Pathology - Exam 3
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Pathology - Exam 3
Pathology Integumentary System Endocrine
Integ and Endocrine Syst
What is the largest organ in the body?
How often are cells replaced?
Every 26-28 days
What are the basic functions of the skin?
What are the layers of the skin from the outermost layer to deepest?
--stratum basal (germinativum)
subcutaneous tissue (hypodermis)
What are the five layers of the epidermis?
stratum basal (germinativum)
Describe the epidermis
stratisfied squamous epithelial
thickest on the palms and soles of feet
Describe the stratum corneum
"horny" outermost layer
20-30 cells thick
thickest in the palms and soles of feet
callus forms from pressure
Describe the stratum lucidium
clear layer of dead flattened keritinocytes
thicker and most prominent in hands and feet
Describe the stratum granulosum
forms waterproof layer
--prevents water loss
langerhans help with immune system
Describe the stratum spinosum
"spiny" appearance due to kerotin fibers
progressive maturation and migration of germinal cells
Describe the stratum basale
undulating layer of columnar and cuboidal cells
undulations produce fingerprints
provides germinal kerotinocytes for regeneration of epidermis
melonin produced here
Name and describe the epidermal cells
: pigment, UV protection
: light touch, mechanoreceptors
: fight infection, decrease as we age, risk of skin cancer increases, dendritic cells
What are the epidermal appendages?
hair follicles (soft keratin)
sebaceous glands (lubrication)
sudoriferous glands (sweat)
Describe the basement membrane and what layer of skin it is found in.
Part of the epidermis
attaches stratum basale to dermis
scaffolding for epidermis
filters substances and moving between dermis and epidermis
semipermeable - nutrients from dermis
blisters occur here due to friction between basement membrane and papillary dermis
anchors epithelial to loose tissue
Describe the dermis layer of the skin
--returns water, proteins, other substances to the blood
high water content
What are the functions of the dermis?
nutritional support to epidermis
houses epidermal cells and growth factors for epidermal replication and dermal repair after trauma
thermoregulation through control of skin blood flow
contains immune cells
--defense against foreign invaders
sensory assist to epidermis for info on environment
What are the dermal cells?
fibroblasts (collagen/elastin) flexability
--modulate lymphocyte function and promote growth
mast cells - histamines
What are the structures of the dermis?
erector pilae muscles
pacinean corpuscle and free nerve endings (vibration and pressure)
Describe the subcutaneous tissue in the skin.
aka - hypodermis
--shiny whitish yellow in color
if cut -> see blood
stores energy and vitamins A D E and K
cushioning over bony prominences
deeper lymphatic vessels here
--fibrous white connective tissue
--seperate structures facilitating movement
Describe the deeper tissue in the skin
: bloody red is normal
: white regularly arranged fibers
: white regularly arranged fibers
: white irregularly arranged fibers
: milky white, hard when probed
What are superficial thickness wounds?
wounds caused by shearing, friction, and mild burn
healing occurs by regeneration of epithelial cells on wound surface an migration of epidermal cells across the surface
affects epidermis layer only
skin remains intact
examples - blisters, 1st degree burns
Describe partial thickness wounds
effects epidermis and part of the dermis
accessory structures are spared (hairs and glands stay in tact)
heals similarly to superficial thickness wounds
eschar may form
--dessicated necrotic tissue
examples - road rash, deeper burns
Describe full thickness wounds
effects epidermis, dermis, and into subcutaneous tissue
muscle, tendon, and bone can be involved
Describe the biomechanics of the skin
normal skin has elastic, tensile and viscous properties
much of elasticity comes from viscous elements (viscoelastic)
tendons are very stiff and elongate very little
--due to parallel arrangement of thick collagen
--due to different proportions of glycosaminoglycans
--ability of skin to recoil when pinched
--decreases with dehydration
What type of wounds heal by re-epithelialization?
superficial and partial thickness wounds
What are the three phases of healing?
Describe the inflammation phase of healing
"exudative" phase for homeostasis and fight infection
--forms plug to stop bleeding
coagulation and fibrin formation
neutrophils, macrophages, and mast cells
--assist with destruction and removal of bacteria and cellular debris
--secrete inflammatory mediators
--phagocytosis and proteolysis
What are the cardinal signs of inflammation?
decrease in function (functio laesa)
Describe the proliferation phase of healing
begins as early as 48 hours
--sprouting of capillaries
--tiny red dots in wound bed
--tissue fills wounds
--temporary matrix of vascular connective tissue formation (laid down by fibroblasts)
--red, beefy, shiny, granular beds
--if trauma -> may cause bleeding
--decrease in size of wound
--actin-rich myofibroblasts pull wound margins together
--keratinocytes migrate across wound
--slowed by debris
--clean/moist facilitates movement
needs warm environments with high oxygen and nutriant demands
Describe maturation/remodeling phase of healing
maturation of collage, scar formation, and epithelialization
rosy, pink scar
remodeling of collagen fibers as they thicken, reorganize and mature
--scar color similar to surrounding tissues
9 days - 2 years after injury
tissue strength - 15-20% initially, 80% of original when healed
What are the three types of wound healing?
What is primary intention of wound healing?
uses sutures, staples, adhesives
minimal inflammatory phase
proliferation is epithelialization
What is secondary intention of wound healing?
allow wounds to heal on own
used for wounds with tissue loss, irregular edges, tissue necrosis, high microbial count, or presence of debris
increased healing time
granulation has to be generated to close
increased healing time
What is tertiary intention of wound healing?
delayed primary closure
leaving wound open until closing is prudent
wound is not allowed to granulate
closure of wound after time to start healing
combo of primary and secondary
needs cleansing of wound prior to closure
What factors affect healing?
What intrisic factors affect healing
perfusion and oxygenation
neurologically impaired skin
What extrinsic factors affect healing?
irradiation and chemo
What iatrogenic factors affect healing?
inappropriate wound care
How does age affect the healing process?
decreased immune system
--decreased inflammatory response
dermal and epidermal atrophy
--increased risk of skin tears
decreased collagen synthesis
decreased dermal vascularity (decreased nutrition)
decreased oil and sweat activity decreased barrier
How does nutrition affect the healing process?
: increased wound complications
: vital to wound healing
: risk of protein depletion
: provide energy for repair and regeneration
: needed to build new tissue and aid in immune function
: essential fuel and vitamin transport
How do comorbidities affect healing?
disease processes that affect tissue perfusion affect wound healing (PVD, anemia, COPD)
--ineffective immune system increases infection risk (HIV/AIDS, steroids, chemo)
--increased risk of skin breakdowns and delayed repairs
How does temperature affect healing?
as temperature decreases, speed of healing decreases
What is involved in a wound assessment?
tests and measures
--gait, locomotion, balance
--ROM, MMT, posture
What is involved in a wound evaluation?
clues concerning the
of the wound and prognosis for healing
surrounding skin color
How does color affect a wound evaluation?
strong indication for vascular supply
How does odor affect a wound evaluation?
clean wounds have no smell
foul (fecal smell)
--gram negative bacteria
How does drainage affect a wound evaluation?
thick, creamy drainage indicates infection
type - serous (clear), sanguinous (pinkish)
Why does evaluating the surrounding skin color help?
melanin and hemoglobin
--primary determinates of skin color
palor suggests arterial insufficiency
--due to desaturated hemoglobin
--severe arterial insufficiency
--severe CHF or pulmonary disease
heavy pigmented skin
--hyperemia produces violet/eggplant color
look at nail beds and lips
--indicators of poor arterial circulation
--dry, scaly, leathery skin
--hair loss (epidermal appendage)
What are the different types of tissue?
: yellow or white strings or thick clumps
: pink or beefy red tissue, shiny, moist, granular appearance
: new pink or shiny tissue, grows in from edges
: eschar, black , firmly adheres to the wound bed
: wound completely covered
What is involved in a physical exam of a wound?
What does shape determine about a wound?
: associated with pressure
: associated with vascular insufficiency
: has "peninsulas and bays", areas of healthy skin surrounded by necrosis, associated with venous insufficiency
What do edges determine about a wound?
: quicker to heal
: slower to heal
: signs of chronic wound
What does temperature determine about a wound?
check severity of inflammatory response by temperature of surrounding skin
increased in skin temperature due to developing cellulitis or infection
decreased temperature caused by arterial insufficiency
decreased temperature delays healing by reducing oxygen release
What does size determine about a wound?
length and width
--tracing, photographic grid
greatest length by greatest width method
--cotton tip applicator, tunneling stick
surrounding skin errythema
How do you determine the volume of a wound?
fill wound with Hydrogel from a syringe
Limb girth of a wound
document landmarks for reproductability
pitting, or firm?
Describe vascular testing of a wound
--dorsal pedis, posterior tibial, popliteal pulses
--tests surface arterial blood flow
-- ~30 seconds to normally return
dependent rubor test
--tests arterial flow
--supine, lift leg, observe initial color, after 1 minute, observe change in color of foot. ~15-20 seconds to return. >40 seconds with insufficiency
ankle brachial index (ABI)
--measure BP on arm and on ankle
--divide ankle pressure by arm pressure
--normal indext is 1.0
--<0.95 - narrowing
--<0.8 - intermittent claudation
What are the different patterns of PT treatment for wounds?
: prevention/risk reduction
: superficial skin involvement
: partial-thickness skin involvement
: full thickness skin involvement
: skin involvement extending into fascia, muscle, or bone, and scar formation
What does the endocrine system regulate and control?
works with the nervous system
water and salt balance
What are the major glands of the endocrine system?
What is the role of the hypothalamus?
link between endocrine and nervous system
nerve cells control pituitary gland by producing chemicals that either stimulate or supress hormone secretion
What is the role of the pituitary gland?
controls other glands
anterior lobe secretes
: ACTH, TSH, GH, LH, FSH, prolactin (produced after childbirth, stimulates milk production)
posterior lobe secretes:
--ADH (controls body water and balance by acting on kidneys to modify urine out)
--oxytocin (triggers contraction of uterus during labor
What is the role of the thyroid gland?
regulates metabolic rate, growth and development and protein synthesis
) - blood stream
-- triiodothyroix (T
) - cell functioning
--calcitonin - stimulates calcium deposits in bone
What is the role of the parathyroid gland?
increases blood levels of calcium by removal of calcium from bone to increase levels in the blood
What is the role of the adrenal gland
--acts primarily on kidney to promote absorption of sodium and excretion of potassium
--increase of sodium levels contribute to retention of water and increased blooe volume
absence of aldosterone
--sodium is excreted resulting in decrease blood volume and decreased blood pressure
--produced in response to stress
--increase blood glucose by stimulating liver to produce glucose from stored, non-glucose sources
--decreased swelling by inhibiting immune system response to injury or infection
--prednisone produced from cortisol
What is the role of the adrenal medula?
composed of modified neurons
secretes hormones in response to stress
stimulate fight or flight response of sympathetic nervous system
--increase HR and BP
--dilate airways to facilitate oxygen flow to lungs
What is the role of the pancreas?
digestive and endocrine gland
islet or langerhans are cells that secrete
--insulin (removal of glucose from blood to store as glycogen, promotes build up of fats and proteins and uses as energy source)
--glucagon (increases levels of glucose in blood, released from alpha cells)
secretes digestive enzymes into duodenum through pancreatic duct
What is the role of the adipose tissue?
secretes hormones responsible for:
--cell growth and development
What is the role of the gonads?
LH from pituitary gland stimulates sex hormones
responsible for secondary sex characteristics such as facial hair and breast development
What is the role of the pineal gland?
light from eye stimulates gland through optic nerve
melatonin is formed at night
longer nights = increased levels of melatonin
--levels vary with seasons and time of day
melatonin helps regulate (rhythms):
Describe basis for Endocrine Disorders
more prevalent in women than in men
most disorders prepresent hypofunction of gland secondary to:
--defects in development
--decrease hormone stimulation
--infection, neoplasia, hemorrage, or infarction
Muscle weakness, myalgia, and fatigue associated with what endocrine diseases?
acromegaly (GH - pituitary)
cushings syndrome (Cortisol - adrenal)
Bilateral carpal tunnel syndrome associated with what endocrine diseases?
Neuromuscular signs and symptoms of the endocrine system
--deposits of calcium salts in joint cartilage
--5-10% have underlyng endocrine or metabolic disease
within anterior pituitary gland
growth hormone deficiency
--delayed grouth and puberty
--neurologic signs if caused by tumore
--lifetime hormone replacement
What is hypofunction of the posterior pituitary?
result from the posterior pituitary gland
diabetes insipidus -> RARE
--lack of secretion of vasopressin antidiuretic (ADH)
--water not reabsorbed in kidneys
--excretion of large amounts of dilute urine
--expect patient to be fatigued and irritable due to nocturia
What are the symptoms and treatment for hypofunction posterior pituitary?
imbalance of water
hydration and replacement of ADH
What is hyperfunction of the posterior pituitary?
abnormal enlargement of skeleton due to hypersecretion of GH
clinical signs and symptoms
--enlargemnet of face, hands, and feet
associated musculoskeletal signs
--carpal tunnel, hand pain and stiffness, back pain (thoracic and/or lumbar)
overgrowth of long bones
grows past growth plate
timely diagnosis is key
removal of tumor (if present)
What are thyroid gland diseases?
What is a goiter?
enlargement of the thyroid gland due to iodine, deficient diet, inflammation or tumor
pressure on trachea and esophagus causes difficultly breathing and swallowing
may or may not be regional
surgery if affecting trachea
What is thyroiditis?
inflammation of thyroid due to infection or autoimmune process
is most common form
--early disease hyperfunction
--late disease hypofunction
long term hormone therapy
What are the different types of hyperthyroidism?
execessive secretion of thyroid hormone
causes general increase in body metabolism
gerneralized enlargement of gland
protruding eye (exopthalamus)
What are they signs of hyperthyroidism in adults >50
purple anterior tibia
What is hypothyroidism?
insufficient production of thyroid hormone
generalized depression of body metabolism
untreated congenital hypothyroidism in infants was called Cretinism (now
: neonatal hypothyroidism)
mostly 30-60 years old, 50% in families, 95% impaired
What are the signs and symtoms of hypothyroidism?
proximal muscle weakness
slowed speeched and mental function
muscle and joint edema
respitory muscle weakness
poor wound healing
What is the treatment for thyroid gland diseases?
ongoing synthetic hormones
What are the musculoskeletal effects of hypothyroidism?
CTs may develop before other signs
proximal muscle weakness
myalgias and trigger points
muscle and joint edema
What is hyperparathyroidism?
usualled caused by tumor
causes release of calcium by bone and accumulation of calcium in the blood stream
excessive calcium leads to bone damage, hypercalcemia, kidney damange
What are the symptoms of hyperparathyroidism?
bone demineralisation and bone pain
proximal muscle weakness and fatigability
GI problems and pancreatitis
slow mental ability, personality changes
concurrent illness and surgery can induce acute arthritic episodes
--condrocalcinos and calcified tendinitis
What is hypoparathyroidism?
usually back accidental removal of the parathyroid gland, but sometimes genetic disease, tumor/trauma
muscles weakness and pain
hypocalcemia leading to muscle spasms, parethesias, tetany, and cardiac arrythmias
actue episodes can be life theratening and treated with calcium replacement
can be idiopathic - children 9x>adults, women 2x > men
: pharmacologic management
What are the adrenal gland diseases?
hypofunction (Addisons disease)
What are the risk factors for hypofunction of the pituitary gland?
salt loss from profuse diaphoresis
treated by administering exogeneous cortisol
fatal if not treated
What is Cushings Disease?
hyperfunction of the adrenal gland
hypercortisolism from over secretion of ACTH from the
What is Cushings Syndrome?
hyperfunction of the adrenal gland
oversecretion or excessive corticosteroid meds
corticosteroid administration must be stopped gradually so normal adrenal function can resume
What are the symtoms of hyperfunction of the adrenal gland?
abnormal fat distribution
moon shaped face
enlarged supraclavicular pads
protuberant abdomen with purple striae
What are the two categories of adipose tissue?
: specialized tissue for thermoregulation "baby fat"
: storage of triglycerols as long-term reservoir of energy
What is the role of adipose tissue in the endocrine system?
secretes proteins which have important roles in fat metabolism, feeding behavior, hemostasis, vascular tone, energy balance and insulin sensitivity
What are the proteins of adipose tissue?
: leptin and adiponectin
: tumor necrosis factor, resistin, interleukin-6, IL-8, acylation-stimulation protein, and angiotension and plasma activator inhibitor
Obesity and cancer are increasing link for:
breast cancer (after 65 years)
greater risk for cancer
--worst outcome - recurrance, malignancy and lifespan
How is adipose tissue and Type 2 diabetes related?
excessive white adipose tissure
visceral and hepatic fat are key
subcutaneous fat (little insulin resistance)
What is visceral fat?
fat that accumulates around organs
intra abdominal deposits
What is diabetes?
persistnt elevation in blood glucose caused by a
deficiency in insulin production by the beta cells of the pancreas (in the presence or absence of insulin resistance)
What impact on health does diabetes have?
6th leading cause of death
changes life expectancy 5-10 years
vascular disease 2x to 4x
nerve damage in 60-70%
kills 1 in every 3 minutes
Types of cells involved in glucose regulation
--acts on liver to release glucagon
--increase blood sugar
insulin (decrease blood sugar)
--stops glucagon and GH
--decrease blood sugar
Role of Islet Cells in Glucose Regulation after intake of food
after intake of food, blood glucose increases
beta cells release insulin
insulin transports glucose
cascade leads to decreased blood glucose
Role of Islet Cells in Glucose Regulation When Hemoglycemic
decreased blood glucose
alpha cells release glucagon
stimulated liver to release glucose
increases blood glucose and homeostasis restored
Type 1 Diabetes
about 10% of all cases
cell-mediated autoimmune destruction of beta cells
--usually leading to absolute insulin deficiency
onset before age 30
beody weight at onset is normal or thin
Type 2 Diabetes
about 90% of all cases
onset usually after age 35
insulin production may be below or above normal
ineffective insulin action at cellular level
20-30% require insulin injections
body weight at onset:
obese in 80%
diabesity - obesity dependent DM in children
oral hypoglycemic agents
obesity or weight gain
related to other IRS signs (hyperlipidemia, acanthosis nigricans)
older (increased obesity =decreased age, fatter and younger)
Physiology of Type 2 Diabetes
impaired insulin secretion = insulin deficiency
increased hepatic glucose production
decreased glucose uptake = insulin resistance
Criteria for adult screening for diabetes
test a fasting plasma glucose in:
all adults over age 45 years (repeat every 3 years)
particularly those with BMI >25
younger adults if BMI >25 and one or more risk factors
Risk factors for Type 2 Diabetes
primary relative with diabetes
high-risk ethinic group
previous gestational diabetes
Diagnostic Criteria to Determine Diabetes
fasting plasma glucose:
measures percentage of glycated hemoglobin or HbA1c, in blood
how dody handles sugar
look back over time
~120 days (lifespan of blood cell)
What is prediabetes?
occurs when body can't utilize glucose
incomplete transfer of glucose into cells (for use as energy) by insulin due to:
--body cells don't recognize insulin (decreased insulin sensitivity)
--cells top responding to action on insulin (increased insulin sensitivity)
increases blood glucose (but not as high as DM)
inslin resistant cells stop responding to action of insulin
What is metabolic syndrome?
a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and T2DM
diagnosis is established when >3 risk factors are present
What are the risk factors for metabolic syndrome?
--men - >102cm (>40 in)
--women - >88cm (>35in)
--men - < 40mg/dl
--women - < 50 mg/dl
- > 130/85
> 110 mg/dl
Signs and symptoms of Diabetes
weight loss (T1DM>T2DM)
recurring badder infection in skin and gums
numbness and tingling in hands and feet
slow healing of cuts and bruises
assymptomatic becaue of physical adaption
fatigue and weakness
What is acanthosis nigricans?
hyperpigmented velvety patches of skin in axillary regions and in neck
prediabetic and diabetics
Insulin resistace may lead to
--high TG and low HDL
Complications of diabetes
--cornoary artery disease
--venal artery disease
--peripheral vascular disease
decreased microcirculation to skin and organs
decreases in wound healing and blood flow
How does hyperglycemia affect diabetic patients?
retinopathy, cataracts and glaucoma
--lead to blindness
--cause death or disability
neuropathy, microalbuminuria, and gross albuminuria
--lead to kidney failure
--can cause death or disability
neuropathy (peripheral and autonomic)
--lead to amputation
--can cause death and disability
What is diabetic retinopathy, treatments and preventions
bood vessels in back of eye affected
hemmorages and exudates
--growth of new vessels
--leads to vision loss
--yearly dilated rentinal exam
--blood glucose control (intensive combined therapy)
--BP control (ace inhibitors)
--no contraindication to asprin
laser therapy for proliferative retinopathy or macular edema
more prevelant in T1DM
25x increase in diabetics
What are the two types of neurological complications with diabetes?
gastroparesis, diarrhea, incontinence
charcot's join - arthropathy
How do you approach a patient in PT when they arrive in a confused lethargic state?
finger-stick glucose test
immediate physician referral
alteration in mental status caused by
Treatment for diabetes
diet whole grains
What are the causes of hyperglycemia?
chronic liver disease
What are the symptoms of hyperglycemia?
What is ketoacidosis?
ketones in blood and urine
fruity acetone breath
immediate care is essential
defer Rx if BS > 300-350 or 240 with ketosis until levels are corrected
critical level BS >450 - NO EXERCISE
What are the symptoms of hypoglycemia?
increased heart rate
numbness in lips/tounge
blood glucose <70
can appear <60-70
rapid large drop
(ie. 400 to 200)
can also hae glycemic effects
hold Rx until BS is corrected
critical level <50
How does exercise affect patients with diabetes?
musculosckeletal activities increase glucose homeostasis
new activity at a well-tolerated intensity and duration
patients with active retinopathy and neuropathy should aboid anything that auses increased BP
increases in BP may cause further damage
ok to do low impact activities, strength training preferred (initially)
pre-existing conditions may limit working to goal HR
may have difficult with thermoregulation
no resistance training, valsalva
do not exercise alone
when initiating exercise program, T1DM may:
monitor BG beofre exercising, every 30 min and then 15 min after
exercise >20min continuous aerobic activity
reduce insulin dose
increase food intake
eat 10-15g carbo snack for each 30 min of exercise
place fluid loss adequetly
high intensity exercise
exercise placing head below waist (bad for retinopathy), increases BP
avoid insulin injection to active extremities
PT implications for diabetics
gentle, progressive program
patient education - self management