Ultimate Block 6 Deck

Risk factors for breast cancer

1. gender (males 1/100 cases) 2. age - usu post-menopausal 3. early menarche/late menopause 4. obesity 5. atypical hyperplasia (5x incr risk) 6. first-degree relative with breast cancer

what epithelium lines lobules and ducts of breast?

2 layers of epithelium 1. inner luminal layer (columnar) - makes milk 2. outer myoepithelial layer - contractile fxn to eject milk towards nipple

fibrocystic change cancer risk: ductal hyperplasia and sclerosing adenosis

2x increased risk for invasive carcinoma -risk increased for both breasts sclerosing adenosis - can show up calcified on mammogram increase in glands in lobule with collagen deposition

fibrocystic change cancer risk: atypical hyperplasia

5x increased risk for invasive carcinoma -risk increased for both breasts depending on location can be atypical ductal hyperplasia or atypical lobular hyperplasia

hypertrophic cardiomyopathy

60-70% of cases are familial, autosomal dominant (most commonly due to mutations in genes encoding sarcomeric proteins, such as myosin binding protein C and β-myosin heavy chain). Can be associated with Friedreich ataxia. Causes syncope during exercise and may lead to sudden death in young athletes due to ventricular arrhythmia. Pompe Disease (Type II GSD). Findings: S4, systolic murmur. May see mitral regurgitation due to impaired mitral valve closure Diastolic dysfunction ensues. Marked ventricular concentric hypertrophy (sarcomeres added in parallel), often septal predominance. Myofibrillar disarray and fibrosis.

ventricular fibrillation

A completely erratic rhythm with no identifiable waves. Fatal arrhythmia without immediate CPR and defibrillation. Most important shockable cardiac arrest rhythm. The ventricles suddenly attempt to contract at rates of up to 500 bpm. This rapid and irregular electrical activity renders the ventricles unable to contract in a synchronized manner, resulting in immediate loss of cardiac output. The heart is no longer an effective pump and is reduced to a quivering mess. Unless advanced life support is rapidly instituted, this rhythm is invariably fatal. Prolonged ventricular fibrillation results in decreasing waveform amplitude, from initial coarse VF to fine VF and ultimately degenerating into asystole due to progressive depletion of myocardial energy stores.

atrial flutter

A rapid succession of identical, back-to-back atrial depolarization waves. The identical appearance accounts for the "sawtooth" appearance of the flutter waves. Treat like atrial fibrillation. Definitive treatment is catheter ablation. Atrial flutter with predominantly 2:1 conduction. In contrast to atrial fibrillation, flutter waves are distinct waves, rate usually 250 - 300 bpm. Most atrial flutter arises from just above the tricuspid valve, so the flutter waves will be negative in II, III, and aVF, producing a "sawtooth" pattern to the baseline. Atrial flutter can be seen in similar conditions as atrial fibrillation.

Fat Soluble Vitamins

A, D, E, K. Absorption dependent on gut and pancreas. Toxicity more common than for water-soluble vitamins because fat-soluble accumulate in fat. Malabsorption syndromen with steatorrhea (CF and celiac disease), or mineral oil intake can cause fat-soluble deficiencies.

drugs used in heart failure and which ones affect mortality

ACE inhibitors or angiotensin II receptor blockers, β-blockers (except in acute decompensated HF), and spironolactone dec mortality. Thiazide or loop diuretics are used mainly for symptomatic relief. Hydralazine with nitrate therapy improves both symptoms and mortality in select patients.

Water soluble vitamins

B1 (thiamine: TPP) B2 (riboflavin: FAD, FMN) B3 (niacin: NAD+) B5 (pantothenic acid: CoA) B6 (pyridoxine: PLP) B7 (biotin) B9 (folate) B12 (cobalamin) C (ascorbic acid) All wash out easily from body except B12 and B9 (folate). B12 stored in liver for ~ 3-4 years. B9 stored in liver for ~ 3-4 months. B-complex deficiencies often result in dermatitis, glossitis, and diarrhea. Can be coenzymes (eg, ascorbic acid) or precursors to organic cofactors (eg, FAD, NAD+).

lyme disease

Caused by Borrelia burgdorferi, which is transmitted by the Ixodes deer tick (also vector for Anaplasma spp. and protozoa Babesia) Natural reservoir is the mouse (and important to tick life cycle). Common in northeastern United States. Stage 1 - Early localized: erythema migrans (typical "bulls-eye" configuration is pathognomonic but not always present), flu-like symptoms. Stage 2 - Early disseminated: secondary lesions, carditis, AV block, facial nerve (Bell) palsy, migratory myalgias/transient arthritis. Stage 3 - Late disseminated: encephalopathies, chronic arthritis

restrictive cardiomyopathy

Causes - Postradiation fibrosis, Loeffler syndrome, Endocardial fibroelastosis (thick fibroelastic tissue in endocardium of young children), Amyloidosis, Sarcoidosis, Hemochromatosis (although dilated cardiomyopathy is more common) (Puppy LEASH). Loeffler syndrome — associated with hypereosinophilic syndrome, histology shows eosinophilic infiltrates in myocardium. Diastolic dysfunction ensues. Can have low-voltage ECG despite thick myocardium (especially amyloid). Decreased compliance of the ventricular endomyocardium that restricts filling during diastole Presents as congestive heart failure; classic finding is low-voltage EKG with diminished QRS amplitude

atrial fibrillation

Chaotic and erratic baseline with no discrete P waves in between irregularly spaced QRS complexes. Irregularly irregular heartbeat. Most common risk factors include hypertension and coronary artery disease (CAD). Can lead to thromboembolic events, particularly stroke. Causes: Hypertension, hyperthyroidism, CAD, rheumatic heart/valve disease, binge drinking, and heart failure; Isolated atrial amyloidosis of ANP (deposited in the atrium w/normal aging and increases the risk of atrial fibrillation); Sleep Apnea; Anything that inc Atrial Pressure (eg, hypertension/mitral stenosis) Treatment includes anticoagulation, rate control, rhythm control, and/or cardioversion. Absent a wave on Jugular Venous Pulse.

heart conduction pathway

Conduction pathway—SA node>atria>AV node>bundle of His>right and left bundle branches>Purkinje fibers>ventricles; left bundle branch divides into left anterior and posterior fascicles. SA node "pacemaker" inherent dominance with slow phase of upstroke. AV node—located in posteroinferior part of interatrial septum. Blood supply usually from RCA. 100-msec delay allows time for ventricular filling. Pacemaker rates—SA > AV > bundle of His/ Purkinje/ventricles. Speed of conduction—Purkinje > atria > ventricles > AV node.

Wernicke-Korsakoff syndrome

Confusion, ophthalmoplegia, ataxia (classic triad) + confabulation, personality change, memory loss (permanent). Damage to medial dorsal nucleus of thalamus, mammillary bodies

ductal carcinoma in situ can present how?

-calcification on mammography -usu doesn't form a mass no invasion of basement membrane

what are the benign breast lesions that can have calcification on mammography?

-fat necrosis -sclerosing adenosis of fibrocystic change

causes of galactorrhea

-nipple stimulation -prolactinoma -drugs

prinzmetal angina

Episodic chest pain unrelated to exertion. Occurs at rest 2° to coronary artery spasm; transient ST elevation on ECG. Smoking is a risk factor, but hypertension and hypercholesterolemia are not. Triggers may include cocaine, alcohol, and triptans. Due to coronary artery vasospasm; Represents reversible injury to myocytes (no necrosis) EKG shows ST-segment elevation due to transmural ischemia. Relieved by nitroglycerin or calcium channel blockers

Vitamin B12 (cobalamin)

Function: FUNCTION DEFICIENCY Cofactor for methionine synthase (transfers CH3 groups as methylcobalamin) and methylmalonyl-CoA mutase. Important for DNA synthesis. Deficiency: Macrocytic, megaloblastic anemia; hypersegmented PMNs; paresthesias and subacute combined degeneration (degeneration of dorsal columns, lateral corticospinal tracts, and spinocerebellar tracts) due to abnormal myelin. Associated with increased serum homocysteine and methylmalonic acid levels, along with 2° folate deficiency. Prolonged deficiency irreversible nerve damage. Found in animal products. Synthesized only by microorganisms. Very large reserve pool (several years) stored primarily in the liver. Deficiency caused by malabsorption (eg, sprue, enteritis, Diphyllobothrium latum), lack of intrinsic factor (pernicious anemia, gastric bypass surgery), absence of terminal ileum (surgical resection, eg, for Crohn disease), or insufficient intake (eg, veganism). Anti-intrinsic factor antibodies diagnostic for pernicious anemia.

Vitamin K (phytomenadione, phylloquinone, phytonadione) function

Function: Activated by epoxide reductase to the reduced form, which is a cofactor for the γ-carboxylation of glutamic acid residues on various proteins required for blood clotting. Synthesized by intestinal flora. -K is for Koagulation. Necessary for the maturation of clotting factors II, VII, IX, X, and proteins C and S. Warfarin inhibits vitamin K-dependent synthesis of these factors and proteins. Deficiency: Neonatal hemorrhage with PT and aPTT but normal bleeding time (neonates have sterile intestines and are unable to synthesize vitamin K). Can also occur after prolonged use of broad-spectrum antibiotics. Not in breast milk; neonates are given vitamin K injection at birth to prevent hemorrhagic disease of the newborn.

Vitamin E (tocopherol/tocotrienol)

Function: Antioxidant (protects RBCs and membranes from free radical damage).High-dose supplementation may alter metabolism of vitamin K enhanced anticoagulant effects of warfarin. Deficiency: Hemolytic anemia, acanthocytosis, muscle weakness, posterior column and spinocerebellar tract demyelination. Neurologic presentation may appear similar to vitamin B12 deficiency, but without megaloblastic anemia, hypersegmented neutrophils, or increase serum methylmalonic acid levels.

Vitamin A (retinol)

Function: Antioxidant constituent of visual pigments (retinal); essential for normal differentiation of epithelial cells into specialized tissue (pancreatic, mucus secreting); prevents squamous metaplasia. Used to treat measles and APL Retinol is Vitamin A --> retin-A (used to treat wrinkles and Acne) -oral isotretinoin for sever cystic acne Found in liver and leafy vegetables Deficiency: Night blindness (nyctalopia), dry, scaly skin (xerosis cutis), corneal deregulation (keratomalcia); Bitot spots of conjunctiva; immunosuppresion Excess: Acute- nausea, vomiting, vertigo, and blurred vision Chornic- alopecia, dry skin (scaliness), hepatic toxicity, and enlargement arthraligas, psedotumor cerebra Teratogenic (cleft palate, cardiac) -negative pregnancy test and two forms of contraception are required before isotretinoin

Vitamin C (ascorbic acid)

Function: Antioxidant; also facilities iron absorption by reducing it to Fe2+ state. Necessary for hydroxylation of proline and lysine in collagen synthesis. Necessary for dopamine beta-hydrolase, which converts dopamine to NE -Ancillary treatment for methemoglobinemia Deficiency: Scurvy—swollen gums, bruising, petechiae, hemarthrosis, anemia, poor wound healing, perifollicular and subperiosteal hemorrhages, "corkscrew" hair. Weakened immune respons Excess: Nausea, vomiting, diarrhea, fatigue, calcium oxalate nephrolithiasis. Can risk of iron toxicity in predisposed individuals (eg, those with transfusions, hereditary hemochromatosis).

Vitamin B7 (biotin)

Function: Cofactor for carboxylation enzymes -pyruvate carboxylase: pyruvate (3C) --> oxaloacetate (4C) -Acetyl-CoA carboxylase: acetyl-CoA (2C) --> malonyl-CoA (3C) -Propionyl-CoA carboxylase: propionyl-CoA (3C) --> methymalonyl-CoA (4C) Deficiency: rare. Dermatitis, alopecia, enteritis. Caused by Abx use or excessive ingestion of raw egg whites

Vitamin B2 (riboflavin)

Function: Component of flavors FAD and FMN, used as cofactors in redox reactions, eg, the succinate dehydrogenase reaction in TCA cycle FAD and FMN are derived from riboFlavin Deficiency: Cheilosis (inflammation of lips, scaling and fissures at the corners of mouth), Corneal vascularization

Vitamin B3 (niacin)

Function: Constituent of NAD+, NADP+ (used in redox reactions). Derived from tryptophan. Synthesis requires B2 and B6. Used to treat dyslipidemia; lowers levels of VLDL and raises HDL Deficiency: Glossitis. Severe leads to pellagra, which can be caused by Hartnup disease, malignant carcinoid syndrome (increase tryptophan metabolism), and isoniazid (decrease B6). Pellagra- Diarrhea, Dementia (and hallucinations), Dermatitis (C3/C4 dermatome circumferential "broad collar" rash [Casal necklace], hyper pigmentation of unexposed limbs Hartnup- autosomal recessive. Deficiency of neutral amino acid (tryptophan) transporter in proximal renal tubular cells and or erythrocytes --> neutral aminoaciduria and decrease absorption from gut --> decrease tryptophan conversion to niacin --> pellagra-like symptoms. Treat with high protein diet Excess: facial flushing (induced by prostaglandins, not histamine, can avoid by taking aspirin with niacin), hyperglycemia, hyperuricemia

Vitamin B6 (pyridoxine)

Function: Converted to pyridoxal phosphate (PLP), a cofactor used in transamination (ALT/AST), decarboxylation reactions, glycogen phosphorylates. Synthesis of cystathione, heme, niacin, histamine, neurotransmitters. Deficiency: Convulsions, hyper irritability, peripheral neuropathy (deficiency inducible by isonaizd and OCT), sideroblastic anemia due to impaired hemoglobin synthesis and excess iron

Vitamin B9 (folate)

Function: Converted to tetrahydrofolic acid (THF), a coenzyme for 1-carbon transfer/methylation reactions. Important for the synthesis of nitrogenous bases in DNA and RNA; Found in leafy green vegetables. Absorbed in jejunum. Folate from foliage. Small reserve pool stored primarily in the liver. Deficiency: Macrocytic, megaloblastic anemia; hypersegmented polymorphonuclear cells (PMNs); glossitis; no neurologic symptoms (as opposed to vitamin B12 deficiency). Labs: homocysteine, normal methylmalonic acid levels. Most common vitamin deficiency in the United States. Seen in alcoholism and pregnancy. Deficiency can be caused by several drugs (eg, phenytoin, sulfonamides, methotrexate). Supplemental maternal folic acid at least 1 month prior to conception and during early pregnancy to risk of neural tube defects.

Zinc

Function: Mineral essential for the activity of 100+ enzymes. Important in the formation of zinc fingers (transcription factor motif). Deficiency: Delayed wound healing, hypogonadism, decreased adult hair (axillary, facial, pubic), dysgeusia, anosmia, acrodermatitis enteropathica A . May predispose to alcoholic cirrhosis.

Vitamin B1 (thiamine)

Function: Thiamine pyrophosphate (TPP), a cofactor for several dehydrogenase enzyme reactions -pyruvate dehydrogenase (glycolysis link to TCA) -alpha-ketoglutarate dehydrogenase (TCA cycle) -Transketolase (HMP shunt) -Branched-chain ketoacid dehydrogenase Deficiency: impaired glucose breakdown --> ATP deletion worsened by glucose infusion; Highly aerobic tissues (brain, heart) affected first. In alcoholic/malnourished, give thiamine before dextrose to decrease risk of Wernicke encephalopathy Diagnosis --> increase RBC transketolase activity following B1 adminstration

Vitamin B5 (pantothenic acid)

Function: essential component of CoA (cofactor for acyl transfers) and fatty acid synthase Deficiency: Dermatitis, enteritis, alopecia, adrenal insufficiency

right heart failure

Hepatosplenomegaly (nutmeg liver) - inc central venous pressure>inc resistance to portal flow. Rarely, leads to "cardiac cirrhosis." Jugular Venous Distention - inc venous pressure. Peripheral Edema - inc venous pressure>fluid transudation. Most commonly due to left-sided heart failure; other important causes include left-to-right shunt and chronic lung disease (cor pumonale) Cor pulmonale causes - COPD (Chronic Bronchitis, Emphysema, Bronchiectasis), Pulmonary Hypertension (1° BMPR2 mutation in young adult females or 2° to hypoxemia (e.g., COPD and interstitial lung disease) or increased volume in the pulmonary circuit (CHF); may also arise with recurrent pulmonary embolism

Marasmus

Malnutrition not causing edema. Diet is deficient in calories but no nutrients are absent. Marasmus results in muscle wasting.

second degree AV block includes

Mobitz type I and II

dilated cardiomyopathy

Most common cardiomyopathy (90% of cases). Often idiopathic or familial. Dilation of all four chambers of the heart Systolic dysfunction (ventricles cannot pump), leading to ventricular CHF; complications include mitral and tricuspid valve regurgitation and arrhythmia Causes - Alcohol abuse, wet Beriberi, Coxsackie B viral myocarditis, chronic Cocaine use, Chagas disease, Doxorubicin toxicity, hemochromatosis, sarcoidosis, peripartum cardiomyopathy. ABCCCD. Findings: HF, S3, systolic regurgitant murmur, dilated heart on echo, balloon appearance of heart on CXR

heart remodeling in heart failure

Neurohormonal activation — Progressive HF is associated with neurohormonal activation>progression of structural abnormalities. Net effect is inc release of the 3 "hypovolemic" hormones (renin, norepinephrine, and antidiuretic hormone) proportional to severity of the ventricular dysfunction. Initially adaptive, neurohormonal activation is bad long term - contributes to remodeling. Plasma BNP concentrations are also inc in HF but protects against pathologic remodeling. Role of Angiotensin II — Mechanical stretch directly increases angiotensin II release from cardiac myocytes. AT1 receptors have been identified on fibroblasts that respond to angiotensin II with AT1 receptor-mediated collagen synthesis, an effect that can be reduced by ACE inhibition. Also acting on the AT1 receptor, angiotensin II increases protein synthesis and induces hypertrophy in cardiac myocytes

central sleep apnea

No respiratory effort due to CNS injury/toxicity, HF, opioids. May be associated with Cheyne- Stokes respiration. Treat with positive airway pressure

nipple ulceration and erythema (not infxs)

Paget Disease of the Breast -DCIS that has crept up to involve skin of nipple -always associated with underlying carcinoma

fibroadenoma-like tumor with overgrowth of fibrous component, forming "leaf-like" projections

Phyllodes tumor -post-menopausal females -can be malignant

Mobitz Type I (Wenckebach)

Progressive lengthening of PR interval until a beat is "dropped" (a P wave not followed by a QRS complex). Usually asymptomatic. Variable RR interval with a pattern (regularly irregular). Sinus rhythm (P before every QRS and positive P in lead II) with 2nd degree AV block, Type I (Wenckebach). PR progressively prolongs and then P fails to conduct Every 3rd P wave is not conducted (3 P waves for every 2 QRS or 3:2 conduction). The shortest PR is following the nonconducted P wave. Commonly seen in vagal states or drugs that affect AV conduction.

Kwashiorkor

Protein malnutrition resulting in skin lesions, edema due to decreased plasma oncotic pressure, liver malfunction (fatty change due to decrease apoliportein synthesis). Clinical picture: small child with swollen abdomen MEALS -Malnutrition -Edema -Anemia -Liver (fatty) -Skin lesions (hyperkeratosis/hyperpigmentation)

sleep apnea

Repeated cessation of breathing > 10 seconds during sleep>disrupted sleep>daytime somnolence. Diagnosis confirmed by sleep study. Normal Pao2 during the day. Nocturnal hypoxia>systemic/pulmonary hypertension, arrhythmias (atrial fibrillation/flutter), sudden death. Hypoxia>inc EPO release>inc erythropoiesis

obstructive sleep apnea

Respiratory effort against airway obstruction. Associated with obesity, loud snoring. Caused by excess parapharyngeal tissue in adults, adenotonsillar hypertrophy in children. inc pulse pressure (inc sympathetic tone); Pulsus paradoxus | Treatment: weight loss, CPAP, surgery.

conduction pathway

SA node>atria>AV node>bundle of His>right and left bundle branches>Purkinje fibers>ventricles; left bundle branch divides into left anterior and posterior fascicles.

stable vs. unstable angina

Stable Angina - Chest pain that arises with exertion or emotional stress. Unstable angina - Chest pain that occurs at rest.

first degree AV block

The PR interval is prolonged (> 200 msec). Benign and asymptomatic. No treatment required. Sinus rhythm (P before every QRS and positive P in lead II) with first degree AV block (PR > 0.21 sec) Commonly seen in vagal states (e.g. sleep) and with drugs that affect AV conduction (e.g., beta-blockers, Ca2+ channel blockers such as diltiazem or verapamil, digoxin) Drug Causes: Type II (beta) and IV (Ca2+) Anti-arrhythmics; Digoxin

Third Degree (Complete) AV Block

The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lyme disease. Complete heart block: hallmark is AV dissociation. Complete heart block with ventricular escape usually reflects disease of the conduction system below AV node. Can be seen in acute MI or as natural progression of LBBB with age.

hypertensive emergency treatment

Treat with clevidipine, fenodapam, labetalol, nicardipine, or nitroprusside. Nitroprusside - Short acting; inc cGMP via direct release of NO. Can cause cyanide toxicity (releases cyanide). Fenoldopam - Dopamine D1 receptor agonist - coronary, peripheral, renal, and splanchnic vasodilation. dec BP, inc natriuresis. Also used postoperatively as an antihypertensive. Can cause hypotension and tachycardia.

Duchenne muscular dystrophy

X-linked disorder typically due to frameshift or nonsense mutations>truncated or absent dystrophin protein>progressive myofiber damage. Weakness begins in pelvic girdle muscles and progresses superiorly. Pseudohypertrophy of calf muscles due to fibrofatty replacement of muscle. Waddling gait. <5 years of age. Dilated cardiomyopathy common death cause

breast feeding + fissures?

acute mastitis (staph aureus)

erythematous breast with purulent nipple discharge, may progress to abscess formation

acute mastitis (staph aureus)

dimpling of skin + nipple retraction

advanced invasive ductal carcinoma

S2

aortic and pulmonic valve closure

gross exam shows what for fibrocystic change?

blue-dome appearance of cysts

atrial stunning

cardioversion of atrial fibrillation/flutter to sinus rhythm is associated with a cardioversion related transient mechanical dysfunction of the left atrium and left atrial appendage Result is paradoxical dec left atrial appendage blood flow velocities despite reversion to sinus rhythm Leads to increased risk of developing thromboembolic events hours to weeks after cardioversion of atrial fibrillation to sinus rhythm Causes postcardioversion thromboembolism despite restoration of sinus rhythm

high-grade ductal cells with central necrosis and dystrophic calcification later? cancer risk?

comedo type of DCIS. precancerous.

defibrillator

device that delivers a dose of electric current (called a countershock) to heart, depolarizing a large amount of the heart muscle, and ultimately ending the dysrhythmia

drug used to prevent dilated cardiomyopathy from anthracycline use (doxo and daunorubicin)

dexrazoxane

Chagas disease

dilated cardiomyopathy with apical atrophy, megacolon, megaesophagus; predominantly in South America; Unilateral periorbital swelling (Romaña sign) characteristic of acute stage; Transmission: Reduviid bug ("kissing bug") feces, deposited in a painless bite (much like a kiss) Diagnosis - Trypanosoma cruzi; Trypomastigote in blood smear Treatment - Benznidazole or nifurtimox; Cruzing in my Benz, with a fur coat on

ductal carcinoma biopsy shows?

duct-like structures in desmoplastic stroma

MC type of invasive carcinoma?

ductal carcinoma

well-differentiated tubules that lack myoepithelial cells -good prognosis

ductal carcinoma: tubular carcinoma

breast during pregnancy and after menopause?

during preg undergoes hyperplasia driven by est/prog made by CL (1st tri), fetus, placenta (late). undergoes atrophy in menopause

fibroadenoma features that demonstrate hormone sensitivity

estrogen sensitive mass -grows during pregnancy -painful during menstrual cycle -shrinks with menopause

accessory nipple due to?

failure of involution of mammary ridge -can occur anywhere along the milkline -MC congenital anomaly -usu asx but can be hormone responsive

mass on physical exam or abnormal calcification on mammography (but not breast cancer)

fat necrosis of breast -due to trauma

biopsy that shows necrotic fat with associated calcifications and giant cells

fat necrosis of breast -secondary to trauma

MC benign neoplasm of breast

fibroadenoma

well-circumscribed, mobile, marble-like mass in pre-menopausal female? cancer risk?

fibroadenoma -estrogen sensitive -benign -no increased risk for carcinoma

MC change in pre-menopausal breast? presents as?

fibrocystic change -hormone-mediated presence of fibrosis and cysts -presents as lumpy breast, esp upper outer quadrant

milk production outisde of lactation?

galactorrhea -not a sign of breast cancer

S3

in early diastole during rapid ventricular filling phase. Associated with inc filling pressures (mitral regurgitation, HF) and more common in dilated ventricles (can be normal in children/young adults)

S4

in late diastole ("atrial kick"). Best heard at apex with patient in left lateral decubitus position. High atrial pressure. Associated with ventricular noncompliance (eg, hypertrophy). Left atrium must push against stiff LV wall. Consider abnormal, regardless of patient age

left heart failure

inc pulmonary venous pressure>pulmonary venous distention and transudation of fluid. Presence of hemosiderin-laden macrophages ("HF" cells) in lungs. (PCWP >18) Causes - ischemia, myocardial infarction, dilated cardiomyopathy, restrictive cardiomyopathy, and HTN. Clinical features are due to decreased forward perfusion and pulmonary congestion Pulmonary Edema - Results in dyspnea, paroxysmal nocturnal dyspnea (due to increased venous return when lying flat), orthopnea, and crackles (pulmonary edema) Small, congested capillaries may burst, leading to intraalveolar hemorrhage marked by hemosiderin-laded macrophages ('heart-failure" cells) Decreased flow to kidneys leads to activation of renin-angiotensin system (fluid retention exacerbates CHF; mainstay of treatment is ACE inhibitor

bloody nipple discharge in pre-menopausal female

intraductal papilloma -papillary growth in a large duct -lined by normal epithelial (luminal) and myoepithelial cells

intraductal papilloma vs papillary carcinoma

intraductal papilloma -pre-menopausal female -papillary growth lined by luminar and myoepithelial cells papillary carcinoma -post-menopausal female -no myoepithelial cells lining papillary growth

firm rock hard mass with sharp margins and small, glandular cells + stellate infiltration

invasive ductal carcinoma

plasma cells with chronic inflammation seen on breast biopsy

mammary duct ectasia "green-brown nipple discharge"

periareolar mass with green-brown nipple discharge (seen in multiparous post-menopausal female)

mammary duct ectasia -inflammation with dilation of subareolar ducts -histo shows plasma cells

how does invasive ductal carcinoma present?

mass detected usu by PE or mamography -clinically detected at 2 cm or more -mammographically detected at 1 cm or greater -advanced tumors: can cause dimpling of skin and nipple retraction

S1

mitral and tricuspid valve closure

fibrocystic change cancer risk: fibrosis, cysts, apocrine metaplasia

no increased risk

invasion of nipple by large cells with clear cyto

pagets disease

nipple ulceration + erythema + excematous scaling

pagets disease (underlying carcinoma)

subareolar mass with nipple retraction

periductal mastitis (inflammation of subareolar ducts) usu seen in smokers

diastolic dysfunction

preserved EF, normal EDV; dec compliance often 2° to myocardial hypertrophy. In diastolic heart failure, there is impaired cardiac relaxation and abnormal ventricular filling. Hypertrophic/Restrictive cardiomyopathy

systolic dysfunction

reduced EF, inc EDV; dec contractility often 2° to ischemia/MI or dilated cardiomyopathy. In systolic heart failure, there is reduced cardiac contractility.

why do smokers get periductal mastitis?

relative vitamin A deficiency -results in squamous metaplasia of lactiferous ducts -causes duct blockage and inflammation (myofibroblasts cause nipple retraction)

central acinar compression by fibrosis + peripheral duct dilation

sclerosing adenosis

drugs that can cause gynecomastia?

spironolactone, digoxin, cimetidine, alcohol, ketoconazole (some drugs cause awesome knockers)

MC organism of acute mastitis? tx?

staph aureus tx with dicloxacillin and continued drainage (breastfeeding)

hypertrophic obstructive cardiomyopathy

subset of hypertrophic cardiomyopathy asymmetric septal hypertrophy and systolic anterior motion of mitral valve>outflow obstruction>dyspnea, possible syncope

cardioversion

tachycardia/arrhythmia is converted to a normal rhythm using electricity or drugs

what is the functional unit of the breast?

terminal duct lobular unit (consists of lobules that make milk and duct that drains milk)

Paget Disease of Breast associated with?

underlying carcinoma (usu DCIS)

where is the highest density of breast tissue located?

upper outer quadrant of breast

Vitamin D

D2 = ergocalciferol—ingested from plants. D3 = cholecalciferol—consumed in milk, formed in sun-exposed skin (stratum basale). 25-OH D3 = storage form. 1,25-(OH)2 D3 (calcitriol) = active form. Function: Increase intestinal absorption of calcium and phosphate, Increase bone mineralization at low levels, bone resorption at higher levels. Deficiency: Rickets in children (deformity, such as genu varum "bow legs"), osteomalacia in adults (bone pain and muscle weakness), hypocalcemic tetany. Breastfed infants should receive oral vitamin D. Deficiency is exacerbated by low sun exposure, pigmented skin, prematurity. Excess: Hypercalcemia, hypercalciuria, loss of appetite, stupor. Seen in granulomatous disease ( activation of vitamin D by epithelioid macrophages).

Mobitz Type II

Dropped beats that are not preceded by a change in the length of the PR interval (as in type I). May progress to 3rd-degree block. Often treated with pacemaker.

Beriberi

Dry- polyneuritis, symmetrical muscle wasting Wet- high-output cardiac failure (dilated cardiomyopathy), edema