Cardiovascular System Notes PDF

Cardiovascular System Heart  Cone shape/inverted pyramid  Relatively small roughly same size as a closed fist  Rest: diaphragm  Location: mediastinum o Mass off tissue extending from the sternum to the vertebral column between 2 Lungs o 2/3rds mass of He...

Cardiovascular System Heart  Cone shape/inverted pyramid  Relatively small roughly same size as a closed fist  Rest: diaphragm  Location: mediastinum o Mass off tissue extending from the sternum to the vertebral column between 2 Lungs o 2/3rds mass of Head (L) of body’s midline o Base – broad portion of heart  Posterior, Superior to the Right o Apex – pointed end  Anterior, Inferior to the Left Pericardium  Fibrous connective sac that encloses the heart  Fxn: it protects the heart from trauma & infection  2 Layers of Pericardium o Fibrous Pericardium  Outer-most layer of pericardium  Fxn: anchors the heart on mediastinum; prevents the heart from over stretching o Serous Pericardium  Inner-most layer of pericardium  2 layers of Serous Pericardium  Visceral Serous Pericardium (Epicardium) o Adheres tightly to the heart  Parietal Serous Pericardium o Outermost layer o Adheres tightly to the fibrous pericardium o Outer to Inner  Fibrous -> Parietal SP -> Visceral SP  Pericardial Fluid  ↓ friction in heart  Location: between the Visceral and Parietal SP  ↑ PF: Cardiac Tamponade (Excessive PF) o (-) Pain; Death 2° to MI d/t unable to pump blood  ↓ PF: Pericardial Friction Rub o (+) Pain; Pericarditis Surfaces of the Heart 1. Anterior Surface (Sternocostal S.) a. RA & RV b. RV forms most Anterior Surface of Heart 2. Posterior Surface (Base S.) a. RA & LA b. LA forms most Posterior Surface of Heart 3. Inferior Surface (Diaphragmatic S.) a. RV & LV b. LV forms the apex of Heart Chambers of the Heart 1. 2 Atria a. Receiving chambers b. Anterior wall of the 2 atria, they are rough d/t the presence of (+) pectinate mm. c. (+) interatrial septum i. Oval depression: Fossa Ovalis 1. Remnant of foramen ovale Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions 2. Foramen Ovale: Opening of the interatrial septum of a fetal heart 2. 2 Ventricles a. Pumping Chambers b. Ridges of Cardiac mm. Fiber: trabeculae Carnae c. Papillary Muscle – cone shape structure of trabeculae carnae where the chordae tendinae are attached d. Interventricular Septum Vales of the Heart 1. AV Valves a. Inlet b. Tricuspid, bicuspid (Mitral) 2. SL Valves a. Outlet b. Pulmonic V. c. Aortic V. Blood Flow of the Heart IVC is the largest Vein in the BodyLeft side of the Heart - ↑pressure; Right side of the Heart - ↓pressure Heart Sounds Longer, louder, Lower S1 LUBB Closure of AV Valves Stethoscope Shorter, not as loud as S1 S2 DUBB Closure of SL Valves Rapid Filling S3 In CHF: Ventricular Gallop Phono- of Ventricles Cardiogram Atrial S4 In MI/Hypertension: Atrial Gallop Systole Controlling Centers of the Heart (2) 1. Autonomic N.S. Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions a. Dually Innervated i. Para – ↓ contraction 1. Slow Contraction of the Heart a. Beta-blockers (-olol) b. Calcium Channel Blocker c. Alpha-1-blocker ii. Sympa – ↑ contraction 2. Conducting System a. SA Node – Sinoatrial Node i. Aka Sinus Node (Meyer 1, Peat 2&5) ii. Primary Pacemaker iii. Location: (R) Atrium (General); Superior Septal Wall of the (R) Atrium immediately below slightly lateral to the opening of the Superior Vena Cava (Specific) b. AV Node – Atrioventricular Node i. Junctional Node ii. Location: behind the tricuspid V. iii. MC site for H.B. c. Bundle of His i. Location: interventricular Septum d. Purkinje Fibers i. Locations: surrounds the 2 Ventricles ii. Largest Pacemaker of the Heart” Coronary Artery  Responsible for the blood supply in the heart (R) Coronary A. (L) Coronary A. (R) Atrium (L) Atrium (R) Ventricle (Majority) (L) Ventricle (Majority) (L) Ventricle (Minor) (R) Ventricle (Minor) SA Node Interventricular Septum  Branches o Left Anterior Descending Artery (LADA): Supplies blood in the Anterior Wall and Apical Wall of the (L) Ventricle o Circumflex A.: Supplies blood to the Lateral Wall and Inferior Wall of (L) Ventricle  Case: o (+) MI in (R) Coronary A. is FATAL 2° SA Node Failure o (+) MI in the (L) Coronary A. is FATAL 2° Left Ventricular Failure o MC Coronary A. occluded – (L) CA d/t larger (L) > (R) CA – more blood flow to (L) leads to greater disposition of deposits in that Artery Cardiac Action Potential  5 phases (0-4)  -88 mV Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions Phase 0  Depolarization  Inward current of Na+ Phase 1  Initial Repolarization  ↓ influx of Na+  Outward current of K+ Phase 2  Plateau “Pla-two”  Inward current of Ca2+ Phase 3  Repolarization  ↓ influx of Ca2+  Outward current of K+ Phase 4  Resting Membrane Potential  Returns to -88 mV Cardiac Muscle vs Skeletal Muscle  Involuntary  Few in Ca2+ vs Skeletal Muscle Cardiac Cycle  Pumping action o Diastole – Ventricular Relaxation o Systole – Ventricular contraction Diastole I. Period of Rapid Filling of the Ventricles: AV valves Open, SL valves Closed a. First Third of Diastole – 75% of Blood gets sent from Atrias to Ventricles “Passively” b. Middle Third of Diastole – continuous blood flow c. Last Third of Diastole – 25% of blood gets sent from Atrias to Ventricles “Passively”; Atrial Systole/Atrial Kick Maximum blood flow occurs in the 1st 3rd of Diastole Systole II. Period of Isovolumetric Contraction a. Blood inside the ventricles b. ↑ ventricular pressure c. AV Valves closed, SL Valves closed (only period where all valves closed) III. Period of Ejection a. Afterload – ventricular force required to open the SL Valves b. LV = 80 mmHg (Aorta) Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions c. RV = 8 mmHg (Pulmonary A.) d. SL Valves – open e. First Third of Ejection: 70% of blood – Ventricles to Pulmonary A. & Aorta i. Fast Ejection f. Last 2/3rds of Ejection: 30% of blood – Ventricles to Pulmonary A. & Aorta i. Slow Ejection IV. Period of Isovolumetric Contraction a. Distention of Blood Vessels b. ↓ Ventricular Pressure c. SL Valves Closed Hemodynamics 1. Systolic – highest arterial pressure; 120 mmHg 2. Diastolic – lower arterial pressure; 80 mmHg 3. Pulse Pressure – difference between Systolic BP and Diastolic BP (SBP-DBP); Normal 40 mmHg a. Average pressure of peripheral Pulse = Pulse Pressure 4. End Diastolic Volume (EDV) – amount of blood left after diastole (ventricular relaxation) a. (N) 120 mL -> Preload “Initial Stretching” 5. End Systolic Volume (ESV) – amount of blood left after systole (ventricular contraction) a. (N) 50 mL b. ↑ ESV – (+) CHF 6. Stroke Volume – amount of blood pumped by ventricles per contraction a. (N) 70 mL b. EDV – ESV (120-50=70) 7. Cardiac Output – amount of blood pumped by the ventricles per minute a. (N) 4-6 Liters of Blood (resting CO) b. SV x HR c. (N) HR = 60-100bpm d. To get the Exact HR, use the Apical Pulse. If no choices, use ECG 8. Mean Arterial Pressure (MAP) – arterial pressure with respect to Time a. DBP + 1/3rd Pulse Pressure b. Normal MAP = 120/80 mmHg -> 80 + 13.33 = 93.33 mmHg i. Average pressure for the large arteries in the body ECG  P Wave – A. Depo (Pacemaker Wave)  QRS Complex – V. Depo  T Wave – V. Repo  PR Interval – beginning of Pwave (Board Exam: A. Depo or A. Contraction) to the beginning of QRS Complexes (Board Exam: V. Depo or V. Contraction) o “It is the point from A. Contraction to V. Contraction: Answer – PR Interval  QT Interval: Beginning of QRS Complexes (V. Depo, V. Contraction) to end of T wave (V. Repo, V. Relaxation)  PR Segment: end of P Wave (A. Depo or A. Contraction) to beginning of QRS Complexes (V. Depo, V. Contraction)  ST Segment: end of QRS Complex (V. Depo, V. Contraction) to Beginning of T Wave (V. Repo, V. Relaxation) Segment – lagi na start sa End Interval – lagi na start sa beginning Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions ECG Conditions  Prolonged PR Interval – Heart Block  Wide, Odd, Bizarre QRS Complexes – Premature Ventricular Contraction (PVC)  ST Segment Elevated – Myocardial Infarction (death of the myocardium)  ST Segment Depressed – Myocardial Ischemia (lack of blood in the myocardium) Auscultation of the Valves APMT 254 – Apartment #254 A Right 2ND ICS Sternal Border P M 5TH Left Midclavicular Line T 4th ICS Sternal Border Location of the Valves A ICS 3rd P Left CC M th CC 4 T Right ICS Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions Cardiovascular Conditions Heart Disease 1. Chest Pain (Angina) a. (+) Levine Sign b. Referred Pain d/t Heart Innervated by C3 & T4 i. Jaw ii. Neck iii. Chest iv. Upper Trapezius v. Shoulders vi. Left Arm: Ulnar N. Distribution c. Types of Angina i. Chronic Stable Angina (Predictable Angina) 1. Physical Exertion + Emotional Stress 2. Responds to Rest and Nitrates a. Nitrates i. Administration: sublingual ii. Max: 3 tablets iii. Interval: every 5 min iv. Effect: Vasodilation v. After 3 tablets with no relief of pain call 911/EMS (Letter B in Fortinberry) vi. Relief from Anginal pain should occur within 1-2 minutes (Meyer says how long does relief take) ii. Unstable Angina (Pre-infarction/Progressive/Crescendo Angina) 1. Doesn’t not respond to Rest and Nitrates 2. Contraindicated for exercise either in IPD and OPD d. Nocturnal Angina i. Exertion caused by Dreams ii. Seen with CHF e. Prinzmetal Angina (Variant Angina) i. Female > Male ii. Coronary A. Spasm iii. Only type of angina, Purely Vasospasm 2. Palpitations – “Arrhythmias” – Excessive Heart Beat 3. Dyspnea - (+) SOB 4. Cyanosis – Bluish discoloration of the lips, toes, nail beds 5. Cardiac Syncope – “Fainting” 6. Fatigue Heart Conditions 1. Coronary Artery Disease (CAD) a. Ischemic Heart Disease b. 2° Atherosclerosis affecting the entire Coronary A. Modifiable Risk Factor Non-Modifiable Risk Factor Sedentary Lifestyle Age (55-67 y/o) Obesity Gender (M>F**) Cigarette Smoking* Race (African-American) ↑ BP Family History ↑ Cholesterol – “Statins” *Nicotine – stimulates the fibrinogen (Clotting Factor 1; [if it has “no” in the CF, they are inactive)  Fibrin = Clot Formation **Menopause – M=F d/t Estrogen; Estrogen: stimulates the LDL receptor, causing ↑ Cholesterol in the Systemic circulation 2. Myocardial Infarction (Coronary Occlusion) a. Death of Myocardium Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions b. True MI – ST Segment Elevation + ↑ Cardiac Enzyme 3. Congestive Heart Failure (Cardiac Decompensation) a. Inability of the ventricles to contract effectively b. Most serious complication: Myocardial Infarction c. 2 types of CHF i. (R) Sided Heart Failure -> inability of the (R) Ventricle to contract effectively 1. (+) Congestion in the periphery & organ 2. (+) Bipedal Edema 3. (+) Ascites 4. (+) Hepatomegaly (enlargement of liver) 5. (+) Distention of Jugular Veins 6. (+) Cyanosis ii. (L) Sided Heart Failure -> inability of the (L) Ventricle to contract effectively 1. “Le-Le-Left-Luh-Luh-Lungs” 2. (+) Pulmonary Edema 3. (+) Cough 4. (+) Orthopnea 5. (+) Paroxysmal Nocturnal Dyspnea 6. (+) Cerebral Hypoxia 7. (+) Fatigue 8. (+) Dyspnea (SOB) 4. Pericarditis a. Inflammation of pericardium b. 2° i. bacterial/viral agent ii. Cancer iii. Renal Failure iv. HIV c. (+) Pericardial Friction Rub i. Aggravating Factors: Trunk Movements (side to side movements); mimics chest pain ii. Relieving Factors: Kneeling on all 4’s; position decreases cardiac workload Congenital Anomalies  Hereditary  Shunts they are not closing  Mother: (+) German Measles 1. Atrial Septal Defect (ASD) a. Defect: interatrial Septum b. Shunt: (L) to (R) c. Acyanosis 2. Ventricular Septal Defect (VSD) a. Defect: interventricular septum b. Shunt: (L) to (R) c. Acyanosis 3. Coarctation of Aorta a. Defect: constriction of proximal & distal aorta b. ↑ BP especially in the UE 4. Patent Ductus Arteriosus (PDA) *Ductus Arteriosus -> connects the Pulmonary A. to the Aorta Placenta (Oxygenated Blood) --> Umbilical Cord (contains veins with oxygenated blood; arteries with deoxygenated blood) a. A connection between the Pulmonary A. and the aorta after birth b. Shunt: (L) to (R) Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions 5. Tetralogy of Fallot (TOS) P ulmonary A. Stenosis Overriding of the A orta to the right R ight Ventricular Hypertrophy/Cor Pulmonale I nterventricular Septal Defect (VSD) a. Shunt: (R) to (L) b. True Blue Baby Conditions Affecting the Heart Valves 1. Stenosis - inability of the valve to open fully a. Blood Passes with Difficulty 2. Insufficiency - Inability of the valve to close fully a. Backflow of Blood 3. Prolapse - excessive bulging of the cusp of the valve a. 2 weakness of cusp b. MC Valve: Mitral Valve i. MVP/Barlow’s Syndrome/Floppy Valve Syndrome/Click Murmur Syndrome Laboratory Evidence SGOT Serum Gluthamic Oxalo-acetic Transaminase Peak: 24-48 hours ↑ CPK CK-MB LDH Creatinine Phosphokinase Creatine Kinase-Myocardial Band Lactate Dehydrogenase Peak: 24 hours Peak: 12-24 hours Peak: 3-6 day Diagnostic Tools 1. Chest X-ray – Assess the size of the heart 2. Thallium Stress Test a. Nuclear Stress Test b. Treadmill c. Injection of a Radioactive Agent – Thallium i. Thallium attaches to Normal Tissues (tissues with blood supply) 3. Cardiac Cauterization a. Insertion of a Catheter via the Femoral A. b. Injection of dye – cinefluroscopy “Viewing the entire arterial system” 4. Echocardiogram a. Use of Ultrasound b. Movements of the walls and the valves of the heart 5. Central Line a. Swan Ganz Catheter b. Insertion of a catheter c. Measure the pressure in the heart Surgical Intervention 1. PTCA – Percutaneous Transluminal Coronary Angioplasty a. Insertion of a ballooning tip catheter to compress the occlusion 2. IV Stent – Intravascular Stent a. Wire pliable mesh b. To keep the lumen of the blood vessel open *Cannot place IV Stent without PTCA first 3. CABG – Coronary A. Bypass Graft a. Re-route blood vessels b. Great Saphenous V. c. Internal Mammary A., Internal Thoracic A. d. Radial A. Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions Intensity of Exercise Target Heart Rate = Karvonen’s Formula 60 − 80% (𝑀𝑎𝑥 𝐻𝑅 − 𝑅𝑒𝑠𝑡𝑖𝑛𝑔 𝐻𝑅) + 𝑅𝑒𝑠𝑡𝑖𝑛𝑔 𝐻𝑅 𝑤ℎ𝑒𝑟𝑒 𝑀𝑎𝑥𝐻𝑅 𝑖𝑠 220 − 𝑎𝑔𝑒 Eg. Age: 20, RHR 60. 6(200 − 60) + 60 →.6(140) + 160 → 84 + 60 = 144𝑏𝑝𝑚. 8(140) + 60 → 112 + 60 = 172𝑏𝑝𝑚 Answer = 144-172 Vitalic is Age: 23 with RHR of Cardiac Rehab (Braddom) I. Acute Phase (Inpatient) a. Goal: prevent deformities/complications b. (+) Family Education c. Discharge MET Requirement: 5 METS II. Convalescent Phase (Transitional) a. Goal: to promote a strong scar formation b. Activity: walking, bicycling c. 5-6 METS: descending stairs, sex with wife d. 8-9 METS: Ascending Stairs, playing competitive basketball, sex with mistress e. Discharge MET Requirements: 9 METS III. Training (Outpatient) a. Most Vigorous b. Activity: Stretching, Aerobics, Calisthenics, Plyometrics IV. Maintenance a. Most important cardiac rehab b. Life-long routine of the px Cardiac Rehab (O’Sullivan) I. Inpatient a. Goal: to prepare patient for discharge b. Vital Signs/ECG Monitoring c. Discharge MET Requirement: 5 METS Level METS Activity Level 1 1-1.5 Bed Exercises Arm Support for every meal Level 2 1.5-2 S itting 15-30 minutes L eg Exercises R eclining Upright Chair C ommode Privileges Level 3 2-2.5 Bathroom Privileges Room/Hall Ambulation for 5 minutes Level 4 2.5-3 Trunk Exercises Room/Hall Ambulation 5-7 minutes Level 5 3-4 Arm Exercises Hall Ambulation for 8-10 minutes Level 6 4-5 Progressive Ambulation II. Outpatient a. Actual Exercise Training Program b. THR = Karvonen’s Formula III. Maintenance a. Endurance Training Gold Rank Intensive Review Baguio Batch 2017  Cardiovascular System: Anatomy & Conditions b. Risk Modification continues Criteria for Terminating the Exercise 1. Unstable Angina 2. Active Pericarditis 3. Resting BP 200⁄100 mmHg 4. Acute Systemic Illness/Fever 5. Recent Embolism 6. Uncontrolled Arrhythmias 7. Uncontrolled DM 8. 2nd to 3rd Degree Heart Block a. 1st Degree Heart Block – prolonged PR Interval b. 2nd Degree Heart Block – progressive lengthening of PR Interval c. 3rd Degree Heart Block – Absence of QRS Complex 9. ST Segment Displacement ≥ 2mm a. If you are exercising and there is a 1.5mm downsloping, stop the exercise, (+) Ischemia 10. ↑ Diastolic BP = indicative of CHF * ↑ Intensity = ↑ Systole, Diastolic stays the same * ↓ Intensity = ↓ Systole, Diastolic stays the same Further Notes 1. Patient: (+) SOB, Weakness, Confused -> early warning sign of MI 2. Patient: Post MI + CHF + Claudication (leg pain) -> best initial exercise: 10-15 min daily (low intensity, moderate duration, high in frequency) 3. Patient: Post MI + DM -> while observing the patient in exercise, use ECG throughout exercise -> px prone to silent ischemia 4. Patient: Post MI -> resistive training, make sure training is ≥ 5 METS and has no anginal sx 5. Patient: CABG -> no heavy exercises during the first 3 months Gold Rank Intensive Review Baguio Batch 2017 Pulmonary System I Functions  Ventilation: act of moving air in and out of the lungs (boyle’s law)  Perfusion: pulmonary blood flow o Greatest perfusion base of the lungs because of gravity o Normal V/Q ratio: 0.8 (ventilation: V and Perfusion: Q) 𝐹𝐸𝑉1 𝐹𝑜𝑟𝑐𝑒𝑑 𝐸𝑥𝑝𝑖𝑟𝑎𝑡𝑜𝑟𝑦 𝑉𝑜𝑙𝑢𝑚𝑒 𝑖𝑛 1 𝑠𝑒𝑐 𝐴𝑙𝑣𝑒𝑜𝑙𝑎𝑟 𝑉𝑒𝑛𝑡𝑖𝑙𝑎𝑡𝑖𝑜𝑛 = = 𝐹𝑉𝐶 𝐹𝑜𝑟𝑐𝑒𝑑 𝑉𝑖𝑡𝑎𝑙 𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑃𝑢𝑙𝑚𝑜𝑛𝑎𝑟𝑦 𝐵𝑙𝑜𝑜𝑑 𝐹𝑙𝑜𝑤 (𝑎𝑘𝑎 𝐶𝑎𝑟𝑑𝑖𝑎𝑐 𝑂𝑢𝑡𝑝𝑢𝑡) 4𝐿/𝑚𝑖𝑛 = = 0.8 5𝐿/𝑚𝑖𝑛  Respiration: gaseous exchange o 2 types  External Respiration: between alveoli and capillaries  Internal Respiration: between tissues and capillaries o Arteries (O2 blood) “Ar” = Red; A-A - “Arteries Away” o Veins (Un-O2 blood) “Vlu” = Blue; V-V – Veins Valik  Transport of O2 and CO2  Diffusion of O2 and CO2 o From higher to lower concentration I. Upper Respiratory Tract 1. Nose (Nasal Cavity) a. Large mucosal surface area b. Function: filters and warms air, humidifies air c. Vibrissae: hair in nose, filters air 2. Pharynx (Throat) a. Three types: i. Naso 1. (same fxn as the nose), ii. Oro, laryngo 1. (conduits of air) b. Respiratory & digestive system 3. Larynx (Voice Box) a. Function: voice or sound production, ensures that air will pass through the trachea b. Cartilages (9) i. Thyroid (1) ii. Cricoid (1) iii. Arytenoid (2) iv. Corniculate (2) v. Cuneiform (2) vi. Epiglottis (1) 1. Has sphincter function “Guardian of the airways” II. Lower Respiratory Tract (LRT) Tracheobronchial Tree (23 Generations) Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Conducting Zone 1. Trachea (windpipe) 2. Main Bronchi (+) passageway of air 3. Lobar Bronchi (-) gas exchange 4. Segmental Bronchi 5. Terminal Bronchioles Respiratory Zone 6. Respiratory Bronchioles aka Acinus: Functional unit 7. Alveolar ducts of the Lungs 8. Alveolar sacs 9. Alveoli (Structural unit (+) Passageway of the lungs) (+) gas exchange 10. Capillaries MC Site of Intubation: Trachea Emergency Site of Intubation: Pharynx  2 Zones o Conducting Zone: only passageway, no gas exchange o Respiratory Zone: (+) gas exchange  Functional Unit: acinus  Structural Unit: alveoli  (R) Main Bronchus: Common Area for Large Aspirated Objects o Shorter, Wider, More Vertical in Orientation  (L) Main Bronchus o Narrower, larger, more horizontal  Common Area for Small Aspirated Objects: Lobar Bronchi III. Lungs RIGHT LUNG (3) LEFT LUNG (2) 3 Lobes 2 Lobes & Lingula Horizontal Oblique Fissures Oblique Fissure Upper, lower Upper, Middle, Lower Lingula: tongue shaped upper left lobe Layers of the Lung 1. Parietal Pleura (Outermost) a. Membrane covering the thoracic wall b. Sensitive to Pain Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation 2. Visceral Pleura (Innermost) a. Membrane covering the lungs and its fissures b. Sensitive to stretch 3. Pleural Space (between the Pleura) a. Pressure: -4 mmHg b. + pressure: gunshot wound, pneumothorax c. Contains Pleural Fluid i. Lubricates the pleurae ii. Shock absorber Cells in the Lungs  Types I Cells/Pneumocytes: Flat cells lining the alveoli  Type II Cells/Pneumocytes: synthesizes “Surfactant” o Reduces the surface tension of lungs to prevent atelectasis (lung collapse) o (-) Surfactant  RDS (Respiratory Distress Syndrome) or Hyaline Membrane Disease  *Hering-Breur Reflex (bronchus, bronchioles) o A stretch/inflation reflex that prevents over inflation of the lungs IV. Thorax/Thoracic Cage/Rib Cage A. Boundaries o Anterior: Sternum “AS” o Posterior: Thoracic Cage “PTC” o Lateral: Ribs (12 pairs)  True ribs (ribs 1-7; connected to sternum by costal cartilages)  False Ribs (ribs 8-10; articulates 7th rib with costal cartilages)  Floating Ribs (ribs 11-12; articulates no rib; Rib 11 = T11, Rib 12 = T12) o Superior: Thoracic Outlet o Inferior: Diaphragm Muscles B. Thoracic Cage Mechanisms o Pump-Handle motion: between sternum & ribs 1-6 (↑ A/P Diameter) o Bucket-Handle Motion: between ribs 7-10 (↑ Lateral Diameter) o Caliper Motion: between ribs 8-12 (↑ ICS) o Piston Action: Diaphragm Muscle (Dome Shaped muscle, moves downward during inspiration, upward during expiration) V. Muscles of Respiration [February Board Exam Questions] I. Relaxed Inspiration a. Diaphragm Muscle (Primary Muscle of respiration) b. External Intercostals: ↑ intercostal space, between Rib 1, 2, 3 II. Forced Inspiration S CM U pper Trapezius P ectoralis Major & Minor A nterior, Middle, Posterior Scalenes (AMS) S erratus Anterior, Serratus Posterior Superior (APS) III. Relaxed Expiration a. No muscle involved d/t elastic recoil of lungs and thorax IV. Forced Expiration (eg. Coughing) A bdominals S erratus Posterior Inferior I nternal Intercostals (↓ intercostal space) Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation VI. Controls of Respiration Pons and Medulla Oblongata (PM) – Controls of Respiration Medulla Oblongata (MO) – Automatic Respiratory Center I. Dorsal Respiratory Group (DRG) a. Location: Dorsal Medulla (Nucleus Tractus Solitarius) b. Function: Inspiration (DIN) c. Inspiratory Ramp signal: 2 sec on, 3 sec off II. Ventral Respiratory Group (VRG) a. Location: Ventrolateral Medulla (Nucleus Ambiguus, Retro-ambiguus) b. Function: Expiration (VEX) & Inspiration III. Pneumotaxic Center a. Location: Upper Pons (Nucleus Parabrachialis) b. Function: limits inspiration by “switching-off” the inspiration ramp signal; controls the rate and depth of breathing c. Respiratory Rate: Adult 12-20 cpm IV. Apneustic Center a. Location: Lower pons (PULA: Pneumotaxic Upper, Lower Apneustic) b. Function: prevents “switching-off” the Inspiratory Ramp Signal V. Chemoreceptors a. Central i. Location: Ventral Medulla ii. Stimulus: ↑ hydrogen ions, results in hyperventilation b. Peripheral i. Location: Carotid and Aortic bodies ii. Stimulus: ↓ PaCO2, ↑PaCO2, Acidosis (↓ pH) iii. Board Exam: 1st choice AOTA, 2nd Choice↓ PaO2, 3rd Choice ↑PaCO2, 4th choice Acidosis (↓ pH) VII. Arterial Blood Gas (ABG) pH 7.35 – 7.45 PaCO2 35-45 mmHg HCO3 22-26 mEq/L PaO2 80-100 mmHg SaO2 95-100% pH Relations (Sir Lester’s Way) A. pH inversely related to PaCO2 (Respiratory [lungs]) o Alkalosis ↑ pH = ↓ PaCO2 o Acidosis ↓ pH = ↑ PaCO2 B. pH directly related to HCO3 (Metabolic [kidneys]) o Alkalosis ↑ pH = ↑ HCO3 o Acidosis ↓ pH = ↓ HCO3 Uncompensated Abnormal pH One Gas is Normal Resp. Alkalosis ↑ ↓ N Resp. Acidosis ↓ ↑ N Metab. Alkalosis ↑ N ↑ Metab. Acidosis ↓ N ↓ Partially Compensated All Are Abnormal Resp. Alkalosis ↑ ↓ *RC ↓ Resp. Acidosis ↓ ↑ *RC ↑ Metab. Alkalosis ↑ ↑ ↑ *RC Metab. Acidosis ↓ ↓ ↓ *RC Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Fully Compensated Normal pH Abnormal Gases Resp. Alkalosis N ↓ ↓ Resp. Acidosis N ↑ ↑ Metab. Alkalosis N ↑ ↑ Metab. Acidosis N ↓ ↓ Normal pH = 7.40 RC = Root Cause (typically higher value/lowest value) Signs and Symptoms Condition Signs/Symptoms Abbrev Caused By Resp. Dizziness, Early Tetany, Numbness, Tingling, DENTS Hyperventilation Alkalosis Syncope Resp. Early: Headache, Anxiety, Restlessness, Dyspnea HARDy Hypoventilation Acidosis Late: Disorientation (PBEQ), Somnolence, Coma DiSC Metab. Weakness, Early Tetany, Mental Dullness, ↑ W-E-Men- Vomiting Alkalosis DTRs, Muscle Twitching ↑-Muscle Metab. Nausea, Lethargy, Coma Acidosis (+) Kussmal breathing NaLoCo Diarrhea (↑ rate, ↑ depth, metabolic/ketoacidosis) Buffer System (Sir Jungie’s Way) Alkalosis Acidosis “Mother” pH: 7.35-7.45 ↑ ↓ Respiratory PaCO2: 35-45 mmHg ↓ ↑ Metabolic HCO3: 22-26 mEq/L ↑ ↓ 1. Compensation: “Yes or no” a. Is the pH normal? b. Is there opposing factors? 2. Legend a. If there are “2 Yes” -> Fully compensated b. If there is “1 Yes” -> Partially Compensated c. If there is “2 No” -> Uncompensated d. The value that copies pH, it is the term VIII. Pulmonary Volumes & Capacities TLC (6000mL) VC (4500mL) IC (3500mL) IRV (3000mL) IRV+TV+ER+RV IRV+TV+ERV IRV+TV TV (500mL) IC+FRC IV+ERV FRC (2500mL) ERV (1000mL) VC+RV RV (1500mL) ERV+RV RV (1500mL) Yo-Mi (1st Part) IC (Three 500 IRV (3K) VC (Four 500 [hundred]) TV (500) TLC (6K) [hundred]) ERV (1K) FRC (Two 500) RV (One 500) RV (One-Five) Chorus IRV VC IC (Paused) TV TLC & ERV FRC & RV RV Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation These are the Pulmonary Volumes N’ Capacities IRV VC IC (Paused) TV TLC & ERV FRC Pati RV RV  Tidal Volume (TV – 500mL) o Amount of air inspired or expired with each normal breath  Inspiratory Reserve Volume (IRV – 3000mL) o Amount of air that can still be inspired in after a normal/resting inspiration  Expiratory Reserve Volume (ERV – 1000mL) o Amount of air that can still be expired after a normal/resting expiration  Residual Volume (RV – 1500mL) o Amount of air left inside the lungs after a forceful/maximal expiration  Inspiratory Capacity (IC – 3500mL) o Amount of air that can be maximally inspired in after a normal/resting expiration  Functional Residual Capacity (FRC – 2500mL) o Amount of air left inside the lungs after a normal/resting expiration  Vital Capacity (VC – 4500ml) o Amount of air that can be maximally expired after a maximal inspiration  Total Lung Capacity (TLC – 6000mL) o Amount of air that can be contained inside the lungs after a forceful/maximal inspiration  Volumes: ITER o Spirometer  Cannot measure: RV, FRC, TLC o Body Plethysmography: TLC o Helium/Nitrogen Wash-out: FRC, RV  COPD: volumes ↑  Restrictive Lung Disease: volumes ↓ IX. O2-Hgb Dissociation Curve “Sa Hgb, Apat-Dapat-Dapat-Apat” Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Shift to the Right 1. ↑ Hydrogen Ions or ↓ pH 2. ↑ CO2 3. ↑ temperature 4. ↑ 2,3 DPG (Phosphoglycerate) 5. Exercise “↑ HaCOT 23-Ex” Shift to the Left (Only ↓ PaO2) 1. ↓ Hydrogen Ions or ↑ pH 2. ↓ CO2 3. ↑ Fetal Hgb X. Bohr Effect “Bo-Co2 (Buko)” ↑ Binding of CO2 with Hgb ↓ Will displace O2 ↓ Will promote O2 Transport XI. Haldane Effect “Hal-O2 (Halo-Halo)” ↑ Binding of O2 with Hgb ↓ Will displace CO2 ↓ Will promote CO2 Transport XII. Pulmonary Assessment  Inspection  Auscultation  Palpation  Percussion  “InAus PaPer” I. Inspection Chest Deformity  Barrel Chest (2:2) AP/L Chest Ratio   Pectus Carinatum (Pigeon Chest) (Prominent Sternum)  Pectus Excavation (Funnel Chest)  Normal Anterior/Posterior, Lateral (AP/L) Chest Ratio – 1:2  Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Chest Symmetric Expansion 1. Upper Lobes a. PT: Front of Px b. Thumb: Sternal Notch c. Fingers: Above clavicles 2. Right Middle Lobe/Lingula a. PT: Front of Px b. Thumb: Xiphoid Process c. Finger: Lateral Ribs 3. Lower Lobes a. PT: Behind the Px b. Thumb: Lower Thoracic Spines c. Fingers: Lateral Ribs II. Auscultation  Stethoscope  Normal Breath Sounds 1. Vesicular: soft, low pitched sound 2. Bronchial: loud, hollow/tubular, high pitched sound 3. Bronchovesicular: softer than bronchial  Abnormal/Adventitious Breath Sounds 1. Crackles (Rales): fine discontinued sounds  Ex. Hair Rubbing next to the ear or popping/fizzing soda  (+) Secretions/water 2. Wheezes: continuous high pitched sounds heard on exhalation  Ex. Asthma 3. Stridor: somewhat like muscle breath sounds d/t obstruction of pharynx, larynx, or trachea 4. Rhonchi: somewhat-like snoring d/t (+) secretions  Abnormal Breathing Patterns 1. Dyspnea: rapid rate, shallow depth, irregular rhythm 2. Tachpnea: fast rate, shallow depth, irregular rhythm 3. Bradypena: slow rate, normal to shallow depth, regular rhythm 4. Hyperventilation: fast, ↑ depth, regular rhythm 5. Apnea: absence of ventilation in expiration 6. Apneusis: absence of ventilation in inspiration 7. Cheyne Stokes (waxing & wailing): alternating ↑ & ↓ depth, apnea, regular rhythm 8. Biot’s: slow rate, shallow depth, periods of apnea, somewhat irregular rhythm  Voice Transmission Test 1. Egophony  Normal – “ee”  Abnormal – “aa” (d/t pneumonia, consolidation, pleural effusion) 2. Bronchophony “99” (PBEQ)  Normal: ↓ volume from apex to base Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation  Abnormal: constant volume from apex to base 3. Whisper Pectoriloquy  Normal: Whispered “1-2-3”  Abnormal: Loud “1-2-3” III. Palpation  Tactile Fremitus o Using ulnar border of hand on ICS o Patient says “99” o Normal Vibrations: Normal/Air-Filled Lungs o ↓ Vibrations: hyper-inflated lungs (emphysema) o ↑ Vibrations: hypo-inflated lungs IV. Percussion  Using the middle fingers to tap the ICS  Normal Response: Normal/Air-filled Lungs  Hyper-resonance: Hyperinflated lungs  Hypo-resonance: hypoinflated lungs (Lung Collapse)  Dull: (+) secretions V. Tracheal/Mediastinal Shifting Contralateral Shifting Ipsilateral Shifting Compressive Atelectasis Obstructive Atelectasis Pleural Effusion Pneumonectomy Pneumothorax Lobectomy Hemothorax Segmental Resection “Hinulax” VI. Colors of Sputum  100 mL/day  Best time to collect sputum, early morning  In the lungs – secretions, outside of lungs – sputum Clear Normal Red (+) Blood Rust (+) Pneumonia Pink (+) Pulmonary Edema Yellow Infection Green Pus Purple Neoplasm (Lung Cancer) Flecked (Dark) Carbon Particles Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Pulmonary System II Cases and Conditions I. Chronic Obstructive Pulmonary Disease vs Chronic Restrictive Pulmonary Disease Condition COPD CRPD Chief Problem Problem with expiration Problem with inspiration Etiology (+) Air trapping Due to ↓ lung or chest wall compliance Affected Lung Volumes & ↑ RV ↓ VC Capacities ↑ FRC ↓ IRV ↑ TLC ↓ TLC V/Q Ratio < 0.8 > 0.8 Response to Bronchodilators (+) Response (-) response Examples - Emphysema (most chronic) d/t alterations of - Chronic Bronchitis 1. Lung Parenchyma & Pleura - Asthma 2. Chest Wall - Bronchiectasis 3. Neuromuscular Apparatus - Cystic Fibrosis II. Emphysema vs Chronic Bronchitis Emphysema Chronic Bronchitis Definition Over-distension of air spaces distal to the terminal Chronic, productive cough of at least 3 months bronchioles with destruction of alveolar septa for 2 consecutive years Cause Smoking = ↑ proteolytic enzymes  Destroys Alveolar Sacs Smoking, pollution, occupational hazard  ↓ Alpha-1 Antitrypsin AKA Pink Puffer (Emphysema) Blue Bloater (Bronchitis) Age +⁄− 60 y/o +⁄− 50 y/o *Elderly (Elderly) * Conting Bata (Chronic Bronchitis) Dyspnea Severe Mild Cough Less Prominent More Prominent Dyspnea before cough Cough before dyspnea Sputum Scanty, Mucoid Copious, Purulent *Evaporated Milk *Condensed Milk Bronchial Less Frequent More Frequent Infection Body Often overweight, obese Usually Asthenic with weight loss Build *Chubby na blue *Payat *Cyanotic na baboy X-Ray  Hyper-inflated lungs  (N) Sized lungs  Small Heart  (R) Ventricular hypertrophy  Diaphragm: low & flat  (N) Shaped Diaphragm  +⁄− bullae (pockets of air)  (+) Dirty lung appearance Cor Rare, except at the late stages More prominent Pulmonale Other PE (+) Barrel Chest Cyanotic Findings (+) Use of accessory muscles of respiration (+) peripheral edema III. Asthma Definition Hypersensitivity of bronchial smooth muscle due to various stimuli resulting to widespread bronchoconstriction Age 50% Female (2:1) After 30 y/o Male = Female (1:1) Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Triggering Factors (PBEQ)  Extrinsic o Inhalant Allergens (Pollen, Dust) o Food (Chocolate, Milk, Nuts, seafood, chicken, eggs, tomato) o Animal Hair o Feathers o Pollution o Climate Change o Drug (Aspirin) o Irritant Inhalants  Intrinsic o Upper Respiratory Tract Infections o Emotional Stress o Psychological Stress o Exercise o Fatigue Status Asthmaticus  Severe form of asthma  Persists from days to weeks  Px requires Mechanical Ventilator  Fatal Signs and Symptoms  Triad: Coughing, Wheezing, Dyspnea (CWD) (PBEQ)  (+) Tachypnea  (+) Use of accessory muscles of respiration  Asthma Attack= is terminated by a cough producing a thick, stringy mucus (Kurshmann’s Spirals) IV. Bronchiectasis Definition  Permanent dilation of bronchi/bronchioles d/t recurrent pulmonary infections  Obstruction distal to exudation, dilatation proximal to obstruction Most Commonly Affected  Terminal Bronchioles 2 Types 1. Saccular (Cystic): from large, proximal bronchi down to the 4th generation 2. Cylindrical (Fusiform): from 6th to 10th generations Signs and Symptoms  Hemoptysis  Dyspnea  Fever  Coughing V. Cystic Fibrosis (Mucoviscidosis) Definition Widespread abnormalities of exocrine glands B ronchial Mucus Glands Triad E xocrine Cells of Pancreas S weat Glands *(+) defect of long-arm of chromosome #7 (the long arm is q: the short arm is p) Signs and Symptoms  (+) productive cough leads to too much secretions leads to i(+) bronchial infections Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation  Weight Loss (malabsorption – inability of body to breakdown food)  ↑ NaCl in sweat (sweat test) X-Ray (+) honeycomb lungs Chronic Restrictive Pulmonary Disease I. Interstitial Pulmonary Fibrosis  Aka: Hamman-Rich Disease  Idiopathic  Associated with smoking, family history, collagen disease  Cardinal Sign: progressive dyspnea  Death in 5-6 years after the dx II. Pneumonia (Intra-alveolar Infection) 3 Types A. Bacterial (Streptococcal; Most common) B. Viral C. Aspiration (ex. CVA, ALS; (-) Gag Reflex) Signs and Symptoms  Fever  Chills  Cough  Chest Pain III. Atelectasis (Lung Collapse) 2 Types Primary (Compressive) Secondary (Obstructive) Ex. Pleural Effusion: too much pleural fluid  lung collapse Give px Incentive Spirometry to help px breath S/Sx:  ↑ vibration  Hyporesonance  Asymmetric Expansion  Dyspnea IV. Tuberculosis (TB) Etiology Mycobacterium Tuberculae Incubation Period 2-10 weeks Maximally Infectious First 2 weeks (isolate px in a Negative-P° room, bacteria have trouble traveling through air) Treatment 3-12 months, average 6 months Primary Complex (TB of Children) Infected Active TB Adult transmits TB to Child Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation S/Sx Hallmark: HEMOPTYSIS Cough Fever Wt. Loss Enlargement of Lymph Nodes Drugs (RIPES) R ifampicin I soniazid P yrazinamide E thambutol S treptomycin V. Pulmonary Edema H2O in the alveoli due to unequal capillary P Associated with Left sided heart failure, MI, Mitral Valve disease, Stenosis S/Sx (+) Crackles/rales Nonproductive cough Sputum: pink & frothy Fever Dyspnea VI. Pulmonary Embolism Definition Lodging of large/small particles into the pulmonary venous circulation Most Common Cause Deep Vein Thrombosis Other Causes C lotting Disorder O ral Contraceptives V enous stasis A ir (Trauma) Prevention Ankle Pumps Positive Pulmonary Embolism Treatment Immobilization Signs and Symptoms  Sudden Acute Pain  Cough  Dyspnea VII. Pleuritis & Pleural Effusion Pleuritis: inflammation of pleura Pleural Effusion: excessive accumulation of pleural fluid S/Sx  Sharp/Dull Pain  Doorstop Breathing  Dyspnea  Coughing Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation  (+) Pleural Rub/Friction Pleural Tube (P-Tube) Insertion 8th-9th ICS VIII. Pneumothorax Air/Gas leaking inside the pleural space S/Sx Sudden, Sharp Pain Doorstop Breathing Dyspnea Cough Pleural Tube (P-Tube) Insertion 2nd to 3rd ICS IX. Severe Acute Respiratory Syndrome (SARS) Caused By Corona Virus S/Sx Fever or ↑ in temperature Sore Throat Dry Cough Myalgia Lethargy Etiology Direct transmission within the past 10 days Code “K” MERS-CoV – Middle East Respiratory Syndrome – Corona Virus - MERS-CoV Animal: Camel X. Bronchogenic Carcinoma (Lung Cancer) 3 Types (SOS) a. Small Cell (Most Fatal) b. Oat Cell c. Squamous Cell (Most Common) Signs and Symptoms  Initially: Fever  (+) Hemoptysis  Fatigue  Unexplainable Weight Loss  Hoarseness Pulmonary Rehabilitation I. Postural Drainage (Bronchial Drainage/Chest PT) 2 Goals 1. To prevent accumulation of secretions 2. To remove secretions already there Duration 20 – 30 minutes, Kisner; 45 minutes O’Sullivan, not more than 45-60 minutes Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation Positions  Use of Tilt Table  Trendelenburg/T-Position: head down, feet up o CI for recent cranial surgery bc ↑ ICP  Reverse T-Position: feet down, head up Manual Techniques (3-5 minutes) 1. Percussion 2. Vibration 3. Shaking Do Not Percuss Over  Bony prominence  Breast Tissue  Chest Pain  Thoracic Surgery Lung Map Right Lung Left Lung 10 Segments 8 Segments Apical Apical Posterior Upper Lobes Post Anterior Anterior Superior Lingular Inferior Lingular Lateral Middle Lobe NONE Medial Superior (Apical) Superior (Apical) Anterior Basal Anterior Basal Lower Lobes Posterior Basal Posterior Basal Lateral Basal Lateral Basal Medial Basal Medial Basal I. Upper Lobes Segment Patient Position Percussion Memory Technique Anterior Apical Sitting, leaning backward Below clavicles Apical: Sitting Posterior Apical Sitting, Leaning forward Above scapulae Male: nipple area Anterior Supine, bed flat Female: just above breast 1/4th turn from prone on (R) side The Only Lobe for Left Posterior Reverse T-Position (30°-45°) (L) Scapula Reverse T-Position 18-20 inch head elevation (large pillows) Right Posterior 1/4th Turn from prone (L) side, bed flat (R) Scapula Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation II. Middle Lobe/Lingula Segment Position Percussion Technique 1/4th turn from supine on (L) side Middle Lobe T-Position (15°-30°) Below (R) Nipple 12-16 inch foot/feet elevation The only T-Position that 1/4th turn from supine on (R) side is 15°-30° Lingula T-Position (15°-30°) Below (L) Nipple 12-16 inch foot/feet elevation III. Lower Lobes Segment Position Percussion Anterior Supine; T-Position (30°-45°) Anterior Lower Ribs Posterior Prone; T-Position (30°-45°) Posterior Lower Ribs Left Lateral (R) Sidelying; T-Position (30°-45°) Left Lateral Lower Ribs Right Lateral (L) Sidelying; T-Position (30°-45°) Right Lateral Lower Ribs Superior Prone, bed flat below the Scapulae Gold Rank Intensive Review Baguio Batch 2017  Pulmonary System: Anatomy, Physiology, Conditions, Rehabilitation IV. Breathing Exercises (2-3 reps) 2-3 reps to prevent hyperventilation 1. Diaphragmatic Breathing a. Improves ventilation 2. Pursed Lip Breathing a. For patients with dyspnea, shortness of breath, asthma b. ↑ intrabronchial P° c. Creates (+) P° 3. Segmental Breathing a. For patients with atelectasis, pneumonia b. Apply resistance to lobe with lung collapse 4. Glossopharyngeal Breathing a. Aka Frog Breathing b. For patients with high level SCI, post-polio syndrome c. 8-10 gulps/gasps of air 5. Sustained Maximum Inspiration (SMI) a. Used pre-operatively to prevent atelectasis V. Mediastinal Breathing CONTRALATERAL IPSILATERAL Compressive Atelectasis Obstructive Atelectasis Pleural Effusion Pneumonectomy Pneumothorax Lobectomy Hemothorax Segmental Resection VI. Coughing  “Double Cough” o 1st Cough: to remove secretion o 2nd Cough: to clear the airways o Effective up to 7th Generation (Alveolar Ducts) o For SCI px: press 5lbs of pressure on px abdomen to help  “Endotracheal Suctioning” o Duration 10-15 sec o Effective up to 3rd generation (Lobar Bronchi)  “Tracheal Tickle/Stimulation” o For infants and unconscious patients Gold Rank Intensive Review Baguio Batch 2017 Cell Physiology I. Cell – “the basic living unit of all organism” 1. Structural & Functional Organism  Chemical level > cell > tissues > organ > organism > organ system > organism  Atom + atom = molecules 2. Cell Environment  60% of cell environment  Is made up of H2O  Total Body H2O 1. 40% ICF: fluid that can be found inside the cell 2. 20% ECF: fluids that can be found outside the cell a. 5% plasma (blood) b. 15% interstitial fluid: can be seen between the spaces of tissues 3. Electrolytes ICF ECF K+ Mg+ Na+ - Electrolytes Phosphates Cl- - Found Sulfate HCO3 (Bicarbonate) Proteins- Ca2+ - Organic Anion  Ions  Cation: a + ion  Anion: a n ion  “N+aCl Oak+ 2x” – Sodium, Chloride, Organic Anion, Potassium; inside the circle is Intracellular; with + is positive charge; without is negative  Normal Values of Electrolytes  Sodium: 135-145 mEq/L  Potassium: 3.5-5.0 mEq/L  Calcium: 9-11 mg/dL  Chloride: 95-105 mEq/L II. Parts of the Cell 1. Plasma Membrane/Cell Membrane  Outer covering of the cell  Characteristics B ilayer of Lipids/Fats Head hydrophilic A mpiphatic in Nature Tails hydrophobic S emipermeable Gas (O2 & CO2) small uncharged (urea) -> H2O -> Large Charge (Bacteria)  Proteins R eceptor I on Channels C arriers E nzymes M arkers A dhesions P umps (+) Na-K ATPase Pump 2. Cytoplasm  Inner environment of the cell  (+) Cytosol – jellylike fluid inside the cytoplasm  (+) Organelles – little organs A. Mitochondria – “powerhouse of the cell” 1. Fxn: generates ATP B. Endoplasmic Reticulum – transport of proteins “E-R-oplano” Gold Rank Intensive Review Baguio Batch 2017  Cell Physiology Rough Smooth (+) Ribosome – synthesizes proteins (-) Ribosomes Rough ER – creates a protein – field vesicle (a Smooth ER: responsible for lipid synthesis; small sac containing proteins) detoxification of cells C. Golgi Apparatus – “traffic director of the cell” 1. Fxn: modifies & packages protein field vesicle sent by RER 2. Also produces lysosomes D. Lysosome – “Suicidal Bags” – “Cell Scavenger” – “Demolition Site” 1. Fxn: digest unwanted substances such as bacteria & worn out cells E. Peroxisome – soft replicated 1. Fxn: detoxification of free radicals/harmful substance (alcohol) 2. Free Radicals: destroy proteins and unpaired ions F. Cytoskeleton – “framework of the cell” 1. Fxn: supports the cytoplasm; forms centrioles, spindle fibers, cilia, flagella 2. Centrioles: center for microtubule formation 3. Spindle Fibers/mitotic spindle: assists in separation of chromosomes during cell division 4. Cilia: moves materials over the surface of the cell 5. Flagella “Flagelong”: responsible for the movement of the sperm III. Cell Division 1. Process Mitosis Meiosis Somatic/Body Cells Sex Cells/Gametes (+) Single Parent Cell (+) Single Parent Cell (46 Chromosomes) (46 Chromosomes) 2 diploid daughter cells 2 daughter cells at PMAT 1 (46 Chromosomes each) (46 Chromosomes) “May 2 Sis” (Mitosis) 4 Haploid Daughter Cells (23 Chromosomes each) Phases (PMAT) 1. Prophase  Chromosomes are separated/split  Nucleus & Nuclear envelope disappear away/pulled apart  Centrioles move to opposite poles 4. Telophase  Chromosomes are paired 2. Metaphase  The Final Stage  “Cleavage Furrow”  Chromosomes are aligned midline by the  Nucleoli & Nuclear Envelope Reappear microtubules 3. Anaphase IV. Cell Transport Mechanism 1. Vesicular Transport a. Exocytosis – expulsion of cell content b. Endocytosis Gold Rank Intensive Review Baguio Batch 2017  Cell Physiology i. Phagocytosis: “cell eating” 1. Large Particles (bacteria) ii. Pinocytosis: “cell drinking” 1. Small particles 2. Diffusion: a. Simple: spontaneous mov’t of molecules from higher to lower areas of concentration b. Ex: O2 & CO2 -> lipid soluble substance c. Factors that increases the rate of diffusion i. Increase in temperature ii. Smaller molecules iii. ↑ Partition coefficient (lipid solubility) d. Facilitated Diffusion i. Carrier Mediated “transporters”: uses carrier proteins 1. Ex: Glucose + amino acid 2. The movement of molecules/ions across the membrane can be classified as a. Uniport: movement of 1 specific molecules across the membrane b. Symport: 2 or more molecules move in the same direction c. Antiport: 2 or more molecules move in opposite directions i. Na – moves inside ii. Ca – moves outside ii. Channel Mediated 1. Voltage Gated – uses electrical current 2. Ligand Gated – uses chemicals a. Ex: Ach 3. Osmosis: spontaneous mov’t of H2O from higher to lower areas of concentration a. If solutes: lower to higher 4. Active Transport: uses energy a. Primary Active Transport: uses ATP i. Ex: Na-K ATPase Pump, Cl-, Ca++, Hydrogen Ions b. Secondary Active Transport: uses ATP from primary active transport i. Ex: Na+ co-transport of glucose & amino acids ii. Ex: Na+ counter transport of Ca++ or H+ Ions Gold Rank Intensive Review Baguio Batch 2017 Blood Physiology Blood Values 1. RBC a. Male: 5.2-6.5 million/mm3 b. Female: 4.5-5.5 million mm3 2. Hematocrit: percentage of RBC in formed elements a. Male: 42-52% b. Female: 37-47% 3. Hemoglobin a. Males: 13-18 g/dL (avg: 16 g/dL) b. Females: 12-16 g/dL (avg: 13 g/dL) 4. Erythrocytes Sedimentation Rate: hallmark of inflammation a. Male: exposure of collagen -> Platelets bind with collagen using Von Willebrand Factor (a protein secreted by BV endothelial cells that serves as mediator between collagen & platelets) -> PPF 3. Blood Clotting a. Ca2+ + Labile (5) + Stuart (10) + Phospholipids = forms prothrombin activating factor/Prothrombinase b. Prothrombinase: converts prothrombin to thrombin c. Thrombin converts fibrinogen into fibrin (Fibrin Stabilizing Factor) II. Clotting Factors  Father Please Tell Cupid Love Should Always Be Sweet Caring Devoted Forever 1. Fibrinogen 2. Prothrombin 3. Thromboplastin (Tissue Factor) 4. Ca2+ Ions 5. Labile Factor 7. Stable Factor 8. Anti-Hemophilic Factor A 9. Anti-Hemophilic Factor B (Christmas Disease; Christmas is 9 letters) 10. Stuart Factor 11. Anti-Hemophilic Factor C 12. Anti-Hemophilic Factor D (Hageman) 13. Fibrin Stabilizing Factor III. Blood Typing Type Antigen Antibody Blood Transfusion A A B A, O B B A B, O AB AB (-) A, B, AB, O Universal Recipient Gold Rank Intensive Review Baguio Batch 2017  Blood Physiology O (-) AB O Universal Donor Clumping is Antigen Rh Incompatibility  Mother Rh- + Father Rh+ = Baby Rh+  This Condition is called Erythroblastosis Fetalis/Hemolytic Disease of the Newborn  Only allows the first baby to be normal at birth  Succeeding babies will die or live with complication (CP Athetoid)  Rhogam Injection given 72 hours for the protection of the fetus IV. Pathologies 1. Thrombocytopenia a. ↓ # of platelets b. May lead to bleeding c. Causes i. Dengue ii. ↓ Vitamin K Supply iii. Leukemia iv. Liver Disease (Hepatitis & Cirrhosis) 2. Thrombocytosis a. ↑ # of platelets b. Dangerous c. Causes: Immobility, trauma, Atherosclerosis d. Mx: Blood Thinners I V H eparin O ral W arfarin (Coumadin) 3. Hemophilia a. X-Linked Recessive (Mother is the Carrier) b. Affected: Son c. Types i. A: Classic Hemophilia 1. Most Common Type 2. (-) AHF A/CF8 ii. B: Christmas Disease 1. (-) AHF B/CF9 iii. C: (-) AHF C/CF11 iv. D: (-) AHF D/CF12 d. Mx: i. Transfusion of Clotting Factors e. MC Manifestation: Hemarthrosis f. Contraindicated: Stretching, Strenuous Activity WBC “Leukocytes” 1. For Inflammation & infection 2. For Immunity I. Types 1. Neutrophils a. Most abundant WBC Gold Rank Intensive Review Baguio Batch 2017  Blood Physiology b. Lifespan: blood (4-8 hours); Tissue (4-5 days) c. Fxn: responsible for bacterial infection 2. Eosinophils a. Responsible for parasitic Infection 3. Basophils a. Responsible for allergic reactions because it release histamine 4. Lymphocytes a. 2nd most abundant WBC b. Types: T Cells & B Cells 5. Monocytes a. Largest WBC b. If Matured to tissue --> macrophage i. Macrophage lifespan 1. Blood: 10-20 hours 2. Tissues: ~3months II. Inflammation & Infection  Neutrophils: can ingest up to 20 bacteria  Macrophages: can ingest up to 100 bacteria  Events that takes place during inflammation & infection 1. Stimulus: Trauma and/or infection -> damaged tissue will release a chemotactic substance (affects macrophages & neutrophils) 2. 1st Line of Defense: Macrophage K uppffer Cells (Liver) A lveolar Macrophage L ympoid Macrophages B rain (Microglia) S kin (histiocytes) 3. 2nd Line of Defense: Neutrophils (Circulation)  2 Process  1. Margination – Neutrophils adhere to blood vessel wall  2. Diapedesis – Neutrophils squeeze into BV Capillaries 4. 3rd Line of Defense: 2nd wave of macrophages 5. 4th line of Defense: Bone marrow will produce more macrophage and neutrophils III. Immunity Passive Active Inherited from the Mother Type of immunity acquired from exposure to ex: Breastfeeding Natural disease IgG – Only immunoglobulin that crosses the placenta ex: chicken pox “Napass” came from a donor attenuated bacteria Artificial ex: transfusion of Ig, clotting factors ex: Vaccine IV. Lymphocytes  Types 1. B Cells 1. Origin: bone marrow 2. Fxn: resp for hormonal medicated immunity because it releases Ig G only Ig that crosses placenta A fluid antigen M Food Antigen E allergy Gold Rank Intensive Review Baguio Batch 2017  Blood Physiology D Activates B-Cells 2. T-Cells 1. Origin: Thymus 2. Fxn: resp for cell mediated immunity 3. Types: i. Helper T Cells (CD4) 1. Regulates and directs T Cells & B Cells 2. (-) AIDS ii. Cytotoxic/Killer T-Cells (CD8) 1. Attacks foreign materials iii. Suppressor T-Cells 1. Stops the activity of T-Cells and B-Cells 2. (-) GBS Immune Response 1. Stimulus: Bacteria 2. Macrophage will partially digest the bacteria 3. Macrophages will present the bacteria to cytotoxic/Killer T Cells 4. Killer T-Cells will destroy the bacteria 5. Suppressor T-Cells will stop the activity of cytotoxic/Killer T-Cell V. Types of Allergic Reaction (ACID) 1. Anaphylactic a. Ex: Asthma – Stimulus: Allergens b. If severe: anaphylactic shock i. Widespread vasodilation ii. Ex. Bee Stings 2. Cytotoxic a. Ex: graft rejection, blood transfusion Reaction 3. Immune Complex a. Ex: SLE, RA 4. Delayed Hypersensitivity a. Ex: Contact dermatitis/Eczema; cosmetics VI. Pathologies 1. Leukemia a. ↑ # of WBC b. Types: i. Myelogenous: Cancer of Bone Marrow ii. Lymphogenous: affects lymphoid tissues c. S/Sx: Bone pain, bleeding, weight loss, infection 2. Leukopenia a. ↓ # of WBC b. (+) Infection c. S/Sx: Mouth & colon ulcers d. Tx: Antibiotics Gold Rank Intensive Review Baguio Batch 2017 Peripheral Vascular System  Function: Transportation o O2 o Nutrients o Proteins o Blood  3 Systems o Arterial System o Venous System o Lymphatic System  The framework of the PVS: blood vessel Layers of Blood Vessels 1. Tunica Intima a. Innermost layer of blood vessels b. Layers i. Connective Tissue ii. Basement Membrane iii. Endothelium: only layer present in all blood vessels 2. Tunica Media a. Middle Layer of blood vessels b. Composed of a smooth muscle c. The bulk of the Tunica media is found in Artery 3. Tunica Adventitia a. Outermost layer of Blood Vessels b. Composed of elastic, collagenous fiber c. *bulk found in veins I. Arterial System  Artery o Oxygenated blood away from the heart o Muscular, elastic, tubular extension of the heart  Proximal: ↑ pressure -> elastic  Distal: ↓ pressure -> muscular  Artery -> arterioles -> capillaries: thin in nature “exchange vessel” II. Venous System  Veins: deoxygenated blood towards the heart  (+) Valves  60-64% of blood volume  Capacitance vessel Types of Veins a. Superficial Veins a. Underneath the skin b. 2 great superficial veins in the lower extremity i. Great Saphenous Vein: run on the medial aspect of the leg & thigh to join the femoral vein ii. Lesser Saphenous Vein: run behind the lateral malleolus to the posterior leg to join the popliteal vein b. Perforating/Communicating Veins: connects the superficial veins to the deep veins c. Deep Vein: large vein that already follows the structure of an artery III. Lymphatic System  Lymphatics: carries fluid back to the blood stream o (-) CNS and Cornea  Lymph nodes Gold Rank Intensive Review Baguio Batch 2017  Peripheral Vascular System & Disease o Location: Cervical, Axillary, Inguinal o (+) Macrophages Peripheral Vascular Disease I. Arterial Disease 1. Arteriosclerosis Obliterans (ASO) a. Inflammation + occlusion affecting medium to large arteries b. LE>UE c. Early sign: (+) intermittent claudication d. Late Stage: (+) gangrene e. Affected A. In Non-DM Patient i. Common Iliac A. ii. Femoral A. f. Affected A. in DM Patient i. Femoral A. ii. Tibial A. 2. Thromboangiitis Obliterans TAO a. Inflammation + occlusion affecting small arteries b. UE>LE c. Buerger’s Disease d. Disease of a young male smoker e. Distal Segment to Proximal Segment “Ascending Pattern” 3. Raynaud’s Phenomenon a. Abnormal vasoconstriction reflex affecting the small arteries b. Precipitating Factors: Cold & emotional stress i. Cyclic Color Pattern “French Flag Sign” 1. Pallor 2. Cyanosis 3. Rubor II. Venous Diseases 1. Varicose Veins (VV) a. Swollen, distention of superficial veins b. Affected: (+) valves ↑ pressure LE i. Prolonged Standing ii. Obesity iii. Pregnancy iv. Cross-leg c. S/Sx: Aching, heavy leg with appearance of spider vein 2. Superficial Vein Thrombosis (SVT) a. Inflammation + clot formation affecting superficial vein (saphenous Vein) b. Most serious complication: varicose veins c. S/Sx: pain along the course of the saphenous vein 3. Deep Vein Thrombosis (DVT) a. Inflammation + clot formation affecting deep veins b. Virchow’s Triad H ypercoagulability I ntimal wall damage V enous Statis c. (+) Homan’s Test d. Medical Mx i. Heparin (IV) Gold Rank Intensive Review Baguio Batch 2017  Peripheral Vascular System & Disease ii. Warfarin (Oral) e. Mx: Immobilization f. Most Serious Complication: Pulmonary Embolism g. Best Prevention: early mobilization 4. Chronic Venous Insufficiency (CVI) a. ↑ pressure in deep veins b. MC form of venous diseases c. Stages: i. Stage I: edema + pigmentation ii. Stage II: edema + pigmentation + varicosities + dermatitis iii. Stage III: ulceration –MC manifestation of CVI III. Lymphatic Diseases 1. Lymphadenopathy: enlargement of the lymph nodes with/without tenderness 2. Lymphedema: excessive accumulation of fluids in the lymphatic system Milroy’s Disease congenital edema after birth 1° L. Praecox edema present 35 y/o Genetic Risk is 1,20 falsely elevated DM ii. 1.19 to 0.95 – Normal iii. 0.94 – 0.75 – mild arterial disease + Intermittent claudication iv. 0.74 – 0.50 – moderate arterial disease + resting pain v. Slow Eccentric > Isometrics > slow concentric > fast concentric b. Q: at what velocity can a muscle generate the lowest tension i. Fast Concentric Gold Rank Intensive Review Baguio Batch 2017 Nerve Physiology I. Nerve 1. Parts a. Dendrites: conveys electrical signals towards the cell body b. Axon: conveys electricals signals away from the cell body c. Myelin Shit: acts as an insulator d. Initial Segment: between the Axon Hillock and 1st myelin sheath e. Nodes of Ranvier: between myelin sheathes; for salutatory conduction 2. Myelination C NS O ligodendrocytes: gives myelination in CNS P NS S chwann Cells: gives myelination in PNS 3. Site of Action Potential Initiation a. Q: “Where does the Action Potential generated in a sensory neuron?” i. Initial Segment – Motor Neuron ii. Axon Hillock – General Neuron iii. 1st Node of Ranvier – Sensory Neuron II. Classification of Neurons 1. According to Fiber Types Types Size & Myelination Function Alpha motor neuron innervating skeletal muscle Beta Large & Myelinated sensory neuron responsible for touch & proprioception A Gamma motor neuron innervating muscle spindle Delta sensory neuron for fast/acute pain & temperature Small & Myelinated B preganglionic autonomic (10,9,7,3) C Small & Unmyelinated sensory neurons slow pain (chronic) and temperature 2. According to Numerical Types Name Related Fiber Type A Annulospiral Nerve Endings I B II Flowerspray nerve Ending III A Delta Pain Fibers IV C Fibers *Type Ia & II are considered sensory neurons innervating muscle spindle * Type Ib is a sensory neuron innervating a GTO III. Receptor Organs Muscle Spindle GTO Location Parallel to Muscle Fiber Series to Muscle Reflex Stretch reflex Inverse Stretch Reflex Motor A-Alpha & A-Gamma A-Alpha Neurons Sensory Type Ia & II Type Ib Neurons Stimulus Stretch Tension Response Muscle Contraction Muscle Relaxation Reflex 1. Monosynaptic Reflex: composed of 1 afferent & 1 efferent Gold Rank Intensive Review Baguio Batch 2017  Nerve Physiology a. Ex: DTR 2. Bisynaptic Reflex: composed of 2 afferent & 2 efferent a. Ex: Reciprocal Inhibition 3. Polysynaptic Reflex: composed of 3 or more AFF & EFF a. Flexor withdrawal IV. Membrane Potential 1. Resting Membrane Potential: there is positively charge on the outside & negatively charge inside a. 3 Conditions P umps Na-K ATPase Pump; I ons ECF: Na+, Cl-, HCO3-, Ca++ C harge ICF: K+, Mg+, Phosphate-, Sulfate-, Proteins-, Organic Anion- b. Guyton states that Potassium is 100x more permeable to cell membrane than the Sodium c. Nerve: -70 mV d. Skeletal Muscle: -90 mV e. Cardiac Muscle: -88 mV f. Smooth Muscle: -40 to -60mV i. GIT: -56 mV V. Nerve Action Potential  Rapid changes in membrane potential 1. Depolarization 2. Repolarization 3. Hyperpolarization 4. Resting Membrane Potential  Firing level: an increase in membrane potential of 15-30 mV usually is required to cause an explosive development of Action Potential  “All or None Principle” – action potential are only elicited beyond the firing level Phases of Action Potential 1. Depolarization “Overshoot phase” a. Opening of voltage gated Na+ channel b. Na+ influx c. The change of the cell becomes (+) 2. Repolarization a. 2 Causes i. Rapid closure of voltage gate Na+ Channel/inactivation gates are closed ii. Opening of Voltage gated K+ Channel (Potassium Efflux/Outward) iii. The change of the cell becomes negative 3. Hyperpolarization a. Slow closure of voltage gated K+ channel 4. Resting Membrane Potential a. Na-K ATPase Pump Activates b. “Tri-na out-2K in” – 3 Na will move out, 2 K will move in VI. Concepts 1. Refractory Period a. Absolute Refractory Period: period during which a second Action potential cannot be elicited even with a strong stimulus b. Relative Refractory Period: starts at 1/3 of repolarization onwards i. Stronger than normal stimulus elicits new Action Potential 2. Summation a. Temporal (Time): when 1 nerve discharge, action potential many times b. Spatial Summation (space): when multiple nerve discharge at the same time Gold Rank Intensive Review Baguio Batch 2017 Integumentary System I  Skin o Largest Organ o 15-20% of Body Weight P rotection I nsulation R ecptors in dermis A ids in homeostasis T emperature Regulation E limination S ynthesizes Vit. D O il Production C osmosis 3 Layers of the Skin Epidermis: Outermost Layer 1. 5 Layers/Strata a. Stratum Corneum – Waterproof characteristic; protection against infection b. Stratum Lucidum – located on palms & soles c. Stratum Granulosum – Water retention and Heat regulation d. Stratum Spinosum – protects basale e. Stratum Basale/Germinativum – contains melanocytes; epidermal regeneration Code: “Colugo sa Batok” Superficial to Deep Co Corneum Lu Lucidum Go Granulosum Sa Spinosum Batok Basale Dermis/Corium 1. True Skin Gold Rank Intensive Review Baguio Batch 2017  Integumentary System 2. 2 Layers a. Upper – Papillary – Fingerprints/footprints b. Lower – Reticular 3. 20-30x thicker than epidermis 4. Contains free nerve endings, blood vessels, sebaceous glands 5. Has elastin (elasticity) and collagen (toughness) 6. Skin Turgor test: pinch and lift the skin, skin should rebound 5sec Rete Pegs:  found between the epidermis and dermis  Function: increases the surface area of skin to overcome friction Receptors in Dermis:  Free Nerve Endings: pain, itch  M & M – Merkel’s & Meissner’s: touch  Ruffini’s Corpuscles: heat “Ruffini, maiinit”  Krause end Bulbs – Cold “Krausty Cold”  Pacinian – pressure, vibration Subcutaneous 1. Contains fats & loose connective tissue S upport I nsulation C ushion S torage of Energy Appendages of the Skin 1. Hair: has 3 concentric layers a. 2 Types i. Terminal: coarse, thick, pigmented 1. Scalp, eyebrows (aka supercilia, protects eyes against sweat), eyelashes (protects against foreign bodies, gives us our couture) ii. Vellus: short and fine 1. Chest, arms 2. Nail Gold Rank Intensive Review Baguio Batch 2017  Integumentary System a. Conditions i. Clubbing of nails – pulmonary disease ii. Spoon Nail – fungal infection iii. White spots – trauma 3. Sebaceous Gland a. Aka oil glands b. Produces oil & sebum i. Sebum: white substance; if blocked on skin = whiteheads; if blocked and oxidized = blackheads; if blocked, oxidized and infected = acne ii. MC skin disorder in adolescents: acne vulgaris 4. Sweat Gland a. Aka sudoriferous gland b. 2 Types i. Eccrine/Merocrine: located on the entire surface of skin 1. Drains onto sweat pore 2. Fxn: thermoregulation ii. Apocrine: located on the axillary & genital regions 1. Drains onto hair 2. Fxn: active during emotional stress 5. Erector/Arector Pili Muscle a. A smooth muscle responsible for “goose bumps” (Piloerection) b. Involuntary; caused by stimulus Common Skin Disorders Dermatitis (Eczema) A. Inflammation of skin resulting to itching, redness, and skin lesions B. Causes (AAA) a. Allergic/Contact Dermatitis – d/t harsh soap, poison ivy, chemicals, adhesive tape b. Actinic – d/t sunlight, photosensitivity, UVR c. Atopic/Unknown Dermatitis – d/t associated with allergy, FHx, psychological stress/disorder C. Stages a. Acute – Red, crusting rash & oozing (ARCO) b. Subacute – Skin erythema, scaling, scattered plaques (S3) c. Chronic – Thickened Skin, increased skin markings 2 to scratching, post-inflammatory pigmentation (TIP) D. Mx a. Hydration/lubrication Bacterial Infections A. Impetigo: superficial skin disease resulting to itching, skin lesions, (+) inflammation a. Caused by: staphy & strepto b. Mx: Antibacterial drugs B. Cellulitis: a suppurative inflammation of cellular and connective tissue, (+) Fever a. Caused by: staphy & strepto b. S/Sx: Hot, Edematous, red (HER CELL) c. Mx: Use of Cool, wet dressings; anti-bacterial drugs Gold Rank Intensive Review Baguio Batch 2017  Integumentary System C. Abscess: cavity containing pus & surrounded by inflamed tissue a. Caused by: staphy b. Mx: incising & draining the abscess Viral Infections A. Herpes I (Herpes Simplex): a. Vesicular eruptions on face & mouth b. As a cold sore or fever blister B. Herpes II a. Vesicular eruptions on genitalia b. A STD i. Found on the labia majora on females ii. Found on the shaft of males C. Herpes Zoster (Shingles) a. Caused by Varicella Zoster b. Reactivation of virus lying dormant on the cerebral ganglia or ganglia of posterior nerve roots c. Pain and tingling sensation on cranial and spinal nerve dermatomes d. Vesicles in a linear arc presentation e. Associated with fever, chills, malaise, GIT disturbances f. Involves CN III & V g. III: leads to eye pain h. V: leads to loss of vision (ophthalmic pressure) i. Mx: no cure, anti-viral drugs only to slow down progression D. Warts a. Cause by: Human Papillomavirus (HPV) b. Seen on hands/fingers, feet/toes (direct contact) c. Mx: cryotherapy, acids, electrodessication, curettage, OTC drugs (commonly salicylic acid) Fungal Infections d. Ringworm: forms ring-shaped patches on skin with scales & vesicles i. Types: 1. Tinea Capitis: Scalp Ringworm 2. Tinea Barbae: beard ringworm 3. Tinea Corporis: body ringworm 4. Tinea Unguium: Nail ringworm 5. Tinea Cruris: Jock Itch 6. Tinea Pedis: athlete’s Foot ii. Mx: Griseofulvin (antifungal cream) Parasitic Infections A. Scabies (Mites) a. Burrow unto the skin resulting to itching, redness & pruritus b. Pruritus: itching of skin (you see the px) c. Mx: Scabicide B. Lice (Pediculosis) a. Itching, redness, bite marks; sometimes (+) nits: eggs on the hair follicle b. Commonly seen on scalp, body & genitalia c. Mx: special shampoo/soap Auto-immune Skin Disorder A. Psoriasis: an erythematous plaque covered with silvery scale a. Seen on scalp, ears, body, elbows, hands/fingers, knees, feet/toes b. (+) Arthritis = Psoriatic Arthritis c. (+) Auspitz Sign d. Mx: Long-wave UVR + Psoralens B. Lupus Erythematosus: a chronic, progressive connective tissue disease a. Affects young women (Selina Gomez)\ Gold Rank Intensive Review Baguio Batch 2017  Integumentary System b. 2 Types i. Discoid L.E. 1. Hypopigmentation 2. Hyperpigmentation ii. Systemic L.E. 1. A collagen, vascular disease 2. Affects young, women 3. Involves multiple organ-systems (skin, joints, heart, blood vessels, lungs, kidneys mucous membrane, nervous system) 4. (+) Butterfly/Malar/Wolf-like rash, anemia, allergy, skin lesions, fatigue, arthralgia, arthritis, Raynaud’s phenomenon 5. Mx: systemic corticosteroids, immune-suppressive agents, salicylates & Indomethacin C. Scleroderma: hardening/thickening of skin a. Involves the skin, joints, heart, blood vessels, lungs, kidneys & GI Tract b. (+) Crest Syndrome C alcinosis chalk-like appearance of skin R aynaud’s Phenomenon E sophageal Dysfunction GERD S clerodactyly tightening and contractures of the fingers T elangiectasia D. Dermatomyositis (DM) a. Skin lesions with dermatitis Polymyositis (PM) b. Skin lesions with atrophy of proximal muscles (shoulder/pelvic girdles) c. Mx: Systemic corticosteroids, immune-suppressive agents Skin Cancer Benign A. Seborrheic Keratosis: proliferation of basal cells resulting to raised lesions B. Actinic Keratosis: proliferation of squamous cells; flat round or irregular C. Common mole (Benign Nevus): Proliferation of melanocytes; round or oval; 6mm c. “ABCDs” A symmetry B order C olor D iameter E volving Gold Rank Intensive Review Baguio Batch 2017  Integumentary System Skin Trauma A. Contusion: an injury with intact skin; bruise B. Ecchymosis: extravasations of blood into the subcutaneous tissues d/t fragile blood vessels C. Petechiae: red or purple hemorrhagic spots on skin D. Abrasion: Scraping away of skin d/t a mechanical injury E. Laceration: irregular tear of skin resulting to a torn, jagged wound Skin Assessment A. Pruritus: itching B. Urticaria: smooth, red elevated patches on skin hives C. Edema: anemia; venous/lymphatic obstruction; cardiac, circulatory, or renal decompensation a. Pitting – persistent indentation b. Non-Pitting – ex. Brawny c. Limb Girth Measurement – measures the limb every 2cm throughout limb d. Volumetric Measurement – measures the displaced water after extremity is placed into main tank Changes in Skin Color A. Cherry Red – CO Poisoning B. Pallor (Pale) – anemia, arterial insufficiency, fear, shock, internal hemorrhage, lack of exposure to sunlight C. Cyanosis – bluish discoloration d/t hypoxia, arterial obstruction, CHF, CHD, advanced lung disease a. Central b. Peripheral D. Jaundice – yellowish discoloration d/t liver disease; (+) carotenemia E. Liver Spots – brownish yellow spots d/t aging, pregnancy, uterine/liver malignancies F. Brown Color – d/t venous insufficiency Rash A. local eruptions & redness on skin B. Heat rash, diaper rash, alcohol rash, drug rash Hydration of Skin A. Moist Skin: hot drinks, exercise, pulmonic crisis, anxiety B. Dry Skin: d/t dehydration C. Cold-Sweats: depression, fear, anxiety, AIDS Xeroderma A. Excessive dryness of Skin Skin Lesions I. Flat Spots