Download (Foundation), Inc. Clinical Practices Guidelines 5 th edition :August

Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
GRADUATE SCHOOL
Vigan City
MASTER OF ARTS IN NURSING
Final Examination
ADVANCE PATHOPHYSIOLOGY
1.
Describe the contributions of the early Greek, Italian, and English scholars to the
understanding of anatomy, physiology, and pathology.
a.
Early Greeks
 Avicenna was a Persian physician who adopted many of the Galenic teachings and expanded on them
in his Canon on Medicine, an authoritative work on anatomy. (Siddiquey, Ak Shamsuddin Husain
(2009). Para 8) The most famous and influential of the philosopher-scientists of the Islamic world.
He was particularly noted for his contributions in the fields of Aristotelian philosophy andmedicine.
He composed the Kitāb al-shifāʾ (Book of the Cure), a vast philosophical and scientific encyclopaedia,
and Al-Qanun fi al-Tibb (The Canon of Medicine), which is among the most famous books in
the history of medicine.
Sources :
Avicenna. (20 May 2009). In journal Retrieved 28 June 2009 from (Siddiquey, Ak Shamsuddin
Husain (2009). Para 8)”History of Anatomy”. Bangladesh Journal of Anatomy 7(1)
Avicenna. In Encylopedia Britannica from
http://www.britannica.com/Ebchecked/topic/45755/Avicenna
b.
Italian
 Giovanni battista morgani father of modern anatomical pathology. Italian anatomist and founder of
pathological anatomy, born in Forlì, and educated at the University of Bologna. Morgagni was
appointed professor of anatomy at the University of Padua in 1715. He correlated numerous
postmortem examinations with case histories to discover the relationships between diseases and the
physical changes in organs. He was particularly accurate in his descriptions of the effects of disease
on the heart, lungs, and liver. According to Ventura A. (2000) clinical pathologic conference, we
attempt to make a diagnosis fmm a clinical history and our conclusions are confirmed or denied by
the pathologist’s report of the autopsy, operation, or biopsy,we are reproducing the pages of the De
Sedibus. The use of the clinical pathologic conference is and will be one of the most useful methods
to teach medicine. This may be Giovanni Battista Morgagni’s indelible legacy to medicine. (Early
Italian 2014, p.3)
Source: Early Italian( 20 April 2014). In Article. Retrieved 28 May 2014 from
http://onlinelibrary.wiley.com/doi/10.1002/clc.4960231021/pdf
c. English scholar
 Florence nighthingale In March 1854 the Crimean War broke out and the reports of the sufferings of
the sick and wounded in the English camps created anger in Britain. William Russell, The Times’
correspondent, described the terrible neglect of the wounded, and pointed to the differences between
the facilities provided for British and French soldiers. He asked: ‘Are there no devoted women among
us, able and willing to go forth to minister to the sick and suffering soldiers of the East in the hospitals
of Scutari. Are none of the daughters of England, at this extreme hour of need, ready for such a work
of mercy. Must we fall so far below the French in self-sacrifice and devotedness?’ (The Times, 15 and
22 September 1854).
Source: Contemporary period ( 30 Sept 2011). In Article Retrieved 10 October 2011 from
http://www.victorianweb.org/history/crimea/florrie.html
2. A 30-year-old man sustained a fracture of his leg 2 months ago. The leg had been encased in a
cast, which was just removed. The patient is amazed at the degree to which the muscles in his leg
have shrunk.
a. Would you consider the changes in the patient’s muscles to be a normal adaptive response?
Explain.
 I wound consider the changes in the patient’s muscles to be a normal adaptive response.
According to Handbook of Pathophysiology (2001) Atrophy is a reduction in the size of a cell
or organ that may occur when cells face reduced workload or disuse, insufficient blood flow,
malnutrition, or reduced hormonal and nerve stimulation.
Source: Handbook of Pathophysiology (January 15, 2001): by Springhouse Corporation, With 13
Contributors, Springhouse
b.
Will these changes have an immediate or long-term effect on the function of the leg?
 There is a long-term effect on the function of the leg since our patient was encased in a cast
the patient need to have therapy, regular exercise and full recovery.
3. People who have had a heart attack may experience additional damage once blood flow has been
restored, a phenomenon referred to reperfusion injury.
a. What is the proposed mechanism underlying reperfusion injury?
 According to Rubin, E. et al (2014) Ischemia/reperfusion injury is a common clinical
problem that arises in occlusive cardiovascular disease, infection,shock and many other
settings. I/R injury reflects the interplay of transient ischemia, consequent tissue damage and
exposure of damaged tissue to the oxygen that arrives when blood flow is reestablished
(reperfusion). Initially, ischemic cellular damage leads to the generation of free-radical
species. Reperfusion then provides abundant molecular O 2 to combine with free radicals to
form ROS.(p11)
Source: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
b. What factors might influence this mechanism?

cardiovascular disease

infection

shock (Rubin, E. (2007) p11)
Source: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
4. Every day, blood cells in our body become senescent and die without producing signs of
inflammation, and yet, massive injury or destruction of tissue, such as occurs with a heart attack,
produces significant signs of inflammation. Explain
 According to Rubin, E. et al (2014) Apoptosis is a prearranged pathway of cell death
triggered by a variety of specific extracellular and intracellular signals. It is part of the balance
between the life and death of cells and determines that a cell dies when it is no longer useful or
when it may be harmful to the larger organism. As a self-defense mechanism, cells that are
infected with pathogens or in which genomical terations have occurred are destroyed. In this
context, many pathogens have evolved mechanisms to inactivate key components of the
apoptotic signaling cascades. Apoptosis detects and destroys many cells that harbor dangerous
mutations, thereby maintaining genetic consistency and preventing the development of cancer.
By contrast, as in the case of acquired antibiotic resistance in infectious agents, successful
clones of tumor cells often devise mechanisms to circumvent apoptosis. ( p17)
Source: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
5. A 23-year-old woman with sickle cell anemia and her husband want to have a child but worry that
their child will be born with the disease.
a. What is the mother’s genotype in terms of the sickle cell gene? Is she heterozygous or
homozygous?
 The mother is Homozygous.
b. If the father is found to have no sickle cell gene, what is the probability of their child having the
disease or being a carrier of the disease?
 According to Smeltzer , Suzzane C (1996) Their child will be a carrier of sickled cell disease.
(Smeltzer , Suzzane C (1996) pp124 )
c. If both the mother and father are found to be heterozygous (carriers) of the sickle cell gene,
what are the chances that their child would have sickle cell disease or be a carrier of the trait?
 According to Smeltzer , Suzzane C (1996) In diseases associated with altered recessive genes,
both parents- although disease-free themselves carry one normal allele and one altered allele.
Each child has one chance in four of inheriting two normal alleles; and two chances in four of
inheriting one normal and one altered allele, and therefore being a carrier like both parents.
(Smeltzer , Suzzane C pp127)
Source : Smeltzer , Suzzane C …[et al.] Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
Vol. 1&2 : 12th edition: Lippincott Williams & Wilkins :1996
6. A 26-year-old woman is planning to become pregnant.
a. What information would you give her regarding the effects of medications and drugs on the
fetus? What stage of fetal development is associated with greatest risk?
 According to Pilliteri, A. (2007) Pregnant women takes medications and drugs, prescribed or
over the counter should be ask in order to know the effect on a growing fetus even the
innocent medications and drugs, for instance isotretinoin (Accutane), a vitamin A preparation
taken for acne is associated with spontaneous miscarriage and congenital anomalies. And also
herbal supplements should be avaluated carefully before being taken by pregnant women to be
certain they don’t stimulate uterine contractions. And First trimester where in organogenesis
work out. (Pillitteri, 2007 pp. 249)
b. What is the rationale for ensuring that she has an adequate intake of folic acid before
conception and during pregnancy?
 According to Pilliteri, A. (2007) Folic acid, also known as folate or folacin, is a B vitamin
needed for forming new body cells. Folate occurs naturally in foods; folic acid is the form
produced synthetically for supplements. (Pillitteri, 2007 pp. 231)
Not great enough the intake of folic acid
Adequate intake of folic acid
Megalohemoglobinemia
Increase neural tube disorders in fetus
Low Birth weight
Spina bifida; anencephaly(Pillitteri, 2007 pp.
231)
Source: Pillitteri, Adelle Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family 5th edition: Lippincott Williams & Wilkins, 2007
c. She and her husband have an indoor cat. What precautions should she use in caring for the
cat?

Removing a cat from the home during pregnancy as a mean of prevention is not necessary as
long as the cat is healthy. But taking a new cat is unwise

Not to change a cat litter box

Not to work in soil area where cats may defecate. (Pillitteri, 2007 pp. 288)
Source: Pillitteri, Adelle Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family 5th edition: Lippincott Williams & Wilkins, 2007
7. A 30-year-old woman has experienced heavy menstrual bleeding and is told she has a uterine tumor
called a leiomyoma. She is worried that this means she has cancer.
a. What is the difference between a leiomyoma and a leiomyosarcoma?
Leiomyoma
Leiomyosarcoma
Benign tumor of smooth muscle origin
Malignancy of smooth muscle origin
Colloquially
Soft, shows areas of necrosis on gross
known as a “myoma” or “fibroid
examination, has irregular borders (invasion into
neighboring myometrium)
Does not bulge above the surface when cut.
75% of women over
50 years and above
30 years of age.
Rare before age 20, and most regress
after menopause
Monoclonal, range from 1 mm to more
10 to 15 cm vs. 3 to 5 cm
than 30 cm in diameter
Mitotically
Mitotic activity,
active leiomyomas show brisk mitotic activity
cellular atypia and geographical necrosis are the
but are small and sharply demarcated from the
best diagnostic criteria.
adjacent normal myometrium, and they lack both
geographical necrosis and significant cellular
atypia.
Estrogen promotes their
Usually fatal despite combinations of
growth, although it does not initiate them.
surgery, radiation therapy and chemotherapy.
(Rubin, E. (2007), pp.515-516)
Source: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
b. How would you go about explaining the difference to her?
 By stating that Leiomyoma is benign or noncancerous they don’t have the ability to
metastasize on the other parts of the body and they usually shrink after menopause. And when
signs and symptoms occurs, leiomyoma must be removed by myomectomy or hysterectomy
and there is less chances to recurs. While in leiomyosarcoma it is cancerous and have the
added property of invading contiguous tissues and metastasizing to distant sites, where
subpopulations of malignant cells take up residence, grow anew and again invade and there is
more chances to recurs.
8. A 32-year-old woman has been told that the report of her annual Pap test revealed the presence of
mild dysplasia.
a. What questions should this woman ask as a means of becoming informed about the
significance of these findings?
 What is cervical mild dysplasia? Is it fatal or life threatening?
 If I am having a mild dysplasia, is there a possibility that I will have the cervical cancer?
 What are the causes of cervical mild dysplasia?
 What are the treatments of cervical dysplasia? Is it effective?
 How frequent should I have my pap smear? Is pap smear expensive?
b. In obtaining additional information about the results of her Pap test, the woman is informed
that dysplastic changes are consistent with CIN 1 classification
.
i.
Does this mean that the woman has cervical cancer?
 The woman has no cervical cancer. According to an article Pap Smear (2009) CIN 1 is a
noncancerous condition of abnormal cell growth and often mild dysplasia disappear without
treatment. (para3)
Source: “Pap Smear.” Microsoft® Encarta® 2009 [DVD]. Redmond, WA: Microsoft Corporation,
2008.
ii.
How would these findings translate into the Bethesda System for grading cervical cytology?
Other non-neoplastic findings
Epithelial Cell Abnormalities
Reactive cellular changes associated with:
Squamous cell
Inflammation which includes typical repair
Low Grace Squamous intraepithelial lesion
Encompasing HPV, mild dysplasia and
CN1(Rosa, M. (2 Oct 2010))
Source: Rosa, M. (2 Oct 2010) Citing Websites in Cervix-cytology Bethesda System 2001 for
cerviovaginal cytology reporting Retrieved 30 may 2014 from
http://www.pathologyoutlines.com/topic/cervixcytologybethesda.html
iii.
Cervical cancer is often reffered to as a sexually transmitted disease. Explain.
 According to an article “Cervical Cancer.” (2009) Studies indicate that women increase their
chances of HPV infection by having intercourse at an early age, by having many sex partners,
or by having male partners who have multiple sexual partners. (Para 4)
Source: “Cervical Cancer.” Microsoft® Encarta® 2009 [DVD]. Redmond, WA: Microsoft
Corporation, 2008.
iv.
What type of follow-up care would be indicated?
Lesion
Satisfactory Colposcopy
1.
Precede
by
Unsatisfactory Colposcopy
ASCUS, Diagnostic
ASC-H, LSIL: Follow up every procedures:
6-12 months.
CIN 1
2.
Preceded
AGC:
follow
momths
OR
excisional
LEEP/CONE.
(SGOP, 2008 p1)
by
up
HSIL,
every
6
Doagnostic
excisional procedure. (SGOP,
2008 p1)
Source: Society of gynecologic oncologist of the 7erformance (Foundation), Inc. Clinical Practices
Guidelines 5th edition :August 2008
9. A 30-year-old woman consults her gynecologist because of amenorrhea, and she has been unable to
become pregnant. Her physical exam reveals an obese woman with hirsutism. The physician tells the
woman that she might have a condition known as polycystic ovary disease and that further laboratory
tests are indicated.
a. Among tests ordered are a fasting blood glucose, LH, FSH, and dehydroepiandrosterone
levels. What information can these tests provide that would help in establishing a diagnosis of
polycystic ovarian syndrome?
TEST
FBS
INFORMATION
Evaluate and determine the risk of developing
cardiac disease and diabetes. .(Hurst, M. (2008)
p463)
LH and FSH
Determine the level of LH and FSH. If there is
increase secretion of LH the follicle will burst
and spew the egg out into the peritoneal cavity,
where the fingers on the fallopian tube pull the
egg into the tube to await fertilization.(Hurst, M.
(2008) p463)
Dehydroepiandrosterone
To find out adrenal tumor in women with rapidly
advancing hirsutism and the result will be
frequently mildly elevated in PCOS. (Hurst, M.
(2008) p644)
Source: Hurst, Marlene HurstReview Pathophysiology: Mc Graw Hill :2008
b. What is the probable cause of this woman’s amenorrhea, hirsutism, and failure to become
pregnant?
Probable Cause
Why
Amenorrhea
Due to hormonal imbalance, beginning with
inappropriate gonadotropin secretion that triggers
all the other imbalances, resulting in follicles that
never mature or produce viable ova. (Hurst, M.
(2008) p644)
Hirsutism
Excessive levels of circulating androgen. (Hurst,
M. (2008) p644)
Failure to become pregnant
There is no dominant follicle ever matures,
ruptures or releases an egg. The causes are lack of
GnRH and abnormalities in ovarian and adrenal
hormones. Insulin has a role in survival of
follicles that should have disintegrated. (Hurst,
M. (2008) p644)
Source: Hurst, Marlene Hurst Review Pathophysiology: Mc Graw Hill :2008
10. A 25-year-old woman has been told that her Pap test indicates infection with HPV type 16.
a. What are the possible implications of infection with HPV type 16?
 HPV are the major etiologic factors for squamous cell cancer in the female lower genital tract.
HPV Types 16, is most often linked to intraepithelial neoplasia and invasive cancer.(Rubin, E.
(2007) p499)
Sources: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
b. How might she have acquired this infection?
 Through active sexual intercourse. .(Rubin, E. (2007) p.499)
Sources: Emanuel Rubin, Howard M. Reisner, Essentials of Rubin’s pathology 6th edition : Lippincott
Williams & Wilkins:2007
11. A 35-year-old woman presents with vulvar pruritus, dysuria, dyspareunia, and an odorless, thick,
cheese-like vaginal discharge. She has diabetes mellitus and has recently recovered from a respiratory
tract infection, which required antibiotic treatment.
a.
Given that these manifestations are consistent with Candida infection, what tests might be
used to confirm the diagnosis?
 Diagnosis is made by microscopic identification of spores and hyphae on a glass slide
prepared from discharge specimen mixed with potassium hydroxide.( Suzzane C. et el (1996)
p1674)

Source: Smeltzer , Suzzane C …[et al.] Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
Vol. 1&2 : 12th edition: Lippincott Williams & Wilkins :1996
b. What risk factors does this woman have that predispose to this type of vaginitis?
 Use of antibiotics to treat another infection. Antibiotics can change the normal balance
between germs in the vagina.
 Menstruation
 Use of birth control pills
 Pregnancy
 Obesity and Diabetes
 Weakened immune system
 Use of steroids
>Source: Candidiasis (Yeast Infection). (1 Jun 2014) In emedicinehealth. Retrived 31 May 2014 from
http://www.emedicinehealth.com/candidiasis_yeast_infection/article_em.htm
12. The vital signs of a full-term 1-day-old newborn are as follows: temperature, 101.4°F (axillary);
pulse, 188 beats/ minute; respirations, 70 breaths/minute; blood pressure, 56/36 mm Hg.
a.
What laboratory test or tests should be performed?

CBC

Urinalysis

Chest Xray
b.
What information could be obtained from review of the maternal record that may be helpful in
establishing a differential diagnosis for this infant?

Past Medical history

Past and present health history
c.
What other clinical signs should be assessed?

Chest indrawing

Fast beathing

Grunting

Distended abdomen

Poor feeding

Jaundice
Source: Hurst, Marlene HurstReview Pathophysiology: Mc Graw Hill :2008
13. A preterm newborn, approximately 30 weeks’ gestation, is admitted to the newborn intensive care
unit. The baby exhibits respiratory distress, including tachypnea, retractions, and expiratory grunting.
a. Identify the two most common causes for respiratory distress in this baby.
b. Explain the etiology of the two causes identified.
Causes
Premature baby
Etiology
There is limited pulmonary blood flow which
result from the collapsed state of the fetal lungs—
from poor vascular development in general and
an immature capillary network and because of
increased pulmonary vascular resistance, the
major portion of fetal blood is shunted from the
lungs by way of the ductus arteriosus and
foramen ovale. (Hockenberry, M. (2005), p.273)
Lung Injury
Injury reduces blood flow to the lungs. Hormones
are released platelet aggregation. (Hockenberry,
M (2005), p.273)
Sources: Hockenberry, Marilyn J. Wong’s Essentials of Pediatric Nursing : 7th edition : Elsevier
Mosby: 2005
14. A three year-old cachectic male is brought to your clinic. You suspect parasitism after thorough
history taking.
a. Identify risk factors that may predispose toddlers to intestinal parasitism.

Ascariasis
Transferred to mouth by way of
contaminated food, fingers or toys.
hookworm

Prevalent in warm climates

Discharging eggs on the soil, which are
picked up, causing infection from direct skin
contact with contaminated soil
Visceral Larva Migrans

Transmitted by direct contamination of
hands from contact with dog, cats, or objects or
by ingestion of soil

Trichuriasis
Transmitted from contaminated soil,
vegetable, toys and other objects

Common in moist and warm climate
Occurs most often in undernourished children
living in unsanitary conditions. (Hockenberry, M
2005, pp. 448)

Source: Hockenberry, Marilyn J. Wong’s Essentials of Pediatric Nursing : 7th edition : Elsevier
Mosby: 2005
15. A newborn at your unit starts to exhibit signs of hemolytic anemia after birth.
i. What are the signs and symptoms of G6PD deficiency that could be seen in a
newborn?

Rapid heart rate

Fast breathing

Urine that is dark and yellow-orange

Spike in body temperature

neonatal jaundice,
Source: Glucose-6-Phosphate-dehydrogenase-deficiency (2011). In Article. Retrieved 25 May 2011
from http://www.patient.co.uk/doctor/glucose-6-phosphate-dehydrogenase-deficiency
c. Identify a maternal factor will make you suspect that the newborn has G6PD deficiency.
d.
Being male
e.
Being African American
f.
Having a family history of the condition
g.
Being of Middle Eastern descent
Source: Glucose-6-Phosphate-dehydrogenase-deficiency (2011). In Article. Retrieved 25 May 2011
from http://www.patient.co.uk/doctor/glucose-6-phosphate-dehydrogenase-deficiency
16. What are fetal consequences of mothers with hyperphenylalaninemia who are not receiving a
phenylalanine-restricted diet? Explain how these occur.

According to Wikipedia The fetal consequences are neurologic symptoms, seizues and PKU
which lead to mental retardation and death. (Wkipedia (2014) para 3&4)

Phenylalanine is one of many essential nutrients. It is used by the body to make cells and other
materials which are necessary for the body to work properly. Our bodies requires a certain
amount of phenylalanine to make, neurotransmitters, tooth enamel, hormones, digestive
enzymes,antibodies, hair, eye color pigmentation, skin cells and toe nails. The cells in our
brain make chemicals called 12erformance12tters. Neurotransmitters transmit messages from
ane nerve cell to another within our brain. The body needs a certain amount of phenylalanine
to make these chemicals. Too much phenylalanine and not enough tyrosine interferes with the
formation and 12erformance of neurotransmitters. When phenylalanine levels are in treatment
range, neurotransmitters can deliver clear messages. When phenylalanine levels are
ELEVATED, neurotransmitters CANNOT deliver clear messages.(BIOCHEMISTRY (2013)
pp 22-29)
Sources:
Chapter One Handout: BIOCHEMISTRY 2013. A PDF from http://www.nutriciana.com/metabolics/eatrightstaybright_chapterone.pdf
Genetic disorders with no OMIM In Wikipedia 2014 May 9, 2014 from
http://en.wikipedia.org/wiki/Hyperphenylalaninemia