Midterm Study guide

Diastolic Murmurs 1. What is the first sound heard in Mitral Stenosis (MS)? 2. What follows this ejection click? 3. Where is this murmur best heard?

1. An opening snap or an opening ejection click caused by the rapid opening of the MV and filling of the LV 2. a mid-diastolic rumble aka low-pitched murmur heard all the way to S1 b/c the murmur reduces in intensity and then increases as the LA contact and push the remaining blood into the LV 3. in the MV area at the apex of the heart

Chronic atherosclerotic coronary obstruction usually results in ischemia to the muscle tissue, ID the types of angina 1. Angina Pectoris 2. Stable Angina; recurrent predictable chest pain caused by 3. Prinzmetal angina unpredictable chest pain; almost exclusively at rest, is caused by

1. Angina pectoris is chest pain caused by myocardial ischemia 2. gradual luminal narrowing and hardening of the arterial walls, so that affected vessels cannot dilate in response to increased myocardial demand associated with physical exertion 3. vasospasm of one or more major coronary arteries with or without associated atherosclerosis

List the causes of MR

1. Anything that causes LV dilation (enlargement) such as remodeling post MI, dilated cardiomyopathy (ischemic/nonischemic) 2. Rheumatic fever: early in the course of the disease 3. Endocarditis causing vegetation on vavles 4. Papillary muscle/chordae tendinea disfxn or rupture 5. Calcification of valve

List and ID the areas where you can hear the 4 heart valves

1. Aortic valve is located at the 2nd ICS-R upper SB 2. Pulmonic valve is located at the 2nd ICS-L upper SB 3. Tricuspid valve is located at the 4th ICS-L SB 4. Mitral valve is located at the 5th ICS MidClav Line also known as the Apex of the heart

1. ILD is not one specific lung condition. 2. ILDs are characterized by a combination of

1. It refers to any disease affecting the pulmonary interstitium and typically excludes infectious and neoplastic diseases. 2. interstitial inflammation, fibrosis, and scarring around the alveoli sacs.

List three ways the body can compensate for HF

1. activate the SNS to increase SV and HR 2. increase PL to increase SV 3. Muscular hypertrophy to increase SV

Review the follow case 1. Step 1 Determine the Pattern: based on a FEV1/FVC ratio of 55 would indicate

1. an Obstructive disease as a restrictive disease would be greater than 70%

What does MV prolapse increase your risk for?

1. infective endocarditis 2. certain arrhythmias 3. progress to MR

Which of the following conditions can decrease preload? Fluid overload. Pain. Fever. Hemorrhage.

Hemorrhage.

What is a Hypersensitivity reaction?

Hypersensitivity is an inappropriate immune response to an antigen that results in a pathologic response upon re-exposure.

Anemias can also be classified according to the color of the RBCs: List them

Hypochromic anemia describes RBCs with less hemoglobin than normal. As a result, the RBCs appear pale in color (MCHC is low). Hyperchromic anemia describes RBCs with more hemoglobin than normal. As a result, the RBCs appear a dark hue or red than normal cells (MCHC is high). Normochromic anemia describes RBCs that have a normal amount of hemoglobin. As a result, the RBCs appear neither pale nor dark (MCHC is normal).

Which of the following is considered a late effect of emphysema? Hypoxemia and Hypercapnia. Hypercapnia. Hypoxemia. Hypocapnia.

Hypoxemia and Hypercapnia

Define Diastolic HF

Isolated diastolic heart failure is defined as pulmonary congestion despite a normal stroke volume and cardiac output. Two areas of pathophysiologic changes in the ventricle have been identified in diastolic dysfunction: decreased compliance of the left ventricle and abnormal diastolic relaxation (lusitropy)

Type I: Allergic Reaction What happens with subsequent cross-linking of mast-cell-bound IgE molecules by antigen

On subsequent exposure to the allergen, the IgE molecules located on the sensitized cells induce immediate degranulation of Mast cells. This causes the release of inflammatory mediators such as histamine, leukotrienes, and prostaglandins that results in vasodilation, bronchial smooth muscle contraction, and mucus production.

Choose the interstitial lung diseases that are the most commonly diagnosed: Desquamative interstitial pneumonia Radiation pneumonitis Pneumoconioses Acute interstitial pneumonia Hypersensitivity Pneumonitis Lupus

Radiation pneumonitis Hypersensitivity Pneumonitis Pneumoconioses

Clinical Manifestations of Anemia Decreased tissue oxygenation from anemia can manifest as signs and symptoms of the following:

Severe fatigue Pallor Weakness Dyspnea Dizziness

What are 4 cardinal signs of an acute inflammation:

a. Redness 1) produced by increased oxygenated blood to the area via VD. b. Heat 1) Blood is warmer than surrounding tissue. c. Swelling 1) increased capillary permeability produces edema. d. Pain 1) Injury of nerve fibers/activation of pain receptors by chemicals and swelling elicit pain sensation.

So what is the beneficial purpose of a fever?

a. increases phagocytic activity. b. inhibits bacterial growth via several mechanisms. c. augments the effects of interferons. d. speeds up body reactions that aid repair.

Simple spirometry can be used to measure any of the following EXCEPT: a. Vital capacity. b. Residual volume. c. Tidal volume. d. Inspiratory reserve volume.

b. Residual volume.

Left sided HF can be categorized into two types, id them?

heart failure with reduced ejection fraction, or HFrEF (systolic heart failure), or heart failure with preserved ejection fraction, or HFpEF (diastolic heart failure)

Anaphylaxis is a

type 1 hypersensitivity reaction.

Causes of R sided HF include

1) pulmonary disease that causes pulmonary hypertension. This is the most common cause; 2) right ventricular (MI), which weakens the cardiac muscle; 3) right ventricular hypertrophy (secondary to cardiac damage); 4) tricuspid valve damage (causing backflow of the blood into the right atrium or right ventricle after ejection); 5) secondary failure as a result of left heart failure due to the build-up of pressure in the damage left ventricle.

Impaired function of one of the following components of the immune system leads to immunodeficiency disorders

1. B cells 2. T cells 3. phagocytic cells 4. complement system

Type 4 hypersensitivity reaction 1. What is a classic localized type 4 reaction 2. What distinguishes these reactions

1. Contact dermatitis seen with poison ivy 2. These are delayed reactions because it may take a day or so for the Ag to evoke a cell-mediated immune response

List the signs/symptoms of AR

1. Fatigue 2. Syncope 3. SOB 4. Palpitations 5. Widened pulse pressure: due to blood going back into LA 6. S3 Signaling fluid volume overload & dilated LV 7. Laterally displaced PMI 8. Early Diastolic murmur @ LSB

List the causes of AS

1. Having a Bicuspid Aortic Valve (normal is tricuspid) which becomes calcified and stenosed easier overtime 2. Age-related calcification: overtime the valves become hardened risk factors for this include HTN, HLD, DM and smoking 3. Rheumatic Fever this is more commonly seen in Mitral valve disorders

Exposure-related ILD includes 1. caused by an immune-mediated response ie: "farmer's lung" caused by an exposure to hay 2. caused by inhalation of inorganic substances ie: coal dust, asbestos 3. due to radiation treatment for intrathoracic cancers 4. caused by amiodarone, Nitrofurantoin, methotrexate

1. Hypersensitivity pneumonitis (extrinsic allergic alveolitis) 2. Pneumoconioses 3. Radiation pneumonitis 4. Medication-induced

List the causes of MV prolapse (billowing of the MV into the LA)

1. Idiopathic 2. Secondary to a connective tissue disorder

Idiopathic 1. Idiopathic interstitial pneumonia is poorly understood and include

1. Idiopathic pulmonary fibrosis and Respiratory bronchiolitis-interstitial lung disease-(seen in smokers)

Type 3 hypersensitivity reaction There are 3 sequential phases to a type III reaction. Explain

1. Immune complex formation; complexes are formed in the circulation 2. Immune complex deposition immune complexes are subsequently deposited in vessel walls or extravascular tissues 3. Immune complex-mediated inflammation via complement activation. Most of the tissue damage occurs because neutrophils release large quantities of lysosomal enzymes into the inflammatory site instead of into phagolysosomes where enzymatic activity is contained

1. ID location and significance of S3 sounds hint: ventricular gallop 2. What's the difference if you heart this in a young vs an old person

1. It happens in early diastole during the rapid filling phase of due to the tensing of the chordae tendinea and is a sign of fluid overload as in CHF. It is best heard at the apex of the heart. 2. Normal finding in young people but abnormal finding in elderly (a sign of CHF)

1. What is the first sound heard in MV Prolapse the last systolic murmur? 2. Following this non-ejection click what sounds is hear? 3. Where is this best heard

1. It is the mid-systolic click heard from the tensing of the chordae tendinea/MV leaflets as the MV prolapses from the pressure of the LV contracting 2. The sound of blood leaking back into the LA as seen with MR NOTE: that this is heard AFTER the click so it is a late systolic murmur 3. its heard best at the apex of the heart

1. What is the first sound heard in Mitral Regurg (MR)? 2. Why is this called a holo or pan systolic murmur? 3. Where does the sound radiate to and why?

1. It starts right after S1 b/c the valve closes as it should in S1 but then reopens as seen in MR 2. Because the leakage occurs throughout the entire systole (so the intensity of the sound is continuous btw S1 and S2) 3. It radiates to the L axillae b/c of the blood flow regurgitating back into the LA

1. ID location and significance of S4 sounds hint: atrial gallop 2. What is this caused by

1. It's the sound you hear from the L atrium contracting into a very stiff ventricle heard at the end of diastole just before the next cycle of systole. 2. Its caused by a pressure overload in the aorta from high SVR or an afterload (therefore it is always a pathological finding

The phagocytes or WBCs What are the WBC that appear in high numbers within 3-6 hrs after invasion What are the WBCs that appear 24 hours after invasion

1. Neutrophils make up 70% of our WBCs; they arrive at site of invasion site within minutes 2. Monocytes arrive with 24 hours after the invasion Once they become involved in the inflammatory response they are known as Macrophages

1. What is Residual volume? What is Total Lung Capacity used to distinguish?

1. RV is the amount of air that remains in the lungs after a forceful exhalation. RV + FVC = TLC. Note that the RV cannot be measured by spirometry. 2. If the patient has an obstructive disease, RV and TLC results will be elevated which reveals air trapping and hyperinflation. In restrictive disease, the TLC is needed to confirm true restriction. It can also help in quantifying the degree of restriction.

List causes of MS (having a tight MV)

1. Rheumatic fever seen late in the course of the disease caused by group A streptococcus (starts as strep throat) 2. Endocarditis caused from an infection from bacteria, viruses, or fungi healthy valve: caused by acute Staph Aureus damaged valve: caused by subactue Step Virudans a normal mouth bacteria Prosthetic valve: Staph epidermidus

1. Explain the way the GOLD criteria works to grade the severity of airway disease 2. Indicate the following levels for mild, moderate, severe and very severe

1. Severity is graded according to the FEV1 percent predicted, where normal is greater than 80%.

Remember that all of these bronchial responses are normal to occasional inhalation of airborne irritants. At some point, though, there is the transition from a normal, protective respiratory response to a detrimental effect. This occurs with long-term exposure to airborne irritants that promote

1. Smooth muscle hypertrophy that leads to bronchoconstriction 2. Hypertrophy and hyperplasia of goblet cells that lead to the hypersecretion of mucus 3. Epithelial cell metaplasia that creates non-ciliated squamous cells 4.. Migration of more WBC to the site which leads to inflammation and fibrosis in the bronchial wall 5. Thickening and rigidity of bronchial basement membrane which leads to narrowing of bronchial passageways

1. What is Forced Vital Capacity (FVC) 2. what is the normal range

1. The FVC measures the volume of air in the lungs that can be exhaled. The patient inhales as deep as possible and then exhales as long and as forcefully as possible. 2. Normal 80-120%

Describe each of the following 1. Preload 2. Contractility 3. Afterload

1. The LVEDV (think of this as the degree of stretch exerted-more stretch in a healthy heart = more power) 2. the LV systolic EF (SV-70ml) 3. The resistance to systolic ejection (think of this like the back pressure also known as systemic vascular resistance (SVR)

Describe the formula for each 1. Cardiac Output 2. Stroke Volume 3. Heart rate

1. The amount of blood pumped from each ventricle in a min 2. The volume of blood pumped with each ventricular stroke 3. The number of heart beats in a min

1. What is the first sound heard in Aortic stenosis? 2. Explain the Crescendo murmur which follows the EC? 3. The second sound is followed by a 3. ID the anatomical location of this sound and where it radiates?

1. The sound is an Ejection Click (EC) heard right after S1 caused by the aortic leaflets shooting opening but then abruptly stopping because of the stenosis 2. a midsystolic crescendo/decrescendo murmur: A higher intensity sound (Crescendo) followed by a low intensity sound (Decrescendo) signifying the forceful contraction of the LV followed by its relaxation 3. It can be heart at the upper RSB and radiates to the carotid arteries in the neck

Type 3 hypersensitivity reaction 1. Explain this reaction 2. How does this differ from type 2 reactions

1. These are immune-complex mediated where the Ag-Ab complex becomes soluble in the blood and then are deposited in areas of tissue (joints/kidneys) 2. The primary difference between type II and type III mechanisms is that in type II hypersensitivity antibody binds to the antigen on the cell surface, whereas in type III the antibody binds to a soluble antigen that was released into the blood or body fluids, and the complex is then deposited in the tissues

The pathophys of Extrinsic asthma 1. interleukins go on to activate the eosinophils, which then release chemicals designed to rid the area of the antigen. But in the case of a hypersensitivity 2. Smooth muscle constriction, along with mucus plugs that form. result in

1. These excess chemicals not only destroy the antigen, but also damages the surrounding tissue. Tissue damage is also enhanced by activation of neutrophils 2. hyperinflation of the alveoli and eventual erosion of airway tissue.

1. What is FEV1/FVC ratio 2. This is used to determine what? 3. What is a normal range?

1. This is a calculated ratio that represents the proportion of a person's vital capacity that they are able to expire in the first second of forced expiration to the full, forced vital capacity. 2. Determines if the pattern is obstructive, restrictive or normal 3. If the FEV1/FVC ratio is greater than 70% or greater than the lower limit of normal, then the spirometry test is either normal, or restrictive (which requires more tests)

1. What is a L/R shunt low V/Q? 2. What causes this? *The opposite of a shunt is Dead space ventilation high V/Q which is good ventilation but no perfusion as seen in a pulmonary embolus

1. This is the phenomenon where deoxygenated blood passes from the right ventricle to the left ventricle because of poor ventilation (from COPD) but adequate perfusion 2. Poor ventilation leads to decreased perfusion which causes right to left shunting.

Type I: Allergic Reaction 1. these reactions are mediated by what Ab 2. What is sensitization

1. Type I reactions are IgE-mediated allergic reactions. 2. On initial encounter with an allergen, the individual will first produce IgE antibodies. After the allergen is cleared, the remaining IgE molecules will be bound by mast cells, basophils, and eosinophils that contain receptors for the IgE molecules.

1. What is ventilation 2. Perfusion is the actual exchange of

1. Ventilation is the ability to move air in and out of the lung. It is critical to ensure perfusion. 2. oxygen and carbon dioxide in the blood stream that occurs via the alveoli and pulmonary capillaries.

1. ACS develops when 2. The acute coronary syndromes (ACS) include 3. Myocardial infarction (MI) results when

1. When there is sudden coronary obstruction caused by thrombus formation over a ruptured or ulcerated atherosclerotic plaque 2. unstable angina and myocardial infarction 3. prolonged ischemia causes irreversible damage to the heart muscle usually >20 min

List the causes of AR

1. Widening or aneurysmal changes to the Aortic Annulus 2. Endocarditis 3. Rheumatic fever

Asthma Management 1. The patient receives education on what is 2. A step system is used in the pharmacological management of the patient. meaning

1. a mild, moderate and severe reaction, and depending on where they fit within these categories, they will be provided specific information on its management 2. Step-up means that drug dosages are increased and more added as severity increases or therapy can be stepped down when the symptoms have been controlled for three months

Restrictive Disorders 1. are characterized by 2. Result in difficulty in 3. Due to stiffness in lung compliance or 4. Include interstitial lung disease (ILD), scoliosis, and

1. a reduction in lung volume (TLC) 2. taking air into the lungs 3. chest wall structural abnormality. 4. neuromuscular causes and significant obesity.

Diagnosis of COPD 1. On physical exam; hyperresonance will be identified due to 2. Pulmonary function tests will show <70-80% in both what 3. bronchodilator challenge will result in 4. Chest x-ray will typically demonstrate

1. air trapping 2. FEV1/FVC ratio and FEV1 % predicted 3. no change in the obstructive pattern 4. a flattened diaphragm, distended lung fields and increased thoracic diameter

Type II hypersensitivity reaction 1. Type II reactions occur due to 2. There are 5 general mechanisms, each of which begins with antibody binding to tissue-specific antigens or to Ags that have attached to specific tissue List them:

1. an AB-Ag reaction destroying a target cell or altering its function. The Ag is found on the cell's plasma membrane 2. Complement-mediated lysis of cells Phagocytosis by macrophages Neutrophil-mediated damage Antibody-dependent cell-mediated cytotoxicity (ADCC) Receptor blockage

List causes of HOF hint (causes include anything that increases the tissue demand for oxygenated blood beyond what the heart can supply)

1. anemia, regardless of type, ultimately impair oxygen delivery to the tissues 2. Nutritional deficiencies, especially of the vitamin thiamine, decreases cardiac muscle function and output 3. Hyperthyroidism, fever and sepsis increase basal metabolic rate which leads to increased tissue oxygenation demands

1. ID the four types of left sided heart murmurs 2. Which are heard during systole? (hint which valves are closed) 3. Which are heard during diastole?

1. aortis stenosis, aortic regurg, mitral stenosis and mitral regurg 2. Aortic stenosis and mitral regurg 3. Aortic regurg and mitral stenosis

1. The patient's asthma management plan should include what to do in case of an 2. The patient should be prompted to perform a PEF when they feel sx coming on and if 3. oral glucocorticoids apply in situations where

1. asthma exacerbation and how to anticipate the onset of symptoms. 2. the PEF is 50-79% of their best, then 2-6 puffs of a SABA should be taken three times every 20 minutes followed by a repeat PEF 3. repeat PEFs are <80% or initial PEFs are <50%

1. All asthma symptoms tend to occur 2. Explain why asthma can be worse at night

1. at night or in the early morning hours 2. environmental triggers in the mattress such as dust mites, GERD aggravate asthma symptoms, Post-nasal drip and coughing also contribute to airway irritation. Bronchospasms may occur b/c of airway cooling during the night. cortisol levels decrease during the night. which leads to an increase in histamine levels that lead to increased mucus production and inflammation. There is also decreased levels of epinephrine and increased vagal tone

Asthma Medications 1. Short-Acting Beta-2 Agonists (SABA) (albuterol)-it will act on the 2. Inhaled Corticosteroids (ICS) are used to 3. Mast-cell stabilizers (cromolyn sodium)-are used in situations where patients have cold or exercise-induced asthma. They Inhibit 4. Leukotriene Receptor Antagonists (LTRA)-(Montelukast) -It binds onto the receptors and blocks 5. Omalizumab-an anti-IgE antibody that binds onto the IgE antibody

1. beta 2 adrenergic receptors to cause bronchodilation. 2. reduce inflammation 3. the release of histamine by the mast cells and inhibit eosinophils 4. the reaction of leukotrienes to inhibit bronchospasms and mucus production 5. It helps to decrease bronchospasms, decrease vascular permeability, inflammation and mucus production. It is indicated in the severe stage of asthma

Diastolic Murmurs 1. What is the first sound heard in Aortic Regurg (AR)? 2. Where can this murmur be heard?/explain why

1. it is an Early Diastolic murmur that is decrescendo b/c the noise intensity decreases as blood moves from the aorta (high pressure) to the dilated/relaxing LV (low pressure) 2. On the LSB b/c blood is traveling back from the aorta

Types of Angina 1. Silent Ischemia caused by mental distress does NOT cause angina 2. Unstable angina is caused by transient ischemia that is

1. may be associated only with nonspecific symptoms such as fatigue, dyspnea, or feeling of unease 2. reversible but is a harbinger of impending infarction

1. Spirometry measures what? 2. What are the three important spirometry measurements the NP is concerned with?

1. measures air movement in and out of the lungs during various respiratory maneuvers. The NP can also determine how much air the patient is breathing in and out and how fast the patient is doing it. 2. Forced Vital Capacity (FVC); Forced Expiratory Volume in 1 second (FEV1) FEV1/FVC ratio

List and describe the 4 stages of HF

1. no structural defects but presence of risk factors such as DM, CAD w/o MI 2. Structural defects (rEF, LV hypertrophy, chamber enlargement) no sx 3. Pt has HF and is now symptomatic 4. Refractory HF and require complex interventions (Bi-V pacemaker, LVAD, or heart transplant)

To confirm a diagnosis of asthma two things are needed. 1. First are compatible respiratory symptoms these include *the other key hx your looking for is a trigger for sx 2. In addition, there must be a demonstration of

1. non-productive cough, wheezing initially heard on end-expiration & Chest tightness 2. variable airflow obstruction to diagnose asthma.

1. COPD consists of chronic bronchitis and emphysema and is characterized by an airflow limitation that is 2. Risk factors for COPD include

1. not fully reversible 2. smoking whether it is via cigarette, pipe, cigar or second-hand exposure. Airborne irritants such as air pollutants, chemical fumes or dust. Additionally, anything that affects the lung growth during gestation such as smoking, antibiotic use, and preterm birth, Congential mutation in the alpha-antitrypsin gene

Interstitial Lung Disease (ILD) 1. Patients with restrictive lung diseases cannot fully fill their lungs because 2. Restrictive lung disorders can be classified as

1. of diseased lung tissue or a physical impediment that prevents full chest expansion. 2. as either intrinsic or extrinsic

Gas Exchange 1. The high concentration of CO2 creates unfavorable 2. Decreased perfusion of the pulmonary capillaries with oxygenated blood cells results in 3. The term "blue bloater" is used to describe a patient with

1. or gas exchange-this is what causes (V/Q) mismatch 2. chronic pulmonary hypoxia and cyanosis. 3. chronic bronchitis, with bloater referring to the expanded thorax that these individuals can develop as a result of alveolar hyperinflation.

1. What causes the decreased FVC is this obstructive disease

1. patients have difficulty in fully expiring air from the lungs (decreased FVC) due to expiratory airway obstruction caused by mucus, edema, and loss of elastic recoil, which causes the airway to collapse. This results in the ability of the lung to passively expire air.

1. The most common presenting symptoms of chronic bronchitis are

1. productive and purulent cough, copious sputum production, dyspnea, wheezing, rhonchi, cyanosis of the skin and mucus membranes and peripheral edema. This results in V/Q mismatch

1. In High Output Failure (HOF) the heart cannot 2. How does HOF differ from L/R HF 3. In HOF, the heart cannot keep up with all of the body's demand for oxygen

1. pump enough amounts of blood to meet the circulatory needs of the body, despite normal blood volume and cardiac contractility. 2. the heart is able to effectively increase its output at least for a little while; then becoming low output HF 3. nor maintain an extended increased heart rate and stroke volume in an attempt to supply the body with the oxygen that it needs

Explain the pathophys of R sided HF 1. High pulmonary vascular pressure (increased afterload) will cause an increased right ventricular contraction force in order to eject the blood. Overtime, this will 2. This will increase the amount of blood remaining in the right ventricle and, as a result, increase right ventricular preload, resulting 3. This will increase the amount of blood remaining in the right atrium and, therefore, increase right atrial preload. This causes

1. reduce the ejection fraction and the right ventricle will be unable to eject the normal amount of blood. 2. in the inability for the right atrium to eject the normal amount of blood into the right ventricle. 3. the back-up of blood volume and pressure in the vena cava and systemic veins. Jugular vein distension is characteristic of right heart failure.

The pathophys of Left sided HF: 1. High systemic vascular resistance, or increased afterload, will increase the left ventricular contraction force in order to eject the blood from the left ventricle. Over time, this will 2. As a result, left ventricular preload will be increased, impeding

1. reduce the patient's ejection fraction and the left ventricle will be unable to eject normal a normal amount of blood. This results in an increased amount of blood remaining in the left ventricle. 2. the left atrium from ejecting the normal amount of blood into the left ventricle. This will eventually cause blood to back up into the pulmonary veins.

List key points of Obstructive Disorders 1. Are characterized by a 2. Result in shortness of breath when 3. Causes air "trapping" in lungs 4. Include chronic obstructive pulmonary disorders (COPD) and 5. In persons with asthma are usually fully reversible, whereas

1. reduction in airflow. 2. exhaling air. 3. after full expiration. 4. asthma. 5. defects in persons with COPD typically are not.

The pathophys of Left sided HF: 3. Pressure will also be increased in the pulmonary veins. This increased pressure will force fluid from the pulmonary capillaries 4. If left ventricular heart failure is unresolved,

3. into the pulmonary tissues, which essentially floods those areas. The result is pulmonary edema and dyspnea. 4. volume and pressure will continue to build until it reaches the right side of the heart, contributing to right heart failure as well. In this case, this becomes a biventricular heart failure

Asthma can take two forms: Extrinsic and intrinsic. The two are compared below: Extrinsic 1. Triggered by an allergic, 2. Elevated IgE 3. More common in children Intrinsic 1. Triggered by a variety of 2. No elevation in 3. More common in

Extrinsic 1. chronic reaction (pollen, dust mites, pet dander) 2. is diagnostic 3. children Intrinsic 1. non-allergic factors (chemicals, air borne irritants, infections, exercise, stress, anxiety, GERD, obesity) 2. IgE 3. adults less than 40 years of age

A subjective finding in interstitial lung disease is rhonchi in the upper posterior airways. True False

False

An objective finding in a patient with ILD include productive cough. True False

False

Cells that contain abnormal types of hemoglobin are more susceptible to infection by the parasite that causes malaria True False

False

Identification of the type of anemia involves an examination of size of the RBC only. True False

False

Interstitial lung disease (ILD) includes infectious and neoplastic lung diseases. True False

False

Iron Stores When iron stores are depleted, the cell's mitochondria are still able to utilize iron effectively due to compensatory mechanisms. True False

False

Low Autoantibodies The presence of a low number of autoantibodies is an indicator that the individual will develop an autoimmune disease. True False

False

Simple spirometry includes a measure of residual capacity. True False

False

Sinusitis is considered a primary immunodeficiency. True False

False

The patient with thalassemia is at high risk for stroke. True False

False

The presenting signs and symptoms of an autoimmune disease is similar across all autoimmune diseases. True False

False

Which of the following is a non-modifiable risk factor for Coronary Artery Disease? Hypertension. Hyperlipidemia. Family history. Obesity

Family history.

Clinical Findings in Macrocytic Anemias include:

Fatigue Dyspnea (shortness of breath) Loss of appetite or weight Diarrhea Pallor (pale skin)

Histamine which causes an immediate vascular response, explain

Histamine causes constriction of large vessels walls Which increases blood flow to capillaries this causes redness, itching and heat ·Histamine causes dilation of capillaries and endothelial cell retraction Which increases permeability this leads to fluid leakage and swelling

List some secondary Immunodeficiency Illnesses

Human Immunodeficiency Virus Pneumocystis Carinii Pneumonia Sinus infection Lung cancer Normal Physiologic Conditions a. Examples include pregnancy, infancy, and aging. Nutritional Deficiencies Iatrogenic Deficiencies a. caused by some form of medical treatment. e.g. drugs (chemotherapy), surgery, anesthesia Deficiencies caused by physical trauma a. e.g. burn victims

Choose the types of interstitial lung diseases (ILD) that are commonly associated with smoking: Hypersensitivity pneumonitis Desquamative interstitial pneumonia Sarcoidosis Pneumoconioses Pulmonary Langerhans cell histiocytosis Respiratory bronchiolitis-interstitial lung disease

Hypersensitivity pneumonitis Pulmonary Langerhans cell histiocytosis Respiratory bronchiolitis-interstitial lung disease

List CM of Diastolic HF

Individuals with HFpEF most often present with dyspnea on exertion and fatigue. If diastolic dysfunction is severe, there may be evidence of pulmonary edema (inspiratory crackles on auscultation, pleural effusions). Late in diastole, atrial contraction with rapid ejection of blood into the noncompliant ventricle may give rise to an S4 gallop. chest x-ray shows pulmonary congestion without cardiomegaly

The most common cause of right-sided heart failure is: Pulmonary hypertension. Right ventricular hypertrophy. Myocardial infarction. (MI) Tricuspid valve damage.

Pulmonary hypertension. Cor pulmonale is secondary to pulmonary artery hypertension and consists of right ventricular enlargement leading to HF

A patient with chronic bronchitis is most likely to experience: Respiratory acidosis due to decreased intake of O2. Respiratory alkalosis due to inability to exhale CO2. Respiratory alkalosis due to inability to exhale CO2. Respiratory acidosis due to inability to exhale CO2.

Respiratory acidosis due to inability to exhale CO2

The (blank) lab value will be high in post-hemorrhagic anemia. Reticulocyte count MCV

Reticulocyte count

The (blank) lab values are low in aplastic anemia. MCHC Reticulocyte count

Reticulocyte count

In order to recognize and differentiate the type of anemia that is present, it is important to understand the components that relate to red blood cells and their production. List and define them

Reticulocyte: Immature RBCs. Used to assess bone marrow function. Normal in adults is approximately 3%. Mean Cell Volume (MCV): This measures the average size of the RBC. Normal is 80-100 fL. Mean Corpuscular Hemoglobin (MCH): Average weight of hemoglobin per red cell. Normal is 27-33 pg. Mean Corpuscular Hemoglobin Concentration (MCHC): Average concentration of hemoglobin per erythrocyte. Normal is 32-36%.

Miscellaneous include

Sarcoidosis Vasculitis Eosinophilic pneumonia (acute and chronic) Pulmonary Langerhans cell histiocytosis

Type 4 hypersensitivity reaction What sx and unique hx would you see in a pt with contact dermatitis

Sx onset greater that a few days (>2-3 days) from exposure Symptoms: itchy rash Signs: thickened patches with crusting and oozing clear liquid on the face or hands (or whatever part of the skin was exposed)

Type 3 hypersensitivity reaction What sx would you see in a pt with serum sickness

Symptoms: Fever, swollen hands and knees, achy joints, skin rash Signs: nonblancheable rash, bilateral swollen hands and knees

List the signs/symptoms of AS hint: SAD

Syncope Angina: caused by either CAD or LV hypertrophy Dyspnea Pulsus Pardus (pulse that is slow to rise) LV hypertrophy in AS causes the PMI (point of maximal impulse to shift from 5th ICS MidClavic to the sternal border MAMA-anemia due to the shearing of RBCs on the aortic valve Systolic Ejection murmur-at upper RSB radiating to carotids

Which of the following is an autoimmune disease? Iron deficiency anemia. ABO incompatibility. Systemic Lupus Erythematosus (SLE). Osteoarthritis.

Systemic Lupus Erythematosus (SLE)

Explain the pathophys behind individuals developing iron overload and becoming asplenic by adulthood

This is a type of hemolytic anemia and presents with the classic anemia signs and symptoms in addition to other serious complications. The lysis of large amounts of RBCs put the individual at risk for circulatory iron-overload The abnormal RBCs also occlude cerebral, splenic and glomerular blood vessels and create a high risk for strokes, splenic and kidney damage. Damage to the spleen is especially prevalent. Therefore, many sickle-cell individuals are asplenic by adulthood.

Type II hypersensitivity reaction Receptor blockage (explain this process)

This mechanism does not destroy the cell but rather causes cellular malfunction The antibody binds to the target cell and occupies receptors that would normally bind with other molecules required for normal cell function An example of receptor blockage is hyperthyroidism caused by Graves disease

Type 3 hypersensitivity reaction The size of the immune complexes determines the disease-causing potential. Explain

Very large immune complexes are cleared rapidly from the circulation by tissue macrophages. Very small immune complexes are filtered from the blood at the kidneys. The intermediate-sized complexes are deposited in certain target tissues, where they have severe pathologic consequences. a. glomerulonephritis (kidney) b. vasculitis (vessels) c. arthritis (degenerative joint disease)

Symptoms common to both intrinsic and extrinsic asthma include: Dizziness. Slowed breathing. Wheezing. Elevated heart rate.

Wheezing.

Symptoms common to both intrinsic and extrinsic asthma include: Wheezing. Slowed breathing. Dizziness. Elevated heart rate.

Wheezing.

Unlike emphysema, as discussed above, there is normal amount of elastin. So, the issue is not related to recoil in the restricted lung. The issue is with compliance, which is decreased in a restrictive disorder. Using pulmonary fibrosis as an example, fibrous or scarred tissue increases the elasticity of the lung, but compliance decreases due to the scarring caused by the fibrosis which prevents the lungs from expanding.

With low compliance, the lungs do not ventilate adequately because there is limited air that is able to enter the lung on inhalation. If there is not sufficient air going in, then there cannot be sufficient air going out. Therefore, the FVC will be lower while FEV1 increases.

Aplastic anemia can be caused by: a. Antibiotics. b. Long-standing pulmonary disease. c. Anemia of chronic disease. d. Infections.

a. Antibiotics.

Systemic Lupus Erythematosus The (blank) test is positive in 90% of patients diagnosed with Systemic Lupus Erythematosus (SLE). a. Antinuclear Antibody (ANA) b. Sedimentation rate c. C-Reactive protein d. Rheumatoid factor

a. Antinuclear Antibody (ANA)

Which of the following lab values are normal for the patient with folate deficiency? a. Ferritin. b. Folate. c. MCV. d. Reticulocyte count.

a. Ferritin.

Folic acid is essential to the body because it: a. Plays a major role in the maturing of RBCs. b. Impacts the absorption of vitamin B-12. c. Allows for the production of erythropoietin. d. Prevents cardiovascular disease.

a. Plays a major role in the maturing of RBCs.

Loss of vibratory sense in a patient with Vitamin B-12 deficiency is due to which of the following pathophysiological changes: a. Posterior and lateral column spinal cord changes due to nerve demyelination. b. Cellular atrophy. c. Changes in cerebellar brain function. d. Myelopathy.

a. Posterior and lateral column spinal cord changes due to nerve demyelination.

Hemolytic anemia means literally the "lysis" of red blood cells. It can be caused by

an infectious agent (e. coli), chemical release mediated by own immune system, or because of certain chemicals/drugs. Note that circulating blood contains Vitamin C and RBCs contain glutathione, both of which are natural antioxidants to help protect cells.

Hemoglobinopathies are what?

an inherited disorder of the erythrocytes

Type 3 hypersensitivity reaction Serum sickness can occur b/c of

antigens formed against drugs such as Abx or Ag against foreign serum; this is why they don't administer horse serum anymore

List common clinical manifestations of Systolic HF

are the result of pulmonary vascular congestion and inadequate perfusion of the systemic circulation. Individuals experience dyspnea, orthopnea, cough of frothy sputum, fatigue, decreased urine output, and edema. Physical examination often reveals pulmonary edema (cyanosis, inspiratory crackles, pleural effusions), hypotension or hypertension, an S3 gallop, and evidence of underlying CAD or hypertension. CXR would most likely show pulmonary congestion and cardiomegally

Sickle-cell anemia is an inherited autosomal recessive disorders develop as the result of inheriting

autosomal recessive genetic disorder two abnormal genes, one from each parent.

A patient with human immunodeficiency virus (HIV) was admitted to the acute care facility with difficulty breathing. He is diagnosed with Pneumocytis carinii. Pneumocystis carinii an example of: a. A primary immune disease. b. A secondary immune disease.

b. A secondary immune disease.

In normal gas exchange, which of the following is correct? a. Only the pulmonary artery carries the oxygenated blood. b. After air is breathed in, it diffuses into the pulmonary veins. c. After air is breathed in, it diffuses into the pulmonary capillaries. d. Deoxygenated blood is pumped out through the aorta to into the systemic circulation

b. After air is breathed in, it diffuses into the pulmonary veins.

Type I allergic reaction Mucosa of the eyes, nose, and respiratory tract as a target tissue cause Clinical manifestations of: The underlying mechanism is vasodilation, hypersecretion of mucus, edema, and swelling of the respiratory mucosa

bronchospasm 2) edema 3) thick secretions Examples include conjunctivitis (eyes), rhinitis (nose), asthma (respiratory tract)

The NP notes that a patient's FEV1/FVC ratio is severely reduced. Which of the following conditions is most likely the patient's pulmonary issue? a. Pulmonary hypertension. b. Morbid obesity. c. Chronic asthma. d. Pneumonia.

c. Chronic asthma.

Systemic Lupus Erythematosus Which of the following findings can be used to diagnose Systemic Lupus Erythematosus (SLE)? a. Headache. b. Low back pain. c. Facial rash confined to the cheeks. d. Fever.

c. Facial rash confined to the cheeks.

Renal Disease A renal disease most often associated with autoimmunity is: a. Urinary Tract Infection. b. Renal lithiasis c. Glomerulonephritis d. Cystitis.

c. Glomerulonephritis

The treatment of iron deficiency anemia includes: a. Vitamin-B-12 replacement. b. Ferritin replacement. c. Iron supplementation. d. Blood transfusions.

c. Iron supplementation.

Which of the following indices measures the average size of red blood cells? a. Hemoglobin (Hb). b. Reticulocyte count. c. Mean Corpuscular Volume (MCV). d. Mean Corpuscular Hemoglobin Concentration (MCHC).

c. Mean Corpuscular Volume (MCV).

The patient with aortic stenosis would most likely present with: a. High-pitched murmur. b. Right ventricular hypertrophy. c. Mid-systolic crescendo-decrescendo murmur. d. S3 gallop.

c. Mid-systolic crescendo-decrescendo murmur.

A patient with mitral stenosis would most likely present with: a. Bradycardia. b. High-pitched murmur. c. Rumbling, decrescendo diastolic murmur heard at apex of the heart. d. Holosystolic murmur.

c. Rumbling, decrescendo diastolic murmur heard at apex of the heart.

Which of the following assessment findings would support a diagnosis of Rheumatoid Arthritis (RA)? a. A butterfly rash across the facial cheeks. b. Muscle weakness and ataxia. c. Swollen metacarpophalangeal joints. d. Inflammation in the salivary and lacrimal glands.

c. Swollen metacarpophalangeal joints.

Chronic blood loss anemia is commonly associated with

chronic GI bleeding. Chronic blood loss will deplete iron stores and also produce iron-deficiency anemia

The number one cause of chronic bronchitis is cigarette smoking alpha-antitrypsin deficiency exposure dust exposure to allergens

cigarette smoking

What is the major risk factor for the development of CAD

family history. There is a 50% higher risk for individuals to develop heart disease if they have a first degree relative (especially father) or sibling who has suffered from ACS or premature cardiac death (< age 55 years).

An expected chest x-ray finding for a patient with COPD is a (blank)? flattened diaphragm enlarged heart elongated diaphragm protruding diaphragm

flattened diaphragm

Furthermore, the reduction in RBC level will decrease blood volume, activating the renin-angiotensin-aldosterone (RAA) system, which will result in what?

fluid retention and movement of interstitial fluid into the capillaries. This will not only increase plasma volume, but also dilute the plasma further. The dilute blood flows faster, which creates a hyperdynamic state. This "stresses" the cardiac system and can result in tachycardia or even heart failure.

In a patient with pernicious anemia, (blank) lab values can be normal or low? folate reticulocyte count MCV MCHC

folate

macrocytic, hypochromic, megaloblastic anemias which are caused from

folate and vitamin B12 deficiencies.

How many genes are involved in the synthesis of the alpha protein chains for Hb? How many genes are involved in the synthesis of the beta protein chains for Hb?

four genes located on chromosome number 16 two genes located on chromosome number 11

Foods rich in folic acid include

green, leafy vegetables; citrus fruits; beans, rice and cereal; and folate-fortified foods.

PFTs alone cannot differentiate among the causes of respiratory abnormalities what can they help dx

he PFT can help the NP determine the patient's respiratory pattern, specifically if the abnormality is due to an obstructive or restrictive problem. Once the pattern is identified, PFTs allow the NP to determine the severity of the disease.

The pathophys behind Macrocytic anemias can be explained by: Folate and cobalamin (vitamin B12) are required for red blood cell DNA synthesis; therefore, a deficiency in either results in

impaired DNA replication of the RBC. This causes the erythroblasts to continue to increase in size (macrocytic) instead of undergoing cell division.

Factors causing L sided HF: Disease processes that increase left ventricular afterload

include hypertension and aortic valve disorders.

The pathophysiology of IDA is very simple: Explain

insufficient Fe levels or inability for mitochondria to utilize Fe effectively leads to decreased Hb synthesis and the formation of smaller, paler cells.

Additional causes of B12 deficiency include who is at high risk for B12 deficiency?

insufficient dietary intake, gastritis, H. pylori infections and advanced age. and gastrectomy procedures vegetarians are at high risk for B12 deficiency which may require B12 supplementation.

without adequate intrinsic factor to help with GI absorption, PA is not easily remedied by simple oral B12 supplementation So what is the treatment?

intramuscular injections, sublingual or intranasal formulations are more effective in the treatment of PA.

Aplastic Anemia Contrary to high reticulocyte levels observed in hemolytic and blood loss anemias, the reticulocyte levels are

low in aplastic anemia Aplastic anemia, literally "without 'plasia' or cell growth" can be caused by a variety of factors

Type I: Allergic Reaction GI allergies are caused primarily by foods (milk, chocolate, citrus fruits, eggs, wheat, nuts) and involve

manifested by vomiting, diarrhea, or abdominal pain.

Iron Deficiency Anemia Iron deficiency is categorized as a

microcytic and hypochromic anemia. Iron deficiency anemia (IDA) is the most common type of anemia, Causes of IDA include: Inadequate dietary intake. Chronic and or occult bleeding: hemorrhage, colitis, cirrhosis, GI ulcers, esophageal lesions, or menorrhagia; note that it only takes 2-4 mL (about 1 tsp) of blood loss per day to lose 1-2 mg of iron). Decreased ability to utilize Fe for heme synthesis (e.g. transferrin deficiencies and mitochondrial defects). These are a less common cause of IDA.

The thalassemia(s) are a group of related inherited autosomal recessive genetic disorders. Similar to sickle cell anemia, the affected individual However, unlike sickle cell anemia

must inherit an abnormal Hb gene from both parents. thalassemia is characterized by many different possible genetic mutations on both the alpha- and/or beta-chains. Depending on the mutation, there can be varying degrees of distortion and dysfunction of the RBC

Pulmonary function tests will point to restrictive lung disease and include

normal or slightly low FEV1, low FVC, normal or elevated FEV1/FVC ratio reduced lung volumes

Collectively, sickle cell anemia and the different forms of thalassemia represent the most common genetically inherited disorders. Explain

over 300 million people worldwide have one of these conditions and many millions more are carriers. These conditions are found in people of African, Mediterranean, and Southeast Asian descent.

The clinical manifestations of folate deficiencies are the same as those of Vitamin B12 deficiency, except

patients with folate deficiency anemia do not have the neurological symptoms.

A patient with Chronic Granulomatous Disease of Childhood has a primary immune disease secondary immune disease

primary immune disease

What modifiable risk factors can influence formation of a coronary thrombus?

risk factors such as elevated LDL, cholesterol, smoking and diabetes. overweight (BMI 25-29.9) or obesity (BMI 30 and above). Hypertension, Elevated total cholesterol, elevated low-density lipoprotein (LDL), and/or high-density lipoprotein (HDL)

To definitively diagnose IDA, a

serum ferritin level is needed because its value correlates with the body's total iron stores. Ferritin 12 ng/mL REF 30-300 ng/mL Due to the depletion, the cell's mitochondria are unable to utilize iron effectively, which leads to decreased hemoglobin and the production of smaller (microcytic) and paler (hypochromic) RBCs.

From these six different genetic loci, over 300 different Hb gene defects have been documented. What are the two most common

sickle-cell anemia and thalassemia.

Highlight important health hx from a patient with (IDA) iron defic Anemia?

significant for heavy menstrual cramping and prolonged bleeding OR/AND skipping one or two meals a day-an iron deficient diet

List some indications of when to order PFTs

signs and symptoms of (cough, dyspnea, cyanosis, wheezing, hypoxemia, hypercapnia and lung hyperinflation). When disease progression needs to be determined. When monitoring the effectiveness of drug therapy. When monitoring for potential toxic effects of certain drugs.

The terms normocytic, microcytic, and macrocytic characterizes red blood cells by their:

size

Explain the significance behind a bronchodilator response used in spirometry readings/PFTs?

spirometry may be repeated after the patient receives a bronchodilator. If either the FEV1 or the FEV increases by at least 12% and by at least 200 mL from the pre-bronchodilator values, then the patient has had a significant bronchodilator response.

Type II hypersensitivity reaction What sx would you see in a delayed hemolytic transfusion reaction

symptoms: Fever, chills, SOB and backache Signs: fever >100.F Scleral icterus (jaundice), low hemoglobin <6, and Coombs test reveals the presence of antibodies Symptom onset of this hemolytic reaction can occur a week or more later and it requires an initial exposure for sensitization followed by a subsequent exposure to trigger the hypersensitivity

Type 3 hypersensitivity reaction Give an example of both a systemic and localized Type 3 reaction

systemic reaction. a. serum sickness (autoimmune disorder) b. Raynaud's phenomenon is a sub-type localized reaction. c. SLE see follow card a. the Arthus reaction (allergic reaction) b. A localized reaction is observed

Define Systolic HF

systolic heart failure), is defined as an ejection fraction of <40% and an inability of the heart to generate an adequate cardiac output to perfuse vital tissues The main contributing factor is decreased contractility. Myocardial infarction is the most common cause of decreased contractility; other causes include myocarditis and cardiomyopathies. These diseases can cause Ventricular remodeling

Because of the number of different possible genetic mutations

thalassemia can present in a variety of forms from minor to major and be asymptomatic the most severe forms-Colley's thalassemia.

Blood Loss Anemia This involves situations where the number of RBCs lost is greater

than number of RBCs produced due as the direct result of blood loss is considered blood loss anemia. Blood loss anemia can be acute or chronic.

The pathophysiology of sickle cell anemia involves a single amino acid change on the beta-chain which results in

the formation of elongated, "sickled" Hb molecules (designated HbS) which does not bind oxygen as readily. The sickling of millions of hemoglobin molecules causes distortion of RBCs that house those molecules. This weakens the RBCs and they rupture after only 10-15 days in circulation.

Right side HF is defined as

the inability of the right ventricle to provide adequate blood flow into the pulmonary circulation.

Review the follow case Step 2 Determine the Severity: based on a FEV1 percent predicted of 91

the patient is considered to have mild severity based on the FEV1 percent predicted being >80%

low RBC 4.1 (mcL) Ref 4.7-6.1 (mcL) low Hemoglobin 10.4 (g/dL) Ref 11.6-15 (grams/dL-(females) the patient has low RBCs and Hb which indicates But does the NP have to look at to differentiate the anemia?

the presence of anemia The NP starts by looking at the RBC indices. Specifically, she looks at the MCV and MCHC

Review the follow case Step 2 Determine the Severity; based on FEV1 percent predicted of 47 this would indicate

the severity is severe based on the Gold Criteria

Patients with RA will be treated with drugs to

to reduce the inflammation. These include Disease-Modifying Antirheumatic Drugs (DMARDS), Glucocorticoids and NSAIDS.

Extrinsic asthma is triggered by an allergic reaction triggered by non-allergic factors characterized by no elevation in IgE typically seen in adults less than 40 years of age

triggered by an allergic reaction

Type I allergic reaction Skin allergies produce The underlying mechanism of skin allergies is the localized release of histamine and increased vascular permeability.

urticaria (hives) which is characterized by a wheal-and flare reaction or hay fever

Consider a pt with a FEV1 percent predicted of 50%, would this be indicative of obstructive lung disease?

yes b/c it is less than 80% of normal lower limit

Hyperresonance found on lung percussion with a patient with COPD is primarily due to air trapping consolidation of secretions ruptured alveoli mucus plugs

air trapping

Which of the following is a cause of hemolytic anemia? (Select all that apply.) Drugs. Infection. Transfusion reaction.

all apply

List the three levels or barriers of defense regarding immunity

1st line -the physical, mechanical and biochemical barriers 2nd Line-the inflammatory response 3rd Line-lymphocyte production

Anemia can be caused from which of the following? (Select all that apply.) Increased red blood cell destruction. Impaired red blood cell production. Excessive blood loss.

all of the three

1. ILD should be considered in any patient presenting 2. if they have a history of: 2a. exposure to 2b. Connective 2c. Cancer 2d. Taking meds such as

1. with subacute or chronic, progressive shortness of breath and/or a non-productive cough 2a. Occupational or animal exposure, excluding dogs and cats 2b. tissue disease 2c. Chest irradiation 2d. amiodarone, nitrofurantoin, or methotrexate

Which of the following are iron-rich foods? Spinach. Meat. Lima beans.

They all are

Cancer is a secondary immunodeficiency. True False

True

The MCHC will be normal in which of the following anemias? a. Aplastic anemia b. Post-hemorrhagic anemia c. Hemolytic anemia d. MCHC is normal in all the above anemias

d. MCHC is normal in all the above anemias

1. What is Forced Expiratory Volume in 1 second (FEV1) 2. what is the normal range

1. Amount of air forcefully exhaled from the lungs in the first second. The patient inhales and forcefully exhales as fast as possible (time stops after 1 sec) 2. Normal 80-120%

A patient with chronic bronchitis is at risk for developing pneumonia due to: Inability to cough. Hypoxemia. Overactive cilia in the lungs. Mucus plugs.

Mucus plugs

1. The types of asthma are staged as either 2. Persistent is divided into 3. What types of asthma will show abnormal PFTs: FEV1 and FEV1/FEV ratio

1. intermittent (<2 days/week) or persistent (2-6 days/week) 2. mild, moderate and severe. 3. Moderate and severe

List the signs/symptoms of MR

1. Acute MR-papillary muscle rupture r/t MI this causes flash pulmonary edema 2. Chronic MR-dilated LV r/t ischemia cardiomyopathy this will cause progressive fatigue, SOB, pulmonary congestion L atrial enlargement 3. with chronic MR you can hear a holosystolic murmur at the apex of the heart

Case Review of CAD C.G., a 47-year old male presents to the primary care clinic with complaints of chest pain that occurs when he is working out at the gym. He also tells the NP that his father died of a heart attack at the age of 54 years old. He does report a previous medical history (PMH) of hypertension (HTN). He has a 30-pack-year history of smoking. List his risk factors for CAD

1) male 2) family history of CAD 3) hypertension 4) smoking

Anemia can be caused by

1) impaired RBC production, 2) excessive blood loss, 3) increased RBC destruction OR any combination of the three.

1. Chronic bronchitis is a disease characterized by 2. What causes airflow obstruction and decreased alveolar ventilation 3. The lung damage from chronic bronchitis is

1. bronchial inflammation, hypersecretion of mucus, and chronic productive cough that persists for at least 3 consecutive months for at least 2 successive years. 2. excess mucus production and accumulation, hypertrophy of bronchial smooth muscles, hypertrophy and hyperplasia of bronchial mucus-producing cells 3. irreversible

1. The pathogenesis of chronic bronchitis begins with an exposure to airborne irritant that activate

1. bronchial smooth muscle constriction, mucus secretion and the release of inflammatory mediators (histamine, prostaglandins, leukotrienes, and interleukins) from immune cells located in the lamina propria.

1. Acute inflammation leads to 2. Chronic inflammation can lead to systemic effects of

1. bronchoconstriction partially reversible with bronchodilators 2. weight loss, muscle weakness and increased susceptibility to infection

1. Status asthmaticus may result if 2. In Status asthmaticus hypoxemia worsens, expiratory flow rates further decrease and 3. Signs of status asthmaticus (impending death) may include

1. bronchospasm is not reversed with treatment. 2. ventilation decreases resulting in acidosis. 3. The absence of breath sounds and a PaCO2 greater than 70 mmHg

1. Intrinsic causes of restrictive disorders are due to 2. This class of intrinsic, restrictive lung disorders are known as

1. causes within the lungs or damage to the parenchymal tissue. 2. interstitial lung disease (ILD), or parenchymal disease.

Asthma presentation 1. The typical presentation during the onset of an attack is 2. In more severe attacks, the patient will use

1. chest tightness, expiratory wheezing, dyspnea, non-productive cough, prolonged expiration, tachycardia, and tachypnea. 2. the accessory muscles to breath.

Diagnosis of ILD 1. Diagnosis of ILD is made based on exposure history ask about 2. A chest-x-ray will reveal 3. There are 4 key tests to definitively diagnose ILD

1. exposure to animals, especially birds; medication history, including the use of illicit drugs (methamphetamines, marijuana, smoking crack cocaine) and radiation treatment 2. a honey-comb pattern 3. High resolution CT Pulmonary function tests Bronchoalveolar lavage Lung biopsy

1. Air trapping causes the chest to

1. hyper-expand which leads to increased work of breathing. As a result, patients will develop hypoventilation and hypercapnia.

Intrinsic Asthma 1. Intrinsic asthma can be triggered by a variety of non-allergic factors, each causing a 2. Drugs and Chemicals that cause asthma include 3. In childhood development chronic infection from 4. Explain how GERD can cause intrinsic asthma

1. slightly different variation on the inflammatory process. 2. (NSAIDS) and Airborne irritants like tobacco smoke and pollution 3. RSV, and strain C of the human respiratory virus stimulate an excessive immune response from TH2 cells to stimulate excess production of IgE stimulating mast cell degranulation. 4. acetylcholine released during GERD will not only increase acid production but can also bind to receptors in the respiratory tract and cause bronchial constriction.

List the signs/symptoms of MV prolapse

1. some people are asymptomatic 2. MV prolapse syndrome such as atypical CP Palpitations SOB Dizziness/syncope 3. you'll hear a midsystolic click followed by a murmur caused by MR

Connective tissue disease 1. these are connective tissue diseases that are the result of 2. They include

1. systemic autoimmune conditions 2. Systemic sclerosis (the most common cause) Rheumatoid arthritis Mixed connective tissue disease Systemic lupus erythematosus (least likely cause)

1. If the pt is repeatedly showing normal spirometry, but the NP still suspects asthma because they have symptoms suggestive of asthma then they can order the ` for asthma

1. the Methacholine Challenge Test; Methacholine is a substance that directly stimulates airway smooth muscle cells to cause bronchoconstriction methacholine is administered in escalating doses until either the FEV1 drops by 20% or the maximum dose is achieved

1. Another method for determining variable obstruction is through 2. The patient will record three of these values for both morning and evening. Over one week, if

1. the peak expiratory flow rate. It is simple and convenient to use by the patient in the home setting. 2. these values vary by more than 20%, it is consistent with the variability of obstruction (asthma).

Review the follow case 1. Step 1 Determine the Pattern: Based on a FEV1/FVC ratio of 88.6 this would indicate

1. the presence of a normal or restrictive disease it can NOT be an obstructive disease would have an FEV1/FVC <70-80%

1. Extrinsic causes include conditions where 2. Give examples

1. the problem is from a source outside of the pulmonary system which restricts airflow. 2. For example, scoliosis, Myasthenia Gravis, Guillain-Bare', Atrophic Lateral Sclerosis, and obesity are extrinsic causes

List the signs/symptoms of MS

1. typical sx associated with endocarditis such as fever, chills, elevated WBC count 2. Fatigue, SOB, exercise intolerance or cough 3. L atrial enlargement, pulmonary congestion 4. on auscultation you'll hear a middiastolic rumble and right before this you may hear an opening snap

1. What differentiates asthma from other obstructive diseases is the fact that it is 2. Variability refers to normal spirometry on one occasion 3. Reversibility is defined as an FEV1 that improves by

1. variable and reversible 2. & abnormal or obstructive spirometry on another 3. 12% and 200 mL after the use of a bronchodilator (albuterol)

The pathophys of Extrinsic asthma 1. Mast cell degranulation triggered by the excessive amounts of IgE will 2. Mast cell degranulation releases 3. The vasodilation specifically results in

1. will bind the allergen as it enters the airway. 2. histamine, prostaglandins, leukotrienes, and interleukin cause smooth muscle constriction, mucus secretion and vasodilation. 3. mucosal edema and the migration of even more WBCs to the site.

List causes of aplastic anemia

Chemical or radiation exposure (chemotherapy) Viral induced-Hepatitis, Epstein-Barr virus, Cytomegalovirus Tumors-Multiple Myeloma Antibiotics/anti-seizure drugs/other drugs-PCN, Phenytoin, Diuretics, Antidiabetic drugs, Sulfa drugs Congenital defects-Fanconi's anemia

Of the 4 general categories of ILD, the most common in smokers is:

Pulmonary Langerhans cell histiocytosis Respiratory bronchiolitis-interstitial lung disease Desquamative interstitial pneumonia

ILD can be grouped into four general categories based on etiology: List them

Exposure-related Connective tissue disease Idiopathic Miscellaneous or "other"

List a well known secondary immunodeficiency illness in the US?

A common secondary immunodeficiency is (HIV). HIV is an RNA virus that invades the body through any cell by direct contact of an individual's blood or body secretions. The virus has a strong affinity for CD4+ T-cells. Once the virus invades, it replicates to cause extensive damage to the immune system. Without a normally functioning immune system, the individual becomes susceptible to opportunistic infections, cancer, neurological diseases, wasting, and death

What is an Autoimmune Disease?

A disease in which the body's immune system attacks healthy cells. Especially with aging and even healthy individuals across the life span, individuals may produce small quantities of antibodies (autoantibodies) against their own antigens.

Review the follow case Step 3 evaluate the post bronchodilator response: Pre-bronchodilator FEV1: 1.38 Post bronchodilator FEV1: 2.61 this would indicate

A good bronchodilator response based on a change of >12% or >200ml

So what happens in these regulatory genes that cause cancer?

A point-mutation would be like having a faulty accelerator or brake system A chromosomal amplification would be like having two accelerators A chromosomal translocation would be like switching the brake pedal with the accelerator pedal

Asthma 1. Asthma is a chronic (obstructive) disease which is characterized by 2.

Asthma 1. Asthma is a chronic (obstructive) disease which is characterized by 2.

Where can both S3 and S4 sounds be best heard?

At the apex of the heart with the patient laying in the left lateral decubitus position as this rests the heart on the side of the ribs

Type II hypersensitivity reaction Antibody-dependent cell-mediated cytotoxicity (ADCC) (explain this process)

ADCC is mediated by NK cells. In ADCC, the antibody (IgG and IgE) acts as a link to bring the NK cell and the target cell together in order to allow killing to occur NK cells can be activated without previous antigen exposure and are therefore part of the nonspecific (innate) immune system.

The NP is examining a patient with a longstanding history of chronic bronchitis. Cor pulmonale is expected in the patient that presents with: Hepatomegaly. Venous stasis ulcers. Hypoxia. Hypocapnia.

Hepatomegaly.

There are two types of inflammatory response, acute and chronic list and describe the the acute

Acute or short term response associate with all types of tissue injury a. Lasts <2 weeks b. Includes the 4 classic signs c. Most types of injury and infection involve the acute inflammatory response

What is the role of natural adenosine in the body when there is myocardial ischemia?

Adenosine is also released that stimulates sympathetic nerve fibers that causes atrial and ventricular contraction. In addition, sympathetic stimulation occurs at the upper thoracic dorsal roots of the spinal cord that leads to the arm pain.

Hypertension has its most immediate effect on: Preload. Stroke volume. Afterload. Contractility.

Afterload.

Hypersensitivity can be classified based upon the source of the antigen against which the hypersensitivity response is directed. List the three types Allergy Autoimmunity Alloimmunity

Allergy a. An allergy is an exaggerated response against innocuous environmental antigens. ie: hay fever, hemolysis in drug allergies, gluten, & poison ivy. Autoimmunity a. Autoimmunity is a misdirected immune response against the host's own cells ie: RA, graves disease, T1DM or Systemic lupus Alloimmunity a. Alloimmunity is an immune response that is mounted against antigens from an individual of the same species (directed against beneficial foreign tissues). ie: transfusion reactions, organ rejection or pregnant mom attacking fetus

Choose the drugs that are commonly associated with development of a medication-induced interstitial lung disease (ILD): Nitrofurantoin Lisinopril Amiodarone Warfarin Omeprazole Methotrexate

Amiodarone Methotrexate Nitrofurantoin

What is an Immunodeficiency

An immune deficiency is the failure of the immune or inflammatory response to function normally, resulting in increased susceptibility to infection.

In COPD what two factors lead to cardiac hypertrophy and right-sided heart failure or cor pulmonale

An increase in RBCs and pulmonary vasoconstriction 1. Chronic hypoxia results in the kidneys secreting EPO to increase RBC leading to higher Hct levels but this puts greater strain on the heart from increased blood volume 2. In response to low V/Q ratio the the pulmonary vessels constrict which causes pulmonary HTN that also increases R sided heart strain

What is Anemia?

Anemia is a hematological disorder characterized by a reduction in the total number of circulating red blood cells (RBCs) and/or a decrease in hemoglobin (Hb) amount or function

List types of anemia associated with normocytic (MCV<80 fL)

Anemia of inflammation and chronic disease Hereditary spherocytosis G6PD deficiency Paroxysmal nocturnal hemoglobinuria

Type II hypersensitivity reaction Phagocytosis by macrophages (explain this process)

Antibodies and complement C3b act as opsonins- (glue*) on the cell membrane. Fc/C3b receptors on macrophages bind AB/C3b on opsonized cells. Phagocytosis of target cell follows.

Type II hypersensitivity reaction Neutrophil-mediated damage (explain this process)

Antibody activates complement increasinging C3a and C5a (chemotactic for neutrophils) Binding of neutrophil via Fc/C3b receptors releases granules onto healthy tissue. Degranulation substances and toxic O2 products damage tissue Because the tissue is large, phagocytosis cannot be completed

It is the endothelium, under normal functioning that maintains balance between the vasoconstrictive and vasodilation actions, prevents platelets from aggregating and control of the production of fibrin. Explain the pathophys of atherosclerosis:

Atherosclerosis begins with damage to the endothelium. When the endothelium becomes damaged, our familiar inflammatory processes occur. Macrophages attach to the endothelium, setting up phagocytosis; plaque formation and vasoconstriction also occurs marking the beginning of atherosclerosis. The plaque lesions located in the vessels become enlarged which allows the plaque to progress within the enlarged vessel lumen. The plaque lesion disrupts normal blood flow and causes thrombus formation

Cancer cells are defined by 2 heritable properties.

Autonomy a. The cancer cell has independence from normal cellular controls. Meaning they disregard normal limitations of growth. The majority of malignant cells commonly produce telomerase (enzyme that repairs the telomeres) so the cell becomes immortal Anaplasia a. Anaplasia is the loss of cell differentiation.

List types of anemia associated with Macrocytic (MCV>100 fL)

B12 deficiency (pernicious anemia) Folate deficiency

B12 Deficiency (Pernicious Anemia) results from the autoimmune destruction of the gastric parietal cells which decreases the secretion of intrinsic factor that aids in the absorption of B12-Why is this important?

B12 is needed for DNA maturation and condensation. As a result, a deficiency leads to immature RBCs, lack of functional hemoglobin, and decreased nerve cell myelination.

Explain the pathophys behind splenomegaly and peripheral edema

Because of the large volume of blood flow through the liver and spleen, these areas become engorged, resulting in hepatosplenomegaly. Increased pressure will force fluid from the systemic capillaries into the peripheral tissues, essentially flooding those areas and resulting in peripheral edema.

How does cardiac hypertrophy lead to decompensated HF?

Bulked up cardiac cells demand more O2 but can't get it so they die off Also, ventricular wall thickening leads to a decrease in the size of the chambers decreasing PL thereby SV

Compare the list symptoms btw Chronic bronchitis and Emphysema Clinical Manifestations Productive cough Dyspnea Wheezing History of Smoking Barrel Chest Prolonged Expiration Cyanosis Chronic Hypoventilation- Polycythemia Cor Pulmonale

Chronic Bronchitis Productive cough-classic Dyspnea Late in course Wheezing-Intermittent Minimal History of Smoking-Common Prolonged Expiration-Always present Barrel Chest-Occasional Cyanosis-Common Chronic Hypoventilation-Common Polycythemia-Common Cor Pulmonale-Common Emphysema Productive cough-Late in course with infection Dyspnea-Common Wheezing-Minimal History of Smoking-Common Barrel Chest-Classic Prolonged Expiration-Always present Cyanosis-uncommon Chronic Hypoventilation-Late in course Polycythemia-Late in course Cor Pulmonale-Late in course

Which of the following would indicate obstructive lung disease? Chronic asthma. Pneumonia. Pulmonary fibrosis. Pulmonary hypertension.

Chronic asthma.

List some primary Immunodeficiency Illnesses

Chronic granulomatous Disease of Childhood DiGeorge Syndrome Familial Mediterranean fever Job Syndrome Common Variable Immunodeficiency

A normal, healthy young adult can lose 500-1000mL (10-20%) of blood with minimal effects. But if losses up to 1500 mL of blood occur

Compensation and recovery begin within 24 hours this can result in hypovolemic shock, cardiovascular failure, and death

Which of the following pulmonary function test results are expected in a patient with chronic bronchitis? Increased forced expiratory volume in one second. (FEV1) Increased vital capacity. Decreased FEV1/FVC ratio. Decreased residual volume.

Decreased FEV1/FVC ratio.

Asthma results in: Increased alveolar oxygenation. Decreased alveolar ventilation. Increased alveolar ventilation. Scant mucus production.

Decreased alveolar ventilation.

Chronic bronchitis will decrease which of the following parameters? Increased lung compliance. Decreased forced expiratory flow (FEV1). Decreased diffusing capacity. Decreased total lung capacity.

Decreased forced expiratory flow (FEV1).

Which of the following pulmonary function test results are consistent with asthma? Increased FVC Increased FEV1 and FEV1/FVC. Decreased peak expiratory flow rate. Decreased total lung capacity and residual volume.

Decreased total lung capacity and residual volume.

Aortic Regurg Review

Don't focus on the third point this is heavily convoluted with Aortic stenosis and might confuse you focus on early diastolic murmur heard at the LSB

Which of the following assessment findings would be expected in a patient who presents with urticaria?

Eosinophilia this is because Mast cell degranulation triggers recruitment of eosinophils that cause epithelial damage

Explain the pathophys behind all these causes

In all cases the "agent" destroys the blood-cell producing red bone marrow. The bone marrow is now replaced by fatty yellow marrow, which does not produce blood cells. Loss of blood-cell producing areas eventually leads to pancytopenia: a decrease of all blood cell types.

The NP notes that a patient's FEV1/FVC ratio is normal. Which of the following conditions is most likely the patient's pulmonary issue? Pulmonary fibrosis. Pneumonia. Chronic asthma. Emphysema.

Pulmonary fibrosis.

The effects of an Alpha-antitrypsin 1 deficiency is: Inhibits the immune cell response. Reduction in elastase production. Inability to block the effects of proteolysis. Deactivates neutrophils.

Inability to block the effects of proteolysis.

A lung volume measurement that indicates air trapping in a COPD patient is: Decreased residual volume. Decreased total lung volume. Normal residual volume. Increase residual volume.

Increase residual volume.

If something breaches our 1st line barrier (skin) what happens next

Inflammation occurs Inflammation is a local response to tissue injury.

Thalassemia is similar to sickle cell anemia in that the individual with thalassemia: Inherits an abnormal Hb gene from the mother only Inherits an abnormal Hb gene from both parents Inherits an abnormal Hb gene from one parent Inherits an abnormal Hb gene from the father only

Inherits an abnormal Hb gene from both parents

Asthma is a chronic disease characterized by: Bronchial scarring. Intermittent, reversible airflow obstruction. Air trapping. Airway infection.

Intermittent, reversible airflow obstruction

Asthma is a chronic disease characterized by: Bronchial scarring. Airway infection. Intermittent, reversible airflow obstruction. Air trapping.

Intermittent, reversible airflow obstruction.

List types of anemia associated with Microcytic (MCV<80 fL)

Iron deficiency Anemia Sideroblastic Thalassemia Anemia of chronic disease

Myocardial ischemia is the cause of his chest pain. Explain the pathophys behind his sx

Ischemia occurred because of the narrowing of at least one coronary artery by atherosclerotic plaques. The result is the narrowing of the diameter of the coronary artery. This reduces oxygenated blood flow through the artery that leads to an insufficient oxygen supply to the heart.

How are Leukotrienes and prostaglandins different than histamine

Leukotrienes and prostaglandins function similar to histamine; they are capillary vasodilators but have a prolonged effect and occur later in the inflammatory response

What are the similarities/differences btw AS and PS (pulmonic stenosis)?

Like AS, PS is a crescendo-decrescendo murmur AND it is an Ejection murmur or heard during systole but it does NOT radiate to the carotids

List foods high in B12?

Liver Beef Chicken Pork Caption Whole egg Dairy products (milk, cheese, yogurt)

The (blank) lab value will be normal in post-hemorrhagic anemia MCHC Reticulocyte count

MCHC

List a predominant cause of secondary immune deficiencies worldwide

Malnutrition

What else leads to folate deficiency?

Malnutrition, alcoholism, and interactions with medications (especially anticonvulsants) are common causes of folate deficiency

Macrocytic Anemias As you should recall, macrocytic anemias result from conditions whereby the RBCs are large (MCV>100 dL). Macrocytic anemias are categorized as

Megaloblastic: Folate deficiency and vitamin B12 deficiency Non-megaloblastic: Liver disease, myelodysplastic syndrome, increased reticulocyte count (hemorrhage)

Anemia Classification Anemias can be classified into 3 categories based on the average size of the RBCs (MCV): list them

Microcytic anemia (MCV<80 fL) describes RBCs that are small. Macrocytic anemia (MCV>100 fL) describes RBCs that are large. Normocytic anemia (MCV 80-99 fL) describes RBCs that are normal in size.

ID the differences btw specific and nonspecific immunity

Nonspecific defense system or innate immunity 1. involves Nonspecific mechanisms do not target specific pathogens. 2. it includes: 1st line barriers such as physical and chemical barriers, and Second line barriers: Think (PAINT) phagocytes, antimicrobial proteins, inflammation, natural killer cells and Temp or fever Specific defense system or adaptive immunity 1. This system targets specific invaders such as bacteria, toxins, viruses, & foreign tissues. 2. Mediators include: a. T lymphocytes. b. B lymphocytes. c. macrophages.

Explain the pathophys behind the resistance of these disorders to parasites.

Not only are the abnormal RBCs more resistant to infection, but their shortened lifespan in circulation is not long enough to allow the malaria parasite to complete its reproduction cycle. This allowed our ancestors to be resistant to the deadly consequences of a malarial infection and survive long enough to have children

Which of the following is a modifiable risk factor for Coronary Artery Disease (CAD)? Obesity. Family history. Age. Menopause. Male gender

Obesity.

Compare the findings of the Spirometry measurements below in Obstructive vs Restrictive Disease Forced vital capacity (FVC) Forced expiratory volume in 1 second (FEV1): Normal is > 80% FEV1/FVC ratio: Normal is 70% or greater than the lower limit of normal Total lung capacity (TLC): Normal range is 80-120% of predicted

Obstructive (FVC)Decreased or normal (FEV1) Decreased FEV1/FVC ratio: Less than 70% Total lung capacity (TLC): >120% (represents hyperinflation) Restrictive (FVC): Decreased (FEV1): Decreased FEV1/FVC ratio: Normal or > 70% Total lung capacity (TLC): <80%

What causes gene/chromosomal translocations?

Other factors include chronic inflammation in which cytokines may damage DNA. Examples of this would be H. Pylori which if untreated can lead to stomach cancer

Explain the pathophys behind angina and ACS?

Overtime, plaque buildup can lead to narrowing of the coronary arteries which results in decreased oxygen supply. When atherosclerosis reaches a clinically significant level, the patient will begin to experience angina. Further progression of the disease will result in acute coronary syndrome (ACS), formerly known as myocardial infarction (MI).

What factors bring on the sickling of Hb

Oxidative stress (such as occurs with hypoxia), anxiety, fever, cold, and dehydration further decrease oxygen binding to Hb and increases sickling tendencies

Immunodeficiencies can have either a congenital cause or an acquired cause. Explain the difference btw the two

Primary Immunodeficiency Congenital immunodeficiencies are caused by genetic defects that disrupt lymphocyte development. They are less common and involve antibody deficiencies, B- and T-cell deficiencies, defects in the phagocytic cells and deficiency of complement. Secondary immunodeficiency This is an acquired immunodeficiency that develops after birth and is caused by another illness (e.g. cancer or viral infection) or by normal physiological changes (aging), NOT genetics, they are significantly more common

Distinguish btw L and R sided HF of the following: Jugular vein distention Increased left ventricular afterload Decreased ejection fraction Hepatosplenomegaly Peripheral edema Increased left ventricular preload Cor Pulmonale Pulmonary edema Dyspnea Tricuspid valve damage

R sided: Jugular vein distention, Hepatosplenomegaly, Peripheral edema, Cor Pulmonale, Tricuspid valve damage L sided: Increased left ventricular afterload, Decreased ejection fraction, Increased left ventricular preload, Pulmonary edema, Dyspnea

In order to recognize and differentiate the type of anemia that is present, it is important to understand the components that relate to red blood cells and their production. List and define them

Red blood cells (RBC): The number of erythrocytes in 1 cubic mm of whole blood. Normal for men is 4.7-6.1 mcL. Normal in women is 4.5-5.2 mcL. Hemoglobin (Hb): The oxygen-carrying pigment of red cells. Normal for men is 13.5-17.5 g/dL. Normal for women is 12.0-15.5 g/dL.

Subjective and objective findings in patients with ILD include:

Shortness of breath Non-productive cough Hypoxia Fine crackles, especially during exertion

Explain the clinical manifestations and the associated pathophys (hint: CM present with a decrease in all blood counts (pancytopenia)

Since RBCs are, by far, the most prevalent- bone marrow suppression are first evident by the loss of oxygenation capability with signs and symptoms of hypoxia. This is usually followed by problems with blood-clotting, related to the loss of the second most prevalent blood cell type: platelets. Finally, increased development of infections indicates that WBC production is now affected.

Clinical Findings that an NP would observe in Rheumatoid Arthritis

Subjective: Painful and tender finger joints Stiffness of fingers upon awakening that improves with movement Fatigue Objective: Swollen metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints PIP joints warm to touch and red Rheumatoid nodule on the proximal ulna Decreased ROM of bilateral wrists and fingers

Type I: Allergic Reaction Whether this reaction results in a localized or systemic reaction it's important to note

Target tissues involved are due mainly to the effects of histamine on the Mast cells found in the GI tract, skin, and respiratory tract.

Type II hypersensitivity reaction Complement-mediated lysis of cells (explain this process)

The antibody (IgM or IgG) reacts with an antigen present on the surface of the target cell. The AB-Ag complex fixes with complement MAC attack lyses target cell membrane by drilling holes through the lipid bilayer For example, erythrocytes are destroyed by complement-mediated lysis in individuals with autoimmune hemolytic anemia (ABO incompatibility)

Type 4 hypersensitivity reaction Describe the process of contact dermatitis

The antigen is taken up, processed, and presented to macrophages, leading to epidermal reactions characterized by erythema, cellular infiltration and vesicles

So what causes these changes in our DNA regulatory genes that cause cancer?

UV radiation exposure; from sun or tanning beds chemical exposure: from industrial exposure or second hand smoke, or certain food preservatives

Explain the classic symptoms of inflammation in the synovial lining of the joints in regards to Rheumatoid Arthritis

The complement system is activated when the immune complexes deposit in the synovial tissue that results in the activation of complement. Other mediators that become involved include the kinins, prostaglandins and cytokines. The articular cartilage eventually breaks down because of the actions of the neutrophils and macrophages. They ingest the immune complexes that result in articular cartilage breakdown.

The NYHA Fxnal Classification is based on what?

The impact on the pt's activity caused by the degree of HF symptoms

How does increasing PL lead to decompensated HF

The increased SV makes the myocardial cells have to work harder to pump more blood but b/c they can't get enough O2 they die off leading to overstretched muscle fibers that can't recoil

How are tumors staged?

The letters T , N, and M help determine prognosis T refers to the primary tumor; the higher the number the larger the tumor size N refers to the level of lymph node involvement M refers to the degree of metastasis Ideally, in a tissue biopsy, you'd like T, N and M to be )

Major causes of Diastolic HF include

The major causes of HFpEF include hypertension-induced myocardial hypertrophy and myocardial ischemia with resultant ventricular remodeling. Other causes include aortic valvular disease, mitral valve disease, pericardial diseases, and cardiomyopathies

What is the most important activator of the inflammatory response? Explain.

The mast cell Injury or infection triggers mast cells (located in the skin and RT/GI mucosa) · The degranulate causing the release of histamine which causes an immediate vascular response Upon damage to mast cell membranes, arachidonic acid synthesizes prostaglandins and leukotrienes

autoimmune diseases may occur when the immune system overreacts again self-antigens to the extent that tissue damage occurs what mediates this?

The tissues damage is caused by the autoantibodies and T-cells and in some cases, B-cells that overreact against MHCs

Type 4 hypersensitivity reaction What mediates this reaction

This is a T-cell mediated reaction where no Ag-Ab complex is involved. When the pt comes in contact with the Ag, T-cells are activated leading to epidermal reactions T cells can be Cytotoxic T cells kill target cells directly via toxin (perforin) release. and T helper (TH cells) a. The TH1 cells release cytokines that attract & activate macrophages that induce apoptosis of the target cells via release of lysosomal enzymes

Extrinsic asthma is: Characterized by no elevation in IgE. Typically seen in adults less than 40 years of age. Triggered by an allergic reaction. Triggered by non-allergic factors.

Triggered by an allergic reaction.

In Coronary Artery Disease (CAD), pumping ability of the heart can be impaired due to the deprivation of oxygen. True False

True

Interstitial lung disease refers to any disease affecting the pulmonary interstitium and typically excludes infectious and neoplastic diseases True False

True

Sickle Cell Anemia The pathophysiology of sickle cell anemia involves a single amino-acid change on the beta-chain. True False

True

The basic pathophysiology of iron deficiency anemia is that there are insufficient iron levels or the inability of the cell's mitochondria to utilize iron effectively. True False

True

The characteristic finding of on a chest x-ray of an individual with ILD is a honey-comb pattern True False

True

The following immune components can be involved in autoimmune diseases: T-Cells, B-cells and autoantibodies. True False

True

The four key diagnostic tests for interstitial lung disease are pulmonary function tests, high resolution CT scan, bronchoalveolar lavage and lung biopsy. True False

True

The patient with sickle cell anemia is at high risk for stroke. True False

True

The symptoms that are common to all types of interstitial lung disease are shortness of breath and non-productive cough. True False

True

There are four genes involved in encoding synthesis of the alpha protein chains for Hb and are located on chromosome number 16. True False

True

Acute blood loss of anemia is usually associated with acute GI bleeding and labor and delivery complications. True False

True (as well as trauma)

Acute blood loss anemia is usually associated with

acute GI bleeding, severe trauma, surgical or labor and delivery complications

Allergic contact dermatitis is an example of

Type 4 hypersensitivity reaction.

List some types of Autoimmune diseases and distinguish btw their clinical manifestations?

Types include Rheumatoid Arthritis, Systemic Lupus Erythematosus, Multiple Sclerosis, and Sjogren's Syndrome

Explain the process of a fever?

a fever is another nonspecific, systemic response · Digestion of a pathogen by WBC releases a chemical signal molecule IL-1 from phagocytes IL-1 circulates in the blood stream and stimulates the hypothalamus (which regulates body temp) to release prostaglandins This resets our bodies thermostat which increases core body temp · As our body temp rises peripheral vasoconstriction occurs to shunt blood (and body heat) inward Causing paleness and chills When does the fever go down? · As the pathogen decreases, phagocytosis decreases which drops IL-1 levels which decreases the stimulus of the hypothalamus decreasing the levels of PG · And the hypothalamus is able to reset its thermostat to 98.6F

Review the follow case Step 1 Determine the Pattern: Based on a TLC of 67 this would indicate

a restrictive lung disease as the TLC is <80-120% which would indicate a normal TLC

Normocytic anemias are categorized by normal average red blood cell size (MCV 80-99 dL). When a patient presents with a normocytic anemia, what test should be done?

a reticulocyte count should be performed. (the #of premature RBCs in the bone marrow) If the reticulocyte count is high, the bone marrow is producing many immature RBCs in order to compensate for a loss in number in hemolytic or blood loss anemia If the reticulocyte count is low the bone marrow is not adequately compensation seen in aplastic anemia

Sjogren's Syndrome The major immune system change associated with Sjogren's Syndrome is: a. Autoantibodies and auto-reactive T-cells against apoptotic cells. b. Autoantibodies and auto-reactive T-cells against brain antigens. c. Autoantibodies and auto-active T-cells against DNA and nucleoprotein antigens. c. Autoantibodies and auto-reactive T-cells and B-cells against joint-associated antigens.

a. Autoantibodies and auto-reactive T-cells against apoptotic cells.

Sickle-cell anemia is an: a. Autosomal recessive genetic disorder. b. Immunodeficiency disorder. c. Idiopathic in blood disorder. d. Autosomal dominant genetic disorder.

a. Autosomal recessive genetic disorder.

Which of the following spirometry results indicate restrictive lung disease? a. FEV1, FVC, and total lung capacity reduced; FEV1/FVC ratio normal. b. FEV1 reduced, FVC normal, total lung capacity reduced; FEV1/FVC ratio normal. c. FEV1, FEV, and total lung capacity reduced; FEV1/FVC ratio reduced. d. FEV1, FEV, and total lung capacity normal: FEV1/FVC ratio normal.

a. FEV1, FVC, and total lung capacity reduced; FEV1/FVC ratio normal.

Which of the following would indicate that the patient's iron stores are depleted? a. Ferritin level. b. Vitamin-B-12 level. c. Total iron binding capacity. d. Total RBC count.

a. Ferritin level.

The inflammatory response serves 4 primary functions:

a. Inflammation aids in the disposal of microbes (destroys). b. Inflammation prevents the spread of infection (confines). c. Inflammation prepares the site for tissue repair (initiates repair). d. These chemicals stimulate and enhance further immune response

The most common type of anemia is a. Iron deficiency anemia b. Anemia of chronic disease c. Pernicious anemia d. Thalassemia

a. Iron deficiency anemia

A non-megaloblastic anemia would be caused by a. Liver disease b. Folate deficiency c. Vitamin B-12 deficiency d. Iron deficiency

a. Liver disease

Coronary artery disease (CAD) is mainly the result of: a. Longstanding atherosclerosis b. Hypertension. c. Hyperlipidemia. d. A history of myocardial infarction.

a. Longstanding atherosclerosis

Which of the following will be elevated in a patient with pernicious anemia? a. MCV. b. Folate. c. Serum B-12. d. Reticulocyte count.

a. MCV.

Rheumatic fever is a common cause for a. Mitral Stenosis b. Mitral Valve Prolapse c. Aortic Regurgitation d. Aortic Stenosis

a. Mitral Stenosis also for Mitral regurg but seen early in the course of the disease

Which of the following would normocytic-normochromic indicate? a. The cell is normal in size and normal in hemoglobin level b. The cell is abnormal in shape, but normal in hemoglobin level c. The cell is abnormal in size and abnormal in hemoglobin level d. The cell is normal in size, but low in hemoglobin level

a. The cell is normal in size and normal in hemoglobin level

A patient with mitral regurgitation would most likely present with a a. blowing, holosystolic murmur b. high-pitched murmur c. clear lungs d. bradycardia

a. blowing, holosystolic murmur

In the healthy heart, the response to an increase in preload is for the stroke volume to a. increase b. decrease c. remain constant d. both increase and decrease

a. increase

Elaborate on the causes of a. infectious agent b. ones on immune system c. chemicals/drugs

a. parasitic and helminthic organisms and certain hemolytic toxin-producing strains of the bacterium, Escherichia coli, b. Transfusion Reaction: this occurs from an incorrect or incompatible blood product (type 2 hypersensitivity OR Hemolytic disease of the newborn (Rh incompatibility issue occurring in Rh-mothers and their Rh+ fetus): another type 2 Autoimmune reactions: these can be either congenital or idiopathic in nature. c. Drug-induced: note that drugs/chemicals can break down to form H2O2 (hydrogen peroxide, a free radical) which causes Fe +2 to oxidize to form Fe +3; and this type of iron cannot bind O2 as well.

A deficiency of intrinsic factor will result in a. pernicious anemia b. IDA c. anemia of chronic disease d. aplastic anemia

a. pernicious anemia

Folate Deficiency Anemia Insufficient folate intake or decreased absorption from diet, due to GI problems (often precipitated by alcohol abuse), leads to

abnormal RBC formation and premature death of RBCs. *remember folate helps with RBC maturation

Which of the following is not a clinical characteristic of anemia? a. Fatigue b. Bradycardia c. Dyspnea d. Pallor

b. Bradycardia

The NP is seeing a patient with chronic bronchitis that needs spirometry on today's visit. What pulmonary function test (PFT) findings are anticipated based on the diagnosis of chronic bronchitis? a. Decreased total lung capacity (TLC). b. Decreased forced expiratory flow (FEV1). c. Increased lung compliance. d. Decreased diffusing capacity.

b. Decreased forced expiratory flow (FEV1).

Which of the following conditions could result in iron deficiency anemia? a. Increased absorption of iron-containing foods. b. Excessive bleeding. c. Reduced absorption of Vitamin B-12. d. Reduced intake of Vitamin C.

b. Excessive bleeding.

A transferrin deficiency will most likely result in: a. Pernicious anemia. b. Iron-deficiency anemia. c. Aplastic anemia. d. Hemolytic anemia.

b. Iron-deficiency anemia.

The NP reviews the results of a patient's pulmonary function tests and notes that the FEV1, FVC, and total lung capacity (TLC) are reduced. The FEV1/FVC ratio is normal. Based on interpretation, this reflects: a. The test is invalid. b. Restrictive lung disease. c. Obstructive lung disease. d. Combined obstructive-restrictive lung disease.

b. Restrictive lung disease.

Which of the following lab values will be low in a patient with folate deficiency? a. MCV. b. Reticulocyte count. c. Ferritin. d. MCHC.

b. Reticulocyte count (were dealing with young RBCs)

A patient with normal lungs should be able to exhale (blank) of the forced vital capacity within the first second. a. 50% b. 70% c. 80% d. 90%

c. 80%

Sickle cell anemia and thalassemia are more prevalent in which of the following geographic areas? a. South America. b. North America. c. Africa. d. Australia

c. Africa.

The patient with aortic regurgitation would most likely present with: a. An early, high-pitched diastolic murmur heard at the left lower sternal border b. A diastolic rumbling murmur heart at the apex of the heart c. A systolic crescendo-decrescendo murmur heart at the left upper sternal border d. All of the above

d. All of the above

In hemolytic anemia, the destruction of lysis of RBCs is due to: a. Enzymes or toxins produced by an infectious agent. b. Chemical release medication by one's immune system. c. Effects of drugs. d. All of the above will cause lysis of RBCs.

d. All of the above will cause lysis of RBCs.

Which of the following microcytic anemias is characterized by hyperchromic RBCs? a. B12 deficiency. b. Iron deficiency. c. Folate deficiency. d. Hereditary spherocytosis.

d. Hereditary spherocytosis.

Which of the following statements are correct regarding thalassemia? a. Maintains effective erythropoiesis. b. Is characterized by acute and painful episodes. c. Involves a double amino acid change on the beta chain. d. May have many possible genetic mutations.

d. May have many possible genetic mutations.

Which of the following statements correctly describes the flow of blood between the heart and lungs: a. The pulmonary arteries carry oxygenated blood from the lungs to the heart. b. Oxygenated blood is transported from the lungs to the right atrium of the heart. c. Deoxygenated blood is transported from the left ventricle to the lungs via the pulmonary arteries. d. Oxygenated blood is transported from the lungs to the heart via the pulmonary veins.

d. Oxygenated blood is transported from the lungs to the heart via the pulmonary veins.

Cor Pulmonale is: a. Left ventricular failure secondary to systemic hypertension. b. Left ventricular failure due to a pulmonary disease. c. Right ventricular failure due to systemic hypertension. d. Right ventricular failure secondary to pulmonary hypertension.

d. Right ventricular failure secondary to pulmonary hypertension.

Which of the following is a type of macrocytic anemia? a. Anemia of chronic disease. b. Thalassemia. c. Iron-deficiency anemia. d. Vitamin B-12 deficiency.

d. Vitamin B-12 deficiency.

How does overactivation of the SNS lead to decompensated HF

decreased SNS receptors on the heart from overuse by the SNS lead to downregulation and a decreased response