Reproductive,
Musculoskeletal, and CNS
Ah 120
Fibrocystic Disease of the
Breast
Benign mixture of
fibrotic, cystic lesions
with ductal hyperplasia
Caused by the
stimulating effects of
fluctuating estrogen
levels
Diagnosed by needle
aspiration or surgical
excision
Treated by removing
methylxanthines form
diet and hormonal
therapy eg, birth control
pills
Carcinoma of the Breast
Most common malignancy in
women over 30
Etiology
Heredity

Breast cancer genes BRCA1 and BRCA2
Menopause

Especially with prolonged treatment with
estrogen--progestin
Pathology
Adenocarcinoma
replaces normal tissue
in a glandular
arrangement
surrounded by
connective tissue and
fibrosis
Because of proximity of
axillary lymph nodes, it
metastasizes early and
easily

Most often to lung or
bone
Signs & Symptoms
Begins as a painless
mass that eventually
becomes palpable
Also discharge from
nipple or retraction of
the nipple
Distortion of the breast
surface (mottling or
orange-peel effect)
Discoloration
Ulcerative lesion on
breast surface
Diagnosis
Breast self exam
Needle biopsy
Surgical excision
with biopsy
Ultrasound
Fibrocystic Lesion
Diagnosis (cont.)
Normal
Mammography
Abnormal
Treatment
Surgery


May be radical mastectomy with lymph node
resection
“Lumpectomy” with or without lymph node removal
Chemotherapy and Radiation therapy

May be done prior to surgery to shrink tumor
Hormone Therapy

Long term tamoxifen
Endometriosis
Presence of
endometrial tissue
outside of uterine
lining

Usually retrograde
migration to ovary
but may go
anywhere in the
abdominal cavity
Endometriosis (cont.)
Signs and symptoms vary
throughout the
menstrual cycle
Abdominal and pelvic
pain
Excessive and
abnormal bleeding

Endometrial tissue is still
influenced by hormones
Infertility
Treatment(s)
Hormonal therapy

Eg, birth control pills
Pain meds
Surgical excision of
lesions that cause
intractable pain

Surgical excision
may cause sterility
Endometrial Carcinoma
Adenocarcinoma of the uterus
usually seen in post-menopausal
women
Endometrial Carcinoma (cont.)
Etiology
Irregular menstrual
cycle history
Infertility/no childbirth
Delayed menopause
Pathology
Spreads through uterus,
fallopian tubes, ovaries
and out into peritoneal
cavity

Metastasizes via blood
and lymphatic system
Endometrial Carcinoma (cont.)
Primary symptom is post-menopausal
bleeding
Diagnosis: Pap smear, D&C with biopsy
Treatment: Hysterectomy with hormone
therapy (usually progestin which
increases the risk of breast cancer) and
possibly chemotherapy
Carcinoma of the Cervix
Etiology
Increased “wear and
tear” on the cervix




Promiscuity
STDs
Papilloma virus
Maternal history of DES
Pathology
Spreads to adjacent
structures (usually
urethra/bladder and
rectum)
Metastasizes via
lymphatics
Carcinoma of the Cervix
(cont.)
Signs & Symptoms
Abnormal bleeding
Bladder & kidney
infections (due to
metastatic spread)
Diagnosis
Pap smear followed
by colposcopy
Carcinoma of the Cervix
(cont.)
Treatment
Excision of the lesion
Surgical (partial or total hysterectomy)
 Laser resection

Cryocautery

Freezing the lesion
Radiation (may be done with implants)
Ovarian Lesions
Follicular (retention) cysts,
adenomas, adenocarcinomas
Follicular (Retention) Cyst
Benign, nonneoplastic cyst
May cause pain
and possibility of
rupture

May cause internal
hemorrhage
Usually regress on
their own without
treatment
Cystadenoma
Benign, neoplastic cyst
filled with serous fluid or
mucus
Can become very large
and can be quite painful
Treatment is usually
surgical resection

May require
oophorectomy
Cystadenocarcinoma
Highly malignant
adenocarcinoma
May be primary or
spread from
endometrial carcinoma
Usually no symptoms
until it has metastasized
Elevated CA125
Treated with aggressive
surgery, chemotherapy,
and radiation
Prostatitis
Inflammation usually
caused by STD

Can be acute or chronic
Intense inflammation
with abscesses


Acute: swollen and
squishy
Chronic: swollen and
hardened (because of
fibrosis)
Prostatitis (cont.)
Signs & Symptoms:
Dysuria and nocturia
Low back pain
Pyuria and leukocytosis
May have fever if acute

Signs and symptoms less severe if chronic
Treated with antibiotics
Benign Prostatic Hypertrophy
(BPH)
Enlargement of the
prostate that usually
starts at age 45-50
Caused by hormonal
imbalance

Increased
dihydrotestosterone, a
by-product of
testosterone
metabolization
Causes obstruction of
the urethra as it exits
bladder
BPH (cont).
Signs & Symptoms
Dysuria

Difficulty in starting,
stopping, and controlling
urine flow
May cause cystitis and
pyelonephritis and
complete urethral
obstruction
Treatment: Finasteride
to inhibit
dihydrotestosterone or
surgery (TURP)
Carcinoma of the Prostate
Usually
adenocarcinoma

Very common in men
over 50
Signs and symptoms
are similar to BPH

May also have hematuria
S & S may not appear
until it has metastasized
to another location
Carcinoma of the Prostate
(cont.)
Metastasizes
throughout body, but
preferentially to bone
Diagnosed by:
Digital exam
Elevated PSA or acid
phosphate in blood
Transrectal ultrasound
with needle biopsy
Carcinoma of the Prostate:
Treatment
Surgery and /or
radiation

Surgery may damage
nerves and result in
impotence and
incontinence
For metatstatic spread
– hormone therapy

Removal of testosterone
or addition of female sex
hormones
Testicular Carcinoma
Most common in men under 30
Usual only symptom is a palpable mass
through the scrotum on a testicle
May metastasize via regional lymph nodes
Treatment: orchiectomy

May need chemo and radiation if cancer cells are
found in lymph nodes
Note: testicular cancer cells produce
hormones that are seen in pregnancy. Thus a
male with testicular cancer may have a
positive pregnancy test!
Musculoskeletal Diseases
Bone Fracture Types
Proper healing
requires realignment
and stabilization
Stabilization may be
done through
external fixation
(casts and splints)
or internal fixation
(surgical reduction
with pins and rods)
Abnormalities of the Vertebral
Column
Kyphosis –abnormal
posterior curvature
in upper back
(“hunchback”)
Caused by
degenerative
disease such as
arthritis or by injury
Abnormalities of the Vertebral
Column (cont.)
Lordosis – abnormal
anterior curvature in
the lower back
(“swayback”)
Caused by
congenital defect,
injury, muscular
dystrophies, or poor
posture
Abnormalities of the Vertebral
Column (cont.)
Scoliosis – abnormal
lateral curvature
Due to congenital
defect, poor posture,
injury
May compromise lung
function
Treated with exercises,
physical manipulation,
and in severe cases,
surgery
Herniated Nucleus Pulposus
Herniation of disk
material puts pressure
on nerve roots

Most common in lumbar
spine)
Caused by injury, or
degenerative disease
Causes pain and
paresthesia on affected
side and down affected
leg
Herniated Nucleus Pulposus
(cont.)
Diagnosed by
myelogram, MRI, or CT
Treatment:
Rest, muscle relaxants,
analgesics
Manipulation
Various surgical
procedures
Osteomyelitis
inflammation of bone caused
by infection
Caused by staph or strep


Skin lesions, compound fractures, orthopedic
surgical procedures
More common in children
Damages medullary canal and weakens bone
and makes it prone to further fracture and
deformity
Acute symptoms: bone pain and fever (may
become chronic with minimal symptoms)
Initially treated with antibiotics
Osteoporosis
decrease in bone density due
to calcium loss
Etiology:
Aging, menopause, steroid therapy,
immobilization, low dietary calcium
Causes vertebral column abnormalities and
increases the chances of fracture in weight
bearing joints, eg hip and vertebral column
Treated by:calcium supplements, vitamin D,
and possibly hormone therapy
Osteosarcoma
Malignancy that
develops in long bones


Most common in the
knee (distal portion of
femur)
More common in children
Causes pain and limited
range of motion
Treated with
chemotherapy followed
by surgery
Often metastasizes to
lung
Muscular Dystrophy
Duchenne’s (most severe) and Becker’s (less severe)
Inherited sex-linked recessive disease causing
atrophy of muscle cells and replacement with fibrous
and adipose tissue
Causes postural abnormalities, difficulty with walking
and eventually standing. May progress to affect the
diaphragm and respiration
Treatment is palliative
Myasthenia Gravis
A progressive loss of
muscular strength with
activity and then returns
to normal after rest

Is a descending
weakness/paralysis
Caused by an
autoimmune reaction
which damages the
acetylcholine receptor
site at the myoneural
junction
Treatment: Steroids and
immunosuppressive
drugs, plasmapheresis,
thymectomy
Osteoarthritis
(Degenerative Arthritis)
Degeneration of
cartilage leading to
roughening of the
articular surface of
bones
Caused by aging
and increased wear
and tear

Injury may lead to
arthritis also
Normal Knee
Osteoarthritic Knee
Osteoarthritis (cont.)
Signs and symptoms: painful, swollen
joints with limited range of motion
Treatment: Exercises and physical
therapy, pain meds, joint replacement,
alternative treatments, ie, shark
cartilage
Rheumatoid Arthritis
An autoimmune disease
that affects ALL joints

Usually starts in hands
and feet
Autoantibodies attack
the synovial lining of
joint capsules causing
chronic damage and
fibrosis
Ankylosing (“fusing”) of
joints eventually occurs
Rheumatoid Arthritis (cont.)
Signs and symptoms similar to
osteoarthritis except that all joints
become involved
Patient may also develop skin nodules,
lung fibrosis, and inflammation and
vasculitis in the heart
Treatment is similar to osteoarthritis

Patients may also be put on methotrexate
Central Nervous System
Disease
Cerebral Vascular Disease
Atherosclerosis in circulatory system of the brain

Often starts in the carotid arteries
Risk factors are the same as for coronary artery
disease (atherosclerosis in the coronary
circulation)

Smoking, obesity, high cholesterol, lack of exercise,
high fat diet, hypertension, diabetes, age and heredity
Transient Ischemic Attack
(TIA)
Transient ischemia caused by cerebral
atherosclerosis that produces
symptoms without causing permanent
death of brain tissue

A TIA is to the brain what angina pectoris
is to the heart!
Symptomology usually subsides within
hours
Cerebral Vascular Accident
(CVA)
Neurologic deficit due to severe
and long lasting ischemia
“STROKE” or “BRAIN ATTACK”
Etiology of CVA
Atherosclerosis leading to:
Occlusion in a cerebral
vessel due to thrombus
or embolus and/or
Vessels, brittle from
atherosclerosis, or an
aneurysm,rupture and
hemorrhage
CVA Pathology
Brain cells die from lack
of oxygen
Like heart muscle, the
dead cells are
phagocytosed and
replaced by scar tissue
In CVA due to
hemorrhage, additional
damage is caused by
the pressure buildup
caused by accumulation
of blood
CVA Signs & Symptoms
Change in LOC or
loss of
consciousness

Loss of
consciousness/coma
most common with
hemorrhagic CVA
Hemiparesis
Headache
Unequal pupils
Seizure (common in
CVA caused by
embolus)
N&V
Incontinence
Speech disturbance
Sensory disturbance
CVA Diagnosis
EEG, MRI, CT, Cerebral angiogram
CT Scan
Angiogram
CVA Treatment
Acute is like heart
attack

O2 and, if indicated,
thrombolytics
Hemorrhagic CVA
may require
craniotomy to
control bleeding
Physical therapy,
Occupational
therapy, Speech
therapy
Prevention


Address risk factors
for atherosclerosis
Carotid
Endarterectomy if
indicated
CVA Prognosis
Approximately 30% recover without
neurologic deficit
Approximately 30% recover but have
residual signs and symptoms due to
neurologic deficit
30% die within 6 months CVA
For many, primary residual effect is
seizure disorder (Epilepsy)
Neurologic Deficit
Central Nervous System
Infectious Diseases
Meningitis
Infectious inflammation of the meninges (the 3
layered membrane that surrounds the brain
and spinal cord)
Etiology:
Bacterial: Meningococcus (Neisseria
menigitidis) and Pneumococcus
(Streptococcus pneumoniae)

Meningococcus is most contagious
Viral Meningitis: usually not as severe as
bacterial
Meningitis: Pathology
Yellow-pus exudate
forms in the
meninges around
the brain and spinal
cord
Causes brain
dysfunction due to
increased pressure
Also interferes with
drainage of CSF
Meningitis: Signs and
Symptoms
Often URI manifestations first
Headache
Stiff neck and neck rigidity!
Change in level of consciousness leading to
complete loss of consciousness


Patient often becomes combative and then
lethargic prior to losing consciousness
Still maintain neck rigidity even with loss of
consciousness
Hydrocephalus
Meningitis: Diagnosis and
Treatment
Diagnosed by lumbar
puncture

Shows increased CSF
pressure and appears
cloudy because of
presence of WBCs and
infectious organism
Treatment: Maintain
airway and hydration,
antibiotics for bacteria,
possibly shunt for
hydrocephalus
Meningitis: Complications
Epilepsy
Hydrocephalus
Hearing loss
Learning disability
Brain Abscess
Bacteria or parasite,
eg, tapeworm, that
migrates from
original site of
infection to brain and
causes intense
inflammation with
abscess formation
Usually diagnosed
by MRI or CT scan
Brain Abscess (cont.)
Signs and Symptoms: Depends on
location in brain
Headache, seizures, personality
changes, memory loss, motor and/or
sensory disruption
Treatment: Antibiotic/Antiparasitic drugs
and surgical drainage of the abscess
Encephalitis
Inflammation of the
brain, meninges, and
spinal cord
Usually caused by a
virus: herpes simplex,
HIV, arboviruses
(carried by mosquitoes),
rabies
TB can also cause
encephalitis
“Sleeping Sickness”
Encephalitis (cont.)
Signs and Symptoms:
Fever, headache, agitation and delirium,
seizures, coma/catatonic state
Diagnosis: Lumbar Puncture shows cloudy
CSF with increased WBCs
Treatment: Supportive
Prognosis: High mortality and recovery usually
includes residual neurologic deficit
Myelitis
Inflammation of the
spinal cord, usually due
to a virus

Eg, Poliovirus
Causes inflammation in
the anterior horn cells of
the spinal cord causing
varying degrees of
weakness and paralysis

The higher up in the
spinal cord the
inflammation, the more
complete the paralysis is
Myelitis (cont.)
Often spread through contaminated water
Virus matures in the GI tract before attacking
the spinal cord

Very contagious since it is freely shed in saliva
and fecal material
Treatment: Prevention! Polio vaccine

Acute case requires supportive care often
requiring mechanical ventilation
Recovery can be slow and there is often
residual muscle weakness and atrophy
Guillain-Barre’ Syndrome
Idiopathic Polyneuritis
Widespread acute demyelination of
peripheral nerves and nerve roots with some
axon degeneration
Causes an “ascending” weakness/paralysis
that may last days, weeks, or months


Can not predict how severe, high up, or long the
condition will persist
Worst cases progress to complete paralysis with
respiratory failure due to diaphragmatic paralysis
Guillain-Barre’ (cont.)
Etiology: usually a complication of a viral
infection or viral vaccine

Viral activity is believed to trigger an autoimmune
reaction to myelin
Signs and Symptoms: varying degree of
weakness/paralysis that starts in the legs and
works its way up
Treatment: Supportive including mechanical
ventilation and physical therapy

Patients may experience residual weakness and
muscle atrophy after recovery
Herpes Zoster
(Shingles)
Viral infection of
peripheral
dermatomes that
causes painful,
erythematous,
vesicular lesions
Believed to be
caused by dormant
varicella
Herpes Zoster (cont.)
Outbreak can be triggered by stress,
malnutrition, drug reaction, or another viral
illness


Virus appears to be opportunistic (as are all
Herpes viruses)
Can be very contagious while lesions are still “wet”
Treatment: Steroids (topical and systemic)
After eruption clears, patient may be troubled
by pain at site for weeks or months
CNS Degenerative Diseases
Multiple Sclerosis
A chronic disease, with
periods of remission
and exacerbation,
characterized by
diffuse, focal areas of
degeneration of the
myelin sheath of nerve
fibers in the brain and
spinal cord

Result is build up of scar
tissue (sclerosis)
MS (cont.)
Etiology: Believed to
be an autoimmune
reaction that MAY
be triggered by a
viral infection


Is more common in
colder climates
Heredity also a factor
Diagnosed by MRI
MS (cont.)
Signs and Symptoms (depend on where the
demyelination is occurring):
Usually develops between ages 15-40 and
may include:
Paresthesia, weakness, visual problems,
ataxia, tremors, incontinence, with
progression to total paralysis

Periods of remission and exacerbation
Treatment:Primarily supportive with physical
therapy

Life span usually 25 years after diagnosis
Parkinson’s Disease
Degeneration of the substantia nigra in
the midbrain causing decreased
amounts of dopamine

Lewy bodies are seen in degenerating
substantia nigra
Very common after age 50
Parkinson’s (cont.)
Signs and Symptoms
(caused by dopamine
deficiency):
Resting tremors, masklike expression, muscle
rigidity, shuffling gait,
monotone speech,
possibly dementia
Treatment: L-dopa,
implanted substantia
nigra cells, electrical
stimulation of midbrain,
stem cells(?)
Alzheimer’s Disease
The most common
form of senile
dementia
Degeneration and
atrophy in the cerebral
cortex with formation
of neurofibrillary
tangles and senile
plaques
Results in memory
loss and deterioration
of intellectual functions
Alzheimer’s (cont.)
Exact etiology unknown

Heredity, Down’s Syndrome, viral infection, betaamyloid (cause or manifestation?), A-beta star
Signs and Symptoms - 3 Stages:
Stage 1 – memory loss, poor judgement and
reasoning, spatial and temporal
disorientation, apathy and paranoia
Stage 2 – aphasia, agnosia, incontinence,
continued deterioration of cognitive function
Stage 3 – severe impairment of all cognitive
and motor functions
Treatment: Memory stimulating drugs such as
donepezil (Aricept) and tacrine (Cognex)
Brain Cancer
Most are secondary
tumors that have
metastasized from
elsewhere in the
body
Most commonly
from lung, breast,
colon, bone, or
melanomas
Brain Cancer (cont.)
Primary tumors may
arise from the
meninges, ie
meningioma, which is
benign but may put put
pressure on the spinal
cord or brain
Other primary tumor is
a glioma which is
always malignant

astrocytoma and
glioblastoma multiforme
Brain Cancer (cont.)
Signs Symptoms depend on what part of the
brain the tumor is in and are usually due to
the increase in intracranial pressure caused
by the tumor
Headache, N &V, seizures, memory loss,
cognitive dysfunction, personality change,
motor and/or sensory dysfunction, increased
CSF pressure during lumbar puncture
Brain Cancer (cont.)
Diagnosed by CT scan and/or MRI
Treatment:
Surgical resection (if possible)

Surgery may actually make patient worse!
Chemotherapy and radiation therapy
Epilepsy
A condition of RECURRENT
seizures.
Seizure
A sudden, transient alteration in
electrical activity in the brain
which may cause sensory, motor,
and psychic symptoms as well as
impairment of consciousness
Seizure Etiology
Hypoxia
Toxins
High temperature (febrile)
Electrolyte imbalance
Hypoglycemia
Sleep deprivation
Brain lesions

Neoplasm, abscess, trauma, infection, CVA,
congenital lesions
Besides causing a seizure,
any of these conditions could
make injured brain tissue become
epileptogenic.
However,many cases of epilepsy
are idiopathic!
Epilepsy: Seizure Triggers
Excitation, relaxation, falling asleep,
waking up
Sounds, flashing lights
Hyperventilation, drugs/alcohol, stress,
sleep deprivation
Epilepsy: Seizure Types
Partial – abnormal electrical discharge is
confined to a limited area of the brain at the
onset of the seizure
Simple partial – no impairment of
consciousness. Symptoms depend on area of
brain involved
Complex partial –may have some impairment
of consciousness. Obvious sensory and/or
motor symptoms

May exhibit “automatisms’
Epilepsy: Seizure Types
Generalized – abnormal
electrical activity occurs
throughout brain
causing loss of
consciousness
Absence’ (petit mal)






Common in children
Brief attacks lasting 5-30
seconds
Blank stare , eyes may
blink rapidly
Some loss of muscular
tone
Patient is unaware and
functions normally after
seizure
Often initially diagnosed
as a learning disability
Epilepsy: Seizure Types
Generalized (cont.)
Tonic – Clonic (grand mal)
Tonic phase



Loss of consciousness
with tonic stiffening of all
muscles
Patient does not breathe
and gets cyanotic
Tonic phase may last 1
minute
Clonic phase –
synchronized jerking of
extremities and head


Intense salivation and
tongue biting
May last 1-4 minutes
Post –Ictal phase
Patient is drowsy and
confused

May experience N & V
and incontinence
Treatment During Tonic-Clonic
Tonic phase – help patient down to prevent
them from hitting their head

Do NOT force anything in their mouth!
Clonic phase – move things out of their way
or put pads around them


May lay on side if jerking is not too intense
Do not try to restrain or try to force anything in
their mouth
Post – Ictal – open and clear airway and
assist patient as needed
Epilepsy: Diagnosis
Besides seizure
history, the definitive
diagnosis is made
by an EEG

Normal
May use strobe lights
or hyperventilation
Tonic-Clonic
Epilepsy: Treatment
Anticonvulsants to prevent seizures



Zarontin for absence’ seizures
Tegretol, Depakote
During a seizure, IV Valium may be given to put
patient in post-ictal phase
Surgery if epileptogenic tissue can be
identified and is accessible
Correct problems causing development of
epileptogenic tissue
Sample Test Questions!
An infection with a bacteria that causes
yellow pus to surround the brain and
spinal cord is:
A. Encephalitis
B. Rabies
C. Guillain-Barre’ syndrome
D. Meningitis
E. Thyroiditis
A small percentage of patients with
rheumatoid arthritis may develop:
A. Inflammation of the lung
B. Skin lesions
C. Brain tumors
D. Tetany
E. A and B
Methods used to diagnose
CVA include:
I. CT scan
II. MRI
III. Angiography
IV. EEG
A. I only
B. I and II
C. II and III
D. II and IV
E. I, II, III, and IV
A compound fracture is
defined as:
A. A breakage of two or more bones in
close proximity
B. A breakage of a bone in two or more areas
C. A breakage of a bone so that an end
protrudes through the skin
D. A breakage of bone producing several
slivers of bone
E. B and C
Women who never had children and
develop cancer after menopause
usually have which cancer?
A. Endometrial adenocarcinoma
B. Endometrial squamous carcinoma
C. Cervical adenocarcinoma
D. Cervical squamous carcinoma
E. Fibroadenoma
If metastasis of breast cancer occurs,
what two areas are most commonly
involved?
A. Lung and heart
B. Liver and spleen
C. Lung and bone
D. Ovaries and uterus
E. Prostate and testes
A malignant tumor that originates in the
brain is most likely a:
A. Meningioma
B. Cerebral sarcoma
C. Glioma
D. Encephalocarcinoma
E. Brainoma
A disease of the joints which spreads to
all joints causing permanent deformity
and ankylosing is:
A. Osteoarthritis
B. Osteoporosis
C. Rheumatoid arthritis
D. Degenerative arthritis
E. Osteomyelitis