of radiation. Various forms of mechanical skin trauma induce different lesions a wound or laceration burn frostbite blisters produced by exposure to early summer sun are prime examples of radiation- induced skin lesion 3. The effects of acute injury are different from those caused by chronic or repeated injuries. 4. Skin is covered normally with bacteria that do not affect it adversely. 5. Skin participates in an immune reaction to foreign sub-stances. 6. Skin may be affected by systemic, metabolic, and immune diseases. 7. Skin diseases may present with hypopigmentation or hyperpigmentation. 8. The skin is the most common site of tumors in the human body. 9. The skin has a limited way of responding to injury. Congenital Disorders : ▪ Disorders of the skin that may present at birth, early in life or later ▪ These include minor discolorations (disorder of pigmentation ) called birthmarks or nevus Disorder of Pigmentation : - Vitiligo is a disease in which the pigment cells of the skin, melanocytes, are destroyed in certain areas. immune system attacks and destroys the melanocytes in the skin. - Symptoms and signs of vitiligo include loss of skin color in the form of depigmented, or white, patches of skin in any location on the body. Albinism (albinus – means white) : - A congenital condition also referred to as hypopigmentation - These people are lacking one enzyme that is necessary for the skin to synthesize or absorb melanin - Their appearance is very pale, almost completely white - They have red eyes because their retina also has no pigmentation Mechanical Injury : We are exposed to all kinds of mechanical injury throughout our lives. This type of injury has been categorized as - Blunt trauma : bump into something causing a bruise - Sharp trauma : cut the skin with a sharp object such as a knife Decubitus ulcers : - Pressure sores are areas of damaged skin caused by staying in one position for too long. - They commonly form where bones are close to skin, such as ankles, back, elbows, heels and hips. - Bedridden are at risk , use a wheelchair, or are unable to change position. - They can be a problem for people in nursing homes. Decubitus Ulcers Treatments and Investigations : ▪ Skin conditions require routine cleansing to reduce possibility of infection ▪ Antibiotic creams and steroidal creams may be prescribed to treat infections, inflammations and areas of redness, swelling and subsequent itchiness Recommended treatments: Improve circulation to area – massage Keep skin clean and dry Change position often Use pillows and blankets that relieve pressure Thermal injury : Treatment of burn : ▪ To determine the amount of body area that has been burned the medical world has created the Rule of Nines ▪ Assigns 9% of total body surface to burns affecting ▪ Head and neck and each of the upper extremities ▪ 18% to each lower extremities and to the frontal and posterior surface of the trunk ▪ Any burn exceeding 9% of the total body surface is serious and must be treated in an intensive care or special burn unit ▪ A procedure called debridement is often done to clean up burned areas of skin ▪ To debride means to cut or scrape clean ▪ Skin grafts are used to replace larger areas of burned skin – usually third degree burns ▪ Grafting is where healthy skin and subcutaneous tissue are harvested from an unaffected area ▪ It is then sutured in place over the burned area of skin ▪ Infection is a concern as well as rejection where the implanted graft does not grow or attach to the site Cold injury : Less severe and less life threatening than burns (prolonged exposure can cause death) Foot and frostbite are more common injuries seen in daily medical practice. Other injuries : Electrical injury Contact with unprotected and inadequately isolated electrical wires Radiation injury Sunshine, artificial radiation, such as radio waves, television waves, microwaves, and ultrasound. Sunlight injury Acute exposure to the sun over a short period leads to hyperemia. Prolonged exposure causes sunburn, accompanied by blisters and peeling of the skin (first- or second-degree thermal injury). Treatment : A procedure called debridement is often done to clean up burned areas of skin To debride means to cut or scrape clean Skin grafts are used to replace larger areas of burned skin – usually third degree burns Grafting is where healthy skin and subcutaneous tissue are harvested from an unaffected area It is then sutured in place over the burned area of skin Infection is a concern as well as rejection where the implanted graft does not grow or attach to the site Infections : ▪ One of the main functions of the skin is to protect… ▪ As such, a common disease affecting the skin is infection ▪ There are many types of infection ▪ Bacterial ▪ Fungal ▪ Viral Bacteria infections : 1) Impetigo is a common skin infection caused by bacteria. ▪ It is usually caused by staphylococcal bacteria but can also be caused by streptococcal bacteria. ▪ It is most common in children between the ages of two and six. ▪ It usually starts when bacteria get into a break in the skin, such as a cut, scratch, or insect bite. ▪ Symptoms start with red or pimple-like sores surrounded by red skin. These sores can be anywhere, but usually they occur on your face, arms and legs. The sores fill with pus, then break open after a few days and form a thick crust. They are often itchy, but scratching them can spread the sores. 2) Folliculitis 3) Acne The pathogenesis of acne is not fully understood. Hereditary factors, hormonal factors, and general cleanliness are important. Acne typically begins at puberty, probably under the influence of sex hormones (e.g., androgens, stimulate the development of sebaceous glands on the face, neck, chest, and back) 4) Cellulitis Fungal infections: 1) Candidiasis ( Oral thrush ) 2) Tinea corpora (ring worm) 3) Tinea captious (cradle cap) 4) tinea pedis (Athlete's Foot) Viral infections : 1) Measles 2) Herpes labialis (herpes simplex virus) 3) Shingles (herpes zoster virus) Parasitic infections : 1) Scabies 2) Scabies mite Inflammatory skin conditions : Eczema an inflammatory skin condition consists of several non-contagious conditions where skin is inflamed, red, dry, and itchy. Stress, irritants, allergens, and climate can trigger flare-ups Acne vulgaris At the heart of acne lies the pimple (a plug of fat, skin, and keratin). Often seen on the face, chest, and back, acne is caused by many things, including hormones. Immune disorders : Contact dermatitis is a common type of rash. A rash is an area of irritated or swollen skin. It causes redness, itching, and sometimes small bumps. the rash where x touched the skin, such as a chemical, or something people are allergic to, like poison ivy. Psoriasis : Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with silvery scales. the patches on the elbows, knees, scalp, back, face, palms and feet, but they can show up on other parts of the body. A problem with immune system causes psoriasis. Skin tumors : ▪ Cancer of the skin are divided into four groups ▪ Tumors of epithelial cells ▪ Tumors of pigmentary cells ▪ Tumors of the dermal connective tissue ▪ Tumors of bloodborne “ immigrant” cells ▪ All these tumors may be benign or malignant. ▪ The most common type of skin cancer is caused by Basal cells. Malignant melanoma : ▪ Malignant melanoma is a tumor originating from melanocytes (Figure 18-15). ▪ Approximately one half of malignant melanomas originate from intact skin; the other half arise from freckles and preexisting nevi. ▪ Because melanoma is the most malignant of the skin tumors, it is important to diagnose it as early as possible. Several clinical histologic types of melanoma are recognized. ABCDE can help you remember what to watch for: o Asymmetry - the shape of one half does not match the other o Border - the edges are ragged, blurred or irregular o Color - the color is uneven and may include shades of black, brown and tan o Diameter - there is a change in size, usually an increase o Evolving - the mole has changed over the past few weeks or months Treatment : ▪ Surgery is the first treatment of all stages of melanoma. ▪ Other treatments include chemotherapy and radiation, biologic, and targeted therapies. ▪ Targeted therapy uses substances that attack cancer cells without harming normal cells. CLO 5.1 female reproductive system disorders I. Define selected female reproductive system disorders : Dysfunctional uterine bleeding , Pelvic inflammatory disease, Endometriosis, Carcinoma of the cervix, Prolapse - Uterine; Vaginal wall (Cystocele, Rectocele, Urethrocele, Enterocoele), Sexually transmitted diseases, Infertility, Fibrocystic disease and Carcinoma of the breast II. For each female reproductive system disorders: Briefly describe the pathophysiology · Identify the etiology · Identify signs and symptoms · Define the most performed investigations · State the most common forms of management · III. Apply knowledge in analyzing given case studies · IV. Identify other relevant examples to illustrate disease categories Female Reproductive System External genitalia: Can be seen on physical examination Function is to protect internal genital organs from infectious organisms To enable sperm to enter the body Main structures: Labia major encloses & protects other external reproductive organs Labia minor surrounds the openings to the vagina and urethra Internal genitalia: Cannot be seen on physical examination Main structures of Internal Genitalia - Vagina is the canal that joins the cervix (lower part of uterus) to outside of the body. (Also known as the birth canal) - Uterus (or womb) is the hollow, pear-shaped organ that is home to the developing fetus Divided into two parts Cervix – lower part that opens into the vagina Body – also called the corpus of the uterus (easily expands to hold a developing fetus) A channel through the cervix allows sperm to enter body and menstrual blood to exit - Ovaries (small oval glands on either side of uterus. Produce eggs and hormones) - Fallopian tubes (attached to upper part of uterus and serve as tunnels for the ova to travel from ovaries to uterus. - Conception (fertilization of an egg by a sperm) normally occurs in the fallopian tube. - Fertilized egg then moves to uterus where it implants into lining of the uterine wall Functions of Female Reproductive System o Produces female egg necessary for reproduction (called ova or oocyte ) o Designed to transport the ova to the site of fertilization o Conception (fertilization of an egg by a sperm) normally occurs in the Fallopian Tubes o fertilized egg will implant into the walls of the uterus. o If fertilization or implantation does not take place = menstruate (monthly shedding of the uterine lining) o produces female sex hormones that maintain the reproductive cycle Page 2 of 10 Dysfunctional Uterine Bleeding Abnormal endometrial bleeding that is due to changes in hormone levels Etiology ▪ when the ovaries do not release an egg ▪ The change in hormone levels cause the period to be later or earlier and sometimes heavier than normal Pathophysiology ▪ During an anovulatory cycle, the corpus luteum does not form. ▪ The normal cyclical secretion of progesterone does not occur, and estrogen stimulates the endometrium unopposed. ▪ Without progesterone= endometrium continues to proliferate, eventually outgrowing its blood supply; ▪ It then sloughs incompletely and bleeds irregularly and sometimes profusely or for a long time. Signs and Symptoms 1. Vaginal bleeding between menses/ Metrorrhagia. 2. heavy or prolonged bleeding (menses) longer than 8 days/ Hypermenorrhea 3. menstrual cycle of less than 18 days/ Chronic polymenorrhea. 4. More blood loss during menses and frequent and irregular bleeding between menses/ (menometrorrhagia) 5. Anemia Diagnostic Investigations ▪ Confirming diagnosis: Dilatation and Curettage (D&C) and biopsy. ▪ Hemoglobin level and Hematocrit. ▪ Coagulation tests ▪ Liver function tests (if a liver disorder is suspected) ▪ Thyroid function test (hypothyroidism) ▪ Pelvic ultrasound. Treatment ▪ Hormone therapy : estrogen-progesterone combination therapy (contraceptive bills). ▪ D&C in some cases ▪ Iron supplement ▪ Blood transfusion (in sever anemia cases) Page 3 of 10 Pelvic Inflammatory Disease (PID) any acute, recurrent, or chronic infection of the uterus lining, fallopian tubes and ovaries Pathophysiology Inflammation of Fallopian tube and ovaries which can extend to the connective tissues laying between broad ligaments. Untreated PID may cause infertility. Etiology - Many types of bacteria (most common: gonorrhea or chlamydia - The infection may enter the body during some surgical or office procedures like: Abortion - pelvic surgery - infection during or after pregnancy. Childbirth - Endometrial biopsy - Miscarriage Signs and Symptoms ▪ lower abdomen and pelvis pain ▪ Heavy vaginal discharge with an unpleasant odor ▪ Abnormal uterine bleeding, especially during or after intercourse, or between menstrual cycles ▪ Pain or bleeding during intercourse ▪ Fever, sometimes with chills ▪ Painful or difficult urination Diagnostic Investigations ▪ gram stain of secretion culture. ▪ Blood and urine tests. ▪ HIV and sexually transmitted infections ▪ Ultrasound. ▪ Laparoscopy. Treatment o Antibiotics. o Treatment for partner. o Temporary abstinence Page 4 of 10  Endometriosis ▪ is when endometrial tissue that normally lines the uterus is found outside the endometrium area of the uterus. ▪ It can grow on the ovaries, behind the uterus or on the bowels or bladder & Rarely in other parts of the body. Pathophysiology ▪ displaced endometrial tissue continues to thickens, breaks down and bleeds with each menstrual cycle. ▪ Because this displaced tissue has no way to exit the body, it becomes trapped. ▪ When endometriosis involves the ovaries, cysts called endometriomas may form. - Surrounding tissue can become irritated, eventually developing scar tissue and adhesions - Abnormal bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other. Etiology ▪ Retrograde menstruation: menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. ▪ Transformation of peritoneal cells: transformation of peritoneal cells — cells that line the inner side of your abdomen — into endometrial cells. ▪ Surgical scar implantation: After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision. ▪ Immune system disorder: body may be unable to recognize and destroy endometrial tissue that's growing outside the uterus. ▪ Endometrial cells transport: The blood vessels or lymphatic system may transport endometrial cells to other parts of the body. Signs and Symptoms ▪ Painful periods (dysmenorrhea). ▪ lower back and abdominal pain. ▪ Pain with intercourse. ▪ Pain with bowel movements or urination. ▪ Excessive bleeding. ▪ Infertility. Diagnostic Investigations ▪ Pelvic exam. ▪ Ultrasound. ▪ Laparoscopy. Treatment o Pain medications o Hormone therapy o Conservative surgery o Assisted reproductive technologies (IVF) o Hysterectomy in sever cases Page 5 of 10 Pelvic Support Problems ▪ The pelvic floor is a group of muscles and tendons that form a ‘sling’ across the pelvis ▪ In women it holds the uterus, bladder, bowel and other pelvic organs in place ▪ The pelvic floor can become weak or injured Etiology The main causes are pregnancy and childbirth o Other causes include o Being overweight o Radiation treatment o Surgery o Getting older This condition is also referred to as “pelvic support problems” and is specified according to its anatomical site… Cystocele Enterocele (vaginal hernia) occurs when the supportive tissue between a in which the peritoneal sac containing a portion of the woman's bladder and vaginal wall weakens small bowel extends into the rectovaginal space allowing the bladder to bulge into the vagina. between the posterior surface of the vagina and the anterior surface of the rectum Urethrocele Rectocele (posterior vaginal wall prolapse) Is prolapse of the female urethra into the vagina. occurs when the thin wall of tissue that separates Weakening of the tissues that hold the urethra in the rectum from the vagina weakens, allowing place may cause it to protrude into the vagina. the vaginal wall to bulge. Common Symptoms ▪ Feeling heaviness, fullness ▪ Feeling an urgent need to urinate ▪ Seeing or feeling a "bulge" of the vagina ▪ Feeling pain while urinating ▪ hard time starting to urinate ▪ Leaking stool or having a hard time controlling gas ▪ frequent UTI ▪ Being constipated ▪ stress incontinence Diagnostic Investigations Treatment ▪ Physical exam ▪ Special pelvic muscle exercises ▪ Pelvic exam ▪ A mechanical support device ▪ Special tests. ▪ Surgery (to treat Cystocele)and medicines ▪ The most common procedure is an anterior vaginal wall repair Page 6 of 10 Sexually Transmitted Diseases Bacterial infection spread by contact with genital, anal, and pharyngeal mucosal surfaces Gonorrhea Signs and symptoms In female: none (20%), abdominal discomfort, vaginal discharge, abnormal uterine bleeding If left untreated can result in pelvic inflammatory disease Treatment: antibiotics, but resistant strains are becoming more prevalent Bacterial infection transmitted sexually or contracted congenitally Syphilis - Infected fetuses are stillborn or die shortly after birth 1. Primary :A painless chancre appears at the site of infection and disappears in a few weeks 2. Secondary syphilis: shows signs of pink skin rash, fever, and joint pain. 3. tertiary syphilis characterized by: gummas (lesions of the CNS, blood vessels, bones, and skin) Treatment: Penicillin Responsible for 25–50% of all diagnosed cases of pelvic inflammatory disease Chlamydia Symptoms include Urethritis, penile and vaginal discharges, abdominal, rectal, or testicular pain; painful intercourse; and irregular menses. - Can cause arthritis and urinary tract infections in men, and sterility in women Treatment: Tetracycline 1. Genital warts - caused by human papillomaviruses (HPV) Viral - infections increase the risk of penile, vaginal, anal, and cervical cancers. Infections 2. Genital herpes -caused by Epstein-Barr virus type 2 -characterized by latent periods and flare-ups 3. Congenital herpes -can cause malformations of a fetus -Has been implicated with cervical cancer Treatment: Acyclovir and other antiviral drugs Page 7 of 10 Infertility ▪ Fertility— the ability to produce offspring ▪ Infertility— inability to have children. Etiology o Associated w/ hormonal imbalances o Result from altered function of hypothalamus, anterior pituitary, or ovaries o Typically after long use of birth control pill o Structural abnormalities, small or bicornuate uterus o Obstruction of fallopian tubes o Scar tissue (PID) or endometriosis o Access of viable sperm o Change in vaginal pH o Infection or douches o Excessively thick cervical mucus o Smoking by male or female Diagnostic Investigations ▪ Broad range of tests avail ▪ General health status checked first ▪ Pelvic examinations ▪ Ultrasound ▪ CT scans check for structural abnormalities ▪ Tubal insufflation (gas/pressure measurement) ▪ Hysterosalpingogram (X-ray w/ contrast material) used to check tubes ▪ Blood tests throughout cycle to check hormone levels treatment in vitro fertilization. Page 8 of 10 Diseases of the Breast Fibrocystic Breast Disease (benign) Carcinoma of the Breast (malignant) Pathophysiology ▪ Fibrocystic breasts are composed of tissue ▪ Develop in upper outer quadrant of that feels lumpy or rope-like in texture. breast in ½ of the cases ▪ isn't really a disease /is considered normal. ▪ Central portion of the breast is also common ▪ Most tumors are unilateral Etiology ▪ The exact cause is un known ▪ Major cause of death in women ▪ Reproductive hormones (especially ▪ Incidence increase after age of 20 estrogen ) : Fluctuating hormone levels during your ▪ Strong genetic predisposition menstrual cycle can cause breast discomfort and ▪ Hormones factor areas of lumpy breast tissue that feel tender, sore ▪ Specifically exposure to high estrogen levels and swollen. ▪ Long period of regular menstrual cycles ▪ No kids (nulliparity) ▪ Delay of 1st pregnancy ▪ Role of exogenous estrogen ▪ (birth control pills, supplements) still controversial Signs and ▪ Lump ▪ Initial signs symptoms ▪ Pain single, hard, painless nodule - Mass is ▪ Discharge freely movable in early stage ▪ Skin irritation ▪ Advanced signs ▪ Fixed nodule ▪ Dimpling of skin ▪ Discharge from nipple ▪ Change in breast contour Diagnostic ▪ Clinical breast exam. Biopsy Investigations ▪ Mammogram ▪ Ultrasound. ▪ Fine-needle aspiration. ▪ Breast biopsy. Treatment Mild symptoms - no treatment is needed for ▪ Surgery : Lumpectomy -Mastectomy fibrocystic breasts. ▪ Chemo and radiation If pain or large, painful cysts associated with ▪ If responsive to hormones, removal of fibrocystic breasts: hormone stimulation ▪ Fine-needle aspiration: a hair-thin needle to ▪ Premenopausal women: ovaries drain the fluid from the cyst. Removing fluid removed confirms that the lump is a breast cyst and, in ▪ Postmenopausal women: effect, collapses it, relieving associated hormone-blocking agent discomfort. ▪ Surgical excision. ▪ Pain relievers ▪ Oral contraceptives. Page 9 of 10 Carcinoma of the Breast -pathophysiology : ▪ Develop in upper outer quadrant of breast in ½ of the cases ▪ Central portion of the breast is also common ▪ Most tumors are unilateral ▪ Different types; majority arise from ductal epithelium ▪ Infiltrates surrounding tissue and adheres to skin ▪ Causes dimpling ▪ Tumor becomes fixed when adheres to muscle or fascia of chest wall ▪ Malignant cells spread at early state ▪ 1st to close lymph nodes (nearest : Axillary nodes ) ▪ In most cases, several nodes infected at time of diagnosis ▪ metastasizes quickly to lungs, brain, bone, liver ▪ Tumor cells graded on basis of degree of differentiation or anaplasia ▪ Tumor then staged based on size of primary tumor, # lymph nodes, presence of metastases ▪ Presence of estrogen and progesterone receptors ▪ Major factor in determining how to treat the pt’s cancer ▪ Prognosis ▪ Relatively good if nodes not involved ▪ As # nodes increases, prognosis becomes more negative ▪ May recur years later ▪ Longer the period without recurrence, better the chances ▪ BSE if over 20 yrs. ▪ Mammography routine screening tool ▪ Detect lesions before they become palpable or if they are deep in the breast tissue Page 10 of 10  CLO 5.2 Obstetrics I. Identify disorders and complications of pregnancy, labor and delivery. - Ectopic pregnancy, Abortion, Hyperemesis Gravidarum, Gestational Diabetes, Eclampsia, Abruptio placenta, Placenta previa, Preterm labor, Postmaturity, Prolapse of the cord, Shoulder dystocia, Perineal tears, Postpartum hemorrhage. II. For each female reproductive system disorders: Briefly describe the pathophysiology · Identify the etiology · Identify signs and symptoms · Define the most performed investigations · State the most common forms of management · III. Apply knowledge in analyzing given case studies · IV. Identify other relevant examples to illustrate disease categories Pathology of Pregnancy ▪ The obstetrical period begins from the time of conception until 6 weeks following the delivery of the baby ▪ This is because of hormonal changes that are taking place as well as the uterus and supporting pelvic structures returning to normal size ▪ Any condition that arises during this period, even after delivery of the baby, is considered a pathology of the woman’s pregnancy Pregnancy ▪ Pregnancy has three trimesters, each of which is marked by specific fetal developments. ▪ A pregnancy is considered full-term at 40 weeks; infants delivered before the end of week 37 are considered premature. ▪ Premature infants may have problems with their growth and development, as well as difficulties in breathing and digesting. First Trimester (0 to 13 Weeks) ▪ The first trimester is the most crucial to the baby's development. ▪ During this period, the baby's body structure and organ systems develop. ▪ Most miscarriages and birth defects occur during this period. ▪ The woman’s body also undergoes major changes during the first trimester. ▪ These changes often cause a variety of symptoms, including nausea, fatigue, breast tenderness and frequent urination. ▪ Although these are common pregnancy symptoms, every woman has a different experience. Second Trimester (14 to 26 Weeks) ▪ The second trimester of pregnancy is often called the "golden period" because many of the unpleasant effects of early pregnancy disappear. ▪ During the second trimester, the woman is likely to experience decreased nausea, better sleep patterns and an increased energy level. ▪ However, she may experience a whole new set of symptoms, such as back pain, abdominal pain, leg cramps, constipation and heartburn. ▪ Somewhere between 16 weeks and 20 weeks, she may feel the baby's first fluttering movements. Third Trimester (27 to 40 Weeks) ▪ The woman has now reached the final stretch of pregnancy and is probably very excited and anxious for the birth of her baby. ▪ Some of the physical symptoms she may experience during this period include shortness of breath, hemorrhoids, urinary incontinence, varicose veins and sleeping problems. ▪ Many of these symptoms arise from the increase in the size of the uterus, which expands from approximately 2 ounces before pregnancy to 2.5 pounds at the time of birth. Page 2 of 13  Ectopic Pregnancy pregnancy in which the fertilized ovum implants outside of the uterine cavity and the placenta and the fetus begins to develop there. ▪ can occur in: The ovary, fallopian tube(95%), even the abdominal cavity Pathophysiology ❖ Obstruction or slowing the movement of the fertilized egg through the fallopian tubes to the uterus ❖ The fertilized ovum implants outside of the uterine cavity ❖ It can erode the wall of some of the major vessels, causing bleeding, or destroy the muscle layer of the tube and rupture it. Etiology ▪ the fallopian tube has been pathologically altered by: ▪ PID (Pelvic Inflammatory Disease) ▪ Previous surgery ▪ Endometriosis. Symptoms of ectopic pregnancies ▪ Sharp or stabbing pain ▪ Cramps on one side of pelvis ▪ Weakness, dizziness, or fainting ▪ Abnormal vaginal bleeding ▪ Breast tenderness ▪ Nausea Tests for ectopic pregnancies ▪ Pelvic exam ▪ Human Chorionic Gonadotropin (HCG)/Pregnancy test (LOW Positive) ▪ Progesterone level (Low level) ▪ Hct (normal or decreased) ▪ CBC (WBC normal or increased) ▪ Ultrasound (indicates an empty uterus) Treatment for Ectopic Pregnancy ▪ Methotrexate (allows the body to absorb the pregnancy tissue and may save the fallopian tube) ▪ Rupture of a fallopian tube containing an ectopic pregnancy sac is a catastrophic event that requires immediate surgical intervention to prevent fatal hemorrhage. ▪ Laparoscopic surgery Page 3 of 13 Complications of pregnancy: 1. Abortion, 2. Hyperemesis Gravidarum, 3. Gestational Diabetes 1. Abortion ▪ Abortion: termination of the pregnancy before the fetus is sufficiently developed to survive. ▪ 20 weeks gestation from the LMP (last menstrual period) ▪ Miscarriage: Common term used for spontaneously occurring abortions. Types of Abortion 1. Threatened abortion: when pregnancy is complicated by vaginal bleeding before the 20th week. The cervix is closed. 2. Inevitable abortion: when pregnancy is complicated by vaginal bleeding and cramp-like lower abdominal pain. The cervix is dilated. 3. Incomplete abortion: vaginal bleeding and cramp-like lower abdominal pain. The cervix is dilated. Passage of products of conception. 4. Complete abortion: Passage of products of conception. Bleeding. Cervix closed. 5. Missed abortion: fetus died but is retained in uterus 6. Recurrent abortion: after three spontaneous abortions. 7. Septic abortion: infection accompanies abortion. Etiology Unknown : Fetal : Maternal : 20% of ❖ Defective embryologic development ❖ Placental abnormalities spontaneous ❖ Faulty implantation of fertilized ovum ❖ Endocrine dysfunction abortions ❖ Failure of the endometrium to accept ❖ Acute infectious disease fertilized ovum ❖ Severe trauma ❖ Premature separation of placenta ❖ Shock ❖ Abnormal placental implantation ❖ Tumor ❖ Malnutrition ❖ Psychogenic (e.g. rape) ❖ Immunological Signs and symptoms of abortion ▪ Abdominal cramps ▪ Vaginal bleeding ▪ Passage of product of conception Diagnostic Investigation of Abortion ▪ Pelvic examination ▪ Laboratory test ▪ HCG in blood or urine/ decrease level ▪ Tissues histology ▪ Blood tests (Low hemoglobin and hematocrit) ▪ Ultrasonography Page 4 of 13 Techniques for Abortion Surgical Medical ▪ Dilatation & Curettage ▪ I/v Oxytocin ▪ Vacuum Aspiration ▪ Intraamniotic hyperosmolar fluids ▪ Laparotomy (20% saline, 30% Urea) ▪ Hysterotomy ▪ Prostaglandins ▪ Hysterectomy ▪ Antiprogesterone 2. Hyperemesis Gravidarum ▪ is extreme, persistent nausea and vomiting during pregnancy that can lead to dehydration. Etiology ▪ cause of nausea and vomiting during pregnancy is believed to be a rapidly rising blood level of a hormone called human chorionic gonadotropin (HCG) which released by the placenta. ▪ Extreme nausea and vomiting during pregnancy can happen if pregnant with twins. Signs and symptoms ▪ Severe, persistent nausea during pregnancy, often leads to weight loss ▪ Lightheadedness or fainting Diagnostic Investigation ▪ Blood pressure may be low, Pulse may be high. ▪ Laboratory tests (to check for signs of dehydration) ▪ A pregnancy ultrasound (to check fetus or twins or more babies) ▪ Ultrasound (checks for a hydatidiform mole) Treatment ▪ Small, frequent meals and eating dry foods ▪ Drink plenty of fluids. ▪ Vitamin B6 (no more than 100 mg daily) ▪ anti-nausea medicine. ▪ If the case is very severe, admitted the pregnant woman to the hospital. ▪ Fluids will be given to you through an IV Page 5 of 13 3. Gestational Diabetes ▪ Diabetes is a disease in which blood glucose, or blood sugar, levels are too high. ▪ Gestational diabetes is diabetes that happens for the first time when a woman is pregnant. usually develops during the last half of pregnancy. ▪ It goes away after delivery of the baby, but it increase the risk for having diabetes later. Etiology ▪ Unknown cause ▪ The placenta produces high levels of various other hormones. Which impair the action of insulin in the cells, raising the blood sugar. Diagnostic Investigation Fasting Glucose level Glucose tolerance testing: Drink sweet solution containing a high concentration of glucose Blood sugar level will be checked every hour for three hours. If at least two of the blood sugar readings are higher than normal, pregnant lady will diagnosed with gestational diabetes. Symptoms ▪ For most women, gestational diabetes doesn't cause noticeable signs or symptoms Complication: o Fetal anomalies o Neonatal hypoglycemia, hypocalcemia o Respiratory distress syndrome o Too large baby o Preterm delivery Treatment ▪ Monitoring your blood sugar. four to five times a day / morning and after meals ▪ Healthy diet ▪ Exercise. ▪ Medication ▪ Close monitoring of your baby. Page 6 of 13 Toxemia of Pregnancy: 1. Preeclampsia, 2. Eclampsia 1. Preeclampsia Pathophysiology of Preeclampsia ▪ a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. ▪ usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Signs & Symptoms of Preeclampsia 2 important signs: ▪ Hypertension ▪ Proteinuria with or without edema Symptoms: ▪ Headache and visual disturbances ▪ Decreased urine output ▪ Epigastric pain--- too late! ▪ Decreased levels of platelets in your blood (thrombocytopenia) ▪ Impaired liver function Etiology of Preeclampsia (exact cause involves several factors) ▪ Placenta blood vessels don't seem to develop or function properly. They're narrower than normal blood vessels and react differently to hormonal signaling Causes of this abnormal development may include: ▪ Insufficient blood flow to the uterus ▪ Damage to the blood vessels ▪ A problem with the immune system ▪ Certain genes Diagnosis of Preeclampsia ▪ Urine analysis (Protein in your urine (proteinuria) ) ▪ Blood tests (A low platelet count) ▪ Liver function test (Impaired liver function) ▪ Renal function test (Signs of kidney trouble) ▪ Chest x ray (Fluid in the lungs (pulmonary edema)) ▪ New-onset headaches or visual disturbances ▪ Nonstress test or biophysical profile + Fetal ultrasound. Page 7 of 13 Treatment of Preeclampsia ▪ Antihypertensive Medications to lower blood pressure. ▪ Corticosteroids: can temporarily improve liver and platelet function to help prolong pregnancy. ▪ Anticonvulsant medications: magnesium sulfate in sever cases, to prevent a first seizure. ▪ Bed rest ▪ Hospitalization in severe preeclampsia ▪ Delivery: doctor may induce labor or schedule a C-section right away 2. Eclampsia ▪ Eclampsia is a severe complication of preeclampsia. Where a high blood pressure results in seizures during pregnancy. Etiology ▪ If preeclampsia affects brain, causing seizures, eclampsia will developed. Common symptoms of eclampsia: ▪ seizures ▪ loss of consciousness ▪ agitation ▪ headaches or muscle pain ▪ upper right abdominal pain Diagnosis of Eclampsia ▪ Blood tests ▪ Creatinine test ▪ Urine tests Treatment of Eclampsia Delivering the baby is the only way to cure eclampsia Medications Getting enough calcium. Getting rest proper care and careful monitoring any changes in condition Page 8 of 13 Problems with the placenta: 1. Abruptio placenta, 2. Placenta Previa 1.Abruptio placenta ▪