Pathopsychology

Pathopsychology

Classmate 1 (ML)
A 35 year old woman has been diagnosed with Polycystic Ovarian Syndrome (PCOS). She has been trying to get pregnant for the past 3 years. Her male partner was married before and has 2 children. As the nurse practitioner, describe the following to this woman:
What is the pathophysiology of PCOS and how does it affect fertility?
Polycystic ovary syndrome has at least two of the following conditions: oligo-ovulation or anovulation, elevated levels of androgens, or clinical signs of hyperandrogenism and polycystic ovaries. Polycystic ovaries do not have to be present to diagnose PCOS, and their presence alone does not establish the diagnosis. Although no single factor appears to be the main culprit a hyperandrogenic state is a cardinal feature in the pathogenesis of PCOS, usually accompanied by glucose intolerance/insulin resistance, and hyperinsulinemia significantly aggravating the hyperandrogenic state. Obesity makes insulin resistance worse; insulin in turn affects follicular decline by suppressing apoptosis and stimulates androgen secretion resulting in increased free testosterone levels that affect follicular growth. There appears to be a genetic defect in PCOS making the ovaries more sensitive to insulin’s stimulation of androgen production. In addition there is a dysfunction in follicle development initiated by elevated leptin levels which influence gonadotropin releasing hormone (GnRH). Inapropriate secretion of GnRH initiates a vicious cycle that perpetuates anovulation. Increased frequency of GnRH pulses seems to increase frequency of luteinizing hormone pulses, which in turn causes an increase in androgens; increased androgen secretion by the ovaries contributes to premature follicular failure and persistent anovulation, thus significantly affecting fertility (McCance&Huether 2014).
What are signs and symptoms of PCOS and what diseases are associated with PCOS?
Signs and symptoms of PCOS may appear within 2 years of puberty or after a period of normal menstrual function. They are related to anovulation and hyperandrogenism and include dysfunctional bleeding or amenorrhea, hirsutism, acne, obesity and infertility. Diseases associated with PCOS include Cushing syndrome, acromegaly, premature ovarian failure, simple obesity, congenital adrenal hyperplasia, thyroid disease, androgen-producing adrenal tumors or ovarian tumors, and syndromes with hyperprolactinemia (McCance&Huether 2014).
References
McCance, K., &Huether, S. (2014). Pathophysiology: The biologic basis for
disease in adults and children (7th ed.). St. Louis, Mo: Mosby Elsevier.
Classmate 2 (CA)
Although the incidence is lower than other cancers, ovarian cancer causes more deaths than any other reproductive cancer.
1 Explain the pathophysiology of ovarian cancer and why more deaths occur due to ovarian cancer than other reproductive cancers.
2 What are the risks and signs and symptoms of ovarian cancer
The pathogenesis of ovarian cancer is said to be controversial. Some are associated with genetic mutations but most being sporadic and not associated with inheritance patterns. Newer theories state that sporadic, spontaneous tumors arise from migration of mesoderm origin tissue to the surface of the ovary. Cells of intra-abdominal locations can attach to the ovary and can then interact with transplanted cells to enhance growth and encourage metastases (McCance&Huether, 2014). Two major types of ovarian cancer are epithelial ovarian neoplasms that begin in cells on the surface of the ovary, and germ cell neoplasms that begin in egg cells (Ovarian, Fallopian Tube, and Primary Peritoneal Cancer, n.d.). Epithelial ovarian neoplasms are the most common of the two. Most epithelial malignancies rise from a single cell because of a loss of tumor-suppressor genes and activation of oncogenes. Germ cell tumors can be benign or malignant; malignant tends to be highly aggressive with poor prognosis (McCance&Huether, 2014). Tumors are classified as type I being low grade, or type II known as high grade, based on cellular type. Type I tumors tend to grow slowly and are more resistant to chemotherapy. Type II tumors rapidly grow and are more aggressive but respond well to chemotherapy. Only about 15 percent of cancers are diagnosed early in stage I (McCance&Huether, 2014).
Because of the lack of early symptoms in ovarian cancer and the lack of cost effective screening techniques for early detection, most disease is diagnosed after metastasis has occurred. This is why ovarian cancer is commonly referred to as a silent killer, contributing to the reason why ovarian cancer causes more deaths than any other reproductive cancer (McCance&Huether, 2014).
Risks linked to ovarian cancer include women over 40 with conditions associated with increased ovulation such as early menarche, late menopause, nulliparity, and the use of fertility drugs. Some additional risk factors include obesity and genetic mutations specifically related to the breast cancer susceptibility gene. Factors that reduce the risk of ovarian cancer involve factors that suppress ovulation including pregnancy, prolonged lactation, and contraceptive use that limit ovulation (McCance&Huether, 2014).
Ovarian cancer is generally asymptomatic in early stages, so women do not start noticing symptoms until the disease progresses. Common first symptoms include abdominal distention, loss of appetite, and pelvic pain, but the symptoms are vague so many women fail to notice them (McCance&Huether, 2014). Manifestations of advanced disease can include pain and abdominal swelling, dyspepsia, vomiting, alterations in bowel habits due to obstruction, and abnormal vaginal bleeding in postmenopausal women. Ulcerations through the vaginal wall that can cause bleeding can also develop from the tumor, and tumor obstruction of vascular channels can cause thrombosis (McCance&Huether, 2014).
References
McCance, K., &Huether, S. (2014). Pathophysiology: The biologic basis for disease in
adults and children (7th ed., p. 831-834). St. Louis, Mo.: Mosby Elsevier.
Ovarian, Fallopian Tube, and Primary Peritoneal Cancer. (n.d.). Retrieved
March 21, 2015, from http://www.cancer.gov/cancertopics/types/ovarian

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Classmate 3

An adolescent who’s 16, has had 12 boyfriends in the past 2 years that she has been sexually intimate with and has sporadically used condoms. She is taking oral contraceptives. She is coming to the clinic because of pelvic pain.
1. How would you confirm the diagnosis of pelvic inflammatory disease (PID) and describe the pathophysiology of PID?
Pelvic inflammatory disease (PID) is an acute inflammatory process involving a single organ or a combination of organs in the upper genital tract. PID is mainly caused by sexually transmitted diseases such as chlamydia and gonorrhea (McCance&Huether, 2014). Being that this patient has had 12 boyfriends with sporadic condom use, she is at high risk of contracting a sexually transmitted disease. Her pelvic pain causes much concern for her reproductive system. To confirm diagnosis, I would have to perform a pelvic exam with a witness present; bimanual pelvic examination could reveal pelvic organ tenderness. PID should be considered if a sexually active woman presents with pelvic or abdominal tenderness and at least one of the following: “cervical motion tenderness, uterine tenderness, or adnexal tenderness” (McCance&Huether, 2014, p. 815). I would make sure a thorough history and physical is performed and if the patient were to have fever, vaginal discharge, elevated serum CRP or ESR levels then PID is highly suspected (McCance&Huether, 2014). Absolute criteria for PID would be diagnosed by transvaginal ultrasound, doppler studies, or laparoscopic visualization. Pelvic inflammatory disease is polymicrobial, meaning several microorgansims can cause this disease. The cervix normally produces mucus that prevents upward spread; during PID, bacteria may penetrate the cervical mucus and spread the infection ascending from the vagina and cervix. The resulting inflammatory response causes pain and localized edema (McCance&Huether, 2014). A patient with pelvic inflammatory disease can present with severe symptoms such as abdominal/pelvic pain, fever, dysuria, or vaginal bleeding to no symptoms at all (McCance&Huether, 2014). This patient must inform all of her sexual partners if she does have an STI.

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2. List at least 3 other sexually transmitted infections she is at risk for & list the main signs of symptoms of these other STI’s (be brief)
This patient is at risk for gonorrhea, chlamydia, and bacterial vaginosis. Gonorrhea presents with symptoms such as sudden onset of dysuria or purulent discharge in men. Women diagnosed with gonorrhea sometimes don’t present with symptoms until the infection has spread to the upper reproductive tract and appear with dysuria, vaginal discharge, lower abdominal/pelvic pain, and fever (McCance&Huether, 2014). Chlamydia presents with symptoms of vaginal discharge, bleeding/spotting, and painful urination. Gonorrhea and chlamydia are often asymptomatic. Bacterial vaginosis is not always considered an STI; it is characterized by thin grey-white discharge with a strong odor (McCance&Huether, 2014).
References:
McCance, K., Huether, S. (2014). Pathophysiology: The biologic basis for disease in adult and children (7th ed., p. 813-816). St. Louis, Mo.: Mosby Elsevier.