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During embryonic development, the mesoderm does what?
Aligns into columns along the developing nervous system. Columns divide into segments known as Somites.
When does the first somite appear
20th day of the embryonic period
What are the total number of somites formed?
42-44 pairs by the 5th week
Classifications of the 3 muscles
- 1-Skeletal or striated (voluntary somatic division of N.S.)
- 2- Smooth (involuntary often has autorythmucity Autonomic devision)
- 3- Cardiac (involuntary often has autorythmucity Autonomic devision) "peacemaker"
Characteristics of the 3 muscle types
4 Skeletal Muscle Functions
- 1- Body Movement
- 2- Movement of substances within the body (by sphincters ((pyloric or urinary bladder))
- 3- Stabilizing body position
- 4- Thermogenesis (its by-product generates 85% of all body heat)
5 Muscle Characteristics
- Excitability (Irritability)
Ability of muscle and neurons to respond to a certain stimuli producing an action potential (electrical signal)
Muscles are stimulated by neurotransmitters.
Ability to propagate an action potential along the plasma membrane
Ability to contract (shortening) generating a force to produce work.
Ability to stretch without damaging itself. Muscles usually work in pairs; while one contracts (shortens) the other one relaxes (stretches)
Ability to return to its original shape
The muscle is anchored to the bony structure by what?
Tendons- which are continuous with the external limiting membrane of the muscle.
3 Parts of the Tendons
3 things the muscle should have
-Parts from the striated cross section pic.
Fibers (perimysium internum and externum), Nerve (myelin-rich nerve), and the vessels (artery and vein).
Histology of the Muscle Fibers
- Sarcolemma (plasma membrane)
- Sarcoplasm (cytoplasm)- for glycogen storage and myoglobin
- Nucleous (skeletal type)- Always localized in the periphery of the fiber.
- Mitochondria- Lined in rows, are in close proximity with the contractile proteins of the muscle.
Similar to smooth ER but is used for Ca++ storage essential for muscle contraction
-One of the Special Structures of myosite
Tunnel like folding of the sarcolemma allowing the electrical potential to open the Ca++ chanels inside the sarcoplasmic reticulum releasing it in the adjacent region of the contractile fibers.
Ultrastructure of Myofibrils (3 parts)
- 1- Contractile proteins
- 2- Regulatory proteins
- 3- Structural proteins
- Actin- Thin filaments
- Myosin- Thick filaments
- Attaches directly to the Z disk
- Each filaments posses a myosin binding site covered by tropomyosin- troponin while on relax state running parallel to the filament.
Has a shape that resembles 2 gold clubs twisted together. Its head frorms the cross bridges extending toward actin.
Is stabilized by Titin
What is a thin filament composed of?
300 molecules of myosin
Structural Proteins (5)
- Alpha actinin
Cytoskeletal protein that links the thin filament to the integral membrane proteins of the sarcolemma
Basic functional unit of the skeletal muscle composed untrastructurally by a series of lines, bands, and zones under the electron microscope
-Space between the 2 Z disks
Separates on sarcomere from another and passes through the center of each I band
Z line (disc)
Pale area which only contains thin filaments
Dark area of sarcomere mostly composed of thick filaments
Canter to the "A band" and only contains thick filaments
Divides the H zone
Nerve cell (neuron) from the PNS which has its nucleus at the Anterior Horn of the Spinal Cord and its axon extends to the muscle fiber.
Path of the Motor unit
- Motor neuron Axon with its many synaptic bulb vesicle filed with Ach goes to:
- Synaptic cleft to:
- Motor end plate - muscle fiber receptor for Ach
- (integral protein)
Specialized type of synapse formed between a motor neuron and a muscle fiber. Usually localized in the middle of the muscle fiber allowing spread of potential througout the fiber with simultaneous fiber contraction.
Path to undergo muscle contraction
Nerve impulse ----- Exocytosis of synaptic vesicles ----- Release of Ach into the synaptic cleft ------ Coupling with motor and plate receptors-----Opening of Na+ channels---Change in resting membrane potential----Muscle contraction
Recording of electrical events during the resting and contraction state of a muscle fiber
Clinical Use of a Electromyogram
- Muscle weakness
- Involuntary twitching
- Together with nerve conduction studies helps to determine damage of a nerve fiber.
Electrical impulse----Enters T tubules----Activation of Ca++ releasing channels in sarcoplasmic reticulum with Ca++ release in the sarcoplasma---Free Ca++ attaches to tropin--- Conformational change Troponin-Tropomyosin complex----Exposure of Myosin binding site in Actin
During muscle contraction heads pull on the thin filaments causing them to slide toward the H zone. As the filaments slide inward the sarcomere shortens but he size of the filaments NEVER change. The sliding promotes shortening of the sarcomere and eventually of the entire muscle.
- Sliding filaments mechanism
- -Muscle Contraction-
- While in relax state ATP is attached to an specific binding site in the Myosin head. When activated it splits into ADP + P transferring energy and activating the Myosin head which move toward its actin binding site. Once Ca++ activates the actin regulatory proteins the Myosin heads spontaneously bound accomplishing the sliding process.
- The process will repeat over and over as long as there is ATP and Ca++
Muscle Contraction Steps
- 1- Myosin heads hydrolyze ATP and become reoriented and energized.
- 2- Myosin heads bind to actin, forming crossbridges
- 3- Myosin heads rotate toward center of the sarcomere (power stroke).
- 4- As myosin heads bind ATP, the crossbridges detach from actin.
Ach is rapidly broken down by AChe (Acetylcholinesterase) promoting closure of Na+ channels. This is followed by active recovery of Ca++ through a special pump which returns it to the sarcoplasmic reticulum where CALSEQUESTRIN molecules bind to Ca++
Ca++ concentration in relaxed muscle is 10,000 times lower inside the cytoplasm than inside the sarcoplasmic reticulum.
Contraction requires enormous amount of energy for Ca++ delivery into sarcoplasmic reticulum allowing for relaxation.
Energy sources for muscle metabolism
- Creatine phosphate (100 meter dash)
- Anaerobic respiration (200 meters)
- Aerobic respiration
This is 3-6 times more plentiful than ATP inside the sarcoplasm. When contraction begins and ADP levels increase CK catalyzes the transfer of phosphate group back to ADP regenerating ATP
This source is good only for a fraction of time
- Glucose is broken down into 2 molecules of Pyruvic acid with a net gain of 2 ATP. During exercise there is no delivery of enough oxygen and this prodces the accumulation of lactic acid which diffuses into the blood and may be converted back to glucose in the liver.
- Through this process there is the production of energy that lasts up to 30-40 additional seconds.
- If muscle activity lasts longer than 30 seconds it will depend only in aerobic respiration.
- In activitues that last more than 10 minutes the aerobic respiration provides more than 90 of the energy required.
- In endurance activities it will provide 100% of the energy required.
Inability of forceful muscle contraction after prolonged activity.
Sensation of tiredness (considered a protective mechanism) to avoid damage
Factors in fatigue (6)
- Inadequate release of Ca++ from sarcoplasmic reticulum
- Depletion of creatine phosphate
- Insufficient oxygen delivery
- Depletion of glycogen
- Accumulation of lactic acid
- Inadequate release of acetylcholine
Oxygen consumption and debt
- Conversion of lactic acid into glycogen (liver)
- Resynthesis of creatine phosphate
- Replacement of oxygen removed from myoglobin during excercise.
Skeletal muscle fibers
- Slow oxidative fibers (produces energy (ATP) by oxidative phosphorylation)
- Fast oxydative-glycolitic fibers- preform work in anarobic respiration to produce ATP (limited)
- Fast gycolytic fibers- relies on glycolysis
Slow Oxidative Fibers (SO fibers)
- 1. Smallest in diameter
- 2. Least powerful type of muscle fibers
- 3. Appear Dark Red (more myoglobin)
- 4. Generate ATP mainly by aerobic cellular respiration
- 5. Have a slow speed of contraction (twitch contractions last from 100 to 200 msec)
- 6. Very resistant to fatigue
- 7. Capable of prolonged, sustained contractions for many hours
- 8. Adapted for maintaining posture and for aerobic endurance-type activities such as running a marathon.
Fast Oxidative- Glycolytic Fibers (FOG fibers)
- 1. Intermediate in diameter between the other two types of fibers.
- 2. Contain large amounts of myoglobin and many blood capillaries.
- 3. Have a dark red appearance
- 4. Generate considerable ATP by aerobic cellular respiration
- 5. Moderately high resistance to fatigue
- 6. Generate some ATP by anaerobic glycolysis
- 7. Speed of contraction faster
- 8. Contribute to activities such as walking and sprinting
Fast Glycolytic Fibers (FG fibers)
- 1. Largest in diameter
- 2. Generate the most powerful contractions
- 3. Have low myoglobin content
- 4. Relatively few blood capillaries
- 5. Few mitochondria
- 6. Appear white in color
- 7. Generate ATP mainly by glycolysis
- 8. Fibers contract strongly and quickly
- 9. Fatigue quickly
- 10. Adapted for intense aerobic movements of short duration (weight lifting or throwing a ball)
Overall enlargement of muscle size is due to increase in the size of the individual fibers.
The tension developed remains constant while the muscle changes its length
Used for body movements and for moving objects - such as picking a book up off a table
The tension generated is not enough for the object to be moved and the muscle does not change its length.
- Holding a book steady using an outstretched arm
This type of contraction occurs when you pick up a book
This type of contraction occurs when lowering a book
This type of contraction happens if you hold a book out straight.
2 types of smooth muscle
Visceral and Multiunit
A type of muscle in the small arteries, stomach, intestines, uterus, and urinary bladder.
The Fibers are connected to one another by gap junctions and potentials spread throughout the network.
Visceral type of smooth muscle
A type of muscle in the large arteries, airways, aerector pili, and muscle of the iris.
Each individual fiber posses a motor terminal with few gap junctions. Stimulation causes contraction of only 1 fiber.
Multiunit type of smooth muscle
Ultrastructure of Smooth Muscle
- Less number of contractile fibers
- Lack transverse tubules
- Intermediate filaments attach to dense bodies functionally similar to Z disk.
Contraction of Smooth Muscle fibers
Occur more slowely and last longer. An increase (Ca++) in the cytoplasm initiates contraction. Because it flows from the ectracellular and intracellular regions it occurs more slowly.
What is the role of calmomodulin in muscle?
Couples with Ca++ in cytoplasm
Smooth muscle tone is given by the
Slow movement rate of Ca++ between compartments
All chemical reactions of the body
Overall reactions are exergonic
Overall reactions are endergonic
Chemical substances in food necessary for growth maitenance, and repair.
Types of Nutrients
- Water - one of most important components in the body
Inorganic elements mostly concentrated in skeletal tissue.
Include Ca, P, K, Cu, Co, Zn, Cl, Se,Cr
-Excess are eliminated through urine and feces
- Most work as cofactors in chemical reactions
- 2 types
- -Lipid soluble
- -Liquid soluble
Lipid soluble vitamens
A,D,E and K
Liquid soluble vitamens
B and C
Overall rate of heat production
Resting or fasting state in which the body breaks down nutrients to release energy. Indicator of thyroid hormone concentration
Basal Metabolic Rate- BMR
Kinetic energy measured by temperature and expressed as calories
Amount of heat required to increase the temp of 1 gram of water from 14˚ - 15˚ C
Center for heat regulation localized in the preoptic area (midbrain) receives inpit from thermoreceptors in skin and mucous membranes. Neronal firing is directly proportional to the body temperature.
Heat promoting center
Heat loosing center
Temperature in body structures excluding skin and subcutaneous tissue; always higher than the shell temperature. (rectal thermometer)
Temperature of skin and subcutaneous tissue
ex - temp in mouth
Heat production regulators
- Excercise- increase BMR X15-20%
- Hormones- Thyroid hormone
- Nervous system- sympathetic stimulation
- Body temperature- increase in 1˚ increases BMR x 10%
- Food intake- Increase BMR 10-20%
- Age- Higher in children
- Gender- Slower in women
- Climate- Slower in tropical regions
Preventative measures for heat loss
- Sympathetic stimulation (chemical thermogenesis)
- Muscle contraction (shivering or involuntary thermogenesis)
- Thyroid hormone
Transfer of heat from a warmer object to a cooler one
Conversion of liquid to vapor
Transfer of heat to a substance or object in contact with the body
Transfer of heat by movement of liquid or gas between areas of different temperatures
Abnormally high temp (39˚C or 103˚ F)
Fever producing substance (Interleukin 1) increase in heat production, phagocytic activity and chemical reactions
Adverse effects of fever
- Permanent brain damage
Body temp below (35˚C or 95˚ F) sensation of cold following shivering, confusion, vasoconstricton, muscle rigidity, acidosis, loss of consciousness, hypotension, hypoventilation, fibrillation, loss of reflexes, coma and death.
Most common energy currency
going from ADP + P to ATP
Going from ATP to ADP + P
- Active ion transport
- Muscle contraction
- Synthesis of molecules
- Cell division and growth
- Normally 90% of carbohydrates are used for energy production.
- Over 95% of monosaccharides circulating in blood are in the form of Glucose.
Prefered molecule for energy in Glucose metabolism
Cellular use of energy is dependent on:
- ATP production status
- Amino acid synthesis
- Glycogen synthesis
- Triglyceride synthesis
Polymer of glucose units that serves as glucose storage.
Glycogenesis occurs in:
- Skeletal muscle tissues- only cells that phosphorylates glucose
- - Process is stimulated by Insulin
Total glycogen storage capacity
- 125 gm in liver
- 375 in skeletal muscle
Triglyceride storage capacity of glucose
1 Glucose molecule yields
- 38 ATP going through
- Glycolysis (2 dirctly)
Rate limiting step / key regulator in glycolysis
Phosphofructokinase- process that leads to the formation of the molecule that contains the 2 phosphates
- End product is 2 molecules of Pyruvic Acid
- -Net gain is 2 ATP
Net gain of ATP in Glycolysis is
- 2 ATP
- Total is 4- by breaking down the 2-3 carbon molecules
What happens in aerobic respiration (CAC)
Pyruvic acid (end product of glycolysis) enters the mitochondrial matrix where converted to Acetyl CoA and incorporated in the Citric Acid Cycle
Anabolic or catabolic
- Insulin- anabolic
- glucose- catabolic
What is procuded in the Krebs Cycle?
For each NADP= produce 3 ATP
For each FADH = poduce 2 ATP
Indirect method of producing ATP (proton pump)
- Glycolysis- 2
- CTA- 2
- NADH + H+ (10)= 30
- FADH+ H+ = 4
- Total = 38
Pyruvic acid and NADH+H+ undergoes lactic dehydrogenase to create Lactic acid, which is diffused into the blood stream and goes to liver and makes glucose
Red blood cells are unable to do what
Undergo anaerobic respiration
Pentose phosphate pathway (phosphogluconate pathway)
- Alternate pathway for energy production
- Provides energy independent of the enzymes used in CTA
Excess glucose is broken down and stored where?
Glycogen- in peripheral tisssues (other than liver and muscle, usually amounts necessary for 24 hours)
Lipids- unlimited quantity- reason for overweight people
- Stored in adipose tissue and represent 98% of the total body energy reserve.
- Breakdown by lipase into glycerol and fatty acids
Fatty acids are broken down through
Beta Oxidation which yields Acetyl CoA which enters Krebs cycle to produce ATP
- Transported by proteins
- Lipoproteins (classified by density)
Chylomicrons (exogenous lipids from diet)
- Protein (1-2%)
- Triglycerides (85%)
- Phospholipids (7%)
- Cholesterol (6-7%)
VLDL (endrogenous triglycerides from liver)
- Proteins 10%
- Triglycerides (50%)
- Phospholipids (20%)
- Cholesterol (20%)
LDL (Bad cholesterol)
- Proteins (25%)
- Triglycerides (5%)
- Phospholipids (20%)
- Cholesterol (50%)
HDL (good cholesterol)
- Proteins (40-45%)
- Triglycerides (5-10%)
- Phospholipids (30%)
- Cholesterol (20%)
- Glucose - 36-38 ATP
- Fatty acids, Palmitic Acid, 16 carbon FA = 129 ATP
Regulation of food intake
Intrensic desire for food
Desire for particular type of food
Felling of fullness after a meal
- Provide objective assesment of the basic body functions including:
- Heart rate
- Blood pressure
- Respiratory rate
Other signs that are assessed but not considered vital are:
- Orientation in time, space, and place
- Pain perception
What homeostatic mechanisms were employed by the body during the excercise?
- a. Increased rate of respiration to supply more oxygen to the tissue.
- b. Bronchodilation to increase the amount of air brought into the lungs.
- c. Increased heart rate to supply more oxygen and nutrients to the tissue
- d. Increased blood pressure to supply the tissue with enough oxygen and nutrients, ensure that the brain gets enough blood.
- e. Vasodilation, especially in the capillary beds, to provide more oxygen and nutrients to myocytes.
- f. Sweating for thermoregulation, prevents overheating of the body.
- g. Increased glycogenolysis to provide energy.
- h. Increased osmotic pressure due to increased volume of blood plasma.
What will be the physiological difference between an athletic and a sedentary subject with respect to the results observed during the laboratory experience?
- a. Increased myocardial contractility and tone. This increases the amount of blood flow without exerting as much energy, resulting in a lower heart rate after exercise than in a sedentary subject.
- b. Increased lung capacity. This increases the amount of oxygen available to be delivered to the tissues in a single breath, resulting in less hyperventilation than in a sedentary subject.
- c. Increased anaerobic threshold. An increased period of anaerobic respiration will result in a longer burst of powerful energy in an athlete than in a sedentary subject.
- d. Increased gas exchange in the alveoli. Increased gas exchange at the alveoli results in fewer breaths required to provide the same amount of oxygen to the tissues. This will result in a decreased active rate of respiration in an athletic versus sedentary subject, however it will still be higher than the resting rate of respiration.
- e. Decreased levels of blood lactate. Due to an increased anaerobic threshold, an athletic subject will have lower levels of lactic acid production. This will result in less lactic acid accumulation in muscle than in sedentary subjects, allowing for longer periods of work without muscle fatigue and soreness.
Limitations on lab tests
- Sensitivity (positives)
- Specificity (true negatives)
- Qualitative (pos vs neg)
- Quantitive (determination of units)
When and why should you take lab tests?
- To differentiate between clinical conditions that are difficult to distinguish.
- To begin clinical treatment
- To asses improvement of patient status
Factors Affecting Lab results
- Pre-analtyical (what factors may have occured- mix ups)
- Analytical (not made with proper care of the equipment )
- Post-analytical (lab results mix ups)
Types of Analytes (Samples)
- Most commonly referred sample
- Cell count
- Serum analysis for:
- Cellular Function, Drug concentration, Coagulation status, Special chemistry, Serology
White cell count
- Infectious process
- Shift to R (high granulocytes) vs L (low mononuclear cells, granulocytes)- will tell us if it is Bacterial, parasite, viral.
- Reactive process (responce to something altering a process)
- Neoplastic process
The study of what causes disease, how it spreads, and all the factors that influence it
- Epidemiology is the study of factors affecting the health and illness of populations, and serves as the foundation and logic of interventions made in the interest of public health and preventive medicine.
- It is considered a cornerstone methodology of public health research, and is highly regarded in evidence-based medicine for identifying risk factors for disease and determining optimal treatment approaches to clinical practice.
- In the study of communicable and non-communicable diseases, the work of epidemiologists ranges from outbreak investigation to study design, data collection and analysis including the development of statistical models to test hypotheses and the documentation of results for submission to peer-reviewed journals.
- Epidemiologists also study the interaction of diseases in a population, a condition known as a syndemic.
- Epidemiologists rely on a number of other scientific disciplines, such as biology (to better understand disease processes)
Geographic Information Science
(to store data and map disease patterns) and social science disciplines (to better understand proximate and distal risk factors)
- -Responsibilities, purpose, organization, meaning, data, exams
- -Responsibilities, legality of a medical records, good practice standards
- -Cultural aspects
- -How different cultures view diseases, medicine and healing process
- -Information gathering
- -What, how,when to ask
Comprehensive Adult Health History
- Chief Complaint
- History of Present Illness
- History of Past Illness
- Family History
- Social and Personal History
- Review of Systems
- Marital Status
Source of history
- Is the information reliable?
- Parents, family member, patient.
- Patient is consistent about symptoms?
- Date, time, gender, marital status, occupation, school level.
- Detail the problem (symptoms and concern) making the patient to seek care.
- “Severe throbbing headache accompanied by nausea, dizziness and excessive sensitivity to light since 24 hours ago.”
- Clear chronological account of the problem including onset, setting and manifestations.
- Seven attributes of symptoms:
- Aggravating or Reliving Factors
- Associated Manifestations
- Includes pertinent positive and negative (detailed in review of system) related with the chief complaint who will serve for the differential diagnosis. Also reveals patient’s response to the symptoms or its effects on his life.
- Recount important diseases process affecting the adult population.
- Current health status where you note: tobacco use, alcohol, drugs.
- Any other habit?
- Exercise, diet
HBP, Diabetes Melitis, Hepatitis, Asthma, HIV, hospitalizations, number of sex partners, risky life practices
Date, Indication, type
Menarche, menstruation, pregnancies, deliveries, contraceptive use.
Illness, time frame. Diagnosis, hospitalizations and treatment
Screening tests, immunizations
- Measles, rubella, rubeola, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio.
- (Rheumatic fever is important for us because these patients take a lot of medications such as steroid- which increase IOP and chance of cataracts, dry eye, glaucoma.)
- Age, sex and cause of death of immediate family.
- Review for: HBP, CAD, high cholesterol levels, stroke, diabetes mellitus, thyroid diseases, cancer, arthritis, tuberculosis, headache, mental diseases, suicide thoughts, alcohol or drug addiction.
Personal and Social History
Personality, interests, support, copping style, strength and fears. Includes occupation, last year of school, important life experiences, military services, job history, financial situation, spiritual beliefs, activities of daily living, use of safety measures as seatbelts, protective helmet's, sun block, smoke detector and alternative health practices.
- T- TOLERANCE: How many drinks does it take to make you feel high?
- A- Have people ANNOYED you by criticizing your drinking?
- C- Have you ever felt you ought to CUT-DOWN on your drinking?
- E- EYE OPENER: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
General Healh- history
Detailed history with regards to differential diagnosis of fatigue, weight loss, fever, headaches, dizziness, and malaise
- Feeling of weariness, tiredness, or lack of energy.
- Functional causes: emotional stress, anxiety, depression.
- Endocrine disorders: Addison’s disease, thyroid disease, diabetes mellitus.
- Neurologic disorders: Myasthenia gravis.
- Infectious disease: hepatitis, mononucleosis, tuberculosis, intestinal parasites, endocarditis
- Respiratory disorders- emphysema
- Hematologic disorders- Anemia
- Autoimmune disorders- rheumatoid arthritis, systemic lupus erythematosus. – important- pt uses steroids
- Neoplasic disease.
- Drugs- Alcohol. Sedative hypnotics, environmental toxins
Other medical conditins that can be manifested with fatigue
Hypothyroidism, Diabetes, Hypertension, GI problems, Respiratory problem, neoplasia, mental conditions, depression
Chronic Fatigue Syndrome
a term coined and not a specific conditional disease. Leukemia in children will have a main manifestation of fatigue. So we must find the probable cause of the fatigue by asking questions. We can order tests to be done because we also see other manifestations such as dizziness etc. thus getting us closer to a definite diagnosis.
Good starts in diagnosing fatigue
- Questions such as asking about what kind of medication they take is a good start and also, their age and occupation. With meds most pts don’t know the name and think that OTC are not meds so they won’t tell you. But in fact the meds can cause as side effects, fatigue and dizziness, etc.
- Diabetes pts take the medicine and think they can eat whatever but with all that sugar in the system, not as much oxygen is getting to the cells and creates the feeling of tiredness
- Can occur due to disease of any organ system or also in the absence of serious physical illness. Exercise, and diet. Can be due to psychological problems (depression, anorexia, nervosa, bulimia).
- Many endocrine conditions will produce this weight loss. Would ask for a CMP (comprehensive metabolic Panel), and CBC, triglycerides. If suspecting of chronic disease and depending on the location and history, you can order imaging tests.
- Fever is a natural reaction of the body to an illness and actually helps the body fight infections. It is not an illness.
- A fever is present when the temperature is above 100.5°F (38.0°C) rectal or 99.5°F (37.5°C) oral or ear.
- If pt complains of fever then it must be documented using a thermometer, and not by using the back of the hand.
Causes of fever
- Physiologic causes
- Autoimmune disease
- CNS disease
- Hematologic disease
- Cardiovascular disease
- Gastrointestinal disease
- Endocrine disease
- Miscellaneous causes
exercise, excitement, environment.
SLE, rheumatic fever, polyarteritis nodosa.
cerebral hemorrhage, trauma, tumors, multiple sclerosis.
lymphomas, leukemias, hemolytic anemias, hemorrhage.
myocardial infarction, pulmonary embolism, endocarditis.
inflammatory bowel disease, liver abscess.
Chemical agents: drugs, anesthesia, infection.
psychogenic fever, sarcoidosis, chronic fatigue syndrome.
Grades of fever
- Temperature between 99.8° F - 100.8° F is considered a low-grade fever.
- Between 101° F - 102° F is considered a mild fever.
- Temperature between 102° F - 103° F is considered a moderate fever.
- Around 104° F or above is considered a high fever, and delirium or convulsions may occur.
Other causes of fever
- If pt have had a vaccination in recent days, they will have a slight increase in temp due to the fact of attenuated virus, bacteria, etc. depending on the child, if the temp is about 104 or higher then they might have convulsions although some books say around 108 but you won’t wait until they reach that temp to find out.
- If rash is present with a fever you must act quick because can be caused by meningitis. Collagen related diseases also known as immune related diseases such as rheumatoid arthritis, lupus, etc. and can have many manifestations in different organs and will cause fever. Sometimes chronic diseases can produce fevers and thus conduct tests to determine the cause.
Unknown fever Origin
- Fever over 3 weeks duration, after routine workup there is no diagnosis.
- More than 30% of Fever unknown origin cases in persons older than 50 years are related to connective-tissue disorders and vasculitic disorders.
- Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are the two principal connective-tissue etiologies, accounting for 50% of the cases.
When the fever is an emergency
- If the person /child:
- Acts confused or delirious.
- If a child is under 60 days old (2 months) and has a temperature of 100.5°F need to be seen by a physician right away.
- Has a severe headache, and stiff neck, he or she should be taken to the emergency department immediately.
- Has severe abdominal pain (appendicitis, or obstruction of intestines due to fecal matter, of GI disturbances).
- Has difficulty breathing.
- If the fever is greater than 106°F
- Any person whose immune system is weakened (for example, people with cancer or AIDS.
- Seems dehydrated (no urination for 8 hours, dry tongue, no tears).
- Has a febrile seizure for the first time.
- Has underlying risk factors such as sickle cell anemia or diabetes.
- Tension headache.
- Cluster headache.
- Migraine headache.
- Head injury headache.
- Subarachnoid hemorrhage (SAH).
- Vascular headache.
- Others: sinus, infections, medication side effects.
- Bilateral, constant, daily.
- Viselike, tight, non-throbbing.
- Generalized, located around neck, back of head.
- May be exacerbated by stress, fatigue, glare, noise.
- Majority of all headaches
- Frequently worse in the morning
- May be accompanied by other symptoms of depression
- Most common cause of transient vision loss of the young (20-30 years-old).
- Three times more common in women.
- Gradual build-up, often preceded by “aura”.
- Intense, throbbing, vascular.
- Intensified by light, noise, movement.
- Associated with nausea, photophobia, blurred vision.
- Often family history of migraine.
- May be triggered by psychological stress or diet (caffeine/tyramine).
- Duration 15-45 minutes.
- Pathophysiology: intracerebral arterial constriction / extracerebral arterial dilatation.
- Involvement of serotonin receptors.
- Treatment: beta blockers, nsaids, SSRI (selective serotonin reuptake inhibitors.
- Variation: Ocular migraine, experience visual symptoms of a migraine without headaches.
Cluster headache (migrainous neuralgia)
- Occurs in “clusters”, daily for a few weeks.
- More common in males (30-50 years-old).
- Severe stabbing pain.
- May be orbital or temporal in location.
- Alcohol, smoking, nitroglycerin, stomach ulcers histamines may trigger attack.
- Duration 15 min-3 hours (occurs during sleep).
Temporal arteritis headaches (Giant cell arteritis)
- Can lead to loss of vision.
- Pulsatile pain. These are located at the temporal or occipital area in patients, male or female alike.
- Present in people greater than 55 years of age.
- Examination may show scalp tenderness with a possible dilated temporal artery.
- Patients complain of jabbing neck pain, jaw claudication, fatigue and morning stiffness in the hips and shoulders.
Post traumatic headache
- Occurs after head injury.
- Constant, dull ache.
- Disequilibrium may occur
- Remember! "The worst headaches of your life" headaches
- They cause a change in cosciousness level.
- Can occur in all ages and sexes.
- They are unique in that these headaches interrupt sleep.
- Associated with nausea, visual changes, and they steadily increase the severity.
Red flags- headaches
- Systemic symptoms or illness (including fever, persistent or progressive vomiting, stiff neck, pregnancy, cancer, immunocompromised state, anticoagulant).
- Neurologic signs or symptoms (including altered mental status, focal neurologic symptoms or signs, seizures, or papilledema).
- Onset is new (especially in those age 40 years or older) or sudden.
- Other associated conditions (eg, headache is subsequent to head trauma, awakens patient from sleep).
- Prior headache history that is different (eg, headaches now are of different pattern or are rapidly progressive in severity or frequency).
- When such red flags are present, neuroimaging (computed tomography [CT] or MRI) is indicated to investigate secondary causes of headache.
- having a whirling sensation in the head with a tendency to fall.
- Ask the pt to describe their symptoms by using words other than “dizzy.” the rationale for using other words is that pt’s
- may use dizzy nonspecifically to describe vertigo, unsteadiness, generalized weakness syncope, presyncope, or falling.
- History and clinical differentiation vertigo vs. non-vertigo
- History and clinical differentiation from other conditions
- Probable causes (eye problems, COPD, hypertension, ear infections, arrhythmia, medications-including OTC)
- a disordered state in which the individual or his surroundings seem to whirl.
- Vertigo, a symptom of a balance disorder, is the illusion of movement when no movement is present. This can be caused by a problem of the inner ear balance mechanisms, or by a problem in the brain. While usually harmless, vertigo can be a sign of a serious condition if accompanied by difficulty in speaking or walking, severe headaches, or double vision.
Causes of Vertigo
- Benign paroxysmal positional vertigo or BPPV, which is caused by an inner ear problem and is the most common cause of vertigo. BPPV is characterized by sudden and severe episodes that are nonetheless not serious.
- Inflammation or infection of the inner ear, which can lead to hearing loss if not treated immediately.
- Certain serious medical conditions, including multiple sclerosis and head or neck trauma.
- Cerebellar hemorrhages, which cause vertigo because of decreased blood flow to the brain. In this case, vertigo is accompanied by more serious symptoms, such as difficulty walking and vision impairments.
- Meniere disease, which often also causes ringing in the ear.
- A vague body discomfort as in premoribid state of an illness or depression.
- Subjective feeling of being sick, ill, or not healthy. The feeling is generalized, varying from mild to severe in intensity. It may be the lone clinical manifestation of malaria, or may accompany other signs and symptoms, such as fever, headache, or nausea.
- Type of pain
- Dull cramping
- Severity -scale 1-10
- Right shoulder- Liver
- Under R nipple- Biliary colic
- Near R rib- cholecystitis, pancreatitis, duodenal ulcer
- R inguinal- Appendicitis
- Pubic area- Colon pain
- L Bikini line- Ureteral colic
- Under Belly button- Small intestine pain
- Near L rib- Renal colic
- Above L Breast= heart
- Left upper shoulder- Pancreatitis
- R upper shoulder- Perforated duodenal ulcer
- R Back of underarm- and Middle back- Penetrating duodenal ulcer
- R middle side back- Cholecustitis
- Lower back- Pancreatitis, renal colic
- Above but crack- Rectal lesions
- The area of cutaneous distribution of a single spinal nerve; there is considerable overlap between adjacent dermatomes
- Face is supplied By CN 5- Opthalmic, Maxillary, Mandibular
- General appearance, rashes, moles, nevi, dryness, itching, color change?
- Changes in hair/nails
- Dry nails?
- -Thyroid problems and nutritional problems may be a cause to changes in hair/nails
Goiter, lumps, lymphadenopathy
- Thrill =vibrations= “like the throat of a purring cat”.
- Bruit: is a murmur sound due to blood turbulence, is a vascular sound.
- Meaning: a carotid thrill w/o a bruit in old person may be an indication of arterialnnarrowing, cerebro-vascular condition
Lumps, nipple discharge, self examination
Cough, sputum production, hemoptysis, dyspnea, wheezing
Chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema.
Dysphagia (difficulty in swallowing), odynophagia (painful swallowing), nausea, change in appetite, change in bowel habits, food intolerance, jaundice, hepatitis.
Frequency, urgency, nocturia, dysuria, hematuria
Intermittent claudication, leg cramps, swelling of calves r feet, varicose veins.
Muscle or joint pain, stiffness, arthritis, gout, neck or low back pain.
Nervousness, tension, depression, memory change, suicide attempts.
Changes in mood, attention or speech, changes in orientation, memory, insight, headache, vertigo, dizziness, fainting, seizures, paralysis, tremor
- Propulsive gait
- Scissors gait
- Spastic gait
- Steppage gait
- Waddling gait
a stooped, rigid posture, with the head and neck bent forward.
legs flexed slightly at the hips and knees, giving the appearance of crouching, with the knees and thighs hitting or crossing in a scissors-like movement
a stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction
foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking
a distinctive duck-like walk that may appear in childhood or later in life
Anemia, easy bruising, bleeding, past transfusions, transfusion reactions.
Thyroid problems, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove, hat or shoe size.
Presentations involving abnormal body habits and demeanor
- Weight loss
- Shock syndroms
- Systemic allergic reactions
most common symptoms for which patients seek relief. Highly subjective
regulated rise to a new “set point” of body temperature due to increased heat production (shievering) or decreased heat loss (peripheral vasoconstriction). Hyperthermia: heat load from body or environment exceeds heat loss.
marked, unexplained weight loss often indicates serious physical or psychological illness
often related to overexertion, poor physical conditioning, inadequate rest, obesity, poor nutrition, emotional problems
- occurs when arterial blood circulation is not enough to meet (metabolic) needs. Can lead to death.
- Signs: hypotension, clammy skin, weak pulse, confusion.
- Causes: massive hemorrhage, burns, acute myocardial infarction with heart failure or bacterial sepsis.
Systemic allergic reactions
- immunologically mediated: “immediate” allergic reactions
- mediated by IgE. “Delayed” reactions mainly due to cell mediated immunity. Atopic or spontaneous reactions difficult to determine antigens.
Deviation from physical developmental norms and standards for all ages
- Heriditary disorders
inadequate food intake. Defective absorption of food. Increased need for food. Impaired metabolism of nutrients. Interaction of drugs and nutrients
Rickets: deficient mineralization in bone and cartilage. Muscular dystrophies: myopathies causing progressively severe weakness. Endocrine disorders (e.g. growth hormone deficiency, thyroid deficiency). Metabolic disorders ( e.g. diabetes, errors of amino acid metabolism).
- Prevention is defined as the reduction of risk for future adverse health events.
- Preventive medicine is a medical specialty that encompasses three areas of specialization:
- A) Generic preventive medicine and public health (entomology, pest control, and public health inspections).
- B) Aerospace medicine.
- C) Occupational medicine.
Preventative programs for specific diseases
- Cardiovascular diseases – cholesterol and bp tests
- Cancer- mammograms, colonoscopy, prostate check
- Injury prevention – safety glasses, hard hats
- Life style related problems – alcohol, smoking, diet
- Sexually transmitted disease
- Substance abuse
- Visual and hearing problems – amblyopia before 8
Leading cause of preventable death in US- 2000
- Smoking -18.1%
- Overweight and obesity- 15.2%
- Alcohol consumption- 3.5%
- Infections- 3.1%
- Toxic agents- 2.3%
- Motor vehicle collisions- 1.8%
- Incidents with firearms- 1.2%
- STD- 0.8%
- Drugs- 0.7%
- Screening tests
- Life style changes
- Basically target a specific compound produced before or after tissue injury
- Troponin 1
- CK- MB or myoglobin
- Glucose level
- Hb Ac1
- Asses risk for developing a significant medical disease PSA- prostate
- Provide early detection and follow up of significant model disease Tumor markers.
- Uric acid
- Plasma proteins (albumin, globulin)
- Calcium level (osteoporosis)
- Glucose level
- Radioassay for hormones
- Syphilis tests- VDRL/RPR
Diabetes- check rbc's and hemoglobin
Complete Blood Count (CDC)
measures red blood cell (RBC), hemoglobin, hematocrit, platelet, white blood cell (WBC).
Erythrocyte sedimentation rate (ESR)
Measures speed of RBC sedimentation. No specific test. Diagnostic for temporal arteritis. Norm 0-20 mm/hr. Women have higher sed rates. ESR increases when you have an infection, women higher)
Serum glutamic oxalocetic transaminase (SGOT)
enzyme associated with liver and muscle
Lactate dehydrogenase (LDH)
levels elevated in hemolytic disorders and MI.
Blood urea nitrogen (BUN)
elevated levels may indicate kidney disease.
high levels lead to gout
elevated levels may indicate liver disease (yellow sclera)
measures cardiac rhythm. Reveals conduction abnormalities, hypertrophy, MI, ischemia.
Radioassay for hormones
Radioactive hormone administered to patient. Dilution of radioactive hormone occurs as it mixes with endrogenously secreted hormone.
- VDRL/RPR: venereal disease research lab.
- FTAABS/MHA TP= fluorescent treponemal antibody absorption/treponemal antibody hemagglutination test.
- Six immunizations are currently recommended for routine use in adults:
- Tetanus-diphtheria booster every 10 years (for people ages 19 to 64 years, at least one booster should be tetanus, diphtheria, and a cellular pertussis).
- Influenza (inactivated intramuscular) vaccine once each year for people ages 50 years and older (and special groups under age 50 years; live vaccine (FluMist) can be offered to healthy, no pregnant patients ages 5 to 49 years).
- Pneumococcal vaccine once after age 65 years (and special groups under age 65 years).
- Measles, mumps, and rubella if born in 1957 or afterward and not previously immunized.
- Varicella for people born in 1966 or afterward who have never had varicella infection or previous immunization.
- Human papillomavirus vaccine for females ages 9 to 26 years
- Plain radiography
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Positron emission tomography (PET)
- Radionuclide scanning
- Ultrasonography (US)
- First imaging method indicated to evaluate the extremities, chest, or abdomen
- 1st-line test for detecting fractures (bone is well seen because it is adjacent to gray soft tissues)
- Pneumonia (consolidation of soft tissue and inflammatory exudates are well seen when surrounded by air)
- Intestinal obstruction (dilated, air-filled loops of intestine are well seen because density of air differs from that of surrounding soft tissue).
Normal Chest X ray
- Black = air
- White = something happening in the organs due to air, infactions or tumors
To stabilize a long bone fracture, a plate and screws outside the bone or a rod inside the bone may be used.
Computered tomography (CT)
- Provides 2- and 3-dimensional information not available from plain radiography and with much higher contrast resolution.
- Standard for imaging most intracranial, head and neck, intrathoracic, and intra-abdominal structures.
- Showed a chest CT- a lung mass
Magnetic resonance imaging (MRI)
- MRI is preferred to CT when soft-tissue contrast resolution is important.
- Evaluate intracranial, spinal, or spinal cord abnormalities or to evaluate suspected musculoskeletal tumors, inflammation, trauma, or internal joint derangement (imaging of intra -articular structures may include injection of a gadolinium agent into a joint).
- Also helps in evaluation of hepatic abnormalities (e.g. tumors) and female reproductive organs.
- -Showed a MRI of a brain
Positron emission tomography (PET)
- Testing for myocardial hibernation in patients considered for coronary artery bypass graft surgery or heart transplantation.
- Testing to distinguish metastasis from necrosis and fibrosis in the enlarged lymph nodes of cancer patients.
- Evaluate pulmonary nodules and determine whether they are metabolically active.
- Evaluate lung, colorectal, esophageal, head and neck cancer, lymphoma, and melanoma.
- CT and ET may be used in combo to correlate morphologic and functioal data.
- -Showed a PET scan of a Alzheimer's pt- the affected area was grey.
- Radionuclide may be used in imaging and in specific situations
- Treat disorders (e.g., thyroid disorders).
- Image the skeleton and check for bone metastasis or infection
- Labeled WBCs are used to identify inflammation
- Labeled RBCs are used to localize lower GI bleeding
- Image the biliary system to asses from biliary obstruction and gallbladder disorders.
- Saw The metastasis- breast cancer. And bone scan
- A mode
- B mode
- M mode
Used for ophthalmologic scanning
The type most often used in diagnostic imaging; evaluate the developing fetus and multiple organs including the liver, spleen, kidneys, thyroid gland, testes, breasts, and prostate gland
Image of moving structures
Assestment of fetal heartbeat
Cardiac imaging, most notably of valvular disorders
Assess blood flow
Combines gray-scale (2-dimensional) imaging and Doppler
Principles of basic cardiac life support CPR = cardiopulmonary resuscitation
- Basic life support (BLS) is a specific level of prehospital medical care provide by trained responders in the absence of advanced medical care. Most laypersons can master BLS skill after attending a short course.
- BLS consists a number of life-saving techniques (“ABCs”) of prehospital emergency care:
- A) Airway: protection and maintenance of patient airway (including the use of airway adjuncts such as nasal airway).
- B) Breathing: actual flow of air through respiration (natural or artificial respiration).
- C) Circulation: movement of blood through the beating of the heart or the emergency measure of CPR.
- One rescuer cpr- 2 breaths (1 sec each) after every 30 chest compressions at 100/min
- 2 rescuers cpr- 2 breaths after every 30 compressions at 100 min
- Breath size- each breath should be around 500 ml- caution against hyperventilation
- One rescuer CPR- 2 breaths after every 30 chest compressions at 100/min
- 2 rescuer cpr- 2 breaths after every 15 chest compressions at 100/min
- Breath size- small breaths than for adults- enough to make chest rise.
- One rescuer- 2 breaths after every 30 chest compressions at 100/min.
- Two rescuer- 2 breaths after every 15 chest compressions at 100/min.
- Breath size- only small puffs from rescuers cheeks
Common systemic and ocular side effects of medications
- Cardiac glycosides
- Sedative hypnotics
- Nausea, vomiting, diarrhea, salivation, bronchiolar spasm. Myopia, blurred vision
- Atropine, scopolamine
- Dry mouth, constipation, tachycardia, delirium.
- Mydriasis, blurred vision, paralysis of accommodation
- epinephrine, isoproterenol, dopamine
- Hypertension, tachycardia, tremor, Mydriasis
- Alpha blockers- phentolamine, ergotamine, prazosin - hypertension, reflex tachycardia, decreased pupilary dilator tone
- Beta blockers- propanolol, timolol- hypotension, bradycardia, asthma
- hydralazine, propanolol, clonidine
- excess hypotension, headache, nausea, diarrhea, anorexia
- nitroglycerin, verapamil
- orthostatic hypotension, reflex tachycardia, throbbing headache
- anorexia, nausea, vomiting, diarrhea.
- lidocane, quinidine
- nausea, vomiting, diarrhea, dizziness, tinnitus, headache.
- thiazides, furosemide, spironolactone
- metabolic alkalosis, weakness
- diazepam, phenobarbital
- drowsiness, diminished motor skills, tolerance and dependence.
- phenytoin, carbamazepine, phenobarbital
- ataxia, drowsiness, nystagmus, diplopia
- Lipid panel
- Thyroid panel
- Allergy panel
- Hepatitis panel
- Lymphoma/ Leukemia panel