SGD Gross

Viola, Luis Alfredo B.

E2
1. The patients are with pre existing medical conditions, Diabetes Mellitus
and Hypertension. Discuss briefly these two conditions.
Diabetes, often referred to by doctors as diabetes mellitus, describes a group of
metabolic diseases in which the person has high blood glucose (blood sugar), either
because insulin production is inadequate, or because the body's cells do not
respond properly to insulin, or both. Patients with high blood sugar will typically
experience polyuria (frequent urination), they will become increasingly thirsty
(polydipsia) and hungry (polyphagia).
There are three types of diabetes:
Type 1 Diabetes
The body does not produce insulin. Some people may refer to this type as insulindependent diabetes, juvenile diabetes, or early-onset diabetes. People usually
develop type 1 diabetes before their 40th year, often in early adulthood or teenage
years. Patients with type 1 diabetes will need to take insulin injections for the rest of
their life. They must also ensure proper blood-glucose levels by carrying out regular
blood tests and following a special diet.
Type 2 Diabetes
The body does not produce enough insulin for proper function, or the cells in the
body do not react to insulin (insulin resistance). Some people may be able to control
their type 2 diabetes symptoms by losing weight, following a healthy diet, doing
plenty of exercise, and monitoring their blood glucose levels. However, type 2
diabetes is typically a progressive disease - it gradually gets worse - and the patient
will probably end up have to take insulin, usually in tablet form.
Overweight and obese people have a much higher risk of developing type 2
diabetes compared to those with a healthy body weight. People with a lot of visceral
fat, also known as central obesity, belly fat, or abdominal obesity, are especially at
risk. Being overweight/obese causes the body to release chemicals that can
destabilize the body's cardiovascular and metabolic systems.

scientists believe that the impact of sugary soft drinks on diabetes risk may be a
direct one, rather than simply an influence on body weight.

Gestational Diabetes
This type affects females during pregnancy. Some women have very high levels of
glucose in their blood, and their bodies are unable to produce enough insulin to
transport all of the glucose into their cells, resulting in progressively rising levels of
glucose.Diagnosis of gestational diabetes is made during pregnancy. The majority of
gestational diabetes patients can control their diabetes with exercise and diet.
Between 10% to 20% of them will need to take some kind of blood-glucosecontrolling medications. Undiagnosed or uncontrolled gestational diabetes can raise
the risk of complications during childbirth. The baby may be bigger than he/she
should be.

HYPERTENSION
Hypertension, also referred to as high blood pressure, is a condition in which the
arteries have persistently elevated blood pressure. Every time the human heart
beats, it pumps blood to the whole body through the arteries.
Blood pressure is the force of blood pushing up against the blood vessel walls. The
higher the pressure the harder the heart has to pump.
Hypertension can lead to damaged organs, as well as several illnesses, such as
renal failure (kidney failure), aneurysm, heart failure, stroke, or heart attack.
Researchers from UC Davis reported in the Journal of the American Academy of
Neurology that high blood pressure during middle age may raise the risk of
cognitive decline later in life.
According to Medilexicon's medical dictionary, hypertension means "High blood
pressure; transitory or sustained elevation of systemic arterial blood pressure to a
level likely to induce cardiovascular damage or other adverse consequences."
The normal level for blood pressure is below 120/80, where 120 represents the
systolic measurement (peak pressure in the arteries) and 80 represents the diastolic
measurement (minimum pressure in the arteries). Blood pressure between 120/80
and 139/89 is called prehypertension (to denote increased risk of hypertension),
and a blood pressure of 140/90 or above is considered hypertension.

Hypertension may be classified as essential or secondary. Essential hypertension is

the term for high blood pressure with unknown cause. It accounts for about 95% of
cases. Secondary hypertension is the term for high blood pressure with a known
direct cause, such as kidney disease, tumors, or birth control pills.

2. Poor control of diabetes may lead to Diabetic ketoacidosis. Describe

briefly Diabetic ketoacidosis.
Diabetic ketoacidosis (DKA) is a condition that may occur in people who have
diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It
involves the buildup of toxic substances called ketones that make the blood too
acidic. High ketone levels can be readily managed, but if they aren't detected and
treated in time, a person can eventually slip into a fatal coma.
DKA can occur in people who are newly diagnosed with type 1 diabetes and have
had ketones building up in their blood prior to the start of treatment. It can also
occur in people already diagnosed with type 1 diabetes that have missed an insulin
dose, have an infection, or have suffered a traumatic event or injury.
Causes of Diabetic Ketoacidosis
With type 1 diabetes, the pancreas is unable to make the hormone insulin, which
the body's cells need in order to take in glucose from the blood. In the case of type
2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to
take in glucose from the blood.
Glucose, a simple sugar we get from the foods we eat, is necessary for making the
energy our cells need to function. People with diabetes can't get glucose into their
cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds
up in the bloodstream, and by the time DKA occurs, blood glucose levels are often
greater than 22 mmol/L (400 mg/dL) while insulin levels are very low.
Since glucose isn't available for cells to use, fat from fat cells is broken down for
energy instead, releasing ketones. Ketones accumulate in the blood, causing it to
become more acidic. As a result, many of the enzymes that control the body's
metabolic processes aren't able to function as well. A higher level of ketones also
affects levels of sugar and electrolytes in the body.

DKA may occur with insulin deficiency, under the following circumstances:

during an infection or illness (e.g., urinary tract infection or pneumonia)

after stressful events or trauma (including heart attack, stroke, or surgery)
inadequate insulin treatment (when someone is not yet diagnosed or someone
who is diagnosed but misses a dose of insulin.
3. Describe the topographical representation of the heart. What is
Cardiomegaly? Where is the point of maximal impulse normally located
and compare this to the findings of the patient. Which part of the heart
has the maximal impulse? Give the areas for auscultation of the cardiac
valves.
The heart is a hollow muscular pump, which lies in the middle mediastinum. On its
surface, it has several distinctive features, which are of anatomical and clinical
importance.
Orientation and Surfaces of the Heart

The heart does not have a straightforward

orientation. Once you have grasped the
orientation of the heart, it is much easier to
comprehend the rest of its anatomy.
It is described by many texts as a pyramid
which has fallen over. The apex of this
pyramid pointing in a anterior-inferior
direction.

In its typical anatomical orientation, the heart

has 5 surfaces, formed by different internal
divisions of the heart:

Anterior (or sternocostal) Right ventricle

Posterior (or base) Left atrium

Inferior (or diaphragmatic) - Left and right

ventricles
Right pulmonary Right atrium
Left pulmonary Left ventricle

Borders of the Heart

Separating the surfaces of the heart are its
borders. There are four main borders of the
heart:
Right border Right atrium
Inferior border Left ventricle and right
ventricle
Left border Left ventricle (and some of the left atrium)
Superior border Right and left atrium and the great vessels
CARDIOMEGALY
Cardiomegaly is a general term used to describe any condition that results in an
enlarged heart. There are two types of cardiomegaly:

Dilative - The heart can become enlarged due to dilation of the myocardium. An
example is Dilated Cardiomyopathy (DCM), which is the most common form of nonischemic cardiomyopathy. In DCM, the heart becomes weakened and enlarged, and
congestive heart failure (CHF) quickly follows. Signs and symptoms are those of left
and/ or right heart failure, and signs on autopsy would include central hemorrhagic
necrosis in the liver.
Hypertrophic - Just as our skeletal muscles hypertrophy (grow in size) in response to
increased demand, cardiac muscle undergoes hypertrophy when placed under a
high workload for a prolonged period of time. Some cardiac hypertrophy is normal
and reversible, such as that seen in athletes and pregnant women. Pathologic
hypertrophy is the result of diseases that place increased demand on the heart,
such as chronic hypertension, myocardial infarction, and valvular damage.
Left ventricular hypertrophy (LVH) is the most common type of hypertrophic heart
disease. A common cause of LVH is chronic hypertension, which increases the
afterload on the left ventricle. This means the left ventricle has to increase
contractility and/ or preload to maintain the same stroke volume. Over time the

added stress on the left ventricular myocardium results in muscle hypertrophy and
remodeling of the left ventricle to a less efficient size and shape. This leads to a
diminishing ejection fraction, meaning the heart must work even harder to maintain
cardiac output. The larger heart also demands more blood flow, and so becomes
more susceptible to ischemic injury.

Point of Maximal Impulse (PMI)

The apex beat, also known as the point of maximal impulse (PMI) is defined as the
most lateral and inferior point at which the palpating fingers are raised during each
systole.
The normal location is in the 5th ICS one centimeter medial to the MCL in adults. In
children it is located in the 4th ICS and more laterally.
Normal timing is systolic. Normal area is less than a US quarter. Should be the size
of a finger.
The actual mechanical cause of the apex beat is a little fuzzy in most people's
minds. If you think of the heart as a cannon, and blood as the cannon ball, the apex
beat is the movement of the heart backwards against the chest wall as the blood is
expelled (recoil) according to Newton's Third Law of Motion. Some cardiologists say
the heart doesn't actually move in the thorax. The apex beat doesn't actually mean
that the apex of the heart is located at the palpable site. Supposedly the heart
assumes a spherical shape due to ventricular contraction during systole, and thus
the actual apex is twisting away from the chest wall, however the area ABOVE the
apex moves closer to the chest wall and is palpable
The point of maximal impulse (PMI) is where the cardiac impulse can be best
palpated on the chest wall. Frequently, this is at the 5th intercostal space at the
midclavicular line. When dilated cardiomyopathy is present, this can be shifted
laterally. Also, a hyperdynamic PMI is seen in hyperdynamic states.
AREAS OF AUSCULTATION
Auscultation is an essential part of even a cursory cardiac exam. Listening to the
heart you can gather information about the 1) rate and rhythm, 2) value
functioning (e.g. stenosis, regurgitation/insufficiency), and 3) anatomical defects
(e.g. atrial septal defects, ventricular septal defect (VSD), hypertrophy)
In describing and documenting a murmur, you should be able to characterize 4
properties of an abnormal heart sound:
1.The location of the heart sound on the chest (i.e. where is it heard loudest and
where you can hear the sound at all).

2.The timing of the heart sound (i.e. early diastolic, pan systolic, etc.)
3.The grade or intensity of the heart sound (i.e.1-6 (see table below))
4.The quality and shape of the heart sound (i.e. musical crescendo, harsh snap,
etc.)

Where to place your stethoscope

Picture of 4 typical cardiac ausculation area on the chest.As with palpation of the
heart, auscultation should proceed in a logical manner over 4 general areas on the
anterior chest, beginning with the patient in the supine position. The 4 percordial
areas are examined with diaphragm, including:
.Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal
border) (RUSB right upper sternal border).
Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal
border) (LUSB left upper sternal border).
Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left
sternal border) (LLSB left lower sternal border).
Mitral region (near the apex of the heard between the 5th and 6th intercostal
spaces in the mid-clavicular line) (apex of the heart).

4. Discuss the course of the anterior tibial artery until it becomes the
dorsalis pedis artery
The anterior tibial artery commences at the bifurcation of the popliteal, at the lower
border of the Popliteus, passes forward between the two heads of the Tibialis
posterior, and through the aperture above the upper border of the interosseous
membrane, to the deep part of the front of the leg: it here lies close to the medial
side of the neck of the fibula. It then descends on the anterior surface of the
interosseous membrane, gradually approaching the tibia; at the lower part of the
leg it lies on this bone, and then on the front of the ankle-joint, where it is more
superficial, and becomes the dorsalis pedis.

Relations.In the upper two-thirds of its extent, the

anterior tibial artery rests upon the interosseous membrane;
in the lower third, upon the front of the tibia, and the
anterior ligament of the ankle-joint. In the upper third of its
course, it lies between the Tibialis anterior and Extensor
digitorum longus; in the middle third between the Tibialis
anterior and Extensor hallucis longus. At the ankle it is
crossed from the lateral to the medial side by the tendon of
the Extensor hallucis longus, and lies between it and the first
tendon of the Extensor digitorum longus. It is covered in the
upper two-thirds of its course, by the muscles which lie on
either side of it, and by the deep fascia; in the lower third,
by the integument and fascia, and the transverse and
cruciate crural ligaments.
The anterior tibial artery is accompanied by a pair of ven
comitantes which lie one on either side of the artery; the
deep peroneal nerve, coursing around the lateral side of the
neck of the fibula, comes into relation with the lateral side of
the artery shortly after it has reached the front of the leg; about the middle of the
leg the nerve is in front of the artery; at the lower part it is generally again on the
lateral side.

5. Discuss the gross anatomical features of the pancreas

Elongated, accessory digestive gland that lies retroperitoneally and transversely
across the posterior abdominal wall. Posterior to the stomach between the
duodenum on the right and the spleen on the left The transverse mesocolon
attaches to its anterior margin.

Endocrine as well as exocrine gland

The endocrine portion of the gland is islets of langerhans produces insulin and
glucagon hormones
lies in the epigastrium and left hypochondrium areas of the abdomen
Produces a secretion that hydrolyzes the carbohydrates, proteins and fats
These hormones play a key role in carbohydrate metabolism

 Length varies from 12.5 to 15 cm. and its weight from 60 to 100 gm.

Parts of Pancreas
Head of pancreas lies within the C-shaped concavity of the duodenum;
Uncinate process emerges from the lower part of head, and lies deep to
superior mesenteric vessels.
Neck of pancreas is the constricted part between the head and the body.
It is anterior to the superior mesenteric vessels, and, posterior to the neck of
the pancreas, the superior mesenteric and the splenic veins join to form the
portal vein
Tail of pancreas ends as it passes between layers of the splenorenal
ligament.
Head of Pancreas
Head of the pancreas is the expanded part of the gland in the C-shaped
curve of the duodenum.
It firmly attaches to the medial aspect of the descending and horizontal parts
of
the duodenum.
Uncinate process is a projection from the inferior part of the pancreatic head,
It extends medially to the left, posterior to the superior mesentery artery.
Head of the pancreas rests posteriorly on the IVC, right renal artery and vein,
and the left renal vein. On its way to opening into the descending part of the
duodenum, the bile
duct lies in a groove on the posterosuperior surface of the head or is
embedded in its substance.
Neck of the pancreas is short and overlies the superior mesenteric vessels,
which form a groove in its posterior aspect.
The anterior surface of the neck, covered with peritoneum, is adjacent to the
pylorus of the stomach.
Body of pancreas continues from the neck and lies to the left of the superior
mesenteric vessels, passing over the aorta and L2 vertebra, posterior to the
omental bursa.
The anterior surface of the body of the pancreas is covered with peritoneum
and lies in the floor of the omental bursa and forms part of the stomach bed.
The posterior surface of the pancreatic body is devoid of peritoneum and is
in contact with the aorta, superior mesentery artery, left suprarenal gland,
and left kidney and renal vessels.

Tail of the pancreas lies anterior to the left kidney, where it is closely related
to the splenic hilum and the left colic flexure. The tail is relatively mobile and
passes between the layers of the splenorenal ligament with the splenic
vessels. The tip of the tail is usually blunted and turned superiorly.
Main Pancreatic Duct
The main duct of the pancreas begins in the tail
Runs the length of the gland, receiving numerous tributaries
Opens into the second part of the duodenum with the bile duct on the major
duodenal papilla
At least 25% of the time, the ducts open into the duodenum separately. The
sphincter of the pancreatic duct (around the terminal part of the pancreatic
duct),
the sphincter of the bile duct (around the termination of the bile duct), and
the hepatopancreatic sphincter (of Oddi) around the hepatopancreatic
ampulla are smooth muscle sphincters that control the flow of bile and
pancreatic juice into
the duodenum.
Accessory pancreatic duct opens into the duodenum at the summit of the
minor duodenal papilla. Usually (60%), the accessory duct communicates
with the main pancreatic duct. In some cases, the main pancreatic duct is
smaller than the accessory pancreatic duct and the two are not connected.
Pancreatic lymphatic vessels follow the blood vessels.
Pancreaticosplenic lymph nodes, that lie along the splenic artery.
Some vessels end in the pyloric lymph nodes.
Efferent vessels from these nodes drain to the superior mesenteric lymph
nodes or to the celiac lymph nodes via the hepatic lymph nodes.