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medical school pathology lectures. Year end review of Term3. Endocrine & CNS. Note: Video of this lecture is on on youtube.
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As is our Pathology, so is our Practice.
-- Sir William Osler, M.D. (Father of Modern Medicine & Founding professor of John Hopkins,
developed first residency program for physicians.)
Pathology: The science of medicine !
CPC31: Week Overview2013 Term 3 CPC 1 Title: Endocrine 1/1 Thyroid
System: EndocrineAim: To educate students in Clinical, pathology & population
study of patients with Endocrine disorders (using example of thyroid disorder).
Learning Outcomes:Students will be able
to
1. Demonstrate an ability to take a focused History & carry out a focused clinical examination of patients with neck swelling and systemic symptoms
2. Describe the Pathophysiology of common endocrine disorders.
3. Describe the pathophysiology of thyroid disorders.4. Outline the basic sciences relating to
hypothalamic/pituitary/thyroid axis; thyroid function testing; role of anti thyroid antibodies in differentiating thyroid disease
5. Outline first line treatment of thyroid disorders.
Graves, Hashimoto, MNG, Cancer.
Cushings, Addisons, PheochromocytomaAdenoma, carcinoma
Hyper/Hypo parathyroidism
Head injury, infections, Inflammations & TumoursCentral Diabetes Insipidus, Hypogonadism
Adenoma, Ischemia (Sheehans),Diabetes insipidus,
Atrophy / hyperfunction
DIABETESAdenoma, carcinoma
Tumours, Cysts, Atrophy, Dysfunction
Tumours, Cysts, Atrophy, Dysfunction
Tumours, Cysts,
Hypothal: Tertiary
Pituitary: Secondary
Gland: Primary
Hyper – Thyroidism - Hypo • Hyper-Metabolic… • Hypo-Metabolic…
Nontoxic-Multi Nodular Goitre.
A: conspicuous neck mass. B: Coronal section showing numerous irregular nodules, some with hemorrhage. C: Microscopy: variation in the size of the follicles.
Note: TSH, T3,T4 Normal
(Euthyroid)
Carcinoma of ThyroidType (%) age spread Prognosis
Papillary 60-70 young adults 20-40 (<45y)
Lymphatic, to local nodes
Excellent
Follicular 20-25 Young-middle 40-50 (>45)
Blood stream, especially to bone
Good with radio-iodine therapy.
Psammoma Body
Papillary Carcinoma:
SIADH: Sy of Inappropriate ADH secretion
SIADH
• Too Much ADH• Water Intoxication• Low Serum Sodium• Low Serum Osmolality• High Urine Osmolality
Diabetes Insipitus
• Too Little ADH• Dehydration• High Serum Sodium• High Serum Osmolality• Low Urine Osmolality
ExcessAndrogens
Adrenal Glands:• Cortex (glands)
– Glomerulosa - Mineralocorticoids– Fasciculata - Glucocorticoids– Reticularis – Gonadal hormones
• Medulla (Neural)– Chromaffin cells & sympathetic nerve endings - Noradrenaline
Adrenaline (epinephrine)• Pathology: common.
– Pheochromocytoma – medulla hypertension.– Addison’s disease*– Cushing’s syndrome* & Disease*.– Conn’s syndrome*.– Congenital adrenal hyperplasia(21-hydroxylase deficiency)
Precocious puberty
Pheochromocytoma:• Tumor of medullary Chromaffin cells.• Increased catecholamines• Secondary hypertension.• Young age.• May be familial (MEN syndrome).• Increased Urinary VMA
Waterhouse-Friderichsen Sy• Acute hemorrhagic necrosis (apoplexy).• Shock/Septicemia• Lack of aldosterone• Salt & water loss• Hypovolemic shock• Hypoglycemia.
The adrenals from a child dying of meningococcal septicaemia are destroyed by haemorrhage.
K K
Addison’s Disease:• Chronic adrenal insufficiency.• anorexia, weight loss, vomiting • Weakness, lethargy, hypotension • skin pigmentation • hyponatraemia with hyperkalaemia • chronic dehydration, sexual dysfunction.• Low plasma cortisol.• ACTH high (primary) or low (sec)
• Autoimmune 70%, • Infections (TB, fungal), tumours,
Type I MEN Type II
MEN - Gene - RET
Education is what remains after we have forgotten all the facts taught in the class!--
CPC32: Week Overview2013 Term 3 CPC 2 Endocrine 2 - Diabetes
System: EndocrineAim: To educate students in: Clinical, Pathology & population
study of patients with Diabetes MellitusLearning
OutcomesStudents will be
able to
1. Demonstrate an ability to carry out a focused History & clinical examination of patients with diabetes.
2. Describe the pathophysiology of Diabetes Mellitus Types 1 + 2 and their complications.
3. Outline the Basic sciences relating to endocrine function.
4. Explain the abnormalities of Blood supply common in diabetic patients including - ischaemia, infarction & necrosis.
5. Outline the epidemiology and aetiology of Diabetes Mellitus in Australia and world wide.
6. Outline first-line management and demonstrate an understanding of the process of care of a diabetic patient.
II NIDDMII GDMI IDDM
Sec IDDMSec IDDM
I LADASec IDDM
I IDDMLADA
MODY
Most likely .. What type of DM ?
1. 56 year male obese2. 30 year female following pregnancy3. 8 year old boy, poor growth, DKA.4. 24 year female Cushing’s sy5. 68 Year male following Ca. pancreas.6. 32 male, DM, BMI 18, Anti-GAD +ve.7. 34 year male, extensive tuberculosis.8. 12 year old female following viral fever9. 41y DM2, BMI 17.1, HbA1c 14.1, DKA10.15y male, BMI 16.2, recurrent infect.
DM Questions• Definition? types common? Diagnosis?• Primary & Sec? Congenital? Gestational?• Monogenic? MODY, LADA, drugs?• List functions of Insulin? Antagonists?• Etiology & Pathogenesis of Type 1 & 2.• Stages of DM & their pathological basis?• Obesity & Insulin resistance *
– FFAs, PKC, Adipkines, PPARγ– Inflammation & Insulin resistance.
• Mechanism of β cell destruction type 1, 2.• Islet Amyloid PolyPeptide (IAPP)?
DM Questions• MODY & LADA – pathogenesis, subtypes.• Pathogenesis of Complications:
– Mechanism: AGEs, Activate of PKC, & Polyols.– Infections – common & pathogenesis.– Foot ulcer, Retinopathy (prol & non-prol), – Neuropathy? Central, peripheral, autonomic…– Difference Angiopathy Micro & Macro? MI, Stroke.– Diabetic Nephropathy – albuminuria, KW lesion,
Papillary Necrosis, Pyelonephritis, CRF.– Hypertension, Cataract,
• Metabolic: Diabetic Coma, DKA, HONK **
InsulinAnabolic Steroid
GLUT4 *
only these tissues….!
Obesity & Insulin
resistance.
Diabetes is a state of inflammation
Peripheral Res.
GIP : glucose-dependent insulinotropic polypeptide (GIP)GLP-1: glucagon-like peptide-1 (GLP-1)DPP 4: enzyme dipeptidyl peptidase-4 (DPP-4) – breaks down GIP & GLP-1
Insulin Resistance:
JCU Research…!
Diabetes Classification: (not a single disease)
– Type I – IDDM / Juvenile – 5-10%.– Type II – NIDDM /Adult onset – 90-95%.– MODY – 5% Maturity Onset Diabetes of Youth
• Genetic, sub types MODY 1–6 (3 & 2 common),– LADA – Latent Autoimmune Diabetes in Adults (LADA)– Gestational Diabetes Mellitus.– Other. (neonatal diabetes, – Insulin gene defects)
Endocrinopathy, Downs Sy.
– Excess hyperglycemic stimulus (drugs & disease).• Cushings, Phaeochromocytoma, acromegaly, Steroid therapy.
– Beta cell destruction:• Pancreatitis/tumors/Hemochromatosis – Bronze diabetes.• Infectious – congenital rubella, CMV, TB,
Pathogenesis of Type I DM
Genetic HLA-DR3/4
EnvironmentViral infe..?
Insulin deficiency
Autoimmune InsulitisAb to ß cells/insulin
ß cell Destruction
Secondary DMInflammation,
Tumor, InfectionTrauma
Pancreatitis
Antibodies:Islet cell Ab - ICA
Insulin Auto Ab - IAAGlut. Acid Decarb - GAD65
Type-1 clinical course
Type IIPathogenesis
Relative
Insulin Def.β cell
dysfunction
?
Β cell ExhaustionIDDM
Progression of Type II
Years ..
Type-I Type-II
Insulitis:Lymphocytic infiltrate within islets.
Islet Hyalinization:Central hyaline deposits replacing
dead beta cells(only in late stage…!)
DM:Complications:
DM Microangiopathy – pathogenesis
Normal
Diabetic
Glucose Glycosylation BM damage leak ‘AGE’ deposition
PATHOGENESIS OF DM COMPLICATIONS:1. Chronic Hyperglycemia.2. Glycosylation of BV B. membrane 3. Leakage of proteins, excess BM matrix.4. Narrow, thick, fragile, Leaky BV + Inflam.5. Leakage of LDL, protein, angiogenesis.
• Ischemia• Proteinuria (kidney)• Micro Aneurysms (retina)• Atherosclerosis.
“A man must be big enough to admit his mistakes, smart enough to profit from them, and strong enough to correct them!”
--John C. Maxwell
CPC33: Week over veiw2013 Term 3 CPC 3 Title: Neurology 1 – Head injury, Stroke.
System: CNS-NeurologyAim: To educate students in:
Clinical, Pathology & population study of patients with Head Injury, including non traumatic brain injury & stroke.
Learning Outcomes:
Students will be able to
1. Demonstrate an ability to take a focused history & perform a relevant and focused clinical examination of patients with loss of consciousness/alteration in neurological function
2. Describe the Pathophysiology of cerebrovascular accidents.3. State the Pathophysiology of hypertension (review).4. Recall the components of Basic sciences relating to function of the
brain. 5. Define the Epidemiology and Pathology of cerebrovascular disease
(stroke).6. Describe the Epidemiology of neurological diseases in Australia and
world wide.7. Define the first line management of patients with impaired Glasgow
Coma Scores8. Demonstrate an understanding of the complications of intra-cerebral
events
Learning Objectives:
• CNS: Functional Anatomy, Physiology & Blood supply – Revision
• Stroke: Definition, types, etiology, clinical features, complications.• Brain Ischemia: TIA, Embolic, Hemorrhagic & Ischemic. • Healing in brain tissue – liquifactive necrosis, gliosis.
• Head Injury: types, pathophysiology, clinical & complications.• Concussion, Contusion, Laceration.• Hemorrhage: Epidural, Subdural, Subarachnoid, intra cerebral.• Brain herniation – types & clinical features. Subfalcine, uncal, tonsillar.
• Hypertension: Pathophysiology, diagnosis & Complications *Self Study • Hypertension & CNS damage, Hypertensive encephalopathy.• Epilepsy: Overview, types, pathophysiology, Clinical *Self Study
Pathogenesis
Berry Aneurysm
Incidence
CNS - Blood supply MCA - Common site of Hem
Blunt Head Injury: • Primary Injury:
– Coup & Contra-Coup– Focal damage-concussion, contusion, – Diffuse axonal injury.
• Secondary Injury:– Concussion– Epidural/subdural Hematoma– Oedema– Infection
• Post Traumatic Complications:– Epilepsy– Dementia– Coma.
Coup
Contre Coup
Epidural - Hematoma - Subdural
Sub arachnoidHptn, Atherosclerosis
Old age, fall, delayed symptoms
Dura fixed to skull
Pia fixed to brain
Arachnoid
Subarachnoid Hem: alone is not trauma..!
Think of:• Hypertension, • Berry aneurysm, • Atherosclerosis.
Aetiology:Atherosclerosis – most common.Hypertension, smoking, diabetes.Heart disease – Atrial fibrillationOther:
Trauma – fat embolismTumor, InfectionCaissons disease – Bends *Pacific.
Hypertensive Intracerebral Hem: Sites
1. Putamen-Claustrum2. Cerebral white matter3. Thalamus4. Pons5. Cerebellum
55% - MCA deep br.15101010
MCA stroke.
Left (Dominant) Hemisphere Stroke: Clinical
• Aphasia • Right hemiparesis • Right-sided sensory loss • Right visual field defect • Poor right conjugate gaze • Dysarthria • Difficulty reading, writing, or
calculating
Diagnosis: Recent cerebral infarction in left MCA distribution.Left cerebral hemisphere shows swelling with compression of the lateral ventricle mainly in the frontal area, due to recent infarct in the Middle Cerebral Artery (MCA) distribution. The brain in the MCA area shows discoloration of the cortex and also blurring between the cortex and white matter.
ACA stroke.• Paralysis of contralateral foot
and leg• Sensory loss over toes, foot
and leg• Impairment of gait and stance• Abulia (slowness and
prolonged delays to perform acts)
• Flat affect, lack of spontaneity, slowness, distractibility
• Cognitive impairment, such as perseveration and amnesia
• Urinary incontinenceWikipedia: GNU Free Documentation license
PCA stroke.Peripheral (cortical)• Homonymous hemianopia• Memory deficits• Perseveration (repeat response)• Several visual deficits (cortical
blindness, lack of depth perception, hallucinations)
Central (penetrating)• Thalamus - contralateral sensory loss,
spontaneous pain, mild hemi• Cerebral peduncle - CN III palsy with
contralateral hemiplegia• Brain stem - CN palsies, nystagmus,
pupillary abnormalities
Wikipedia: GNU Free Documentation license
Infarct Pathogenesis:• hypoxia/anoxia.• Na/K pump block. • Calcium influx.• Red neuron, vacuolation.• Cell death, karyorrhexis.• Inflam- neutrophils, hem.• Lympho, Macrophages.• Liquefaction cavity• Peripheral Gliosis (astrocytes)
Hours
1-day
3-day
1 wk.
>4wk
CNS AV Malformations:
• Many types:– AV Malformation *– Cavernous angioma– Telangiectasia– Venous angioma
• Cause of Seizure disorders & hemorrhage.
• Most common congenital vascular malformation.
• Typically located in the outer cerebral cortex underlying white matter.
Hypertension Stroke:
Hemorrhagic stroke (new) & Lacunar infarct (old)
Central Pontine Hem – Herniation, IC pressure
Our greatest glory is not in never falling, but in rising every time
we fall.
-- Confucius
CPC34: Week over view2013 Term 3 CPC
4Title: Neurology 2
System: NeurologyAim: To educate students in:
Clinical, Pathology & population study of patients with dementiaLearning
Outcomes:(Students will be
able to)
1. Demonstrate an ability to take a relevant and focused history and carry out a relevant clinical examination of patients with dementia.
2. Carry out a competent physical examination of neurological system.3. Describe the Pathophysiology & Pathology of common causes of
dementia (Alzheimer’s Disease, multi infarct dementia)4. Recognsise rare neurological causes of dementia (Huntington’s
disease, CJD, HIV).5. Outline the basic sciences relating to structure and function of the
brain. 6. Describe the difference between age associated memory
impairment, mild cognitive impairment and Alzheimer’s disease7. Outline the epidemiology of Alzheimer’s disease and other causes
of dementia in Australia.8. Explain the first line management of common causes of dementia 9. Outline ethical dilemmas in caring for patients with dementia
Broca’s area - Cingulate and Parahippocampal gyri.
Hippocampus: where short-term memories are converted to long-term memories
Thalamus: receives sensory and limbic information and sends to cerebral cortex (cognition)
Limbic system: controls emotions and instinctive behavior (includes the hippocampus and parts of the cortex)
51
CNS Degenerations: Classification
• Neuronal Degenerations.– Primary Degenerations:
• Global – Alzheimer, Lewy body, Fronto-temporal• Selective/System – Parkinsons, Huntingtons, MND
– Secondary Degenerations:• Toxic, metabolic(storage), infections, nutritional.• Alcohol & B12 def.
• Myelin Degenerations:– Demyelinating Disorders - Multiple sclerosis– Dysmylinating disorders – Leukodystrophies.
52• Cortical Atrophy
• Intraneuronal Neurofibrillary tangles
• Interstitial amyloid Neuritic plaques• Loss of neurons with gliosis.
Alzheimers Disease: MorphologyGross Microscopy
53
Pick’s Disease:
• Severe, 40-65y, Rare. • knife blade atrophy of
Frontal & temporal lobe Progressive aphasia / language dysfunction
• Behaviour & personality change.
• Preserved memory.• Micro: Neurons with
round intracytoplasmic Pick’s bodies (tau protein)
54
Diffuse Lewy body Dementia: DLD• 10-15% of Parkinsons with
dementia within a year of motor symptoms.
• impaired memory of recent events, confusion, language problems. (Alzheimer)
• Dementia + visual Hallucinations.
• Lewy body (α-synuclein) in many part of cortex & substantia nigra (global)
• Atrophy of cortex like AD.• Rapidly progressive – early
death.
cortical Lewy bodies (α-synuclein) special stain.
Parkinson’s:• "shaking palsy" • Parkinsonism: Clinical sy.
– Drugs: dopamine antagonists– Toxins: MPTP(heroin), – Diseases: Multiple system atrophy, Post encephalitic.
• Parkinson’s disease – Primary atrophy of substantia nigra. Dopaminergic nerves with α-synuclein - Lewy body.
• Clinical features: – Adults (45-60y), tremor, bradykinesia & rigidity – Diminished facial expressions, stooped posture, – Slow voluntary movements, festinating gait, & fine rolling resting
tremors. Dementia in some cases.– When dementia arises within 1 year of the onset of motor
symptoms, it is referred to Lewy body dementia (LBD).
56
Pathology of Parkinson’s disease:• Gross: Loss of
pigment in substantia nigra.
• Neuronal loss, degeneration,
• Loss of neurons replaced by gliosis (microglia)
• Loss of neuromelanin.• Neuronal
degeneration• Reactive gliosis.• Lewy bodies (α-
synuclein) in neurons.
Parkinson
Normal
L
57
Huntington’s
• Dementia, depression, choreiform movement (Jerking dementia)
• 5th decade. Autosomal dom.• Huntington gene on 4p –
Huntingtin.• Excess CAG tandem
repeats = severity.
Striatal atrophy
Atrophy of caudate & putamen (striatum) Compensatory hydrocephalus of lateral ventricles*.
58
Metabolic CNS Disorders: Alcohol• Vit. B1 (thiamine) def.• In Chronic alcoholics,
malabsorption syndromes.• Wernicke encephalopathy
ataxia, confusion, double vision…
• Korsakoff psychosis: memory loss with confabulations. Hallucinations.
• Cortical atrophy.• Central pontine myelinolysis. • Atrophy of vermis of the
cerebellum.
59
Wernicke's encephalopathy:
Recurrent petechial hemorrhages in the hypothalamus, mamillary bodies with atrophy. Central pontine myelinolysis.
60
Vitamin Def & Neuropathy:
• B1 Wernicke-Korsakoff syndrome
• B2 Peripheral neuropathy,
ataxia,dementia• B6 Convulsions in infants
• B12 - SCDC.• C Scurvy
• E Weakness, sensory loss, ataxia, nystagmus
61
Multiple Sclerosis:• Common 1:1000, adults,
females 2:1, HLA DR2, <50y.• Autoimmune (Gen+Env+AI)• Episodes of Limb Weakness,
paraesthesia.• Relapsing & remitting.• Progressive death in years.• Multiple soft pink plaques of
demyelination- periventricular.• Inflammation, perivascular T
lymphocytes & plasma cells.• CSF - oligoclonal IgG.• Reactive gliosis.
62
Multiple Sclerosis: Demyelinated plaques
Microscopy showed loss of myelination with many lipid macrophages around BV.
63
ALS: Amyotrophic Lateral Sclerosis
• Also known as Lou Gehrig's disease, is the most common type of Motor Neurone Disease (MND).
• Genetic: Mutations in SOD1 gene on Chromosome 21.
• Progressive neuron loss.• Middle age, men, sporadic common,
Familial 10% • Muscle weakness, fasciculations,
spasticity, Sensation normal.• Degeneration of LMN tracts in the
lateral portion of the spinal cord ("lateral sclerosis"). and of UMN - Betz cells in the motor cortex.
Degeneration of lateral and ventral corticospinal tracts (myelin stain).
MND subtypes:• Amyotrophic Lateral Sclerosis*• Progressive muscle atrophy (LMN) • Primary lateral sclerosis (UMN)• Progressive bulbar palsy
64
Dementia Cases:49y woman, chronic cognitive difficulty, irritability, depression, poor movememnts, no significant memory loss, muscle rigidity, wide gait, choriform movements of trunk & limbs. (Father & many of relatives had involuntary movements.)
74y man, mild cognitive decline, slow gait, depression, resting tremors, visual hallucinations, episodes of “absent” “confused” MMSE 27/30, ACE-R score 78/100. Rigid muscles,
Huntington’s Disease
Diffuse Lewy body Dementia
Parkinson’s with Dementia
75y man, rapid decline in cognitive function with fluctuations, MMSE 22/30. Ten point clock face drawing test - 0. Day time sleepiness. Apathy, visual and auditory hallucinations.
65
Dementia Cases:56y man, progressive speech difficulty 2y. Slow to respond, paucity of words. Lack of judgement, disorganized, aggression, impulsive. Good memory. Left hand weakness, progressive motor weakness. MMSE 27/30. FH of dementia.
Dementia pugillistica.
Amyotropic Lateral Sclerosis
59y professional foot ball player. Progressive dementia & tremor.
Fronto-Temporal / Pick’s
58y man, mild cognitive impairment, weakness of distal limbs, loss of muscle mass, fasciculations, rigidity. Babinski sign +ve. Recurrent respiratory infections.
67y man, previously healthy, 3m h/o rapid dementia, weakness of hands & fingers, insomnia, irritability, inability to find his way home. visual hallucinations and tremor, speech difficulty, admitted with Gen. seizure.
CJD – Mad Cow Disease
The only real mistake is the one, from which we learn nothing!
JOHN POWELL:
Alzheimers Pathogenesis: YouTube
CPC35: Week over view2013 Term 3
CPC 5Title: Neurology 3
System: NeurologicalAim: To train students in :
History taking + clinical examination of post ictal/acutely unwell patient; pathology of brain tumours; pathology of meningitis; pathology of epilepsy; process of care + population health especially rural and remote
Learning Outcomes
Students will be able to
1. Demonstrate an ability to take a relevant and focused History & clinical carry out a relevant examination of patients after a witnessed seizure
2. Describe the Pathophysiology of primary and secondary brain tumours; meningitis; epilepsy
3. Recall the relevant basic sciences including normal anatomy and blood supply of the brain
4. Recall the differential diagnoses for a patient with a first fit5. Describe first line management in a patient with a first fit or
altered level of consciousness.
Scenario: MeningitisFever, Headache, neck stiff, Brudzinski sign, Kernig sign, CSF…
Scenario: Brain TumorCrescendo Chronic Morning headache*, Seizures, localizing signs
Scenario: Epilepsy:Negative signs, chronic/recurrent, family / past history.
CNS Infections - Overview• Meningitis – commonest.• Meningo-encephalitis – combined.• Infections of Dura – Pachymeningitis – rare.• Arachnoid – Leptomeningitis – common.• Bacterial, Viral, fungal, TB, (Chem, Ca, drugs)
Subdural Abscess - Sinusitis
Lepto - Meningitis
Cerebrum - normal
Encephalitis
Septic Meningitis: common causesAge Causes
Neonates Escherichia coli, group B streptococci.Children / Adolescents
N. meningitidis, S. pneumoniae, TB
Adults S. pneumoniae, Listeria monocytogenes, TB, crypto,
Asymptomatic carriers nasal spread blood CNS. Headache, photophobia, irritability, clouding of
consciousness & neck stiffness. Limited to lepto-meninges - Acute, inflam, pus. Both cranial and spinal. Cloudy, high protein, low sugar, neutrophils, + Bacteria.
Septic Meningitis-Microscopy
Septic Meningitis-Spinal fluid
Normal Septic Gram +ve Diplococci+Neutrophils
Contraindications for CSF examination:• Increased intracranial pressure.• CNS infarctions (A),
Hydrocephalus (B) abscess (C) or edema(D).
Viral Meningitis:
• Acute, Self limiting, Less severe than bacterial.• Clear CSF, sugar normal, lymphocytes, protein.• Cerebral edema, perivascular lymphocyte cuffing.• Reactive microglial nodules.• Arbovirus*, Herpes, Varicella Zoster, CMV, Polio, Rabies.
Perivascular cuffs of lymphocytes and Microglial nodules
CSF-ExaminationCells Protein Glucose Appearance
0-4 lympho 0.1-0.4(n) 2.7-4.0 (n) Clear colorless
> Poly High Low Turbid
> Lymph High normal Clear
> lymph High Low Opalescent (cob-web)
Norm
Septic
Viral
TB
10 – 10 – 10minutes months
years
"I wasn't living my life. My life was living me. I realised I made many of my decisions without thinking their consequences… “I realised all I really had to do to reclaim my life was to Start making decisions by considering their consequences in the immediate present, near term and distant future.. i.e . In ten minutes, in ten months and in ten years”.
-- The 10-10-10 rule, Suzy Welch.
The 10-10-10 rule…Think about effect of your decision in….
Most common CNS Tumors:
children
Adults(Glioblastoma)
MeningiomaDural Venus sinus
Capsulated,spindle cells in whorls and psammoma bodies (common type).
Astrocytomas
• Adults:–Commonest 80%, Cerebral.–Low Gr: Solid, Fibrillary. –High Gr: glioblastoma multiforme
Varigated, Hemorrhagic - Malignant,.• Children:
–Cystic, Low grade*, Pilocytic– Infratentorial (Cerebellum),
Astrocytomas - Glioma
• Adults:– Commonest 80%, Cerebral.– Low Gr: Solid, Fibrillary glioma – High Gr: glioblastoma multiforme Varigated,
Hemorrhagic - Malignant,.• Children:
– Cystic, Low grade*, Pilocytic– Infratentorial (Cerebellum),
mutations of the metabolic enzyme Isocitrate DeHydrogenase (IDH1 and IDH2) are common in lower-grade astrocytomas. As a result, immunostaining for the mutated form of IDH1 has become an important diagnostic tool for low grade gliomas.
Glioma/GBM:• Commonest • Low high grade.• cerebral supratentorial.• Chromosome 10 (80%)• Most GBMs have lost one
entire copy of C – 10• Microscopy: • Pleomorphic astrocytes,
Necrosis, palisading.
Necrosis
Common CNS Herniations:• Subfalcine: common,
Headache contralateral leg weakness.
• Transtentorial: occulomotor (CN III) paresis (ipsilateral dilated pupil, abnormal EOM's), contralateral hemiparesion.
• Tonsillar: Obtundation.
Why pupils dilate? Sympathetic / parasympathetic Balance.
“Sympathetic system shows sympathy to your dress!”
One of the first duties of the physician is to educate the
masses not to take medicine!
-- Sir William Osler (1849 - 1919), Aphorisms from his Bedside Teachings (1961) p. 105
CPC36: Week over view2013 Term 3 CPC 6 Title: Infections & PUO
System: Infectious diseaseAim: Develop understanding pathology & clinical diagnosis of
patient with pyrexia of unknown originLearning Outcomes:Students will be able
to
1. Demonstrate competency in taking a focused History taking & clinical examination of patients with pyrexia
2. Demonstrate relevant focused physical examination of all systems relevant to a patient with PUO
3. Demonstrate competency in formulating the differential diagnoses of patients with PUO
4. Outline the Management of PUO5. Outline the Basic sciences applicable to PUO including
– Infection & Immunity.6. Describe the pathology of arboviruses including
transmission of disease. (Tropical diseases)
Viral Infections - Bacterial• Infectious Mono. • CMV• HIV• Hepatitis B• Herpes• Viral exanthema-
mumps etc.• Ross River Fever• Dengue• Australian Encephalitis.
• TB• Leptospirosis• Brucellosis• Q Fever• Relapsing fever• Nocardiosis• Typhoid
Tropical Infections• Ross River Fever• Dengue, Leptospirosis• Malaria, Q fever, • Melioidosis.
Major Arboviruses:• Alphaviruses
– Ross River Virus (RRV) – epidemic arthritis– Barmah Forest Fever– Equine Encephalitis – many types.
• Flaviviruses– Dengue – Hemorrhagic fever.– Murray Valley Encephalitis – meningitis like.– Japanese encephalitis – Yellow fever
• Bunyaviruses– LaCrosse encephalitis – Reo viruses – Colorado tick fever
The major arboviruses of concern in Australia are:
• Dengue • Ross River Virus • Barmah Forest Virus • Japanese Encephalitis • Murray Valley Encephalitis Ref: UQ.edu.au
Ross River Fever - Symptoms:• Fever • Rash• Arthritis• Fatigue• Headache• Lymphnode
enlargement.
Warning Signs for Dengue Shock
When Patients Develop DSS:• 3 to 6 days after onset
of symptoms
When Patients Develop DSS:• 3 to 6 days after onset
of symptoms
Initial Warning Signals:• Disappearance of
fever• Drop in platelets• Increase in
hematocrit
Initial Warning Signals:• Disappearance of
fever• Drop in platelets• Increase in
hematocrit
Alarm Signals:• Severe abdominal
pain• Prolonged vomiting• Fever to hypothermia• Change in level of consciousness
Alarm Signals:• Severe abdominal
pain• Prolonged vomiting• Fever to hypothermia• Change in level of consciousness
Four Criteria for DHF:• Fever• Hemorrhagic
manifestations• Excessive capillary
permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic
manifestations• Excessive capillary
permeability• 100,000/mm3 platelets
Melioidosis
A: Cutaneous melioidosis B: lung abscesses on Chest X-RayC: corresponding CT Scan
D: Skin in a fatal disseminated melioidosis. E: splenic abscesses abdominal CT F: Aspirated pus- Prostatic abscessG: Abscesses on a CT scan.
Intracellular gram-neg Burkholderia pseudomallei, Saprophyte in Soil. Northern Australia -"hyperendemic" seasonal peaks in the wet seasons.Inhalation / inoculation / soil or water.
Leptospirosis spirochete:
• Severe jaundice, fever, hemorrhage with renal involvement - Weil’s disease.
• Leptospira icterohemorrhagica..• Zoonotic: Pri. hosts - mammals,
birds, reptiles, Contact with water, food, soil containing urine of infected animals.
• No spread from person to person.• NQ - Banana & dairy farmers.• Biphasic: Flu like first phase
followed in a week by Hemorrhage meninges, liver, renal failure - Weil’s disease.
Icterohemorhagic fever Jaundice + Hemorrhage
Q Fever• “Q - ? In an abattoir in Brisbane. • Coxiella burnetii, highly infectious• Cattle, sheep,goat and other live stock.• Biphasic:Acute & Chronic phase.• Acute: Fever, headache, fatigue, muscle & joint
pains, pneumonia.• Most recover - life long immunity but some
become chronic fatigue, hepatitis, endocarditis, pneumonia - serious.
• Meningitis/encephalitis: in both acute and chronic form in 1% patients.
• Vaccine – pre vaccine testing is important.
Chronic Fatigue Syndrome: (CFS)Infections in CFS:• Herpes, entero vir.• EBV, RRV• Q fever, Lyme &
mycoplasma.
Immunity in CFS.• Reduced
lymphocytes.• Decreased
immunoglobulins.• Altered immune
response to virus.
We can change our lives. We can do, have, and be exactly
what we wish.- - Anthony Robbins
CPC37: Week over view2013 Term 3
CPC 7Title: Multiple Co-morbidities
System: Musculoskeletal, Neurological , CVS, EndocrineAim: Educate students in clinical and pathological processes in
patients with bone abnormalities.Learning
Outcomes:Students will be
able to to
1. Demonstrate competency in History taking skills & focused clinical examination of patients who have sustained trauma
2. Describe the pathophysiology of fractures, osteoporosis, bone tumours (primary and secondary)
3. Describe the risk factors of osteoporosis.4. Describe the Healing in bone and other tissues following
trauma5. Describe the Basic sciences specific to tissue injury and
repair6. Outline the clinical approach to patient with multiple co-
morbidities and polypharmacy
Fracture Healing:
1 day
1-3 Wk (Soft)
6 Wk (Hard)
>8 Weeks
95
96
Paget’s Disease• Unknown etiology:• Excess osteolytic followed by
osteoblastic stage and finally exhaustion of cellular activity (osteosclerotic stage)
• Common (10%), Adult, One or all bones. Mild to severe types.
• Pain, sclerosis, deformity, fracture, nerve compression, deafness.
• Gross: thick, deformed, mosaic bone.
• Micro: mosaic lamellae, sclerosis, increased osteoclasts & blasts.
• Osteosarcoma - late age complication.
97
Vit-D deficiency:• Rickets (Children), Osteomalacia (adults).• Defective mineralization, more osteoid (protein).• Bowing of legs, Lumbar lordosis, rachitic rosary, Harrison
groove, Pigeon breast, Frontal bossing.
Benign - Malignant
Bone Disorders
99
Osteosarcoma:• 10-20y, (secondary in aged)• Knee* & shoulder* painful• Metaphysis of long bones. • Tumor of osteoblasts.• Rb gene mutations.• osteoid forming (fine lacy
microscopic osteoid) microscopic calcification, no lamellae.
• Normal: Checkerboard mix of type 1 & 2 fibers.“One Slow Fat Red Ox”
• Atrophy – neuronal, ischemic, inflammatory.• Myositis (inflam), Muscular Dystrophy (dis-org.)• Myopathy (non inflam) Toxic / Cong.• Tumours: Rhabdomyoma, Rhabdomyosarcoma.
Skeletal Muscle:
100
Normal Re-innervation group atrophy (nerve)
ATPase stain
Atrophic fibres
• Inherited, defective muscle structure. Dystrophin - Xp21.
• Hypertrophy / Atrophy, degeneration fat & fibrosis (pseudohypertrophy)
• Common X linked 2 types:– Duchenne MD – common, early 5y,
severe, death by 20y.– Becker MD -rare, late, less severe.
• Normal at birth, starts with pelvic & limb weakness heart failure.
Muscular Dystrophy:
Remember the Challenge….!Dec 2011:
4th Year Students at JCU School of Medicine set new record.…!!!100% Pass & Class Average over 70%
Yes We Can…!
Wish you all Success, Health,
& Happiness in life.
Need help for exams? You can still contact me..
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