Musculoskeletal System

Function: Gives humans the ability to move using the muscular and skeletal systems. Provides
form, support, stability, and movement to the body. Its primary functions include supporting the
body, allowing motion, and protecting vital organs. The skeletal portion of the system serves as
the main storage system for calcium and phosphorus and contains critical components of the
hematopoietic system (the system that forms cellular blood components).

Usual treatment providers: orthopedist orthopedic surgeon physiatrist (specialist in physical

medicine and rehabilitation).

Key terms and components:

Muscle Contraction
When a muscle contracts, a series of reactions occur. Muscle contraction is stimulated by the
motor neuron sending a message to the muscles from the somatic nervous system.
Depolarization of the motor neuron results in neurotransmitters being released from the nerve
terminal. The space between the nerve terminal and the muscle cell is called the neuromuscular
junction. These neurotransmitters diffuse across the synapse and bind to specific receptor sites
on the cell membrane of the muscle fiber. When enough receptors are stimulated, an action
potential is generated and the permeability of the sarcolemma is altered. This process is known
as initiation.

Joints
Joints connect individual bones and may allow bones to move against each other to cause
movement. Synovial joints, joints that are not directly joined, are lubricated by a solution called
synovial fluid that is produced by the synovial membranes. This fluid lowers the friction between
the articular surfaces and is kept within an articular capsule, binding the joint.

Arthralgia
Joint pain.

Myalgia
Muscle pain. It is often caused by muscle strain or overuse, but can also be a sign of serious
disease.

Tendons
A tendon is a tough, flexible band of fibrous connective tissue that connects muscles to bones.
As muscles contract, tendons transmit the forces to the rigid bones, pulling on them and causing
movement.

Ligaments
A ligament is a small band of dense, fibrous elastic tissue. Ligaments connect the ends of

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bones together in order to form a joint. Most ligaments limit dislocation, or prevent certain
movements that may cause breaks. They increasingly lengthen when under pressure., making
them susceptible to breakage, resulting in an unstable joint.

Bursa
A bursa is a small fluidfilled sac made of fibrous tissue and lined with synovial membrane. It
provides a cushion between bones and tendons and/or muscles around a joint bursa are filled
with synovial fluid and are found around almost every major joint of the body.

Cartilage
A flexible connective tissue found in many areas in the body, including the joints between
bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and
the intervertebral discs. It is not as hard and rigid as bone but is stiffer and less flexible than
muscle. Unlike other connective tissues, cartilage does not contain blood vessels. Because of
this, it heals very slowly.

Vertebral column
The vertebral column houses and protects the spinal cord in its spinal canal. It usually consists
of 33 vertebrae: 24 presacral vertebrae (7 cervical, 12 thoracic, and 5 lumbar) followed by the
sacrum (5 fused sacral vertebrae) and the coccyx (4 frequently fused coccygeal vertebrae). The
24 presacral vertebrae allow movement and render the vertebral column flexible. The
abbreviations C., T., L., S., and Co. are used for the regions, and these are sometimes followed
by V. for vertebra or N. for nerve.

Curvatures
The adult vertebral column presents four anteroposterior curvatures: thoracic and sacral, both
concave anteriorly, and cervical and lumbar, both concave posteriorly.

Lordosis
The inward curvature of a portion of the lumbar and cervical vertebral column. Two segments of
the vertebral column, namely cervical and lumbar, are normally lordotic, that is, they are set in a
curve that has its convexity anteriorly (the front) and concavity posteriorly (behind). Lordosis
may increase due to imbalances in muscle strength and length (such as weak hamstrings, or
tight hip flexors. Excessive lordotic curvature is also called hyperlordosis, hollow back, saddle
back, and swayback. Common causes of excessive lordosis include tight low back muscles,
excessive visceral fat, and pregnancy. Incongruently it can lead to moderate to severe lower
back pain. Rickets, a vitamin D deficiency in children, can cause lumbar lordosis.

Vertebrae
A typical vertebra consists of (1) a body and (2) a vertebral arch, which has several processes
(articular, transverse, and spinous) for articular and muscular attachments. Between the body
and the arch is the vertebral foramen: the sum of the vertebral foramina constitutes the vertebral
canal, which houses the spinal cord. In addition to the transverse and spinous processes,
which serve as short levers, the 12 thoracic vertebrae are connected by joints with paired, long
levers, namely the ribs.

The bodies of the vertebrae are separated from each other by intervertebral discs. The body is
mainly spongy bone and red marrow, but the margins of the upper and lower surfaces consist of
a ring of compact bone, the vertebral endplates. The body is marked on its sides by vascular
foramina.

The vertebral arch consists of right and left pedicles (which connect it to the body) and right and
left laminae. The transverse processes emerge laterally at the junction of the pedicles and
laminae, and the spinous process proceeds posteriorly from the union of the laminae. The
superior and inferior articular processes project vertically from the vertebral arches on each side
and bear articular facets. When vertebra are in their anatomical position, notches between
adjacent pedicles form intervertebral foramina, each of which typically transmitsneural structures
including a spinal ganglion and a ventral root of a spinal nerve.

Intervertebral disc
Intervertebral discs (or intervertebral fibrocartilage) lie between adjacent vertebrae in the spine.
Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a
ligament to hold the vertebrae together.

Discs consist of an outer annulus fibrosus, which surrounds the inner nucleus pulposus. The
annulus fibrosus consists of several layers of fibrocartilage. The strong annular fibers contain
the nucleus pulposus and distribute pressure evenly across the disc. The nucleus pulposus
contains loose fibers suspended in a mucoprotein gel with the consistency of jelly. The nucleus
of the disc acts as a shock absorber, absorbing the impact of the body's daily activities and
keeping the two vertebrae separated. The disc can be likened to a jelly doughnut: whereby the
annulus fibrosis is similar to the dough and the nucleus pulposus is the jelly. If one presses
down on the front of the doughnut the jelly moves posteriorly or to the back. When one develops
a prolapsed disc the jelly/nucleus pulposus is forced out of the doughnut/disc and may put
pressure on the nerve located near the disc. This can give one the symptoms of sciatica.

There is one disc between each pair of vertebrae, except for the first cervical segment, the
atlas. The atlas is a ring around the roughly coneshaped extension of the axis (second cervical
segment). The axis acts as a post around which the atlas can rotate, allowing the neck to
swivel.

Discs are named for the vertebrae which they connect. For example, the disc between the fifth
and sixth cervical vertabrae is designated "C56".

Facet joint
Facet joints link the bones of the spine together in the posterior or back part of the spine. Two
facet joints are present at each spinal segment. They are named for the spinal bones that they
connect. Because there are two joints per level, there is a right and left joint. The facet joints
are important in restricting the motion of the cervical and lumbar spine. They allowed twisting,
flexion and extension motions.

Spinal Nerves
The first cervical nerve emerges between the skull and the atlas, and cervical nerves C2 to 7
continue to leave the vertebral canal above the correspondingly numbered vertebrae. C8
emerges between the C7 and T1 vertebrae, and the remaining spinal nerves leave below the
correspondingly numbered vertebrae.

Osteotomy
A surgical procedure that involves cutting a bone and changing its alignment to relieve stress on
the bone or joint.

Open Reduction Internal Fixation (ORIF)

ORIF involves the implementation of implants to guide the healing process of a bone, as well as
the open reduction, or setting, of the bone itself. Open reduction refers to open surgery to set
bones, as is necessary for some fractures. Internal fixation refers to fixation of screws and/or
plates to facilitate healing. Rigid fixation prevents micromotion across lines of fracture to enable
healing and prevent infection, which happens when implants such as plates (e.g. dynamic
compression plate) are used. ORIF techniques are often used in cases involving serious
fractures, such as comminuted or displaced fractures, or in cases where the bone would
otherwise not heal correctly with casting or splinting alone.

Risks and complications can include bacterial colonization of the bone, infection, stiffness and
loss of range of motion, nonunion, malunion, damage to the muscles, nerve damage and
palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and pins, compartment
syndrome, deformity, audible popping and snapping, and possible future surgeries to remove
the hardware.

Radiography (Xray imaging)

Radiography is the use of Xrays to view a nonuniformly composed material such as the human
body. A heterogeneous beam of Xrays is produced by an Xray generator and is projected
toward an object. According to the density and composition of the different areas of the object a
proportion of Xrays are absorbed by the object. The Xrays that pass through are then captured
behind the object by a detector (film sensitive to Xrays or a digital detector) which gives a 2D
representation of all the structures superimposed on each other.

Computed tomography (CT scan), also xray computed tomography, or computed axial
tomography (CAT scan)
A medical imaging procedure that utilizes computerprocessed Xrays to produce tomographic
images or 'slices' of specific areas of the body. These crosssectional images are used for
diagnostic and therapeutic purposes in various medical disciplines. Digital geometry processing
is used to generate a threedimensional image of the inside of an object from a large series of
twodimensional Xray images taken around a single axis of rotation.

CT has become an important tool in medical imaging to supplement Xrays and medical
ultrasonography. It has more recently been used for preventive medicine or screening for
disease. CT is regarded as a moderate to highradiation diagnostic technique.

CT is often used to image complex fractures, especially ones around joints, because of its ability
to reconstruct the area of interest in multiple planes. Fractures, ligamentous injuries and
dislocations can easily be recognised with a 0.2 mm resolution.

Myelography
A type of radiographic examination that uses a contrast medium to detect pathology of the
spinal cord, including the location of a spinal cord injury, cysts, and tumors. The procedure often
involves injection of contrast medium into the cervical or lumbar spine, followed by several Xray
projections. A myelogram may help to find the cause of pain not found by an MRI or CT.
Myelography has been largely replaced by the use of CT and MRI scans. A CT is typically
performed after radiographic contrast media (dye) has been placed with fluoroscopic guidance
into the sac (dura) surrounding the spinal cord and nerves. A CT myelogram is most useful for
patients who cannot undergo MRI (e.g., those with pacemakers or cochlear implants), or for
those in whom MRI provides limited information (e.g., those with extensive metal in the spine).

Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic
resonance tomography (MRT)
A medical imaging technique used in radiology to visualize internal structures of the body in
detail. An MRI scanner is a device in which the patient lies within a large, powerful magnet
where the magnetic field is used to align the magnetization of some atomic nuclei in the body,
and radio frequency fields to systematically alter the alignment of this magnetization. This
causes the nuclei to produce a rotating magnetic field detectable by the scannerand this
information is recorded to construct an image of the scanned area of the body.

MRI provides good contrast between the different soft tissues of the body, which makes it
especially useful in imaging the brain, muscles, the heart, and cancers compared with other
medical imaging techniques such as computed tomography (CT) or Xrays. Unlike CT scans or
traditional Xrays, MRI does not use ionizing radiation.

Electromyogram (EMG)
A test which measures the electrical activity of muscles at rest and during contraction. It may
help to find diseases that damage muscle tissue, nerves, or the junctions between nerve and
muscle. These problems may include a herniated disc, amyotrophic lateral sclerosis (ALS), or
myasthenia gravis (MG). It may determine the cause of weakness, paralysis, or muscle
twitching. Problems in a muscle, the nerves supplying a muscle, the spinal cord, or the area of
the brain that controls a muscle can cause these symptoms. The EMG does not show brain or
spinal cord diseases.

Nerve conduction study (NCS)

A test which measures how well and how fast the nerves can send electrical signals. It may
help to find damage to the peripheral nervous system, which includes all the nerves that lead
away from the brain and spinal cord and the smaller nerves that branch out from those nerves.
This test is often used to help find nerve problems such as carpal tunnel syndrome or Guillain-
Barr syndrome. Nerve conduction velocity (NCV) is a common measurement made during this
test. The term NCV often is used to mean the actual test, but this may be misleading, since
velocity is only one measurement in the test suite.

Range of Motion (ROM)

Range of motion refers to the distance and direction a joint can move between the flexed
position and the extended position. The act of attempting to increase this distance through
therapeutic exercises (range of motion therapystretching from flexion to extension for
physiological gain) is also sometimes called range of motion.

Each specific joint has a normal range of motion that is expressed in degrees.

Limited range of motion refers to a joint that has a reduction in its ability to move. The reduced
motion may be a mechanical problem with the specific joint or it may be caused by injury or
diseases such as osteoarthritis, rheumatoid arthritis, or other types of arthritis. Pain, swelling,
and stiffness associated with arthritis can limit the range of motion of a particular joint and impair
function and the ability to perform usual daily activities.

Physical or occupational therapy can help to improve joint function by focusing on range of
motion exercises. The goal of these exercises is to gently increase range of motion while
decreasing pain, swelling, and stiffness. There are three types of range of motion exercises:
Passive range of motion (or PROM) Therapist or equipment moves the joint through
the range of motion with no effort from the patient.
Active assistive range of motion (or AAROM) Patient uses the muscles surrounding
the joint to perform the exercise but requires some help from the therapist or equipment
(such as a strap).
Active range of motion (or AROM) Patient performs the exercise to move the joint
without any assistance to the muscles surrounding the joint.

Common Conditions:

Arthritis (any joint)

Arthritis is inflammation of one or more joints. It involves the breakdown of cartilage which
normally protects a joint, allowing it to move smoothly. Cartilage also absorbs shock when
pressure is placed on the joint. Without the normal amount of cartilage, the bones rub together,
causing pain, swelling (inflammation), and stiffness.
 Causes:
autoimmune disease
broken bone(s)
general wear and tear
bacterial or viral infection

Types:
Osteoarthritis (O.A.)/Degenerative Arthritis is the most common type, and is caused
by aging and wear and tear.

Symptoms: swelling, pain and stiffness in the joints

Signs: rubbing, grating, or cracking sounds (crepitation) joint swelling (bones

may feel larger than normal) limited range of motion tenderness when the joint
is pressed normal movement that is painful

Tests: Xray and MRI will show loss of joint space. In advanced cases, wearing
down of the ends of the bone and bone spurs will be found.

Treatment: Cannot be cured, but symptoms can be controlled with medication,

lifestyle changes (e.g. applying heat and cold, resting, protecting joints), physical
therapy, splints and braces, alternative treatments, and surgery.

Medications:
Nonsteroidal antiinflammatory drugs (NSAIDs), including aspirin,
ibuprofen, and naproxen.
Overthecounter remedies: glucosamine, chondroitin sulfate, Capsaicin
(Zostrix) skin cream
Corticosteroids injected into the joint
Artificial joint fluid (Synvisc, Hyalgan) can be injected into the knee to
relieve pain for 3 6 months

Surgeries:
Arthroscopic surgery to trim torn and damaged cartilage
Osteotomy: changing the alignment of a bone to relieve stress on the
bone or joint
Surgical fusion of bones, usually in the spine (arthrodesis)
Total or partial replacement of the damaged joint with an artificial joint
(knee replacement, hip replacement, shoulder replacement, ankle
replacement, elbow replacement)

Degenerative Disc Disease (DDD)

A result of wear and tear on the spinal discs as they age, some people have symptoms
described as degenerative disc disease. Not actually a disease, this is a condition in which pain
is caused by a damaged disc. Damage may include a tear of the annulus fibrosus or swelling or
herniation of the nucleus pulposus. Such a tear may also result in the release of inflammatory
chemical mediators which may directly cause severe pain.

Spinal osteoarthritis is also called spondylosis. If this condition occurs in the zygapophysial
joints (facet joints), it can be considered facet syndrome. If severe, it may cause pressure on
nerve roots with subsequent sensory and/or motor disturbances, such as pain, paresthesia, or
muscle weakness in the limbs. Often the disc will be associated with osteophytes or bone
spurs. They can further reduce movement and lead to nerve compression.

Causes and Risk Factors:

Drying out of the disc, which is about 80% water at birth
Daily activities and sports. By the age of 60, most people have some degree of disc
degeneration, but not everyone has back pain as a result.
Injuries cause inflammation and resulting pain

Symptoms:
Pain that is worse when sitting. While seated, the discs of the lower back have
three times more load on them than when standing.
Pain that gets worse when bending, lifting or twisting
Feeling better while walking or even running than while sitting or standing for
long periods of time
Feeling better changing positions often or lying down
Periods of severe pain that come and go. These last from a few days to a few
months before getting better. They can range from nagging pain to severe,
disabling pain.
Pain can affect the low back, buttocks and thighs or the neck, depending on
where the affected disc is. It may radiate to the arms and hands
Numbness and tingling in the extremities
Weakness in the leg muscles or foot drop may be a sign that there is damage to
the nerve root

Pathologic changes:

Disc protrusion/bulge the outermost layers of the annulus fibrosus are still intact,
but can bulge when the disc is under pressure. In contrast to a herniation, none
of the nucleus pulposus escapes beyond the outer layers.

Disc herniation the annulus fibrosus is torn, allowing the nucleus pulposus to
bulge out beyond the damaged outer ring. Minor herniations may heal within a
few weeks. Severe herniations may not heal on their own and may require
surgical intervention.

Nerve root compression Pain due to nerve root compression has certain
characteristics: it tends to follow a dermatomal distribution it may be
accompanied by paresthesia or sensory loss in a dermatomal distribution it is
associated with a loss of power in the muscles innervated by the root.

Radiculopathy Each segment of the spinal cord gives rise to a ventral or

anterior motor and a dorsal or posterior sensory nerve root. The spinal nerve
roots can be damaged as they traverse the spinal (vertebral) canal, but are
especially vulnerable in the intervertebral foramina, where the ventral and dorsal
spinal roots join to form the spinal nerves. The consequence of nerve root
damage (from any cause) is known as a radiculopathy. The onset of root pain
due to intervertebral disc herniation is often abrupt, but it may also develop over
several hours or days after the start of back pain. Radicular pain is induced or
aggravated by movement. Violent pain brought on by coughing or sneezing is a
common complaint.

Sciatica Lumbosacral radiculopathies produce the syndrome of sciatica, and the

root pain of sciatica is almost invariably accompanied or preceded by back pain.
Sciatic pain usually is rather diffuse and difficult to localize. On occasion,
specific areas or points along the course of the sciatic nerve are tender and
painful. The dull pain associated with radiculopathy is often more prominent in
the proximal supply area of the damaged nerve root. It is usually deep, referred
to the muscles, bones or joints. The sharper pain is more likely to radiate along
dermatomal boundaries.

Brachialgia Cervical radiculopathies produce the syndrome of brachialgia, or

arm pain. The root pain of brachialgia is almost invariably accompanied or
preceded by neck pain.

Signs and Tests:

Posture, flexibility, range of motion, alignment, and curvature of the
spine are assessed during physical examination.
Sometimes, a neurological exam is performed to evaluate reflexes,
muscle strength, and nerve involvement.
Straight leg raise test (SLR or Lasegues sign) is done during
physical examination to determine whether low back pain is caused by an
underlying herniated disc. If the patient experiences sciatic pain when the
straight leg is at an angle of between 30 and 70 degrees, then the test is
positive and a herniated disc is likely to be the cause of the pain.

Imaging and Other Diagnostic Tests:

 Imaging: Xray and CT may be helpful, but MRI is most helpful in diagnosing
DDD. Xrays of the spine can be used to pinpoint narrowed disc space,
fractures, bone spurs, and arthritis. CT scan can be used to evaluate bone
structures and determine how much space is available for the nerve roots. MRI
scan can be used to detect bulging discs, herniation, and nerve root
compression.
Discography/CT: a technique of injecting the discs with dye and taking a CT
scan while the patient identifies the quality and severity of the pain in each
individual disc tested.
Electromyography (EMG, myogram): a neurodiagnostic test used to assess the
health and function of the muscles and the nerves that control the muscles.
Bone scan involves injecting a small amount of radioactive material into the
blood stream that travels through the body and collects in the bones. A computer
scanner is used to detect signs of arthritis.

Treatment: One or a combination of treatments such as physical therapy,

chiropractic manipulative therapy (CMT) and other chiropractic treatments,
osteopathic manipulation, antiinflammatory medications such as NSAIDs,
traction, or spinal injections often provide adequate relief of symptoms.

Surgery may be recommended if the conservative treatment options do not

provide relief within two to three months. If leg or back pain limits normal activity,
if there is weakness or numbness in the legs, if it is difficult to walk or stand, or if
medication or physical therapy are ineffective, surgery may be necessary, most
often spinal fusion.

Common surgeries:

Discectomy and Fusion: The intervertebral disc is removed and replaced with a
small plug of bone or other graft substitute, and in time, that will fuse the
vertebrae. Supplementary bone tissue, either from the patient (autograft) or a
donor (allograft), is used in conjunction with the body's natural bone growth
(osteoblastic) processes to fuse the vertebrae. Fusing of the spine is used
primarily to eliminate the pain caused by abnormal motion of the vertebrae by
immobilizing the faulty vertebrae themselves

Posterolateral fusion places the bone graft between the transverse

processes in the back of the spine. These vertebrae are then fixed in
place with screws and/or wire through the pedicles of each vertebra
attaching to a metal rod on each side of the vertebrae.

Interbody fusion places the bone graft between the vertebra in the area
usually occupied by the intervertebral disc. In preparation for the spinal

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 fusion, the disc is removed entirely

Corpectomy: removes a portion of the vertebra and adjacent intervertebral discs

to allow for decompression of the spinal cord and spinal nerves. A bone graft,
and in some cases a metal plate and screws, is used to stabilize the spine.
Corpectomy is often performed in association with some form of discectomy.

Dynamic stabilization: Following a discectomy, a stabilization implant is

implanted with a 'dynamic' component. This can be with the use pedicle screws
or an interspinous spacer with bands. These devices off load pressure from the
disc by rerouting pressure through the posterior part of the spinal column. Like a
fusion, these implants allow maintain mobility to the segment by allowing flexion
and extension.

Facetectomy: Excision of the articular facet of a vertebra to increase space.

Foraminotomy: A procedure that enlarges the vertebral foramen to increase the

size of the nerve pathway. This surgery can be done alone or with a laminotomy.

Intervertebral disc arthroplasty: also called Artificial Disc Replacement (ADR), or

Total Disc Replacement (TDR), is a type of arthroplasty. It is a surgical procedure
in which degenerated intervertebral discs in the spinal column are replaced with
artificial ones in the lumbar (lower) or cervical (upper) spine.

Laminectomy: part of the lamina is removed or trimmed to widen the spinal

canal and create more space for the spinal nerves and relieve pressure on the
spinal cord.

Laminoplasty: involves cutting the lamina on both sides of the affected

vertebrae (cutting through on one side and merely cutting a groove on the other)
and then "swinging" the freed flap of bone open thus relieving the pressure on
the spinal cord. The spinous process may be removed to allow the lamina bone
flap to be swung open. The bone flap is then propped open using small wedges
or pieces of bone such that the enlarged spinal canal will remain in place.

Laminotomy: A procedure that removes only a small portion of the lamina to

relieve pressure on the nerve roots.

Microdiscectomy: removes disc material through a very small incision using a

microscope.

Percutaneous disc decompression: reduces or eliminates a small portion of the

bulging disc through a needle inserted into the disc, minimally invasive.
 Spinal decompression: A noninvasive procedure that enlarges the Intra
Vertebral Foramen (IVF) by aiding in the rehydration of the spinal discs.

Spondylolisthesis (subluxation of vertebrae)

The anterior or posterior displacement of a vertebra or the vertebral column in relation to the
vertebrae below. Forward slippage of one vertebra on another is referred to as anterolisthesis,
while backward slippage is referred to as retrolisthesis. Spondylolisthesis can lead to a
deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or
compression of the exiting nerve roots (foraminal stenosis).

Typical physical changes that occur in an individual with spondylolisthesis will be a general
stiffening of the back and a tightening of the hamstrings, with a resulting change in both posture
and gait. The posture will typically give the appearance that the individual leans forward slightly
and/or that they are suffering from kyphosis (hunchback). In more advanced cases, the gait
may change to give the appearance of more of a "waddle" than a walk, where the individual
rotates the pelvis more due to the decreased mobility in the hamstrings.

An individual suffering from spondylolisthesis will typically experience generalized pain in the
lower back, along with intermittent shocks of shooting pain beginning in the buttock traveling
downward into the back of the thigh and/or lower leg. Sciatica that extends below the knee and
may be felt in the feet. Sometimes symptoms include tingling and numbness. An increase in
activity level, for an individual experiencing pain of this type, will likely cause the individual to
experience an increase in pain levels in the day(s) following the activity due to inflammation of
the soft tissues, which is alleviated with reduced activity and/or rest.

2 Types:

Isthmic occurs when one vertebral body slips forward on the one below it because of a
small fracture in a piece of bone that connects the two joints on the back side of the
spinal segment. The fracture is usually due to cumulative stress. Isthmic
spondylolisthesis occurs most commonly in the L5S1 level of the spine, the lowest level
of the lumbar spine. It does happen rarely above this level, at L4L5 or L3L4, but at these
levels trauma (rather than cumulative stress) is a more common cause of the fracture.

The fracture itself is known as a spondylolysis.

The severity of the slippage is usually measured after taking a sideview Xray, and then
graded on a scale of 1 to 4. The slippage is measured from the amount the upper
vertebral body slips forward on the lower vertebral body:

Low grade: Grade 1: 25% or less of vertebral body has slipped forward
 Grade 2: 26% 50%
High grade: Grade 3: 51% 75%
Grade 4: 76% 100%
Over 100% is Spondyloptosis, when the vertebra completely falls
off the supporting vertebra.

Degenerative Degenerative spondylolisthesis is a disease of the older adult that

develops as a result of facet arthritis and facet remodeling. Narrowing of the canal in
degenerative spondylolisthesis has been termed the "napkin ring effect." Imagine the
spinal canal as a series of napkin rings with one of the rings slid forward in comparison
to the others. The classic symptomology of patients with symptomatic degenerative
spondylolisthesis are similar to those with symptomatic lumbar spinal stenosis which
can be either neurogenic claudication or radiculopathy (either unilateral or bilateral
radiculopathy) with or without low back pain. Neurogenic claudication is thought to result
from central canal narrowing that is exacerbated by the listhesis (forward slip). The
classic symptoms of neurogenic claudication are bilateral (both legs) posterior leg pain
that worsens with activity, but is relieved by sitting or forward bending.

Treatment: Patients with symptomatic spondylolisthesis are initially offered

conservative treatment consisting of activity modification, pharmacological
intervention, and a physical therapy consultation.

Medication:
Antiinflammatory medications (NSAIDS) in combination with
acetaminophen (Tylenol) may be tried initially.
If severe radicular component is present, a short course of oral steroids
such as Prednisone or Methylprednisolone may be considered.
Epidural steroid injections, either interlaminar or transforaminal,
performed under fluoroscopic guidance can help with severe radicular
(leg) pain.

Orthoses (brace) may be of benefit for some patients but should be used
on a temporary basis to prevent spinal muscle atrophy and loss of
proprioception.

Surgical intervention:
Posterolateral fusion
Fusion with decompression

Spinal stenosis and neural foraminal stenosis

Each of the 33 bones of the spine has a large central opening for the spinal cord. Spinal
stenosis is abnormal narrowing of the spinal canal (central canal) that may occur in any of the
regions of the spine. This narrowing causes a restriction to the spinal cord, resulting in a
neurological deficit.

Additional openings, called foramina, allow the nerves branching from the spinal cord to travel to
the arms, legs and other parts of the body. Normally, nerve roots have enough room to easily
slip through the foramina. However, with age and conditions like arthritis, a foramen may
become clogged. Bony spurs can develop inside and press on the nerves.

The most common forms of spinal stenosis are cervical spinal stenosis, at the level of the neck,
and lumbar spinal stenosis, at the level of the lower back. Thoracic spinal stenosis, at the level
of the midback, is much less common. In lumbar stenosis, the spinal nerve roots in the lower
back are compressed which can lead to symptoms of sciatica. Cervical cord stenosis may lead
to serious symptoms such as major body weakness and paralysis.

Causes: Aging/degeneration, bone spurs, thickening of ligaments

Signs and Symptoms:

Common: Pain, numbness, weakness, paresthesia (sensation of tingling,
burning), standing discomfort, and loss of motor control. Doctors will check for
pain with hyperextension of the spine (bend backwards), and neurological
function.
Other: Nocturnal pain, gait disturbance, structural deformity, severe pain upon
lying down, severe or progressive neurologic deficit, lower back pain
People with more severe stenosis may have problems with bowel and bladder
function and foot disorders.

Tests: MRIs are helpful because they show more structures, including nerves,
muscles, and ligaments, than seen on xrays or CT scans.

Treatment: Medicine, weight loss, physical therapy, lumbar brace or corset,

surgery.

Medications: NSAIDs and acetaminophen corticosteroid injections

anesthetic injections

Surgery: Decompressive laminectomy laminectomy with or without

fusion

Ankylosing spondylitis
A longterm disease that causes inflammation of the joints between the spinal bones, and the
joints between the spine and pelvis. It eventually causes the affected spinal bones to join
together. The cause of ankylosing spondylitis is unknown, but genes seem to play a role.

Symptoms:
 The disease starts with low back pain that comes and goes.
Pain and stiffness are worse at night, in the morning, or after inactivity. It
may affect sleep.
The pain typically gets better with activity or exercise.
Back pain may begin in the sacroiliac joints (between the pelvis and the
spine). Over time, it may involve all or part of the spine.
Loss of motion or mobility in the lower spine. Difficulty fully expanding the
chest because the joints between the ribs are involved.
Fatigue is also a common symptom.
Other, less common symptoms include:
Eye inflammation or uveitis
Heel pain
Hip pain and stiffness
Joint pain and joint swelling in the shoulders, knees, and ankles
Loss of appetite
Slight fever
Weight loss

Tests may include:

CBC (complete blood count)
ESR (erythrocyte sedimentation rate)
HLAB27 antigen
Xrays of the spine and pelvis
MRI of the spine

Treatment:
NSAIDs may be prescribed to reduce inflammation and pain.
Corticosteroid therapy or medications to suppress the immune system
may also be prescribed. Drugs called TNFinhibitors (etanercept,
adalimumab, infliximab), which block an inflammatory protein, have been
shown to improve the symptoms of ankylosing spondylitis.
Some health care professionals use drugs that block cell growth
(cytotoxic drugs) in people who do not respond well to corticosteroids or
who are dependent on high doses of corticosteroids.
Surgery may be done if pain or joint damage is severe.
Prescribed exercises may help improve posture and breathing.

Complications:
Some patients may have pulmonary fibrosis or restrictive lung disease.

Myelopathy
Spinal cord compression caused by inflammatory diseases (e.g. rheumatoid arthritis) or disc
degeneration.

Symptoms:
When the spinal cord is slowly compressed, people may develop symptoms such
as tingling and numbness, weakness (trouble lifting objects, dropping things),
difficulty walking, widebased gait, coordination problems/clumsiness, neck pain
and stiffness.

Signs: Abnormal reflexes (usually overactive, hyperreflexia) weakness

numbness atrophy (muscles deteriorate and shrink).

Tests: Xray, MRI, and CT myelogram

Treatment: NSAIDs, soft collars, epidural steroid injections, chiropractic

manipulation, surgical intervention.

Surgery:
Anterior cervical diskectomy and fusion
Anterior cervical corpectomy and fusion.
Bone graft
Laminectomy
Laminoplasty

Scoliosis
Scoliosis is an abnormal curving of the spine. Everyones spine naturally curves a tiny bit. But
people with scoliosis have a spine that curves too much. The spine might look like the letter C
or S.
Types:
Idiopathic scoliosis: Cause is unknown. This is the most common type.

Congenital scoliosis: This type of scoliosis is present at birth. It occurs when the ribs or
spine bones do not form properly.

Neuromuscular scoliosis: This type is caused by a nervous system problem that affects
your muscles, such as cerebral palsy, muscular dystrophy, spina bifida, and polio.

Signs and Symptoms Usually there are no symptoms. But symptoms can include:
Backache or lowback pain
Tired feeling in the spine after sitting or standing for a long time
Uneven hips or shoulders (one shoulder may be higher than the other)
Spine curves more to one side

Tests:
 Xray of the spine
MRI of the spine
Spinal curve measurement (scoliometer screening)

Treatment: Treatment depends on many factors, including the cause, the location of the
curve, the size of the curve, and whether the person is still growing. A back brace
prevents further curving. Surgery may be need.

Complications of scoliosis can include:

Breathing problems (in severe scoliosis)
Low back pain
Lower selfesteem
Persistent pain if there is wear and tear of the spine bones
Spinal infection after surgery
Spine or nerve damage from an uncorrected curve or spinal surgery

Osteoporosis
Osteoporosis is the thinning of bone tissue and loss of bone density over time. It is the most
common type of bone disease. Osteoporosis occurs when the body fails to form enough new
bone, when too much old bone is reabsorbed by the body, or both. Calcium and phosphate are
two minerals that are essential for normal bone formation. As you age, calcium and phosphate
may be reabsorbed back into the body from the bones, which makes the bone tissue weaker.
This can result in brittle, fragile bones that are more prone to fractures, even without injury.

Many times, a person will have a fracture before becoming aware that the disease is present.
By the time a fracture occurs, the disease is in its advanced stages and damage is severe.

Causes: leading causes of osteoporosis are a drop in estrogen in women at the time of
menopause and a drop in testosterone in men. Other causes include confinement to
bed chronic rheumatoid arthritis, kidney disease, or eating disorders taking
corticosteroid medications and some antiseizure drugs hyperparathyroidism and
vitamin D deficiency.

Symptoms: There are no symptoms in the early stages of the disease.

Symptoms that appear as the disease progresses include:
Bone pain or tenderness
Fractures with little or no trauma
Loss of height (as much as 6 inches) over time
Low back pain due to fractures of the spinal bones
Neck pain due to fractures of the spinal bones
Stooped posture or kyphosis, also called a "dowager's hump"

Signs and Tests:

 Simple xrays of bones are not very accurate in predicting whether someone is
likely to have osteoporosis, though they may show fractures or collapse of spinal
bones in severe cases.
Bone mineral density testing (specifically a densitometry or DEXA scan) is used
to predict the risk for bone fractures in the future.
A special type of spine CT that can show loss of bone mineral density,
quantitative computed tomography (QCT), may be used in rare cases

Treatment:
Medication: Medications are used to strengthen bones when:
Osteoporosis has been diagnosed by a bone density study.
Osteopenia (thin bones, but not osteoporosis) has been diagnosed by a
bone density study, if a bone fracture has occurred.

It is critical to prevent falls. People with osteoporosis should avoid

sedating medications, slippery surfaces, and hazards to reduce the risk of
fractures.

Rheumatoid Arthritis (R.A.) is an autoimmune disease, which means the body's immune
system mistakenly attacks healthy tissue. Its cause is unknown. Infection, genes, and hormone
changes may be linked to the disease.

Symptoms: morning stiffness which lasts more than one hour warm, tender, stiff
joints when not used fatigue loss of range of motion joint deformity chest pain
when breathing (pleurisy) dry eyes and mouth (Sjogren syndrome) eye burning,
itching, and discharge nodules under the skin (usually sign of more severe
disease numbness, tingling, or burning in the hands and feet sleep difficulties

Signs and Tests:

Rheumatoid factor test
AntiCCP antibody test
Complete blood count
Creactive protein
Erythrocyte sedimentation rate
Joint ultrasound or MRI
Joint xrays
Synovial fluid analysis

Treatment: RA usually requires lifelong treatment, including medications,

physical therapy, exercise, education, and possibly surgery. Early, aggressive
treatment for RA can delay joint destruction. Disease modifying antirheumatic
drugs (DMARDs) are the first drugs usually tried in patients with RA. They are
prescribed in addition to rest, strengthening exercises, and antiinflammatory
drugs. Physical therapy can delay the loss of joint function.

Medications:
DMARDs: Methotrexate (Rheumatrex), Leflunomide (Arava) and
chloroquine. These cause serious side effects and frequent blood tests
are required while taking them.

Antiinflammatory: Aspirin and NSAIDs (e.g. ibuprofen and naprosen)

Longterm use can cause stomach problems and heart problems

Celecoxib (Celebrex): another antiinflammatory, with potential for

serious side effects including heart disease and stroke

Antimalarial medications: hydroxychloroquine (Plaquenil) which may

take weeks or months to provide any benefit

Corticosteroids: reduce joint swelling and inflammation. Because of

longterm side effects, corticosteroids should be taken only for a short
time and in low doses when possible.

Biologic agents (e.g. white blood cell modulators including abatacept

(Orencia) and rituximab (Rituxan) tumor necrosis factor (TNF) inhibitors
including adalimumab (Humira), etanercept (Enbrel), infliximab
(Remicade), golimumab (Simponi), and certolizumab (Cimzia) and
Interleukin6 (IL6) inhibitors: tocilizumab (Actemra). These are given
when other medicines for rheumatoid arthritis have not worked. Most are
given subcutaneously or intravenously. People taking these drugs must
be watched very closely because of serious risk factors, including
infections from bacteria, viruses, and fungi, leukemia or lymphoma, and
psoriasis

Surgeries:
Removal of the joint lining (synovectomy)
Total joint replacement in extreme cases may include total knee, hip
replacement, ankle replacement, shoulder replacement, and others

Complications:
Damage to lung tissue (rheumatoid lung)
Increased risk of hardening of the arteries
Spinal injury when the neck bones become damaged
Inflammation of the blood vessels (rheumatoid vasculitis), which can
lead to skin, nerve, heart, and brain problems
Swelling and inflammation of the outer lining of the heart (pericarditis)
 and of the heart muscle (myocarditis), which can lead to congestive heart
failure

Psoriatic Arthritis Psoriasis is a common, chronic skin condition that causes red patches on
the body. About 1 in 20 people with psoriasis will develop arthritis with the skin condition. In
most cases, psoriasis comes before the arthritis.

Symptoms: The arthritis may be mild and involve only a few joints, particularly
those at the end of the fingers or toes. In some people, the disease may be
severe and affect many joints, including the spine, resulting in stiffness, burning,
and pain, most often in the lower spine and sacrum. People who also have
arthritis usually have the skin and nail changes of psoriasis. Often, the skin gets
worse at the same time as the arthritis.

Signs: Joint swelling skin patches (psoriasis) and pitting in the nails tenderness

Tests: Xrays of the joints

Treatment: Antiinflammatory medication, steroid injections, and surgery in rare

cases. Rest, exercise, hot and cold therapy, and physical therapy may help.

Medications:
NSAIDS
DMARDs (when the disease is more severe): Leflunomide,
Methotrexate, Sulfasalazine
TNF inhibitors: Adalimumab (Humira), Etanercept (Enbrel), Golimumab
(Simponi), Infliximab (Remicade)

Surgeries:
Replace or repair damaged joints (rare cases)

Repetitive Stress Disorder (Repetitive Stress Injury (RSI) or Overuse Syndrome)

An injury to a part of the body that is caused by overusing or exerting to much stress on that
body part. Stress occurs when the body part is called on to work harder, stretch farther, impact
more directly or otherwise function at a greater level then it is prepared for. The immediate
impact may be minute, but when it occurs repeatedly the constant stressing cause damage.
The term repetitive stress disorder identifies a large group of conditions that result from using
the body in a way it is not designed for or capable of comfortably working.

These conditions are often focused on a joint and usually affect the muscle, bone, tendon or
bursa of the joint. However other anatomical features and areas can be stressed and their
response to that stress can be an injury.

20
20
Some common examples of repetitive stress disorders are:
Carpal Tunnel Syndrome
Tendonitis
Bursitis
Tennis Elbow
Trigger Finger

Carpal Tunnel Syndrome (CTS)

Carpal tunnel syndrome is pressure on the median nerve the nerve in the wrist that supplies
feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or
muscle damage in the hand and fingers.

The median nerve provides feeling and movement to the "thumb side" of the hand (the palm,
thumb, index finger, middle finger, and thumb side of the ring finger).

The area in your wrist where the nerve enters the hand is called the carpal tunnel. This tunnel is
normally narrow, so any swelling can pinch the nerve and cause pain, numbness, tingling or
weakness. This is called carpal tunnel syndrome.

Causes: Carpal tunnel syndrome is common in people who perform repetitive motions
of the hand and wrist. Typing on a computer keyboard is probably the most common
cause of carpal tunnel. Other activities that commonly cause it are: sewing, driving,
assembly line work, painting, writing, use of tools (especially hand tools or tools that
vibrate), playing certain sports and musical instruments. Several medical problems are
associated with CTS, including bone fractures, diabetes, alcoholism, hypothyroidism,
kidney failure, obesity, and R.A.

Symptoms:
Numbness or tingling in the thumb and next two or three fingers of one or both
hands
Numbness or tingling of the palm of the hand
Pain extending to the elbow
Pain in wrist or hand in one or both hands
Problems with fine finger movements (coordination) in one or both hands
Wasting away of the muscle under the thumb (in advanced or longterm cases)
Weak grip or difficulty carrying bags (a common complaint)
Weakness in one or both hands

Signs: During physical exam (PE), the doctor may find:

Numbness in the palm, thumb, index finger, middle finger, and thumb side of
the ring finger
Weak hand grip
Tinel's sign: tapping over the median nerve at the wrist may cause pain to
 shoot from the wrist to the hand
Phalen's test: Bending the wrist forward all the way for 60 seconds will usually
result in numbness, tingling, or weakness

Test:
Electromyography (EMG)
Nerve conduction velocity tests
Wrist xrays

Treatment: Splints hot and cold compresses NSAIDs corticosteroid injections,

given into the carpal tunnel area, may relieve symptoms for a period of time
changes to work conditions surgery

Surgery:
Carpal Tunnel Release: Symptoms often improve with treatment, but
more than 50% of cases eventually require surgery. Surgery is often
successful, but full healing can take months. Carpal tunnel release is a
surgical procedure that cuts into the ligament that is pressing on the
nerve. Surgery is successful most of the time, but it depends on how long
the nerve compression has been occurring and its severity.

Ulnar Neuropathy
Ulnar neuropathy is a disorder involving the ulnar nerve. Ulnar neuropathy may be caused by
entrapment of the ulnar nerve at the elbow or wrist with resultant numbness and tingling into the
fourth and fifth fingers.

When the nerve compression occurs at the elbow, it is called "cubital tunnel syndrome."

Causes:

Near the elbow: Compression during surgery, blunt trauma, deformities (e.g.,
rheumatoid arthritis), metabolic derangements (e.g., diabetes), transient occlusion of
brachial artery during surgery, subdermal contraceptive implant, venipuncture,
hemophilia leading to hematomas, malnutrition leading to muscle atrophy and loss of
fatty protection across the elbow and other joints, cigarette smoking.

At Guyons canal: ganglionic cysts, tumor, blunt injuries with or without fracture,
aberrant artery, or idiopathic.

Signs:
Motor function can be assessed by testing for a positive Froments sign, or
making an OK sign (which the patient will be unable to do). Little finger abduction
can be tested as well.
 Weakness may be a presenting complaint, but the complaint may be expressed
in subtle ways, such as complaints of the little finger getting caught on the edge
of the pants pocket when the patient puts his hands into the pocket. Because of
the ulnar dysfunction, the patient cannot abduct the fifth digit tightly against the
fourth because of weakness of the interosseous muscles. The finger tends to
stick out and get caught on objects.
Complaints of weak grip. Many of the grip muscles are ulnar.
Froment sign: the thumb flexes at the distal joint due to the the median
innervated flexor pollicis longus partially compensating for the weakened
adductor pollicis

Tests:
Xrays may show bone spurs or other conditions that might be compressing the
nerve. They do not show actual compression of the ulnar nerve.

Nerve conduction studies determine how well the nerve is working and help
identify where it is being compressed. During a nerve conduction test, the nerve
is stimulated in one place and the time it takes for there to be a response is
measured. Several places along the nerve will be tested and the area where the
response takes too long is likely to be the place where the nerve is compressed.

Nerve conduction studies can also determine whether the compression is also
causing muscle damage. During the test, small needles are put into some of the
muscles that the ulnar nerve controls. Muscle involvement is a sign of more
severe nerve compression.

Treatment: NSAIDs, steroid injections, bracing or splinting, nerve gliding

exercises, surgery.

Surgery:
Cubital tunnel release: the ligament "roof" of the cubital tunnel is cut and
divided. This increases the size of the tunnel and decreases pressure on
the nerve.
Ulnar nerve anterior transposition: More commonly, the nerve is moved
from its place behind the medial epicondyle to a new place in front of it.
This is called an anterior transposition of the ulnar nerve. The nerve can
be moved to lie under the skin and fat but on top of the muscle
(subcutaneous transposition), within the muscle (intermuscular
transposition) or under the muscle (submuscular transposition). Moving
the nerve to the front of the medial epicondyle prevents it from getting
caught on the bony ridge and stretching when you bend your elbow.
Medial epicondylectomy: Another option to release the nerve is to
remove part of the medial epicondyle. This technique also prevents the
 nerve from getting caught on the boney ridge and stretching when the
elbow is bent.

Fibromyalgia (FMS)
Fibromyalgia is a common syndrome in which a person has longterm, bodywide pain and
tenderness in the joints, muscles, tendons, and other soft tissues. Fibromyalgia has also been
linked to fatigue, sleep problems, headaches, depression, and anxiety.

Cause: Unknown. Possible causes may include physical or emotional trauma

abnormal pain response areas in the brain that are responsible for pain may react
differently in fibromyalgia patients sleep disturbances infection, such as a virus,
although none has been identified

Associated conditions: chronic neck or back pain, chronic fatigue syndrome, depression,
hypothyroidism, Lyme disease, sleep disorder.

Symptoms:
Painful areas are called tender points. Tender points are found in the soft tissue
on the back of the neck, shoulders, chest, lower back, hips, shins, elbows, and
knees. The pain then spreads out from these areas.
The pain may feel like a deep ache, or a shooting, burning pain.
The joints are not affected, although the pain may feel like it is coming from the
joints.
Awakening with body aches and stiffness, which may last all day
Pain may get worse with activity, cold or damp weather, anxiety, and stress
Fatigue, depressed mood, and sleep problems are seen in almost all patients
with fibromyalgia. Many say that they can't get to sleep or stay asleep, and they
feel tired when they wake up
Symptoms may also include:
Irritable bowel syndrome (IBS)
Memory and concentration problems
Numbness and tingling in hands and feet
Palpitations
Reduced ability to exercise
Tension or migraine headaches

Signs and Tests:

To be diagnosed with fibromyalgia, you must have had at least 3 months of
widespread pain, and pain and tenderness in at least 11 of 18 areas, including:
Arms (elbows)
Buttocks
Chest
Knees
 Lower back
Neck
Rib cage
Shoulders
Thighs

Treatment: physical therapy, exercise and fitness program, stressrelief methods,

including massage and relaxation techniques. Cognitive behavioral therapy can
be an important part of treatment.

Medications:
Doctors may prescribe an antidepressant or muscle relaxant.
Duloxetine (Cymbalta), pregabalin (Lyrica), and milnacipran (Savella) are
approved specifically for treating fibromyalgia.
Other drugs are also prescribed to treat it: antiseizure drugs, other
antidepressants, muscle relaxants, pain relievers, sleeping aids.
Severe cases of fibromyalgia may require a referral to a pain clinic

Myofascial Pain Syndrome (MPS)

Myofascial Pain Syndrome is also a localized musculoskeletal pain producing condition whose
diagnostic and management criteria differ from FMS but still considered by many only a subtype
of FMS.

The common important feature to both conditions is muscle pain along with the taut or rope like
bands in the muscles. In MPS, the painful points in the taut bands are called trigger points
(TP). These points are so precise and painful that on their palpation, patient shows a jump
sign associated with referred pain. The tender points within the sore muscle of fibromyalgia
are not associated with jump sign or referred pain.

Compartment Syndrome
A serious condition that involves increased pressure in a muscle compartment. It can lead to
muscle and nerve damage and problems with blood flow.

Thick layers of tissue, called fascia, separate groups of muscles in the arms and legs from each
other. Inside each layer of fascia is a confined space, called a compartment. The compartment
includes the muscle tissue, nerves, and blood vessels. Fascia surrounds these structures,
similar to the way in which insulation covers wires.

Fascia do not expand. Any swelling in a compartment will lead to increased pressure in that
area, which will press on the muscles, blood vessels, and nerves. If this pressure is high
enough, blood flow to the compartment will be blocked. This can lead to permanent injury to the
muscle and nerves. If the pressure lasts long enough, the muscles may die and the limb may
need to be amputated.
Swelling that leads to compartment syndrome occurs from trauma such as a car accident or
crush injury, or surgery. Swelling can also be caused by complex fractures or soft tissue injuries
due to trauma. Longterm (chronic) compartment syndrome can be caused by repetitive
activities, such as running. The pressure in a compartment only increases during that activity.
Compartment syndrome is most common in the lower leg and forearm, although it can also
occur in the hand, foot, thigh, and upper arm.

Symptoms: The hallmark symptom of compartment syndrome is severe pain that

does not go away with pain medicine or with raising the affected area. In more
severe cases, symptoms may include:
Decreased sensation
Paleness of skin
Weakness

Signs and Tests:

Pain when the compartment is squeezed
Severe pain with movement of the affected area (for example, a person
with compartment syndrome in the foot or lower leg will experience
severe pain when moving the toes up and down)
Swollen and shiny skin

To confirm the diagosis, the health care provider will directly measure the
pressure in the compartment. This is done using a needle attached to a pressure
meter into the compartment. The needle is inserted into the affected area.
Specific pressure measurements will lead to a diagnosis of compartment
syndrome. When the health care provider suspects chronic compartment
syndrome, this test must be performed during and after the activity that causes
pain.

Treatment:
Surgery is needed. Long surgical cuts are made through the fascia to relieve the
pressure. The wounds can be left open (covered with a sterile dressing) and
closed during a second surgery, usually 48 72 hours later. Skin grafts may be
needed to close the wound.

In more severe cases, amputation may be required.

Prognosis:
With prompt diagnosis and treatment, the outlook is excellent for recovery of the
muscles and nerves inside the compartment. However, the overall prognosis will
be determined by the injury leading to the syndrome.
 Permanent nerve injury and loss of muscle function can result if the diagnosis is
delayed. This is more common when the injured person is unconscious or heavily
sedated and cannot complain of pain. Permanent nerve injury can occur after 12
24 hours of compression.

Complex regional pain syndrome (CRPS)

Formerly Begum Syndrome, this is a chronic progressive disease characterized by severe pain,
swelling and changes in the skin. It often affects an arm or a leg and may spread to another part
of the body and is associated with dysregulation of the autonomic nervous system resulting in
multiple functional loss, impairment and disability. Though treatment is often unsatisfactory,
early multimodal therapy can cause dramatic improvement or remission of the syndrome in
some patients. The International Association for the Study of Pain has proposed dividing CRPS
into two types based on the presence of nerve lesion following the injury.

Type I, formerly known as reflex sympathetic dystrophy (RSD), Sudeck's

atrophy, reflex neurovascular dystrophy (RND) or algoneurodystrophy, does
not have demonstrable nerve lesions.

Type II, formerly known as causalgia, has evidence of obvious nerve damage.

Cause: Currently unknown. Precipitating factors include injury and surgery, although
there are documented cases that have no demonstrable injury to the original site.

Gout
A condition usually characterized by recurrent attacks of acute inflammatory arthritisa red,
tender, hot, swollen joint. The metatarsalphalangeal joint at the base of the big toe is the most
commonly affected (approximately 50% of cases). Other joints, such as the heels, knees, wrists
and fingers, may also be affected. Other symptoms may rarely occur along with the joint pain,
including fatigue and a high fever. Longstanding elevated uric acid levels (hyperuricemia) may
result in other symptomatology, including hard, painless deposits of uric acid crystals known as
tophi. Extensive tophi may lead to chronic arthritis due to bone erosion. Elevated levels of uric
acid may also lead to crystals precipitating in the kidneys, resulting in stone formation and
subsequent urate nephropathy.

Gout is caused by elevated levels of uric acid in the blood. The uric acid crystallizes, and the
crystals deposit in joints, tendons, and surrounding tissues. Treatment with nonsteroidal anti-
inflammatory drugs (NSAIDs), steroids, or colchicine improves symptoms. Once the acute
attack subsides, levels of uric acid are usually lowered via lifestyle changes, and in those with
frequent attacks, allopurinol or probenecid provide longterm prevention.

Dietary causes account for about 12% of gout, and include a strong association with the
consumption of alcohol, fructosesweetened drinks, meat, and seafood. Other triggers include
physical trauma and surgery. The occurrence of gout is partly genetic.
Gout frequently occurs in combination with other medical problems. Metabolic syndrome, a
combination of abdominal obesity, hypertension, insulin resistance and abnormal lipid levels,
occurs in nearly 75% of cases. Other conditions commonly complicated by gout include:
polycythemia, lead poisoning, renal failure, hemolytic anemia, psoriasis, and solid organ
transplants

Hernia
A protrusion of an organ or the fascia of an organ through the wall of the cavity that normally
contains it. There are different kinds of hernia, each requiring a specific management or
treatment.

By far the most common hernias develop in the abdomen, when a weakness in the abdominal
wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal
organs covered with peritoneum, may protrude. Another common hernia involves the spinal
discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the
mediastinum through the esophageal opening in the diaphragm.

Hernias may or may not present with either pain at the site, a visible or palpable lump, or in
some cases more vague symptoms resulting from pressure on an organ which has become
"stuck" in the hernia, sometimes leading to organ dysfunction.

Symptoms may not be present in some inguinal hernias while in some other hernias, including
inguinal, they are. Symptoms and signs vary depending on the type of hernia. In the case of
reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt.
When standing, such bulge becomes more obvious. Besides the bulge, other symptoms include
pain in the groin that may also include a heavy or dragging sensation, and in men, there is
sometimes pain and swelling in the scrotum around the testicular area.

Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant
symptom is that they cannot return to the abdominal cavity when pushed in. They may be
chronic, although painless, and can lead to strangulation. Strangulated hernias are always
painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases
due to bowel obstruction.

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Special Senses

Special senses are any of the five senses related to the organs of sight, hearing, smell, taste,
and touch.

Visual System

Function: the part of the central nervous system which enables organisms to process visual
detail, as well as enabling several nonimage forming photoresponse functions. The visual
system plays an important role in the ability of an individual to control balance and maintain an
upright posture. The psychological manifestation of visual information is known as visual
perception, a lack of which is called blindness.

Usual treatment providers:

Ophthalmologist An eye surgeon who is a Doctor of Medicine (MD).
Ophthalmic medical practitioner A medical doctor (MD) who specializes in ophthalmic
conditions but who has not completed a specialization in ophthalmology.
Optometrist A Doctor of Optometry (OD) treats eye diseases and disorders and
specializes in optics and vision correction.

Key terms and components:

Eye
The eye is a fused twopiece unit. The smaller frontal unit, more curved, called the cornea is
linked to the larger unit called the sclera. The corneal segment is typically about 8 mm (0.3 in) in
radius. The sclerotic chamber constitutes the remaining fivesixths its radius is typically about
12 mm. The cornea and sclera are connected by a ring called the limbus. The iris the color of
the eye and its black center, the pupil, are seen instead of the cornea due to the cornea's
transparency. To see inside the eye, an ophthalmoscope is needed, since light is not reflected
out. The fundus (area opposite the pupil) shows the characteristic pale optic disk (papilla),
where vessels entering the eye pass across and optic nerve fibers depart the globe.

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The eye is made up of three coats, enclosing three transparent structures. The outermost layer
is composed of the cornea and sclera. The middle layer consists of the choroid, ciliary body,
and iris. The innermost is the retina, which gets its circulation from the vessels of the choroid as
well as the retinal vessels, which can be seen in an ophthalmoscope. Within these coats are
the aqueous humor, the vitreous body, and the flexible lens. The aqueous humor is a clear fluid
that is contained in two areas: the anterior chamber between the cornea and the iris and
exposed area of the lens. The lens is suspended to the ciliary body by the suspensory ligament
(Zonule of Zinn), made up of fine transparent fibers. The vitreous body, the posterior chamber,
is a clear jelly that is much larger than the aqueous humor, present behind lens and the rest,
and is bordered by the sclera, zonule, and lens. They are connected via the pupil.

OD (oculus dexter)
Right eye.

OS (oculus sinister)
Left eye.

OU (oculi uterque)
Both eyes.

Visual field
The field of vision is that portion of space in which objects are visible at the same moment
during steady fixation of gaze in one direction. The monocular visual field consists of central
vision, which includes the inner 30 degrees of vision and central fixation, and the peripheral
visual field, which extends 100 degrees laterally, 60 degrees medially, 60 degrees upward, and
75 degrees downward.

A normal visual field is an island of vision measuring 90 degrees temporally to central fixation,
50 degrees superiorly and nasally, and 60 degrees inferiorly. Visual acuity increases from
movement discrimination in the extreme peripheral vision to better than 20/20 in the center of
vision. Depression or absence of vision anywhere in the island of vision is abnormal.

Peripheral vision
Part of vision that occurs outside the very centre of gaze. There is a broad set of noncentral
points in the field of view that is included in the notion of peripheral vision. "Far peripheral" vision
exists at the edges of the field of view, "midperipheral" vision exists in the middle of the field of
view, and "nearperipheral", sometimes referred to as "paracentral" vision, exists adjacent to
the center of gaze.. The loss of peripheral vision while retaining central vision is known as
tunnel vision, and the loss of central vision while retaining peripheral vision is known as central
scotoma.

Retina
A lightsensitive tissue lining the inner surface of the eye. The optics of the eye create an image
of the visual world on the retina, which serves much the same function as the film in a camera.
Light striking the retina initiates a cascade of chemical and electrical events that ultimately
trigger nerve impulses. These are sent to various visual centers of the brain through the fibers of
the optic nerve.

Optic nerve
The optic nerve, also known as cranial nerve 2, transmits visual information from the retina to
the brain.

Visual acuity
20/20 vision is a term used to express normal visual acuity (the clarity or sharpness of vision)
measured at a distance of 20 feet. If you have 20/20 vision, you can see clearly at 20 feet what
should normally be seen at that distance. If you have 20/100 vision, it means that you must be
as close as 20 feet to see what a person with normal vision can see at 100 feet. 20/20 does not
necessarily mean perfect vision. 20/20 vision only indicates the sharpness or clarity of vision at
a distance. There are other important vision skills, including peripheral awareness or side vision,
eye coordination, depth perception, focusing ability and color vision that contribute to overall
visual ability.

Some people can see well at a distance, but are unable to bring nearer objects into focus. This
condition can be caused by hyperopia (farsightedness) or presbyopia (loss of focusing ability).
Others can see items that are close, but cannot see those far away. This condition may be
caused by myopia (nearsightedness).

When checking visual acuity, one eye is covered at a time and the vision of each eye is
recorded separately, as well as both eyes together. In the Snellen fraction 20/20, the first
number represents the test distance, 20 feet. The second number represents the distance that
the average eye can see the letters on a certain line of the eye chart.

Visual efficiency
Visual efficiency skills include: depth perception, color perception, and oculomotor skills such
as eye teaming, eye movement, and eye focusing speed and accuracy. An individual with
20/20 vision can still have problems with visual efficiency skills. The Visual Efficiency
Evaluation (VEE) is a specialized test battery that carefully examines the visual system. Many
patients have good eyesight, 20/20 or better, but have symptoms due to poor visual efficiency.

Table 1: Percentage of Visual Acuity Efficiency Corresponding to the BestCorrected Visual

Acuity Measurement for Distance in the Better Eye
Snellen Percent visual acuity
efficiency
 English Metric

20/16 6/5 100

20/20 6/6 100

20/25 6/7.5 95

20/30 6/9 90

20/40 6/12 85

20/50 6/15 75

20/60 6/18 70

20/70 6/21 65

20/80 6/24 60

20/100 6/30 50

For people who have worse than 20/400 vision, a different eye chart can be used that measures
beyond 20/400 vision, or, for the most accurate measurements, a Low Vision Chart can be
moved closer to the patient to measure the smallest letter that they can see at a lesser distance.
It is common to record vision worse than 20/400 as Count Fingers (CF at a certain number of
feet), Hand Motion (HM at a certain number of feet), Light Perception (LP), or No Light
Perception (NLP). The conversion of Snellen Acuity to Count Fingers Acuity is as follows:

20/800 CF10' (Count Fingers at ten feet)

20/1000 CF 8'
20/1143 CF 7'
20/1333 CF 6'
20/1600 CF 5'
20/2000 CF 4'
20/2666 CF 3'
20/4000 CF 2'
20/8000 CF 1'

Common Conditions:
Retinopathy
Retinopathy is a general term that refers to some form of persistent (i.e. inflammation) or acute
(i.e. photon beam radiation) damage to the retina of the eye. Vascular remodeling occurs over
periods of time where the patient may not fully realize the extent of their disease, until it is too
late. Frequently, retinopathy is an ocular manifestation of systemic disease as seen in diabetes
or hypertension.

Early diabetic retinopathy: when diabetic retinopathy is in the mild or moderate stage,
good blood sugar control can usually slow the progression of diabetic retinopathy.

Advanced diabetic retinopathy: proliferative diabetic retinopathy requires prompt

surgical treatment. Sometimes surgery is also recommended for severe nonproliferative
diabetic retinopathy. Surgery often slows or stops the progression of diabetic
retinopathy, but it's not a cure. Because diabetes is a lifelong condition, future retinal
damage and vision loss are possible.

Treatment: Depending on the specific problems, options may include:

Focal laser treatment: stops or slows the leakage of blood and fluid in the eye
Scatter laser treatment: shrinks the abnormal blood vessels
Vitrectomy: This procedure can be used to remove blood from the middle of the
eye (vitreous) as well as any scar tissue that's tugging on the retina.

Glaucoma
Glaucoma refers to a group of eye conditions that lead to damage to the optic nerve. In most
cases, damage to the optic nerve is due to increased pressure in the eye, also known as
intraocular pressure (IOP). Glaucoma is the second most common cause of blindness in the
United States.

Symptoms:
OpenAngle Glaucoma
Most people have no symptoms
Once vision loss occurs, the damage is already severe
There is a slow loss of side (peripheral) vision (also called tunnel vision)
Advanced glaucoma can lead to blindness
AngleClosure Glaucoma
Symptoms may come and go at first, or steadily become worse
Sudden, severe pain in one eye
Decreased or cloudy vision, often called "steamy" vision
Nausea and vomiting
Rainbowlike halos around lights
Red eye
Eye feels swollen
 Congenital Glaucoma
Symptoms are usually noticed when the child is a few months old
Cloudiness of the front of the eye
Enlargement of one eye or both eyes
Red eye
Sensitivity to light
Tearing

Treatment: The goal of treatment is to reduce eye pressure. Treatment depends

on the type of glaucoma. Most people can be treated successfully with eye
drops. You may also be given pills to lower pressure in the eye. Other
treatments include:
Laser therapy called an iridotomy
Eye surgery if other treatments do not work

In an acute angleclosure attack, which is a medical emergency, blindness will

occur in a few days if it is not treated. Treatment includes:
Eye drops
Medicines to lower eye pressure, given by mouth and intravenously

Cataracts
A cataract is a clouding of the lens of the eye that affects vision. Most cataracts are related to
aging. Cataracts are very common in older people. A cataract can occur in either or both eyes.
It cannot spread from one eye to the other.

The lens is a clear part of the eye that helps to focus light, or an image, on the retina. The retina
is the lightsensitive tissue at the back of the eye. In a normal eye, light passes through the
transparent lens to the retina. Once it reaches the retina, light is changed into nerve signals that
are sent to the brain. The lens must be clear for the retina to receive a sharp image. If the lens
is cloudy from a cataract, the image will be blurred.

Although most cataracts are related to aging, there are other types of cataract:
1. Secondary cataract. Cataracts can form after surgery for other eye problems, such as
glaucoma. Cataracts also can develop in people who have other health problems, such
as diabetes. Cataracts are sometimes linked to steroid use.
2. Traumatic cataract. Cataracts can develop after an eye injury, sometimes years later.
3. Congenital cataract. Some babies are born with cataracts or develop them in childhood,
often in both eyes. These cataracts may be so small that they do not affect vision. If they
do, the lenses may need to be removed.
4. Radiation cataract. Cataracts can develop after exposure to some types of radiation.

How cataracts affect vision:

1. Clumps of protein reduce the sharpness of the image reaching the retina. The lens
consists mostly of water and protein. When the protein clumps up, it clouds the lens and
reduces the light that reaches the retina. The clouding may become severe enough to
cause blurred vision. Most agerelated cataracts develop from protein clumpings.

When a cataract is small, the cloudiness affects only a small part of the lens, there may
not be noticeable changes in vision. Cataracts tend to "grow" slowly, so vision gets
worse gradually. Over time, the cloudy area in the lens may get larger, and the cataract
may increase in size. Seeing may become more difficult. Vsion may get duller or blurrier.

2. The clear lens slowly changes to a yellowish/brownish color, adding a brownish tint to
vision. As the clear lens slowly colors with age, vision gradually may acquire a brownish
shade. Over time, increased tinting may make it more difficult to read and perform other
routine activities. This gradual change in the amount of tinting does not affect the
sharpness of the image transmitted to the retina. With advanced lens discoloration, a
person may not be able to identify blues and purples.

Symptoms:
Cloudy or blurry vision.
Colors seem faded.
Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear
around lights.
Poor night vision.
Double vision or multiple images in one eye. (This symptom may clear as the
cataract gets larger.)
Frequent prescription changes in eyeglasses or contact lenses.

Tests:
1. Visual acuity test. This eye chart test measures how well you see at various
distances.
2. Dilated eye exam. Drops are placed in the eyes to widen, or dilate, the pupils. A
special magnifying lens is used to examine the retina and optic nerve for signs of
damage and other eye problems.
3. Tonometry. An instrument measures the pressure inside the eye.

Treatment:
The symptoms of early cataract may be improved with new eyeglasses, brighter lighting,
antiglare sunglasses, or magnifying lenses. If these measures do not help, surgery is
the only effective treatment. Surgery involves removing the cloudy lens and replacing it
with an artificial lens. Sometimes a cataract should be removed even if it does not cause
problems with vision. For example, a cataract should be removed if it prevents
examination or treatment of another eye problem, such as agerelated macular
degeneration or diabetic retinopathy.
 Surgery:
1. Phacoemulsification, or phaco. A small incision is made on the side of the cornea. The
doctor inserts a tiny probe into the eye. This device emits ultrasound waves that soften
and break up the lens so that it can be removed by suction. Most cataract surgery today
is done by phacoemulsification, also called "small incision cataract surgery."
2. Extracapsular surgery. A longer incision is made on the side of the cornea to remove
the cloudy core of the lens in one piece. The rest of the lens is removed by suction.

After the natural lens has been removed, it often is replaced by an artificial lens, called
an intraocular lens (IOL). An IOL is a clear, plastic lens that requires no care and
becomes a permanent part of the eye.

Macular Degeneration (AMD)

Macular degeneration is an eye disorder that slowly destroys sharp, central vision. This makes it
difficult to see fine details and read. A part of the retina called the macula makes vision sharper
and more detailed. AMD is caused by damage to the blood vessels that supply the macula,
which harms the macula.

Types of AMD:
Dry AMD occurs when the blood vessels under the macula become thin and brittle.
Small yellow deposits, called drusen, form. Almost all people with macular degeneration
start with the dry form.

Wet AMD occurs in only about 10% of people with macular degeneration. New
abnormal and very fragile blood vessels grow under the macula. This is called choroidal
neovascularization. These vessels leak blood and fluid. This form causes most of the
vision loss associated with the condition.

Symptoms of Dry AMD:

Blurred vision
Objects in central vision look distorted and dim, and colors look faded
Trouble reading
Blurred spot in center of vision gradually enlarges and darkens

Symptoms of Wet AMD:

Straight lines appear distorted and wavy
There may be a small dark spot in the center of vision that gets larger over time
Central vision loss can occur very quickly
Tests:
Eye exam
Amsler grid
 Fluorescein angiogram
Fundus photography
Optical coherence tomography (OCT)

Treatment:
In advanced or severe dry AMD, no treatment can restore lost vision
In early AMD, patients must not smoke, and a combination of certain vitamins,
antioxidants, and zinc may prevent the disease from getting worse
For wet AMD, laser surgery, photodynamic therapy, and special medications
(antiangiogenesis, antiVEGF therapy) may be used.

Contraction of the visual fields

1. The diagram of the right eye illustrates the extent of a normal visual field as measured with a
III4e stimulus. The sum of the eight principal meridians of this field is 500 degrees.
2. The diagram of the left eye illustrates a visual field contracted to 30 degrees in two meridians
and to 20 degrees in the remaining six meridians. The percent of visual field efficiency of this
field is: (2 30) + (6 20) = 180500 = 0.36 or 36 percent visual field efficiency.

Sources:
http://www.visionfirstfoundation.org/vision_faq.php
http://en.wikipedia.org/wiki/Human_eye
http://www.mdsupport.org/library/acuity.htm http://en.wikipedia.org/wiki/Visual_system
http://www.mayoclinic.com/health/diabeticretinopathy/ds00447/dsection=treatmentsanddrugs
http://www.aoa.org/x4695.xml
http://www.socialsecurity.gov/disability/professionals/bluebook/2.00SpecialSensesandSpeech
Adult.htm#2_02
http://www.ncbi.nlm.nih.gov/books/NBK220/
http://www.nlm.nih.gov/medlineplus/ency/article/001000.htm
http://www.nei.nih.gov/health/cataract/cataract_facts.asp

Auditory and Vestibular Systems (hearing and balance)

Function:
The auditory system is the sensory system for the sense of hearing.

The vestibular system detects motion of the head in space and in turn generates reflexes that
are crucial for our daily activities, such as stabilizing the visual axis (gaze) and maintaining head
and body posture. In addition, the vestibular system provides us with our subjective sense of
movement and orientation in space. The vestibular sensory organs are located in the petrous
part of the temporal bone in close proximity to the cochlea, the auditory sensory organ.

Although the vestibular system is a separate entity from the auditory portion of the inner ear, it is
part of the inner ear.

Usual treatment providers:

Otolaryngologist (ear, nose and throat doctor, or ENT)
Otologist/Neurotologist
Neurologist
Otoneurologist
Ophthalmologist
Neuroophthalmologist
Audiologist

Key terms and components:

Outer ear
The folds of cartilage surrounding the ear canal are called the pinna. Sound waves are reflected
and attenuated when they hit the pinna, and these changes provide additional information that
will help the brain determine the direction from which the sounds came. The sound waves enter
the auditory canal, a deceptively simple tube. The ear canal amplifies sounds that are between
3 and 12 kHz. At the far end of the ear canal is the eardrum (or tympanic membrane), which
marks the beginning of the middle ear.

Middle ear
Sound waves traveling through the ear canal will hit the tympanic membrane, or eardrum. This
wave information travels across the airfilled middle ear cavity via a series of delicate bones: the
malleus (hammer), incus (anvil) and stapes (stirrup). The middle ear still contains the sound
information in wave form it is converted to nerve impulses in the cochlea.

Inner ear
The inner ear consists of the cochlea and several nonauditory structures.

Cochlea
The cochlea is the auditory portion of the inner ear. It is a spiralshaped cavity in the bony
labyrinth

Tinnitus
Noise (ringing, roaring, clicking, or hissing) in the ears. Tinnitus is a symptom of an underlying
condition, such as agerelated hearing loss, ear injury or a circulatory system disorder.

Conditions:

Hearing loss
Hearing loss that occurs gradually as you age (presbycusis) is common. heredity and chronic
exposure to loud noises are the main factors that contribute to hearing loss over time. Other
factors, such as earwax blockage, can prevent your ears from conducting sounds as well as
they should.

Types of Hearing Loss:

Conductive hearing loss: Conductive hearing loss occurs when sound is not
conducted efficiently through the outer ear canal to the eardrum and the tiny bones
(ossicles) of the middle ear. Conductive hearing loss usually involves a reduction in
sound level or the ability to hear faint sounds.

Causes: fluid in the middle ear, ear infection, allergies, poor eustachian tube
function, perforated eardrum, benign tumors, impacted earwax (cerumen),

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 absence or malformation of the outer ear, inner ear, or ear canal.

Treatment: This type of hearing loss can often be corrected medically or

surgically.

Sensorineural hearing loss: hearing loss in which the root cause lies in the
vestibulocochlear nerve (Cranial nerve VIII), the inner ear, or central processing centers
of the brain.

Causes: Most sensory hearing loss is due to poor hair cell function. The hair
cells may be abnormal at birth, or damaged during the lifetime of an individual.
There are both external causes of damage, like noise trauma and infection, and
intrinsic abnormalities, like deafness genes.

This type of hearing loss can also be caused by prolonged exposure to very loud
noise, for example, being in a loud workplace without hearing protection, or
having headphones set to high volumes for a long period.

Treatment: sensorineural hearing loss has been treated with hearing aids, which
amplify sounds at preset frequencies to overcome a sensorineural hearing loss in
that range or cochlear implants, which stimulate the cochlear nerve directly.

Mnire's disease
Meniere's disease is an inner ear disorder that affects balance and hearing. The exact cause of
Meniere's disease is unknown. It may occur when the pressure of the fluid in part of the inner
ear gets too high. In some cases, Meniere's disease may be related to head injury or middle or
inner ear infection. Other risk factors are allergies, alcohol use, family history, fatigue, recent
viral illness, respiratory infection, smoking, stress, use of certain medicines.

Symptoms:
Drop in hearing
Pressure in the ear
Ringing or roaring (tinnitus) in the affected ear
Vertigo
Other symptoms include diarrhea, headaches, abdominal pain, uncontrollable
eye movements.
With severe vertigo or dizziness, the following may occur:
Severe nausea, vomiting, and sweating often occur
Symptoms get worse with sudden movement.
Often, the person will need to lie down.
The dizziness and feeling of being offbalance will last from about 20 minutes to a
few hours
Hearing loss may occur, usually in one ear, but may affect both
 Hearing tends to recover between attacks but gets worse over time
Tests:
Neurological examination may show problems with hearing, balance, or eye
movement.
A hearing test or audiogram will show the hearing loss that occurs with
Meniere's. Hearing may be near normal after an attack.
Caloric stimulation tests eye reflexes by warming and cooling the inner ear with
water. Abnormal results on this test can be a sign of Meniere's disease.
Electrocochleography (ECOG)
Electronystagmography (ENG) or videonystagmography (VNG)
Head MRI scan

Treatment: There is no known cure for Meniere's disease. Lifestyle changes and some
treatments can often help relieve symptoms. Cutting the vestibular nerve with a surgical
procedure helps control vertigo. Removing part of the inner ear with a procedure called
labyrinthectomy helps with vertigo, but causes complete hearing loss.

http://www.scholarpedia.org/article/Vestibular_system
http://en.wikipedia.org/wiki/Auditory_system
http://en.wikipedia.org/wiki/Inner_ear
http://www.mayoclinic.com/health/hearingloss/DS00172
http://www.asha.org/public/hearing/disorders/types.htm
http://en.wikipedia.org/wiki/Sensorineural_hearing_loss
http://www.hearingloss.org/content/typescausesandtreatment
http://www.mayoclinic.com/health/tinnitus/DS00365
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001721/
Respiratory System

Function: The primary function of the respiratory system is to supply the blood with oxygen in
order for the blood to deliver oxygen to all parts of the body. The respiratory system does this
through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This
exchange of gases is the respiratory system's means of getting oxygen to the blood.
Respiration is achieved through the mouth, nose, trachea, lungs, and diaphragm.

Usual treatment providers:

Pulmonologist Pulmonology is a branch of internal medicine.
Thoracic surgeons perform major surgical procedures on the heart and lungs.

Key terms and components:

Lungs
The lungs performs a multitude of vital functions. Breathing is the most essential of these
functions. With each breath, the lungs take in oxygen and remove carbon dioxide.
The oxygen we breathe enters the lungs via the main windpipe (trachea), which branches into
two main tubes supplying the right and left lung, respectively. These tubes progressively branch
22 additional times to form more than 100,000 smaller tubes (bronchi, bronchioles) and more
than 300 million air sacs (alveoli), which are only about 0.3 mm in diameter.

The lungs are also important in the body's defense against infection and other harmful
environmental factors. While the nose is the first line of defense against inhaled harmful
materials, the lungs provide the second line of defense. Inhaled particles (smoke, pollution) or
infectious agents (bacteria, viruses) pass through the mouth or nose and lodge in the lungs.
Mucus, a sticky fluid produced in the lungs, can trap these inhaled agents and aid the lungs'
protective white blood cells (macrophages, neutrophils) in the engulfment and destruction of
bacteria and other harmful materials. The larger airways have tiny hairlike cells called cilia that
aid in this process. The cilia beat with a rhythm fast enough, and a force sufficient enough, to
propel mucus and cells up the airways to be coughed out or swallowed.

When a person smokes, the cilia are inactivated or destroyed, allowing thick mucus to
accumulate and compromise lung defense.
Diaphragm
A large muscle located between the chest and the abdomen. When it contracts, it is forced
downward causing the abdomen to expand. This causes a negative pressure within the chest
forcing air into the lungs. The negative pressure also pulls blood into the chest, improving the
venous return to the heart.

Spirometry (Pulmonary Function Tests or PFT)

The determination of lung volumes in time by breathing into a dedicated machine response to
bronchodilators and diffusion of carbon monoxide.

Lung diffusion testing

Measures how well the lungs exchange gases. This is an important part of lung testing, because
the major function of the lungs is to allow oxygen to "diffuse" or pass into the blood from the
lungs, and to allow carbon dioxide to "diffuse" from the blood into the lungs.

Bronchodilator
A substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory
airway and increasing airflow to the lungs. Bronchodilators may be endogenous (originating
naturally within the body), or they may be medications administered for the treatment of
breathing difficulties.

FVC (Forced Vital Capacity)

The total volume of air expired after a full inspiration. Patients with obstructive lung disease
usually have a normal or only slightly decreased vital capacity. Patients with restrictive lung
disease have a decreased vital capacity.

FEV1 (Forced Expiratory Volume in 1 Second)

The volume of air expired in the first second during maximal expiratory effort. The FEV1 is
reduced in both obstructive and restrictive lung disease. The FEV1 is reduced in obstructive
lung disease because of increased airway resistance. It is reduced in restrictive lung disease
because of the low vital capacity.

FEV1/FVC
The percentage of the vital capacity which is expired in the first second of maximal expiration. In
healthy patients the FEV1/FVC is usually around 70%. In patients with obstructive lung disease
FEV1/FVC decreases and can be as low as 2030% in severe obstructive airway disease.
Restrictive disorders have a near normal FEV1/FVC.

FEF2575% (Forced Midexpiratory Flow Rate)

The average rate of airflow during the midportion of the forced vital capacity. This is reduced in
both obstructive and restrictive disorders.
DLCO (Diffusing Capacity of the Lung for Carbon Monoxide)
Carbon monoxide can be used to measure the diffusing capacity of the lung. The diffusing
capacity of the lung is decreased in parenchymal lung disease and COPD (especially
emphysema) but is normal in asthma.

Peak flow
Measurement of how quickly air moves out of the lungs. Peak flow values of 50% 80% of a
specific person's best results are a sign of a moderate asthma attack, while values below 50%
are a sign of a severe attack.

Polysomnography
Sleep studies commonly used for the diagnosis of sleep apnea.

Dyspnea
Shortness of breath (SOB) or air hunger. Difficult or labored breathing. Dyspnea on exertion
(DOE) can be normal, but may also be a symptom of serious disease of the lungs, airway, or
heart.

Cyanosis
Bluish color of the skin due to insufficient oxygen in the blood.

Hypoxemia
Lower than normal level of oxygen in the blood

Edema
Abnormal accumulation of fluid in body tissues

Pneumonia
Inflammation of the lungs

Rales
Abnormal respiratory sound characterized by fine crackles

Rhonchi
Lowpitched, snorelike, gurgling, or rattling sounds, usually caused by airway secretions and
airway narrowing.

Wheezing
Breathing with a rasp or whistling sound a sign of airway constriction or obstruction

Common Conditions:

Asthma
A disorder that causes the airways of the lungs to swell and narrow, leading to wheezing,
shortness of breath, chest tightness, and coughing. When an asthma attack occurs, the
muscles surrounding the airways become tight and the lining of the air passages swells. This
reduces the amount of air that can pass by. In sensitive people, asthma symptoms can be
triggered by breathing in allergycausing substances (called allergens or triggers).

Common Asthma triggers: Animals, dust, changes in the air or in food, exercise, mold,
pollen, respiratory infections, such as the common cold, strong emotions (stress),
tobacco smoke. Aspirin and other NSAIDs provoke asthma in some patients.

Symptoms:
Cough
Pulling in of the skin between the ribs when breathing (intercostal retractions)
Shortness of breath that gets worse with exercise or activity
Wheezing which:
Comes in episodes with symptomfree periods in between
May be worse at night or in early morning
May go away on its own
Gets better when using drugs that open the airways (bronchodilators)
Gets worse when breathing in cold air
Gets worse with exercise
Gets worse with heartburn (reflux)
Usually begins suddenly
Chest tightness
Tests:
Arterial blood gas
Blood tests to measure eosinophil count (a type of white blood cell) and IgE (a
type of immune system protein called an immunoglobulin)
Chest xray
Lung function tests
Peak flow measurements

Treatment: Control drugs to prevent attacks and quickrelief drugs for use during attacks
Control drugs:
Inhaled corticosteroids prevent airways from swelling Leukotriene inhibitors,
Cromolyn sodium (Intal) or nedocromil sodium (Tilade)Longacting betaagonist
inhalers also help prevent asthma symptoms.
Quickrelief drugs:
Shortacting bronchodilators (inhalers), such as Proventil, Ventolin, and Xopenex
oral steroids (corticosteroids)

COPD (Chronic Obstructive Pulmonary Disease)

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Chronic obstructive pulmonary disease is one of the most common lung diseases. It causes
difficulty breathing. There are two main forms of COPD: chronic bronchitis, which involves a
longterm cough with mucus, and emphysema, which involves destruction of the lungs over
time. Most people with COPD have a combination of both conditions.

Chronic Bronchitis
Inflammation of the main air passages to the lungs. Bronchitis may be shortlived (acute)
or chronic, meaning that it lasts a long time and often recurs. Chronic bronchitis is a
longterm condition. People have a cough that produces excessive mucus. To be
diagnosed with chronic bronchitis, you must have a cough with mucus most days of the
month for at least 3 months.

Worsened by: Air pollution, allergies, certain occupations (such as coal mining, textile
manufacturing, or grain handling), infections. Smokers, children and the elderly, and
persons with heart or lung disease are at risk for chronic bronchitis.

Symptoms:
Cough that produces mucus
Chest discomfort
Fatigue
Fever usually low
Shortness of breath worsened by exertion or mild activity
Wheezing
Ankle, feet, and leg swelling
Bluecolored lips from low levels of oxygen
Frequent respiratory infections (such as colds or the flu)

Signs and Tests:

Chest xray
Lung function tests/Spirometry
Pulse oximetry helps determine the amount of oxygen in the blood. Arterial blood
gas is a more exact measurement of oxygen and carbon dioxide levels.
Sputum samples may be taken to check for signs of inflammation or bacterial
infection.

Treatment: Refrain from smoking aspirin or acetaminophen humidifier prescribed

inhalers.

Emphysema
Destruction of the lungs over time. Emphysema occurs when the air sacs in the lungs
are gradually destroyed, causing progressively worsening shortness of breath. Smoking
is the leading cause of emphysema.
 As it worsens, emphysema turns the spherical air sacs into large, irregular pockets with
gaping holes in their inner walls. This reduces the surface area of the lungs and, in turn,
the amount of oxygen that reaches the bloodstream. Emphysema also slowly destroys
the elastic fibers that hold open the small airways leading to the air sacs. This allows
these airways to collapse when exhaling, so the air in the lungs can't escape.

Symptoms:
Shortness of breath eventually, even while at rest

Tests:
Chest xray
CT scan
Pulmonary function tests
Blood tests for arterial blood gas, to determine how much oxygen and carbon
dioxide are in the blood.

Treatment:
Treatment may slow the progression of emphysema, but it can't reverse the
damage. Inhalers, oxygen, and medications are used to relieve symptoms and
prevent complications.

Surgery:
Lung volume reduction surgery (LVRS) may be performed. It is a procedure
which removes approximately 2035% of the poorly functioning, space occupying
lung tissue from each lung. By reducing the lung size, the remaining lung and
surrounding muscles (intercostals and diaphragm) are able to work more
efficiently.

Sarcoidosis
A disease in which inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or other
tissues. The cause of the disease is unknown. In sarcoidosis, tiny clumps of abnormal tissue
(granulomas) form in certain organs of the body. Granulomas are clusters of immune cells.
The disease can affect almost any organ of the body, but it most commonly affects the lungs.

Symptoms: There may be no symptoms. When symptoms occur, they can

involve almost any body part or organ system in your body.

Almost all patients have lung or chest symptoms:

Chest pain (most often behind the breast bone)
Dry cough
Shortness of breath
Symptoms of general discomfort or uneasiness often occur:
Fatigue
 Fever
Joint achiness or pain (arthralgia)
Overall feeling of discomfort, illness, or lack of wellbeing
Weight loss (one of the most common symptoms in children)
Skin symptoms:
Hair loss
Raised, red, firm skin sores (erythema nodosum), almost always on the
front part of the lower legs
Rash
Scars that become raised or inflamed
Nervous system symptoms may include:
Headache
Seizures
Weakness on one side of the face
Eye symptoms include:
Burning
Discharge from the eye
Dry eyes
Itching
Pain
Vision loss
Other symptoms of this disease:
Dry mouth
Fainting spells if the heart is involved
Nosebleed
Swelling in the upper part of the abdomen

Signs and Tests:

Biopsy of the lung, using bronchoscopy, is needed to diagnose the
condition
Abnormal breath sounds (such as rales)
Enlarged liver
Enlarged lymph glands
Enlarged spleen
Rash
Chest xray to see if the lungs are involved or lymph nodes are enlarged
CT scan of the chest
Lung gallium scan
This disease may affect the results of the following lab tests:
Calcium levels (urine, ionized, serum)
CBC
Immunoelectrophoresis serum
Liver function tests
 Quantitative immunoglobulins (nephelometry)
Serum phosphorus

Treatment: Sarcoidosis symptoms will often get better on their own slowly
without treatment. Patients whose eyes, heart, nervous system, or lungs are
involved may need to be treated with corticosteroids (prednisone or
methylprednisolone). Therapy may continue for 1 or 2 years. The most severely
affected patients may need lifelong therapy. Drugs that suppress the immune
system (immunosuppressive medicines) are sometimes also needed:
The drug used most often is methotrexate, but azathioprine and
cyclophosphamide are also sometimes recommended.
Hydroxychloroquine is useful for skin sarcoidosis.

About 30 50% of cases get better without treatment in 3 years. About 20% of
people whose lungs are involved will develop lung damage.

Complications:
Fungal lung infections (aspergilloma)
Glaucoma and blindness from uveitis (rare)
Kidney stones from high calcium levels in blood or urine
Osteoporosis and other complications of taking corticosteroids for long
periods of time.
Pulmonary hypertension

Sleep Apnea
Sleep apnea is a common disorder in which you have one or more pauses in breathing or
shallow breaths while you sleep. Breathing pauses can last from a few seconds to minutes.
They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again,
sometimes with a loud snort or choking sound.

Sleep apnea usually is a chronic condition that disrupts your sleep. You often move out of deep
sleep and into light sleep when your breathing pauses or becomes shallow.
This results in poor sleep quality. Sleep apnea is one of the leading causes of excessive
daytime sleepiness.

The most common type of sleep apnea is obstructive sleep apnea. This most often means that
the airway has collapsed or is blocked during sleep. The blockage may cause shallow breathing
or breathing pauses.

Central sleep apnea is a less common type of sleep apnea. This disorder happens if the area of
your brain that controls your breathing doesn't send the correct signals to your breathing
muscles. As a result, there is no effort to breathe for brief periods. Central sleep apnea is more
common in people who have certain medical conditions or use certain medicines.

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 Symptoms:
One of the most common signs of obstructive sleep apnea is loud and
chronic (ongoing) snoring. Pauses may occur in the snoring. Choking or
gasping may follow the pauses.
Daytime sleepiness
Morning headaches
Memory or learning problems and not being able to concentrate
Feeling irritable, depressed, or having mood swings or personality
changes
Urination at night
A dry throat when you wake up

Tests:
Polysomnography is used to diagnose sleep apnea. An overnight
polysomnography test involves monitoring brain waves, muscle tension, eye
movement, respiration, oxygen level in the blood and audio monitoring. (for
snoring, gasping, etc.). The second kind of polysomnography test is a home
monitoring test.

Treatment:
Behavioral changes or oral appliances, for mild sleep apnea
CPAP (continous positive airway pressure): used to treat moderate to severe
sleep apnea. CPAP is a machine that forces air into the nose via a nose mask,
keeping the airway open and unobstructed. For more severe apnea, there is a
Bilevel (BiPAP) machine.
Abstinence from alcohol before bedtime is an important part of treating sleep
apnea

Surgery:
Given the several sites where airway obstruction may exist, there are several
types of operations currently used to treat sleep apnea. The most common is
uvulopalatopharyngoplasty, or UPPP. The success rate of this operation is about
50 percent.

http://www.fi.edu/learn/heart/systems/respiration.html
http://en.wikipedia.org/wiki/Pulmonology
http://meded.ucsd.edu/isp/1998/asthma/html/spirexp.html
http://en.wikipedia.org/wiki/Bronchodilator
http://www.nlm.nih.gov/medlineplus/ency/article/003854.htm
http://www.stethographics.com/main/physiology_ls_rhonchi.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001196/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002078/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001153/
http://www.mayoclinic.com/health/emphysema/DS00296
http://www.cts.usc.edu/lungvolumereductionsurgery.html
http://www.mayoclinic.com/health/emphysema/ds00296/dsection=testsanddiagnosis
http://www.emedicinehealth.com/emphysema/page5_em.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001140/
http://www.nhlbi.nih.gov/health/healthtopics/topics/sleepapnea/
http://www.stanford.edu/~dement/apnea.html http://sleepapnea.org/diagnosisand-
treatment/treatmentoptions.html http://www.amsa.org/healingthehealer/breathing.cfm
http://www.aarc.org/klein/lungs.asp

Circulatory and Cardiovascular Systems

The circulatory system is an organ system that passes nutrients (such as amino acids,
electrolytes and lymph), gases, hormones, blood cells, etc. to and from cells in the body to help
fight diseases, stabilize body temperature and pH, and to maintain homeostasis.

Two types of fluids move through the circulatory system: blood and lymph. Lymph is essentially
recycled blood plasma after it has been filtered from the blood cells and returned to the
lymphatic system.

The blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph
nodes, and lymph vessels form the lymphatic system. The cardiovascular system and the
lymphatic system collectively make up the circulatory system.
The main components of the human cardiovascular system are the heart, blood, and blood
vessels. It includes: the pulmonary circulation, a "loop" through the lungs where blood is
oxygenated and the systemic circulation, a "loop" through the rest of the body to provide
oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of
blood, which consists of plasma, red blood cells, white blood cells, and platelets. Also, the
digestive system works with the circulatory system to provide the nutrients the system needs to
keep the heart pumping.

Usual treatment providers: cardiologist electrophysiologist cardiac and vascular surgeons.

Key terms and components:

Cardiac
Related to the heart.

Vascular
Related to the blood vessels.

Blood
A specialized bodily fluid in animals that delivers necessary substances such as nutrients and
oxygen to the cells and transports metabolic waste products away from those same cells.

Complete blood count (CBC)

Also known as full blood count (FBC), or full blood exam (FBE), or blood panel. A test panel
that gives information about the cells in a patient's blood.

Plasma
Blood plasma is the strawcolored liquid component of blood that normally holds the blood cells
in whole blood in suspension. It makes up about 55% of total blood volume.

White blood cells (WBCs)

White blood cells help fight infections. They are also called leukocytes. There are five major
types of white blood cells: Basophils, Eosinophils, Lymphocytes (T cells and B cells),
Monocytes, and Neutrophils.

Red blood cells (RBCs)

RBCs contain hemoglobin, which carries oxygen. How much oxygen your body tissues get
depends on how many RBCs you have and how well they work.

Hemoglobin (Hb or Hgb)

Ironcontaining oxygentransport in the red blood cells. Hemoglobin in the blood carries oxygen
from the lungs to the rest of the body, where it releases the oxygen to burn nutrients (to provide
energy). It also collects the resultant carbon dioxide to bring it back to the lungs.

Platelets
Platelets are the smallest of the three major types of blood cells. The normal platelet count is
150,000350,000 per microliter of blood. The principal function of platelets is to prevent
bleeding.

Systemic circulation
Systemic circulation supplies nourishment to all of the tissue located throughout your body, with
the exception of the heart and lungs because they have their own systems. Systemic circulation
is a major part of the overall circulatory system.

The blood vessels (arteries, veins, and capillaries) are responsible for the delivery of oxygen
and nutrients to the tissue. Oxygenrich blood enters the blood vessels through the heart's main
artery called the aorta. The forceful contraction of the heart's left ventricle forces the blood into
the aorta which then branches into many smaller arteries which run throughout the body. The
inside layer of an artery is very smooth, allowing the blood to flow quickly. The outside layer of
an artery is very strong, allowing the blood to flow forcefully. The oxygenrich blood enters the
capillaries where the oxygen and nutrients are released. The waste products are collected and
the wasterich blood flows into the veins in order to circulate back to the heart where pulmonary
circulation will allow the exchange of gases in the lungs.

During systemic circulation, blood passes through the kidneys. This phase of systemic
circulation is known as renal circulation. During this phase, the kidneys filter much of the waste
from the blood. Blood also passes through the small intestine during systemic circulation. This
phase is known as portal circulation. During this phase, the blood from the small intestine
collects in the portal vein which passes through the liver. The liver filters sugars from the blood,
storing them for later.

Coronary circulation
Coronary circulation refers to the movement of blood through the tissues of the heart.

Pulmonary circulation
Pulmonary circulation is the movement of blood from the heart, to the lungs, and back to the
heart again.

The veins bring wasterich blood back to the heart, entering the right atrium throughout two
large veins called vena cavae. The right atrium fills with the wasterich blood and then contracts,
pushing the blood through a oneway valve into the right ventricle. The right ventricle fills and
then contracts, pushing the blood into the pulmonary artery which leads to the lungs. In the lung
capillaries, the exchange of carbon dioxide and oxygen takes place. The fresh, oxygenrich
blood enters the pulmonary veins and then returns to the heart, reentering through the left
atrium. The oxygenrich blood then passes through a oneway valve into the left ventricle where
it will exit the heart through the main artery, called the aorta. The left ventricle's contraction
forces the blood into the aorta and the blood begins its journey throughout the body.

The oneway valves are important for preventing any backward flow of blood. The circulatory
system is a network of oneway streets. If blood started flowing the wrong way, the blood gases
(oxygen and carbon dioxide) might mix, causing a serious threat to your body.

Conduction system
Electrical impulses from your heart muscle (the myocardium) cause your heart to contract. This
electrical signal begins in the sinoatrial (SA) node, located at the top of the right atrium. The SA
node is sometimes called the heart's "natural pacemaker." An electrical impulse from this
natural pacemaker travels through the muscle fibers of the atria and ventricles, causing them to
contract. Although the SA node sends electrical impulses at a certain rate, your heart rate may
still change depending on physical demands, stress, or hormonal factors.

Heart
The heart is located between the lungs in the middle of the chest, behind and slightly to the left
of the breastbone (sternum). A doublelayered membrane called the pericardium surrounds the
heart like a sac. The outer layer of the pericardium surrounds the roots of the heart's major
blood vessels and is attached by ligaments to the spinal column, diaphragm, and other parts of
the body. The inner layer of the pericardium is attached to the heart muscle. A coating of fluid
separates the two layers of membrane, letting the heart move as it beats, yet still be attached to
your body.

The heart has 4 chambers. The upper chambers are called the left and right atria, and the lower
chambers are called the left and right ventricles. A wall of muscle called the septum separates
the left and right atria and the left and right ventricles. The left ventricle is the largest and
strongest chamber in your heart. The left ventricle's chamber walls are only about a halfinch
thick, but they have enough force to push blood through the aortic valve and into your body.

Myocardium
The muscle tissue of the heart. It is composed of striated, involuntary muscle cells (myocytes,
cardiac) connected to form the contractile pump to generate blood flow.

Right atrium
Receives blood returning to the heart from the superior and inferior vena cava. The superior
vena cava returns deoxygenated blood from the head, neck, arm and chest regions of the body
to the right atrium. The inferior vena cava returns deoxygenated blood from the lower body
regions (legs, back, abdomen and pelvis) to the right atrium.

Left atrium
Receives blood returning to the heart from the pulmonary veins. The pulmonary veins extend
from the left atrium to the lungs and bring oxygenrich blood back to the heart.
Right ventricle
The right ventricle pumps the blood to the lungs to be reoxygenated.

Left ventricle (LV)

The left ventricle pumps the blood throughout the body.

Interatrial septum
The wall of tissue that is a sectional part of the left and right atria of the heart

Interventricular septum (median septum)

The wall separating the left and right ventricles of the heart

Aortic valve
The aortic valve opens the way for oxygenrich blood to pass from the left ventricle into the
aorta, the body's largest artery, where it is delivered to the rest of the body.

Mitral valve (MV)

The mitral valve lets oxygenrich blood from the lungs pass from the left atrium into the left
ventricle.

Pulmonary valve
The pulmonary valve controls blood flow from the right ventricle into the pulmonary arteries,
which carry blood to the lungs to pick up oxygen.

Tricuspid valve
The tricuspid valve regulates blood flow between the right atrium and right ventricle.

Arteries
The heart pumps blood out through one main artery called the dorsal aorta. The main artery
then divides and branches out into many smaller arteries so that each region of your body has
its own system of arteries supplying it with fresh, oxygenrich blood.

The muscular wall of the artery helps the heart pump the blood. When the heart beats, the
artery expands as it fills with blood. When the heart relaxes, the artery contracts, exerting a
force that is strong enough to push the blood along. This rhythm between the heart and the
artery results in an efficient circulation system.

Veins
Veins are similar to arteries but, because they transport blood at a lower pressure, they are not
as strong as arteries. Veins receive blood from the capillaries after the exchange of oxygen and
carbon dioxide has taken place. Therefore, the veins transport wasterich blood back to the
lungs and heart. It is important that the wasterich blood keeps moving in the proper direction
and not be allowed to flow backward. This is accomplished by valves that are located inside the
veins. The valves are like gates that only allow traffic to move in one direction. The vein valves
are necessary to keep blood flowing toward the heart, but they are also necessary to allow
blood to flow against the force of gravity.

Capillaries
The smallest of a body's blood vessels which are part of microcirculation. These microvessels
enable the exchange of water, oxygen, carbon dioxide, and many other nutrients and waste
chemical substances between blood and surrounding tissues.

Blood flows away from the heart via arteries, which branch and narrow into the arterioles, and
then branch further still into the capillaries. After the tissue has been perfused, capillaries join
and widen to become venules and then widen more to become veins, which return blood to the
heart.

Aorta
The largest artery in the body, originating from the left ventricle of the heart and extending down
to the abdomen, where it bifurcates into two smaller arteries (the common iliacs). The aorta
distributes oxygenated blood to all parts of the body through the systemic circulation. The aorta
is divided into five segments/sections:

Ascending aorta the section between the heart and the arch of aorta
Arch of aorta the peak part that looks somewhat like an inverted "U"
Descending aorta the section from the arch of aorta to the point where it divides
into the common iliac arteries
Thoracic aorta the half of the descending aorta above the diaphragm
Abdominal aorta the half of the descending aorta below the diaphragm

Carotid arteries
The left and right common carotid arteries are arteries that supply the head and neck with
oxygenated blood they divide in the neck to form the external and internal carotid arteries.

Coronary arteries
The heart receives its own supply of blood from the coronary arteries. Two major coronary
arteries branch off from the aorta near the point where the aorta and the left ventricle meet.
These arteries and their branches supply all parts of the heart muscle with blood.

The right coronary artery (RCA) branches into the right marginal artery and posterior
descending artery. The RCA supplies the right atrium, right ventricle, and bottom portion of both
ventricles and back of the septum. The main portion of the right coronary artery provides blood
to the right side of the heart, which pumps blood to the lungs. The rest of the right coronary
artery and its main branch, the posterior descending artery, together with the branches of the
circumflex artery, run across the surface of the heart's underside, supplying the bottom portion
of the left ventricle and back of the septum.

The left main coronary artery (left main trunk) branches into the circumflex artery and the left
anterior descending artery (LAD). The circumflex artery supplies blood to the left atrium, and
the side and back of the left ventricle. The LAD supplies the front and bottom of the left
ventricle and the front of the septum.

Pulmonary artery
A large artery that sends oxygenpoor blood into the lungs to be enriched with oxygen. It is one
of the only arteries (other than the umbilical arteries in the fetus) that carry deoxygenated blood.

Pulmonary veins
Large blood vessels that carry oxygenated blood from the lungs to the left atrium of the heart.
There are four pulmonary veins, two from each lung. They carry oxygenated blood, which is
unusual since almost all other veins carry deoxygenated blood.

Superior vena cava

The second largest vein in the human body. The superior vena cava moves blood from the
upper half of the body to the heart.

Inferior vena cava

The large vein that carries deoxygenated blood from the lower half of the body into the right
atrium of the heart. It is posterior to the abdominal cavity and runs alongside of the vertebral
column on its right side. It enters the right atrium at the lower right, back side of the heart.

Blood pressure
The pressure exerted by circulating blood upon the walls of blood vessels, and one of the
principal vital signs. When used without further specification, "blood pressure" usually refers to
the arterial pressure of the systemic circulation. During each heartbeat, blood pressure varies
between a maximum (systolic) and a minimum (diastolic) pressure. A persons blood pressure
is usually expressed in terms of the systolic pressure over diastolic pressure and is measured in
millimetres of mercury (mmHg), for example 140/90.

Heart rate (pulse)

The number of heartbeats per minute. A normal heart rate for children over 10 and adults
(including seniors) is 60 100 beats per minute.

Diastole and Systole

A heartbeat is a twopart pumping action that takes about a second. As blood collects in the
upper chambers (the right and left atria), the heart's natural pacemaker (the sinoatrial or SA
node) sends out an electrical signal that causes the atria to contract. This contraction pushes
blood through the tricuspid and mitral valves into the resting lower chambers (the right and left
ventricles). This part of the twopart pumping phase (the longer of the two) is called diastole.
The second part of the pumping phase begins when the ventricles are full of blood. The
electrical signals from the SA node travel along a pathway of cells to the ventricles, causing
them to contract. This is called systole. As the tricuspid and mitral valves shut tight to prevent a
back flow of blood, the pulmonary and aortic valves are pushed open. While blood is pushed
from the right ventricle into the lungs to pick up oxygen, oxygenrich blood flows from the left
ventricle to the heart and other parts of the body.

If the diastole part of the twopart pumping phase is abnormal, this is called diastolic
dysfunction.
In some people with heart failure, the ventricles do not relax properly during diastole. If the
ventricles are not relaxed, the pressure inside of them will increase as blood from the next
heartbeat tries to enter. This can lead to extra pressure and fluid in the blood vessels of your
lungs (called pulmonary congestion) or in the blood vessels leading back to your heart (called
systemic congestion).

Diastolic dysfunction occurs more often in people with certain types of cardiomyopathy.

Systolic dysfunction
LV systolic dysfunction is assessed using the ejection fraction (the percentage of the end
diastolic volume ejected during systole). In most cases, this is estimated by eye from all
the available echo views. A normal ejection fraction is 50%80%, but values as low as
5% are compatible with life (endstage heart failure).

Diastolic dysfunction
A normal LV ejection fraction in the presence of heart failure syndrome leads to a search
for diastolic dysfunction. Typical echo findings in diastolic dysfunction are normal LV
cavity size, thickened ventricle, and reversed E/A ratio.

Atrioventricular node (AV node)

A part of the electrical control system of the heart that coordinates the top of the heart. It
electrically connects atrial and ventricular chambers.

Sinus node (sinoatrial node or SA node)

The impulsegenerating (pacemaker) tissue located in the right atrium of the heart, and thus the
generator of normal sinus rhythm.

Sinus rhythm
The normal regular rhythm of the heart set by the natural pacemaker of the heart called the
sinoatrial (or sinus) node. The lack of normal sinus rhythm is an arrhythmia, an abnormal heart
rhythm.

Palpitations
Palpitations are heartbeat sensations that feel like the heart is pounding or racing. You may
simply have an unpleasant awareness of your own heartbeat, or may feel skipped or stopped
beats. The heart's rhythm may be normal or abnormal. Palpitations can be felt in the chest,
throat, or neck.

Arrhythmia
The heart's electrical system controls the rate and rhythm of the heartbeat. With each
heartbeat, an electrical signal spreads from the top of the heart to the bottom. As the signal
travels, it causes the heart to contract and pump blood.

A problem with the rate or rhythm of the heartbeat is called an arrhythmia.. During an
arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. A heartbeat that is
too fast is called tachycardia. A heartbeat that is too slow is called bradycardia.

Most arrhythmias are harmless, but some can be serious or even life threatening. During an
arrhythmia, the heart may not be able to pump enough blood to the body. Lack of blood flow can
damage the brain, heart, and other organs.

Supraventricular tachycardia (SVT)

A general term that refers to any rapid heart rhythm originating above the ventricular tissue.
Supraventricular tachycardias can be contrasted to the potentially more dangerous ventricular
tachycardias rapid rhythms that originate within the ventricular tissue.

Ventricular tachycardias
Rapid rhythms that originate within the ventricular tissue.

Heart block
A type of arrhythmia, heart block occurs if the electrical signal is slowed or disrupted as it moves
from the upper to the lower chambers of the heart.

Regurgitation
The backward flow of blood through a defective heart valve.

Atherosclerosis
Hardening of the arteries. It occurs when fat, cholesterol, and other substances build up in the
walls of arteries and form hard structures called plaques. Over time, these plaques can block
the arteries and cause problems throughout the body. Hardening of the arteries is a process
that often occurs with aging. However, high blood cholesterol levels can make this process
happen at a younger age. For most people, high cholesterol levels are the result of an
unhealthy lifestyle most commonly, eating a diet that is high in fat. Other lifestyle factors are
heavy alcohol use, lack of exercise, and being overweight. Other risk factors include diabetes,
family history of atherosclerosis, high blood pressure, and smoking.

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Cholesterol
An organic chemical substance classified as a waxy steroid of fat. It is an essential structural
component of human cell membranes and is required to establish proper membrane
permeability and fluidity. Although cholesterol is important and necessary for human health,
high levels of cholesterol in the blood have been linked to damage to arteries and
cardiovascular disease.

Highdensity lipoprotein (HDL)

One of the five major groups of lipoproteins, which, in order of sizes, largest to smallest, are
chylomicrons, VLDL, IDL, LDL, and HDL, which enable lipids like cholesterol and triglycerides to
be transported within the waterbased bloodstream. In healthy individuals, about thirty percent
of blood cholesterol is carried by HDL.

Lowdensity lipoprotein (LDL)

A group of lipoproteins that enable transport of multiple different fat molecules, including
cholesterol, within the water around cells and within the waterbased bloodstream. Studies have
shown that higher levels of typeB LDL particles (as opposed to typeA LDL particles) promote
health problems and cardiovascular disease, they are often informally called the bad cholesterol
particles.

Triglycerides
Triglycerides are formed by combining glycerol with three molecules of fatty acid. They are a
mechanism for storing unused calories. Their high concentration in blood correlates with the
consumption of starchy and other high carbohydrate foods. High levels of triglycerides in the
bloodstream have been linked to atherosclerosis and, by extension, the risk of heart disease
and stroke.

Hypercholesterolemia
Abnormal cholesterol levels. Higher concentrations of LDL and lower concentrations of
functional HDL are strongly associated with cardiovascular disease because these promote
atheroma development in arteries (atherosclerosis).

Hyperlipidemia
Abnormally elevated levels of any or all lipids and/or lipoproteins in the blood. It is the most
common form of dyslipidemia (which also includes any decreased lipid levels). Hyperlipidemias
are divided in primary and secondary subtypes. Primary hyperlipidemia is usually due to genetic
causes (such as a mutation in a receptor protein), while secondary hyperlipidemia arises due to
other underlying causes such as diabetes.

Stenosis
An abnormal narrowing in a blood vessel or other tubular organ or structure. It is also
sometimes called a stricture (as in urethral stricture). Stenoses of the vascular type are often
associated with unusual blood sounds resulting from turbulent flow over the narrowed blood
vessel.
Myocarditis
Inflammation of the heart muscle.

Cardiomegaly
Enlarged heart. Not a disease, but rather a symptom of another condition. The term
"cardiomegaly" most commonly refers to an enlarged heart seen on chest Xray before other
tests are performed to diagnose the specific condition causing the cardiomegaly. One may
develop an enlarged heart temporarily because of a stress on the body, such as pregnancy, or
because of a medical condition, such as the weakening of the heart muscle, coronary artery
disease, heart valve problems or abnormal heart rhythms. It is usually treatable. Treatment for
enlarged heart is aimed at correcting the underlying cause. Treatment for an enlarged heart can
include medications, medical procedures or surgery.

Edema
Edema is swelling caused by excess fluid trapped in the body's tissues. Although edema can
affect any part of the body, it's most commonly noticed in the hands, arms, feet, ankles and
legs. Edema can be the result of medication, pregnancy or an underlying disease often heart
failure, kidney disease or cirrhosis of the liver. Taking medication to remove excess fluid and
reducing salt intake usually relieves edema. When edema is a sign of an underlying disease,
the disease itself requires separate treatment.

Edema is referred to as "pitting" when, after pressure is applied to a small area, the indentation
persists for some time after the release of the pressure. Peripheral pitting edema is the more
common type, resulting from water retention. It can be caused by systemic diseases, pregnancy
in some women, either directly or as a result of heart failure, or local conditions such as varicose
veins, thrombophlebitis, insect bites, and dermatitis.

Nonpitting edema is observed when the indentation does not persist. It is associated with such
conditions as lymphedema, lipoedema and myxedema.

Vasospasm
A condition in which a blood vessels spasm leads to vasoconstriction (constriction of blood
vessels). When blood vessels constrict, the flow of blood is restricted or slowed.This can lead to
tissue ischemia and death (necrosis).

Ischemia
A restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed for
cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems with blood
vessels, with resultant damage to or dysfunction of tissue. It also means local anemia in a given
part of a body sometimes resulting from congestion (such as vasoconstriction, thrombosis or
embolism).
Thrombus
Blood clot or solid mass of platelets and/or fibrin (and other components of blood) that forms
locally in a vessel.

Embolus
A piece of a thrombus that has broken free and is carried by the bloodstream and lodges so as
to obstruct or occlude a blood vessel.

Syncope
Syncope is a medical term used to describe a temporary loss of consciousness due to the
sudden decline of blood flow to the brain. Syncope is commonly called fainting or passing out.

There are several types of syncope. Vasovagal syncope usually has an easily identified
triggering event such as emotional stress, trauma, pain, the sight of blood, or prolonged
standing. Carotid sinus syncope happens because of constriction of the carotid artery in the
neck and can occur after turning the head, while shaving, or when wearing a tight collar.
Situational syncope happens during urination, defecation, coughing, or as a result of
gastrointestinal stimulation. Syncope can also be a symptom of heart disease or abnormalities
that create an uneven heart rate or rhythm that temporarily affect blood volume and its
distribution in the body. Syncope isnt normally a primary sign of a neurological disorder, but it
may indicate an increased risk for neurologic disorders such as Parkinsons disease, postural
orthostatic tachycardia syndrome (POTS), diabetic neuropathy, and other types of neuropathy.
Certain classes of drugs are associated with an increased risk of syncope, including diuretics,
calcium antagonists, ACE inhibitors, nitrates, antipsychotics, antihistamines, levodopa,
narcotics, and alcohol.

Angina
Chest pain caused by restricted blood flow to the heart (called ischemia). It often occurs when
you are under emotional or physical stress, such as exercise. When the heart doesn't get
enough oxygen from the coronary arteries, it causes a squeezing chest pain or pressure across
the chest that usually goes away after you stop the activity. The most common cause of angina
is hardening of the arteries (atherosclerosis).

Prinzmetal angina, also known as variant angina or angina inversa, is a syndrome typically
consisting of angina (cardiac chest pain) at rest that occurs in cycles. It is caused by
vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle
tissue in the vessel walls rather than directly by atherosclerosis (buildup of fatty plaque and
hardening of the arteries). It occurs more in younger women.

Chest pain that is fairly predictable and usually occurs during exercise is called stable angina. It
is relieved with rest or nitroglycerin. Chest pain that occurs when you are resting, or at
unpredictable times, is known as unstable angina.
Hypokalemia
Hypokalemia is a lowerthannormal amount of potassium in the blood. Potassium is needed for
cells, especially nerve and muscle cells, to function properly. A small drop in potassium usually
doesn't cause symptoms. However, a big drop in the level can be life threatening, and may
cause abnormal heart rhythms (dysrhythmias), especially in people with heart disease.

Common tests:

Electrocardiogram (ECG or EKG)

An electrocardiogram is a test that records the electrical activity of the heart. An ECG is used to
measure any damage to the heart how fast the heart is beating and whether it is beating
normally the effects of drugs or devices used to control the heart (such as a pacemaker) the
size and position of the heart chambers. An ECG is a very useful tool for determining whether a
person has heart disease. It may be ordered in response to complaints of chest pain or
palpitations.

Electrodes are placed on each arm and leg, and six electrodes are placed at defined locations
on the chest. These electrode leads are connected to a device that measures potential
differences between selected electrodes to produce the characteristic ECG tracings. Normally,
when an ECG is recorded, all leads are recorded simultaneously, giving rise to what is called a
12lead ECG.

P wave
In electrocardiography, during normal atrial depolarization, the main electrical vector is
directed from the SA node towards the AV node, and spreads from the right atrium to the
left atrium. This turns into the P wave on the ECG. Absence of the P wave may indicate
atrial fibrillation, sinoatrial block, or junctional rhythm. Peaked P waves indicate right
atrial hypertrophy (P pulmonale). A P wave with increased amplitude can indicate
hypokalemia. It can also indicate right atrial enlargement. A P wave with decreased
amplitude can indicate hyperkalemia. Bifid (split) P waves indicate left atrial hypertrophy
(P mitrale), while a saw tooth formed P wave may indicate atrial flutter.

QRS complex
The QRS complex is a name for the combination of three of the graphical deflections
seen on a typical electrocardiogram (ECG). It is usually the central and most visually
obvious part of the tracing. It corresponds to the depolarization of the right and left
ventricles of the heart. The Q, R, and S waves occur in rapid succession, do not all
appear in all leads, and reflect a single event, and thus are usually considered together.
A Q wave is any downward deflection after the P wave. An R wave follows as an upward
deflection, and the S wave is any downward deflection after the R wave. The T wave
follows the S wave, and in some cases an additional U wave follows the T wave.
T wave
In electrocardiography, the T wave represents the repolarization (or recovery) of the
ventricles. Twave inversion (negative T waves) can be a sign of coronary ischemia,
Wellens' syndrome, left ventricular hypertrophy, or central nervous system (CNS)
disorder.

ST Elevation
ST elevations refers to a finding on an electrocardiogram, wherein the trace in the ST
segment is abnormally high above the isoelectric line. The ST segment corresponds to
a period of ventricle systolic depolarization, when the cardiac muscle is contracted.
Subsequent relaxation occurs during the diastolic repolarization phase. The normal
course of ST segment reflects a certain sequence of muscular layers undergoing
repolarization and certain timing of this activity. When the cardiac muscle is damaged or
undergoes a pathological process (e.g. inflammation), its contractile and electrical
properties change. Usually, this leads to early repolarization, or premature ending of the
systole.

ST elevation may be present on all or some leads of ECG. It can be associated with
myocardial infarction, Prinzmetal's angina, acute pericarditis, left ventricular aneurysm,
hyperkalemia, acute myocarditis, pulmonary embolism, and other conditions.

Bundle branch block (BBB)

A distinctive, abnormal pattern displayed by an ECG. The cardiac electrical system has
two bundle branches the right and the left and in BBB, one or the other of these
bundle branches is no longer conducting electrical impulses normally. People with BBB
usually will have either right bundle branch block (RBBB) or left bundle branch block
(LBBB), depending on which of the two bundle branches is "blocked." The significance of
having a BBB will vary from person to person.

When the bundle branches are functioning normally, the right and left ventricles contract
nearly simultaneously. BBB occurs when one of the bundle branches becomes
diseased or damaged, and stops conducting electrical impulses that is, one of the
bundle branches becomes "blocked." The chief effect of a bundle branch block is to
disrupt the normal, coordinated and simultaneous contraction of the two ventricles. The
contraction of one ventricle (the one whose bundle branch is blocked) occurs slightly
after the contraction of the other.

Right bundle branch block (RBBB)

In RBBB, the right bundle branch no longer conducts electricity. So the heart's electrical
impulse enters the ventricles using only the left bundle branch which means the left
ventricle receives the elecrical impulse first. Then, from the left ventricle, the electrical
impulse finally makes its way to the right ventricle. As a result, the two ventricles no
longer receive the electrical impulse simultaneously. First the left ventricle receives the
 electrical impulse, then the right.

RBBB often occurs in medical conditions that affect the right ventricle or the lungs, so a
finding of RBBB on the ECG ought to trigger a screening exam for such conditions.
These include pulmonary embolus (blood clots to the lung), chronic obstructive
pulmonary disease (COPD), coronary artery disease (CAD), atrial septal defect,
ventricular septal defect, and valvular heart disease. However, this ECG pattern also
occasionally occurs in healthy people.

Left bundle branch block (LBBB)

In LBBB, the opposite occurs. Here, the left bundle branch no longer conducts electricity.
So the electrical impulse enters the ventricles through the right bundle branch, and is
carried first to the right ventricle (first panel). From there, it finally spreads to the left
ventricle (second panel). Once again, the two ventricles no longer receive the electrical
impulse simultaneously.

LBBB is somewhat less common than RBBB, and its presence usually indicates
underlying cardiac pathology. LBBB is commonly seen with dilated cardiomyopathy,
hypertrophic cardiomyopathy, hypertension, aortic valve disease, CAD, and a variety of
other cardiac conditions. While occasionally LBBB occurs in apparently healthy people,
its appearance should trigger a thorough search (as opposed to a simple screening) for
underlying cardiac problems.

In some people especially in patients with heart failure and reduced left ventricular
ejection fractions the fact that the contraction of the left ventricle is delayed in LBBB
actually does cause a measurable decrease in cardiac efficiency and cardiac function.

With either type of BBB, therefore, the electrical signal spreads across the ventricles
sequentially, as opposed to simultaneously. This sequential spread of the impulse (i.e.,
first the right ventricle, then the left, or vice versa) means that it takes longer for the
impulse to spread throughout both ventricles. This means that, with either type of BBB,
the QRS complex on the ECG is wider than normal.

Complete heart block

If both the right and left bundle branches are completely blocked (a condition called
"bilateral" BBB), the electrical impulse will not be able to reach the ventricles at all. This
is a form of "complete heart block," and unless spontaneous electrical impulses arise
within the ventricles (a socalled "ventricular escape rhythm"), the ventricles stop beating
and death occurs.

Stress Test
Stress testing provides information about how your heart works during physical stress. Some
heart problems are easier to diagnose when your heart is working hard and beating fast.
During stress testing, you exercise to make your heart work hard and beat fast. Tests are done
on your heart while you exercise. If another medical problem that prevents the patient from
exercising during a stress test, the doctor may administer a medicine to make the heart work
hard, as it would during exercise. This is called a pharmacological stress test.

Doctors usually use stress testing to help diagnose coronary heart disease (CHD). They also
use stress testing to find out the severity of CHD.

A stress test can detect the following problems, which may suggest that the heart isn't getting
enough blood during exercise:
Abnormal changes in the heart rate or blood pressure
Symptoms such as shortness of breath or chest pain, especially if they occur at low
levels of exercise
Abnormal changes in the heart's rhythm or electrical activity

Holter monitor
A Holter monitor is a machine that continuously records the heart's rhythms. The monitor is
usually worn for 24 48 hours during normal activity.

Echocardiogram (ECHO)
A sonogram of the heart. Also known as a cardiac ultrasound, it uses standard ultrasound
techniques to image twodimensional slices of the heart. The latest ultrasound systems now
employ 3D realtime imaging.

In addition to creating twodimensional pictures of the cardiovascular system, an

echocardiogram can also produce accurate assessment of the velocity of blood and cardiac
tissue at any arbitrary point using pulsed or continuous wave Doppler ultrasound. Other
parameters measured include cardiac dimensions (luminal diameters and septal thicknesses)
and E/A ratio.

Ejection fraction
Ejection fraction is a measurement of the percentage of blood leaving your heart each time it
contracts. No matter how forceful the contraction, it doesn't empty all of the blood out of a
ventricle. The term "ejection fraction" refers to the percentage of blood that's pumped out of a
filled ventricle with each heartbeat. Because the left ventricle is the heart's main pumping
chamber, ejection fraction is usually measured only in the left ventricle (LV).

A normal LV ejection fraction is 55 to 70 percent. The ejection fraction may decrease due to:
Weakness of your the muscle, such as dilated cardiomyopathy
A heart attack that has damaged the heart
Heart valve problems
Longstanding, uncontrolled high blood pressure
E/A ratio
When flow across the MV is assessed with Pulse Wave (PW) Doppler, two waves are
characteristically seen. These represent passive filling of the ventricle (early [E] wave) and
active filling with atrial systole (atrial [A] wave). Classically, the Ewave velocity is slightly greater
than that of the A wave. However, in conditions that limit the compliance of the LV, two
abnormalities are possible:

reversal in which the A wave is greater than the E wave. This indicates slow filling
caused by older age, hypertension, left ventricular hypertrophy (LVH), or diastolic
dysfunction
exaggeration of normal a tall, thin E wave with a small or absent A wave. This
indicates restrictive cardiomyopathy, constrictive pericarditis, or infiltrative cardiac
disease (eg, amyloidosis)

Angiography
A medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs
of the body, with particular interest in the arteries, veins and the heart chambers. This is
traditionally done by injecting a contrast agent into the blood vessel and imaging using Xray
based techniques, such as fluoroscopy.

Common procedures and devices:

Angioplasty
A procedure used to open narrow or blocked coronary (heart) arteries. The procedure restores
blood flow to the heart muscle. During the procedure, a thin, flexible catheter (tube) with a
balloon at its tip is threaded through a blood vessel to the affected artery. Once in place, the
balloon is inflated to compress the plaque against the artery wall. This restores blood flow
through the artery. Doctors may use the procedure to improve symptoms of CHD, such as
angina. The procedure also can reduce heart muscle damage caused by a heart attack.

Cardiac catheterization
During cardiac catheterization, a thin, plastic tube (catheter) is inserted into a vein in the arm or
leg and then moved to the heart most likely the left ventricle. Using images taken during the
catheterization, your doctor can see how your blood pumps through your heart.

Cardioversion
A medical procedure done to restore a normal heart rhythm. Cardioversion is most often done
by sending electric shocks to the heart through electrodes placed on the chest. Occasionally,
cardioversion may be performed using only medications.

Coronary bypass surgery

Surgery for people whose coronary arteries have become narrowed or blocked by fatty material
called plaque. Heart bypass surgery creates a new route, called a bypass, for blood and
oxygen to reach the heart. It uses blood vessels taken from another part of the body to go
around or bypass blocked or narrowed coronary (heart) arteries. The bypass allows more
blood and oxygen to flow to the heart muscle.

Implantable cardioverter defibrillator (ICD)

An electronic device that constantly monitors the heart rhythm. When it detects a very fast,
abnormal heart rhythm, it delivers energy to the heart muscle. This causes the heart to beat in a
normal rhythm again. It has a generator, one or more leads, and an electrode for each lead.
These components work very much like a pacemaker. However, the ICD is designed to deliver
an electrical shock to the heart when the heart rate becomes dangerously fast, or fibrillates.

Pacemaker
A small device that is placed under the skin near the heart to help control the heartbeat. People
may need a pacemaker for a variety of reasons mostly due to an arrhythmia.

Radiofrequency ablation
Ablation is a procedure used to treat some types of rapid heartbeat. A physician guides a
catheter with an electrode at its tip to the area of heart muscle where the damaged site is
located. Then, radiofrequency energy is transmitted to the site of the pathway. Heart muscle
cells in a very small area (about 1/5 of an inch) die and stop conducting the extra impulses that
caused the rapid heartbeats.

Stent
A stent is a small mesh tube that is used to treat narrow or weak arteries. it is placed in an artery
as part of an angioplasty. A stent helps support the inner wall of the artery in the months or
years after angioplasty. Doctors also may place stents in weak arteries to improve blood flow
and help prevent the arteries from bursting. Stents usually are made of metal mesh, but
sometimes they're made of fabric. Fabric stents, also called stent grafts, are used in larger
arteries. Some stents are coated with medicine that is slowly and continuously released into the
artery. These stents are called drugeluting stents. The medicine helps prevent the artery from
becoming blocked again.

Common Cardiac Conditions:

Atrial fibrillation (AF or Afib)

The most common type of arrhythmia, AF occurs if rapid, disorganized electrical signals cause
the heart's two upper chamberscalled the atria to fibrillate. The term "fibrillate" means to
contract very fast and irregularly. In AF, blood pools in the atria. It isn't pumped completely into
the ventricles. As a result, the heart's upper and lower chambers don't work together as they
should, and the heart cannot pump as much blood as the body needs.

When AF isn't noticed, it can increase the risk of stroke. In some people, AF can cause chest
pain or heart failure, especially if the heart rhythm is very rapid. AF may happen rarely or every
now and then, or it may become an ongoing or longterm heart problem that lasts for years.

If the atrial fibrillation/flutter is part of a condition called sick sinus syndrome, the sinus node
may not work properly. The heart rate may alternate between slow and fast beats. As a result,
there may not be enough blood to meet the body's needs.

Other Causes: Alcohol use, congestive heart failure, coronary artery disease, heart
surgery, heart valve disease, hypertension, hypertrophic cardiomyopathy, medications,
overactive thryoid gland, pericarditis.

Symptoms:
Pulse that feels rapid, racing, pounding, fluttering, irregular, or too slow
Sensation of feeling the heart beat (palpitations)
Shortness of breath
Confusion
Dizziness, lightheadedness
Fainting
Fatigue
Loss of ability to exercise
Symptoms may begin or stop suddendly, as Afib may stop or start on its own.

Signs and Tests:

Heart rate may be between 100 to 175 (normal is 60100)
Fast heartbeat heard with stethoscope
ECG
Holter monitor

Treatment and Management:

Emergency treatment such as electrical shocks or medicine to slow the heartbeat
Medications include: betablockers, calcium channel blockers, and digitalis.
Blood thinners such as heparin, warfarin, and dabigatran reduce the risk of blood
clots, but increase the risk of bleeding
Radiofrequency ablation
Pacemaker

Atrial flutter (AFL)

Atrial flutter (AFL) is the second most common type of arrhythmia. It is typically initiated by a
premature electrical impulse arising in the atria. In AFL, the atria (the upper chambers of the
heart) beat too fast. AFL makes it harder for the heart to pump blood effectively. With the blood
moving more slowly, it is more likely to form clots. If the clot is pumped out of the heart, it could
travel to the brain and lead to a stroke or heart attack. Without treatment, AFL can also cause a
fast pulse rate for long periods of time. This can weaken the heart muscle over time, and
potentially lead to heart failure. Without treatment, AFL can also cause atrial fibrillation.

70
70
While this rhythm occurs most often in individuals with cardiovascular disease (e.g.
hypertension, coronary artery disease, and cardiomyopathy) and diabetes, it may occur
spontaneously in people with otherwise normal hearts.

Symptoms:
Palpitations
Shortness of breath
Chest pains
Lightheadedness or dizziness
Nausea
In some patients, nervousness and feelings of impending doom
Over time, with loss of normal heart function: effort intolerance (exertional
breathlessness), nocturnal breathlessness, or swelling of the legs or
abdomen.

Treatment and Management:

In general, managed the same as Afib
Cardioversion
Ablation
Anticoagulation agent (blood thinners) to reduce risk of blood clots

Cardiomyopathy
Cardiomyopathy is a disease that weakens and enlarges the heart muscle (myocardium). There
are three main types of cardiomyopathy dilated, hypertrophic and restrictive. The most
common form of cardiomyopathy is dilated cardiomyopathy. Cardiomyopathy makes it harder
for the heart to pump blood and deliver it to the rest of the body. Cardiomyopathy can lead to
heart failure. People with cardiomyopathy are often at risk of dangerous forms of irregular heart
beat and sudden cardiac death.

Most cardiomyopathies are extrinsic (primary pathology is outside of the myocardium itself).
The most common cause of an extrinsic cardiomyopathy is ischemia. Ischemia can be
understood as poor oxygen supply of the heart muscle (the demand for oxygen is higher than
the current supply).

An intrinsic cardiomyopathy is defined as weakness in the muscle of the heart not due to an
identifiable external cause.

Signs and Symptoms:

Dyspnea
Peripheral edema
chest pain
Types:
Primary/intrinsic cardiomyopathies
Genetic
Hypertrophic cardiomyopathy (HCM or HOCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Isolated ventricular noncompaction
Mitochondrial myopathy
Mixed
Dilated cardiomyopathy (DCM)
Restrictive cardiomyopathy (RCM)
Acquired
Takotsubo cardiomyopathy
Loeffler endocarditis
Secondary/extrinsic cardiomyopathies
Metabolic/storage
amyloidosis
hemochromatosis
Inflammatory
Chagas disease
Endocrine
diabetic cardiomyopathy
hyperthyroidism
acromegaly
Toxicity
chemotherapy
Alcoholic cardiomyopathy
Neuromuscular
muscular dystrophy
Nutritional diseases
Obesityassociated cardiomyopathy[7]
Other
"Ischemic cardiomyopathy" is a weakness in the muscle of the heart due
to inadequate oxygen delivery to the myocardium with coronary artery
disease being the most common cause. Not supported by current
cardiomyopathies classification schemes

Tests: ECG A pattern characteristic of left ventricular hypertrophy may be present. Flat
or inverted T waves are most common, often with lowvoltage QRS complexes.
Intraventricular conduction defects and bundle branch block, especially left bundle
branch block, are also common. An echocardiogram is useful to detect wall motion
abnormalities or a pericardial effusion. Chest radiographs can be normal or can show
evidence of congestive heart failure with pulmonary edema or cardiomegaly.
 Treatment: Treatment depends on the type of cardiomyopathy, but may include
medication (conservative treatment) or iatrogenic/implanted pacemakers for slow heart
rates, defibrillators for those prone to fatal heart rhythms, ventricular assist devices
(LVADs) for severe heart failure, or ablation for recurring dysrhythmias that cannot be
eliminated by medication or cardioversion.

The goal of treatment is often symptom relief, and some patients may eventually require
a heart transplant. Due to the severity of the disease, treatment requires the use of
numerous chemicals and drugs, which have to be taken for the rest of the patient's life.

Congestive or Chronic Heart Failure (CHF)

Heart failure, also known as congestive heart failure (CHF), means that the heart cannot pump
enough blood to meet the body's needs. Over time, conditions such as narrowed arteries in the
heart (coronary artery disease) or high blood pressure gradually leave the heart too weak or stiff
to fill and pump efficiently.

Risk factors and conditions that cause heart failure: coronary artery disease, high blood
pressure, high cholesterol, diabetes or obesity.

Systolic heart failure: The heart muscle cannot pump (eject) the blood out of the heart
very well.

Diastolic heart failure: The heart muscles are stiff and do not fill up with blood easily.

Both of these problems mean the heart is no longer able to pump enough oxygenrich blood out
to the rest of the body, especially during exercise or activity.

As the heart's pumping action is lost, blood may back up in other areas of the body. Fluid builds
up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive
heart failure. Coronary Artery Disease (CAD or CHD) is the most common cause of CHF. It
can also occur as a result of cardiomyopathy. Other heart problems that may cause heart
failure are congenital heart disease, heart attack, heart valve disease, and some types of
arrhythmias. Emphysema, overactive thyroid, underactive thyroid, and severe anemia can also
cause or contribute to CHF.

Signs and Symptoms: Symptoms of heart failure often begin slowly. At first, they
may only occur during activity. Over time, symptoms may even ben noticed at
rest.
Cough
Fatigue, weakness, faintness
Loss of appetite
Need to urinate at night
Pulse that feels fast or irregular, or a sensation of feeling the heart beat
 (palpitations)
Shortness of breath when you are active or after you lie down
Swollen (enlarged) liver or abdomen
Swollen feet and ankles
Waking up from sleep after a couple of hours due to shortness of breath
Weight gain
Fast or difficult breathing
Irregular or fast heartbeat and abnormal heart sounds
Leg swelling
Neck veins that stick out (are distended)
Sounds ("crackles") from fluid buildup in your lungs, heard through a
stethoscope
Swelling of the liver or abdomen

Tests:
Cardiac stress tests
Echocardiogram
Heart catheterization
MRI of the heart
Nuclear heart scans

Lab tests:
Kidney function (BUN, creatinine, creatinine clearance, urinalysis)
CBC to check for a low blood count or anemia
Test for brain natriuretic peptide (BNP)
Sodium and potassium levels

Treatment:
Medications are used to treat symptoms and prevent worsening of CHF.
Medications by be prescribed to:
Help the heart muscle pump better
Keep blood from clotting
Lower cholesterol levels
Open up blood vessels or slow heart rate so the heart doesn't have to
work as hard
Replace potassium
Rid the body of excess fluid and salt (sodium)
Surgeries and Devices:
Coronary bypass surgery (CABG) and angioplasty may help improve
blood flow to the damaged or weakened heart muscle.
Heart valve surgery may be done if changes in a heart valve are causing
the heart failure.
Pacemaker can help treat slow heart rates or help both sides of the heart
 contract at the same time.
Defibrillator to control lifethreatening abnormal heart rhythms.

ENDSTAGE HEART FAILURE

Severe heart failure occurs when treatments no longer work. Certain treatments
may be used when a person is waiting for a heart transplant:
Intraaortic balloon pump (IABP)
Left ventricular assist device (LVAD)

Coronary Artery Disease/Heart Disease (CAD or CHD)

A narrowing of the small blood vessels that supply blood and oxygen to the heart. Coronary
heart disease is caused by the buildup of plaque in the arteries to your heart. This may also be
called hardening of the arteries. As a result, blood flow to the heart can slow down or stop.
This is the leading cause of death in the United States for men and women.

Symptoms:
Chest pain or angina is the most common symptom. Pain may also be felt in the neck,
arms, stomach, or upper back.

Women, the elderly, and people with diabetes are more likely to have symptoms other
than chest pain, such as:
Fatigue
Shortness of breath
Weakness

Tests:
Coronary angiography/arteriography
CT angiography
Echocardiogram
Electrocardiogram (ECG)
Electronbeam computed tomography (EBCT) to look for calcium in the lining of
the arteries the more calcium, the higher your chance for CHD
Exercise stress test
Heart CT scan
Magnetic resonance angiography
Nuclear stress test

Treatment: Patients may be prescribed medicines to treat blood pressure, diabetes, or

high cholesterol levels. Goals for treating these conditions in people with CAD:
Blood pressure less than or equal to 140/90 (even lower for some patients with
diabetes, kidney disease, or heart failure)
Glycosylated hemoglobin (HbA1c) levels less than or equal to 7% for people with
diabetes
 LDL cholesterol level less than or equal to 100 mg/dL (even lower for some
patients)
Medications to treat CAD:
ACE inhibitors to lower blood pressure and protect the heart and kidneys
Aspirin, with or without clopidogrel (Plavix) or prasugrel (Effient) to help
prevent blood clots from forming in your arteries
Betablockers to lower heart rate, blood pressure, and oxygen use by the
heart
Calcium channel blockers to relax arteries, lower blood pressure, and
reduce strain on the heart
Diuretics ("water pills") to lower blood pressure and treat heart failure
Nitrates (such as nitroglycerin) to stop chest pain and improve blood flow
to the heart
Statins to lower cholesterol

Surgeries and Procedures:

Minimally invasive heart surgery
Angioplasty and stent placement, called percutaneous coronary interventions
(PCIs)
Coronary artery bypass surgery

Myocardial infarction (MI or heart attack)

A heart attack occurs when blood flow to a part of the heart is blocked for a long enough time
that part of the heart muscle is damaged or dies. If the blood flow is blocked, the heart is
starved of oxygen and heart cells die. Most heart attacks are caused by a blood clot that blocks
one of the coronary arteries.

A hard substance called plaque can build up in the walls of your coronary arteries. This plaque
is made up of cholesterol and other cells. A heart attack can occur as a result of plaque buildup.
The plaque can develop cracks or tears. Blood platelets stick to these tears and form a
blood clot. A heart attack can occur if this blood clot completely blocks oxygenrich blood
from flowing to the heart. This is the most common cause of heart attacks.
The slow buildup of plaque may almost block one of the coronary arteries. A heart attack
may occur if not enough oxygenrich blood can flow through this blockage. This is more
likely to happen when the body is stressed (for example, by a serious illness).

Cardiogenic shock is a state in which the heart has been damaged so much that it cannot
supply enough blood to the organs of the body. This condition is a medical emergency.

Symptoms: Chest pain is the most common symptom. It may move from the chest to
the arms, shoulder, neck, teeth, jaw, belly area, or back. Other symptoms include:
Anxiety
Cough
 Fainting
Lightheadedness, dizziness
Nausea or vomiting
Palpitations
Shortness of breath
Sweating
Fatigue

Signs and Tests:

Abnormal sounds (crackles) in lungs, a heart murmur, or other abnormal sounds.
Rapid pulse.
Blood pressure may be normal, high, or low.
A troponin blood test can show if there is heart tissue damage. This test can
confirm the occurrence of a heart attack.
Coronary angiography to test blood flow
ECG
ECHO
Stress test
Nuclear stress test

Emergency Treatment:
Angioplasty is often the first choice of treatment.
Stent placement to prevent the artery from closing up again.
Medication to break up clot(s)

Treatment post heart attack:

Antiplatelet drugs (blood thinners) such as aspirin, clopidogrel (Plavix), or
warfarin (Coumadin), to help keep your blood from clotting
Betablockers and ACE inhibitor medicines to help protect your heart
Statins or other drugs to improve your cholesterol levels
Cardiac rehabilitation program
slowly increase exercise level
learn lifestyle changes

After having a heart attack, chances of having another one are higher.

Common Circulatory Conditions:

Aneurysm
An abnormal widening or ballooning of a portion of an artery due to weakness in the wall of the
blood vessel. Common locations for aneurysms include: the aorta, the brain (cerebral
aneurysm), in the leg behind the knee (popliteal artery aneurysm), in an artery in the spleen
(splenic artery aneurysm).
High blood pressure, high cholesterol, and cigarette smoking may raise your risk of certain
types of aneurysms. High blood pressure is thought to play a role in abdominal aortic
aneurysms. Atherosclerotic disease (cholesterol buildup in arteries) may also lead to the
formation of some aneurysms. Pregnancy is often linked to the formation and rupture of splenic
artery aneurysms.

Symptoms: Symptoms depend on the location of the aneurysm:

If it is near the bodys surface, pain and swelling with a throbbing mass is often
seen.
Aneurysms within the body or brain often cause no symptoms.
If an aneurysm ruptures, pain, low blood pressure, a rapid heart rate, and
lightheadedness may occur. The risk of death after a rupture is high.

Tests:
CT scan
Ultrasound

Complications:
Compression of nearby structures such as nerves, which may lead to weakness
and numbness (most common with aneurysms that occur in the artery behind the
knee)
Infection, can lead to bodywide illness and rupture
Rupture, which can cause massive bleeding that may lead to death
Massive bleeding is commonly seen with abdominal aortic aneurysms,
mesenteric artery aneurysms, and splenic artery aneurysms.
Rupture of brain (cerebral) aneurysms can cause stroke and death

Treatment:
Surgery is generally recommended
Some patients may have endovascular stent repair
Aortic aneurysms in the upper chest (the ascending aorta) are usually operated
on right away. Aneurysms in the lower chest and the area below the stomach
(the descending thoracic and abdominal parts of the aorta) may not be as life
threatening. Aneurysms in these locations are watched for varying periods,
depending on their size. If they become about 5 centimeters (almost 2 inches) in
diameter, continue to grow, or begin to cause symptoms, you may need to have
surgery to stop the aneurysm from bursting.

Hypertension (HTN or HBP)

High blood pressure. Hypertension increases chances of having a stroke, heart attack, heart
failure, kidney disease, and early death. Many factors affect blood pressure, including: amount
of water and salt in the body, the condition of the kidneys, nervous system, or blood vessels,
and hormones levels. Other risk factors include obesity, stress/anxiety, alcohol, famiy history,
diabetes, and smoking.

When no particular cause of hypertension is found, it is called essential hypertension.

Hypertension caused by another medical condition is called secondary hypertension. This

may be due to the following:

Chronic kidney disease

Disorders of the adrenal gland (pheochromocytoma or Cushing syndrome)
Pregnancy
Medications such as birth control pills, diet pills, some cold medications, and
migraine medications
Narrowed artery that supplies blood to the kidney (renal artery stenosis)
Hyperparathyroidism

Malignant hypertension is very high blood pressure that comes on suddenly and quickly and is
dangerous.

The following table shows the classification of blood pressure adopted by the American Heart
Association for adults who are 18 years and older. It assumes the values are a result of
averaging blood pressure readings measured at two or more visits to the doctor:

Category systolic, mmHg diastolic, mmHg

Hypotension < 90 < 60

Desirable 90119 6079

Prehypertension 120139 or 8089

Stage 1 Hypertension 140159 or 9099

Stage 2 Hypertension 160179 or 100109

Hypertensive Crisis 180 or 110

Symptoms: Most of the time, there are no symptoms. If a person is suffering from
malignant hypertension, it may be accomanied by: severe headache, nausea or
vomiting, bad headache, confusion, changes in vision, or nosebleeds.
 Treatment: Hypertension can usually be controlled with medicine and lifestyle changes.
Common medications include:
Diuretics are also called water pills. They help the kidneys remove some sodium
from the body. As a result, your blood vessels don't have to hold as much fluid
and blood pressure goes down.
Betablockers make the heart beat at a slower rate and with less force.
Angiotensinconverting enzyme inhibitors (also called ACE inhibitors) relax blood
vessels, which lowers blood pressure.
Angiotensin II receptor blockers (also called ARBs) work in about the same way
as angiotensinconverting enzyme inhibitors.
Calcium channel blockers relax blood vessels by stopping calcium from entering
cells.
Blood pressure medicines that are not used as often include:
Alphablockers help relax blood vessels, which lowers blood pressure.
Centrally acting drugs signal the brain and nervous system to relax blood
vessels.
Vasodilators signal the muscles in the walls of blood vessels to relax.
Renin inhibitors, a newer type of medicine for treating high blood pressure, act by
relaxing the blood vessels.

Peripheral vascular disease/Peripheral artery disease (PVD or PAD)

A condition of the blood vessels that leads to narrowing and hardening of the arteries that
supply the legs and feet. Plaque builds up on the walls of the arteries, causing the arteries to
become narrower. The walls of the arteries also become stiffer and cannot widen (dilate) to
allow greater blood flow when needed. As a result, when the leg muscles are working harder
(such as during exercise or walking) they cannot get enough blood and oxygen. Eventually,
there may not be enough blood and oxygen, even when the muscles are resting.

Symptoms: pain, achiness, fatigue, burning, weakness, or discomfort in the

muscles of your feet, calves, or thighs. This is also called claudication. These
symptoms usually appear during walking or exercise and go away after several
minutes of rest. Slowly, these symptoms come on more quickly and with less
exercise. The legs or feet may feel numb while at rest. The legs also may feel
cool to the touch, and the skin may appear pale.

When PAD becomes severe, it may cause pain and cramps at night, pain or
tingling in the feet or toes, which can be so severe that even the weight of clothes
or bed sheets is painful, pain that is worse when the leg is elevated, and ulcers
that do not heal.

Complications:
Blood clots or emboli that block off small arteries
Coronary artery disease

80
80
 Impotence
Open sores (ischemic ulcers) on the lower legs
Tissue death (gangrene)

Examination:
During an examination, the health care provider may find:
A whooshing sound with the stethoscope over the artery (arterial bruits)
Decreased blood pressure in the affected limb
Loss of hair on the legs or feet
Weak or absent pulses in the limb
When PAD is more severe, findings may include:
Calf muscles that shrink (wither)
Hair loss over the toes and feet
Painful, nonbleeding ulcers on the feet or toes (usually black) that are
slow to heal
Paleness of the skin or blue color in the toes or foot (cyanosis)
Shiny, tight skin and thick toenails

Tests:
Blood tests may show high cholesterol or diabetes
Angiography of the arteries in the legs (arteriography)
Blood pressure measured in the arms and legs for comparison
(ankle/brachial index, or ABI)
Doppler ultrasound exam of an extremity
Magnetic resonance angiography or CT angiography

Treatment:
Specialized exercise programs
Medications:
Aspirin or Plavix to keep blood from clotting in arteries
Cilostazol to dilate the affected artery or arteries, for moderate to
severe cases if not a candidate for surgery
Cholesterol medication
Pain relievers
Surgery:
Angioplasty and stent placement of the peripheral arteries
Peripheral artery bypass surgery of the leg
Some cases require amputation of a limb

Avascular Necrosis (Osteonecrosis)

Bone death caused by poor blood supply to the area. It is most common in the hip and shoulder,
but can affect other large joints such as knee, elbow, wrist and ankle. It occurs when part of the
bone does not get blood and dies. After a while, the bone can collapse. If this condition is not
treated, the joint will deteriorate and this will become severe arthritis.

Osteonecrosis can be caused by disease, or a severe trauma, such as a break or dislocation,

that affects the blood supply to the bone. Many times, no trauma or disease is present. This is
called "idiopathic osteonecrosis" meaning it occurs without any known cause.

Causes:
Longterm treatments with steroids
Excessive alcohol use
Sickle cell disease
Radiation therapy
Gaucher disease
Decompression sickness from a lot of deep sea diving
Dislocation or fractures around a joint
Some diseases that may be associated with the development of this condition include:
Gout
Atherosclerosis
Diabetes
When osteonecrosis occurs in the shoulder joint, it is usually due to longterm treatment
with steroids or a history of trauma to the shoulder.

Symptoms: There are no symptoms in the early stages. As bone damage worsens, the
following symptoms may occur:
Pain in the joint that may increase over time, and will become very severe if the
bone collapses
Pain that occurs even at rest
Limited range of motion
Groin pain, if the hip joint is affected
Limping, if the condition occurs in or below the hips

Complications: Advanced osteonecrosis can lead to osteoarthritis and permanent

decreased mobility. Severe cases may require joint replacement.

Tests:
Xray
MRI
Bone scan
CT scan

Treatment:
If an underlying condition is known, the health care provider will focus treatment
on the underlying condition. For example, blood thinners for a blood clotting
disorder.
 If the condition is found very early, the patient will be prescribed pain relievers
and instructed to limit the use of the affected area. This may include using
crutches if a hip, knee, or ankle is affected.
Range of motion exercises may be needed
Although nonsurgical treatment may slow its progression, most people will need
surgery

Surgery:
A bone graft
A bone graft along with its blood supply (vascularized bone graft)
Cutting the bone and changing its alignment to relieve stress on the bone or joint
(osteotomy)
Total joint replacement
Removing part of the inside of the bone (core decompression) to relieve pressure
and allow new blood vessels to form

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http://www.cvphysiology.com/Arrhythmias/A013.htm
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http://www.fi.edu/learn/heart/systems/coronary.html
http://en.wikipedia.org/wiki/Circulatory_system#Human_cardiovascular_system
http://www.fi.edu/learn/heart/systems/pulmonary.html
http://www.texasheartinstitute.org/hic/anatomy/anatomy.cfm
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=mesh&term=Myocardium
http://biology.about.com/od/anatomy/ss/AtriaOfTheHeart.htm
http://www.worldinvisible.com/apologet/humbody/heart.htm
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http://en.wikipedia.org/wiki/Aorta
http://www.fi.edu/learn/heart/vessels/veins.html
http://my.clevelandclinic.org/heart/heartbloodvessels/coronaryarteries.aspx
http://my.clevelandclinic.org/disorders/pulmonary_artery_stenosis/hic_pulmonary_artery_stenosi
s.aspx
http://en.wikipedia.org/wiki/Pulmonary_vein
http://en.wikipedia.org/wiki/Hemoglobin
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http://www.nhlbi.nih.gov/health/healthtopics/topics/arr/
http://www.mtworld.com/tools_resources/lab_values.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001224/
http://www.mayoclinic.com/health/enlargedheart/ds01129
http://en.wikipedia.org/wiki/Edema
http://www.nlm.nih.gov/medlineplus/ency/article/003081.htm
http://www.umm.edu/altmed/articles/angina000010.htm
http://www.nhlbi.nih.gov/health/healthtopics/topics/stress/
http://en.wikipedia.org/wiki/Echocardiography
http://www.nlm.nih.gov/medlineplus/ency/article/003877.htm
http://en.wikipedia.org/wiki/Ischemia
http://en.wikipedia.org/wiki/Blood_pressure
http://www.ncbi.nlm.nih.gov/books/NBK2215/
http://www.texasheartinstitute.org/HIC/Topics/Cond/ddisfunc.cfm
http://www.nhlbi.nih.gov/health/healthtopics/topics/stents/
http://www.nhlbi.nih.gov/health/healthtopics/topics/angioplasty/
http://www.mayoclinic.com/health/pacemaker/MY00276
http://nyp.org/health/cardiacpaceover.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001510/
http://en.wikipedia.org/wiki/Prinzmetal%27s_angina
http://www.nlm.nih.gov/medlineplus/ency/article/002338.htm
http://www.ninds.nih.gov/disorders/syncope/syncope.htm
http://www.mayoclinic.com/health/cardiomyopathy/DS00519
http://en.wikipedia.org/wiki/Sinus_node
http://en.wikipedia.org/wiki/QRS_complex
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Abla
tionforArrhythmias_UCM_301991_Article.jsp http://www.nhlbi.nih.gov/health/health-
topics/topics/af/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001236/
http://www.hrsonline.org/patientinfo/heartrhythmdisorders/aflutter/
http://www.umassmed.edu/strokestop/module_one/thrombus_embolus.html
http://www.mayoclinic.com/health/heartfailure/DS00061
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001211/
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http://www.heart.org/HEARTORG/Conditions/WhatIsCoronaryBypassSurgery_UCM_309003
_Article.jsp http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004449/
http://heartdisease.about.com/cs/arrhythmias/a/BBB.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001246/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002109/
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claudication.aspx
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004519/
Digestive System

Digestion is the process of breaking down food into molecules small enough for the body to
absorb. Proteins, carbohydrates, and fat in our diets must be broken down and later,
reassembled in forms useful to our body. Digestion begins when food is broken down by the
mouth and ends when processed waste exits the body. Several organs are involved in this
process and compose the gastrointestinal tract.

Usual treatment providers: gastroenterologist hepatologist (liver specialist)

Key terms and components:

Gastrointestinal (GI)
Related to the stomach and intestines.

Alimentary canal (gastrointestinal tract or GI tract or digestive tract)

The passage through which food passes, including the mouth, esophagus, stomach, intestines,
and anus.

Salivary glands
Glands located in the mouth that produce saliva. Saliva contains enzymes that break down
carbohydrates (starch) into smaller molecules.

Esophagus
The long tube between the mouth and the stomach. It uses rhythmic muscle movements (called
peristalsis) to force food from the throat into the stomach.

Stomach
A sacklike, muscular organ that is attached to the esophagus. Both chemical and mechanical
digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of
acids and enzymes.

Liver
A large organ located above and in front of the stomach. It filters toxins from the blood, and
makes bile (which breaks down fats) and some blood proteins.

Pancreas
An enzymeproducing gland located below the stomach and above the intestines. It releases the
hormones insulin and glucagon, as well as enzymes that help in digestion.

Gallbladder
A small, saclike organ located by the duodenum. It stores and releases bile (a digestive
chemical which is produced in the liver) into the small intestine.

Intestines (bowel)
The part of the alimentary canal located between the stomach and the anus. The small
intestine is further subdivided into the duodenum, jejunum and ileum while the large intestine is
subdivided into the cecum and colon.

Small intestine
After leaving the stomach, food enters the duodenum, the first part of the small intestine. It then
enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine,
bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other
digestive enzymes produced by the inner wall of the small intestine help in the breakdown of
food.

Duodenum
The first part of the small intestine it is Cshaped and runs from the stomach to the jejunum.

Jejunum
The long, coiled midsection of the small intestine it is between the duodenum and the ileum.

Ileum
The last part of the small intestine before the large intestine begins.

Large intestine
After passing through the small intestine, food passes into the large intestine. In the large
intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food.
Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and
Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine
is called the cecum (the appendix is connected to the cecum). Food then travels upward in the
ascending colon. The food travels across the abdomen in the transverse colon, goes back down
the other side of the body in the descending colon, and then through the sigmoid colon.

Cecum
The first part of the large intestine the appendix is connected to the cecum.

Appendix
A small tube located on the cecum. It is a structure that is thought to have lost all or most of its
original function through the process of evolution. Some scientists have recently proposed that
the appendix may harbor and protect bacteria that are beneficial in the function of the human
colon.

Ascending colon
The part of the large intestine that run upwards it is located after the cecum.

Transverse colon
The part of the large intestine that runs horizontally across the abdomen.

Descending colon
The part of the large intestine that run downwards after the transverse colon and before the
sigmoid colon.

Sigmoid colon
The part of the large intestine between the descending colon and the rectum.

Rectum
The lower part of the large intestine, where feces are stored before they are excreted.

Anus
The opening at the end of the digestive system from which feces (waste) exit the body.

Lumen
The inside space of a tubular structure, such as an artery or intestine. In the context of the
digestive system, it is the interior of the GI tract. Nutrients are absorbed as food passes through
the lumen.

Epithelium
Epithelia are formed of cells that line the cavities in the body and also cover flat surfaces. The
intestinal epithelium is the epithelium that covers the small and large intestine. Epithelial cells in
the small intestine are a type of brush border cell that are joined together by tight junctions to
form an impermeable membrane.

Muscularis mucosa (or lamina muscularis mucosae)

The thin layer of smooth muscle found in most parts of the gastrointestinal tract, located outside
the lamina propria mucosae and separating it from the submucosa. In the gastrointestinal tract,
the term mucosa or "mucous membrane" refers to the combination of epithelium, lamina propria,
and (where it occurs) muscularis mucosae.

The muscularis mucosae is composed of several thin layers of smooth muscle fibers oriented in
different ways which keep the mucosal surface and underlying glands in a constant state of
gentle agitation to expel contents of glandular crypts and enhance contact between epithelium
and the contents of the lumen.

Lamina propria mucosae

The lamina propria is a constituent of the moist linings known as mucous membranes or
mucosa, which line various tubelike parts of the body. It is a thin layer of loose connective
tissue which lies beneath the epithelium and together with the epithelium constitutes the
mucosa.

The lamina propria contains capillaries and a central lacteal (lymph vessel) in the small
intestine, as well as lymphoid tissue. Lamina propria also contains glands with the ducts
opening on to the mucosal epithelium, that secrete mucus and serous secretions. The lamina
propria is also rich in immune cells known as lymphocytes. The term mucosa or mucous
membrane always refers to the combination of the epithelium plus the lamina propria.

Submucosa
In the gastrointestinal tract, the submucosa is the layer of dense irregular connective tissue or
loose connective tissue that supports the mucosa, as well as joins the mucosa to the bulk of
underlying smooth muscle. Identification of the submucosa plays an important role in diagnostic
and therapeutic endoscopy.

Peritoneum
A thin membrane that lines the inside wall of the abdomen and covers most of the intra-
abdominal organs. The peritoneum is made of epithelial cells. By producing a lubricating fluid,
the peritoneum helps the organs to move smoothly inside the abdomen.

Peritoneal cavity
A potential space between the parietal peritoneum and visceral peritoneum, that is, the two
membranes that separate the organs in the abdominal cavity from the abdominal wall.

Ileus
A blockage of the intestines.

Ileitis
An inflammation of the ileum.

Polyp
An abnormal growth of tissue projecting from a mucous membrane.

Ascites
Accumulation of fluid in the peritoneal cavity.

Esophageal varices
Abnormal, enlarged veins in the lower part of the esophagus. Esophageal varices occur most
often in people with serious liver diseases. Esophageal varices develop when normal blood
flow to your liver is slowed. The blood then backs up into nearby smaller blood vessels, such as
those in the esophagus, causing the vessels to swell. Sometimes, esophageal varices can
rupture, causing lifethreatening bleeding.

Hiatal hernia
A condition in which part of the stomach sticks upward into the chest, through an opening in the
diaphragm. It results in chest pain, heartburn, and swallowing difficulty.

Hepatic encephalopathy
A worsening of brain function that occurs when the liver is no longer able to remove toxic
substances in the blood. Ammonia, which is produced by the body when proteins are digested,
is one of the harmful substances that is normally made harmless by the liver. Many other
substances may also build up in the body if the liver is not working well. They can cause
damage to the nervous system. Hepatic encephalopathy may occur suddenly in people who
previously had no liver problems when damage occurs to the liver. More often, the condition is
seen in people with chronic liver disease.

Common tests and procedures:

Upper gastrointestinal endocscopy (UGI) or esophagogastroduodenoscopy (EGD)

A procedure used to visually examine the upper digestive system with a tiny camera on the end
of a long, flexible tube. A gastroenterologist uses endoscopy to diagnose and, sometimes, treat
conditions that affect the esophagus, stomach and beginning of the small intestine (duodenum).

Esophageal manometry
A thin, pressuresensitive tube is passed through the mouth or nose and into the stomach. Once
in place, the tube is pulled slowly back into the esophagus. When the tube is in the esophagus,
the patient is asked to swallow. The pressure of the muscle contractions will be measured along
several sections of the tube. While the tube is in place, other studies of the esophagus may be
done.

Colonoscopy
An internal examination of the colon (large intestine) and rectum, using an instrument called a
colonoscope. The colonoscope has a small camera attached to a flexible tube that can reach
and examine the entire length of the colon.

Sigmoidoscopy
A procedure used to see inside the sigmoid colon and rectum (the lower part of the large
intestine), using a sigmoidoscope. The sigmoidoscope has a small camera attached to a
flexible tube. Tissue samples may be taken with a tiny biopsy tool inserted through the scope.
Polyps may be removed with heat (electrocautery). Images may be taken.

Capsule endoscopy
Regular endoscopies and colonoscopies cannot get to the small intestine, but doctors can
examine the small intestine through a capsule endoscopy. A capsule endoscopy is a small, pill
shaped camera. It is swallowed and then travels through the digestive system. It records video
of the small intestine and sends the video to a monitor where the doctor can watch it. Capsule
endoscopies cannot be used if there is any narrowing of the digestive system.

Barium xray
In this procedure, a substance called barium is used to coat the lining of the digestive tract.
Then xrays are taken. Areas coated with barium show up white on xray film. This allows the
doctor to check for signs of IBD.

Fundoplication
Hiatal hernia surgery. The surgeon first repairs the hiatal hernia with stitches. The surgeon then
tightens the opening in the diaphragm to keep the stomach from bulging through. Some

90
90
surgeons place a piece of mesh in the repaired area to make it more secure. The surgeon then
uses stitches to wrap the upper part of the stomach around the end of the esophagus. This
creates pressure at the end of the esophagus and helps prevent stomach acid and food from
flowing back up. This may be done with an open repair, or a laparoscopic repair. A
laparoscope is a thin, hollow tube with a tiny camera on the end.

Endoluminal fundoplication is a procedure that is done to help prevent reflux. It uses an

endoscope to place small clips where the esophagus meets the stomach. These clips help
prevent food or stomach acid from backing up.

Jejunostomy tube (Jtube) or percutaneous endoscopic jejunostomy (PEJ)

A tube inserted through the skin and abdominal wall into the jejunum, a part of the small
intestine. The tube is used for feeding and helps to maintain good nutrition, hydration, and body
weight. The tube is put in place for those who cannot take in enough food or drink by mouth.
Most people with Jtubes have trouble digesting food, emptying their stomachs, or have had a
type of abdominal surgery that requires time to heal.

Ostomy
A surgically created opening in the abdomen that allows waste or urine to leave the body.

Colostomy
A surgical procedure that brings one end of the large intestine out through the abdominal wall.
Waste moving through the intestine drain into a bag attached to the abdomen.

Ileostomy
An opening in the abdominal wall that is made during surgery. Ileostomies are used to deliver
waste out of the body when the colon or rectum is not working properly. The ileum will pass
through a stoma (opening) and empties into a small bag. Possible complications include
infection and problems with the stoma.

Small bowel resection

Surgery to remove part or all of the small bowel (small intestine). It is done when part of the
small bowel is blocked or diseased.

Strictureplasty
In this surgery, the doctor widens the strictured, or narrowed, area without removing any part of
the small intestine. The surgeon guides an inflated balloon attached to a catheter through the
intestine. If the balloon encounters resistance, it may indicate the presence of a stricture, which
is a narrowing in the intestine. To open up the stricture, a cut is made lengthwise along its
length. The cut is then sewn up in the opposite direction, which has the overall effect of
widening the stricture without removing any bowel. Multiple strictures may be treated during one
surgery.
Proctocolectomy
Removal of the colon and rectum.

Ileoanal anastomosis surgery (Jpouch)

The most common surgery for ulcerative colitis. A proctocolectomy is performed. The surgeon
then attaches the ileum to the inside of the anus where the rectum was, creating an internal
pouch. Waste is stored in the pouch and passes out of the anus in the usual manner. Its primary
advantage is that you can eliminate waste normally afterward. In many cases, ileoanal
anastomosis can be performed laparoscopically.

The most common complication of ileoanal anastomosis is pouchitis, an inflammation of the

newly constructed pouch lining. Pouchitis can cause symptoms similar to those of ulcerative
colitis, including diarrhea, abdominal and joint pain, fever, and dehydration. The risk of pouchitis
increases the longer the J pouch is in place, and also if you smoke or have inflammatory joint
disease or certain skin diseases.

Paracentesis
A procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic
fluid for diagnostic or therapeutic purposes.

Common conditions:

Inflammatory bowel disease (IBD)

A group of disorders in which the intestines (small and large intestines or bowels) become
inflamed.

This inflammation causes symptoms such as:

Severe or chronic (almost all of the time) pain in the abdomen (belly)
Diarrhea may be bloody
Unexplained weight loss
Loss of appetite
Bleeding from the rectum
Joint pain
Skin problems
Fever
Constipation
Mouth ulcers
Swollen gums

Symptoms can range from mild to severe. Also, symptoms can come and go, sometimes going
away for months or even years at a time. When people with IBD start to have symptoms again,
they are said to be having a relapse or flareup. When they are not having symptoms, the
disease is said to have gone into remission.
Inflammatory bowel disease (IBD) can cause a number of problems outside of the digestive
tract. One common problem that occurs because of loss of blood from the digestive tract is
anemia. Anemia means that the amount of healthy red blood cells, which carry oxygen to
organs, is below normal. This can make a person feel very tired.

Other health problems include:

Arthritis and joint pain
Weak bones and bone breaks
Inflammation in the eye and other eye problems
Liver inflammation
Gallstones
Red bumps or ulcers on the skin
Kidney stones
Delayed puberty and growth problems (in children and teens)
In rare cases, lung problems
Some of these problems are caused by poor absorption of nutrients. Others are due to
inflammation in parts of the body other than the digestive tract. Some of these problems get
better when the IBD is treated. Others must be treated separately.

No one knows for sure what causes IBD. Experts think that abnormal action of a person's
immune system may trigger IBD. Stress and eating certain foods do not cause IBD, but both
can make IBD symptoms worse. IBD is more common in people who have family members with
IBD. Smoking also seems to affect a person's risk of getting IBD. People who smoke are more
likely to develop Crohn's disease but less likely to develop ulcerative colitis.

The most common forms of IBD are ulcerative colitis and Crohns disease. The diseases are
very similar. In fact, doctors sometimes have a hard time figuring out which type of IBD a
person has. The main difference between the two diseases is the parts of the digestive tract
they affect.

Crohns disease
It causes inflammation of the lining of your digestive tract, which can lead to abdominal
pain, severe diarrhea and even malnutrition.

Crohn's disease can affect all layers of the intestinal wall. Areas of the intestines most
often affected are the last part of the small intestine, called the ileum, and the first part of
the large intestine. However, Crohn's disease can affect any part of the digestive tract,
from the mouth to the anus. Inflammation in Crohn's disease often occurs in patches,
with normal areas on either side of a diseased area.

When the small intestine becomes inflamed, as in Crohn's disease, it is less able to
absorb nutrients from food. These nutrients leave the body in the bowel movement. This
is one reason why people with Crohn's disease don't get enough nutrients, along with
not having much appetite. Also, the undigested food that goes into the large intestine
makes water absorption harder. This causes a watery bowel movement, or diarrhea.

The inflammation caused by Crohn's disease often spreads deep into the layers of
affected bowel tissue. Swelling and scar tissue can thicken the intestinal wall. This
narrows the passageway for food that is being digested. The area of the intestine that
has narrowed is called a stricture. Also, deep ulcers may turn into tunnels, called fistulas,
that connect different parts of the intestine. They may also connect to nearby organs,
such as the bladder or vagina, or connect to the skin. And as with ulcerative colitis,
ulcers may cause a hole to develop in the wall of the intestine.

Like ulcerative colitis, Crohn's disease can be both painful and debilitating, and
sometimes may lead to lifethreatening complications.

While there's no known cure for Crohn's disease, therapies can greatly reduce the signs
and symptoms of Crohn's disease and even bring about longterm remission. With
treatment, many people with Crohn's disease are able to function well.

Ulcerative colitis
Ulcerative colitis affects the top layer of the large intestine, next to where the stool is.
The disease causes swelling and tiny open sores, or ulcers, to form on the surface of the
lining. The ulcers can bleed and produce pus. In severe cases of ulcerative colitis, ulcers
may weaken the intestinal wall so much that a hole develops. Then the contents of the
large intestine, including bacteria, spill into the abdominal cavity or leak into the blood.
This causes a serious infection and requires emergency surgery.

In ulcerative colitis, the small intestine absorbs nutrients as it should, but inflammation in
the large intestine keeps it from absorbing water, causing diarrhea.

Testing for IBD:

Blood tests for signs of inflammation and anemia.
Stool sample tested for blood. It is also tested for signs of an infection that can
trigger a flareup of IBD.
Colonoscopy or sigmoidoscopy
Xrays with barium
Computerized axial tomography (CT or CAT scan)
Capsule endoscopy

Crohns disease may also alter the results of the following tests:
Albumin
Creactive protein
Erythrocyte sedimentation rate
 Fecal fat
Hemoglobin
Liver function tests
White blood cell count

Treatment: Treatments for inflammatory bowel disease (IBD) may include:

Medicines
Surgery
Changes in diet
Nutritional supplements
Reducing stress and getting enough rest
Treatment will depend on:
Symptoms and how severe they are
Which part of the digestive tract is affected
Health problems outside the digestive tract

Most people with IBD take medicine to control their symptoms. If medicines cannot
control their disease, some people will need surgery.

Medicines:
Aminosalicylates given as pills, through an enema, or in a suppository,
depending on which part of the digestive tract is inflamed. Possible side effects
include nausea, vomiting, heartburn, diarrhea, and headache.
Corticosteroids powerful and fastacting drugs that suppress the immune
system. They are given for short periods of time to treat IBD flareups. They are
not given longterm because of possible serious sideeffects. Side effects may
include increased risk of infection, bone loss, diabetes, and high blood pressure.
Immunomodulators suppress the immune system. They can take a long time to
work (as much as 6 months for full effect). But, unlike corticosteroids, they can be
taken longterm to prevent relapse. Like corticosteroids, these medicines may
raise the risk of infection. Other side effects are uncommon but may include
nausea, vomiting, and headache.
Biologic therapies proteins that block substances in the body that help cause
inflammation. Biologics used to treat IBD block a substance called tumor necrosis
factor alpha (TNFalpha). AntiTNFalpha therapies have been used for years to
treat Crohns disease and are now being used for ulcerative colitis. AntiTNFalpha
therapies like infliximab, adalimumab, and certolizumab are used to treat people
with moderate to severe IBD when other therapies don't work. Infliximab has also
been used to treat people with Crohn's disease who have open, draining fistulas.
Infliximab is given intravenously (into the vein) by a
doctor or nurse. But adalimumab and certolizumab can be taken at home by
injecting under the skin. These therapies may lower the bodys ability to fight
diseases, raising chances of having a serious infection. Other side effects may
 include stomach pain, rash, and nausea.
Drugs to relieve diarrhea and pain are sometimes used to treat IBD symptoms,
but some overthecounter drugs can make symptoms worse.

Surgeries:

Surgery for ulcerative colitis: About 25 to 40 percent of people with ulcerative colitis
need surgery at some point in their lives. Surgery that removes the entire large intestine
can completely cure ulcerative colitis. After the large intestine is removed, surgeons
perform one of two types of operations to allow the body to get rid of food waste:

ileostomy
ileoanal anastomosis

Surgery for Crohns disease: About 65 to 75 percent of people with Crohn's disease
need surgery at some point in their lives. Surgery can relieve symptoms and correct
problems like strictures, fistulae, or bleeding in the intestine. Surgery can help relieve
Crohn's disease symptoms. But, since Crohn's disease occurs in patches, surgery
cannot cure the disease. If a part of the small or large intestine is removed, the
inflammation may then affect the part next to the section that was removed. Common
surgeries for Crohns disease are:

Strictureplasty
Bowel resection
Proctocolectomy with ileostomy

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a disorder that leads to abdominal pain and cramping,
changes in bowel movements, and other symptoms. IBS is not the same as inflammatory bowel
disease (IBD). In IBS, the structure of the bowel is not abnormal.

It is not clear why patients develop IBS. Sometimes it occurs after an infection of the intestines.
This is called postinfectious IBS. There may also be other triggers.
Signals go back and forth between the bowel and brain. These signals affect bowel function and
symptoms. The nerves can become more active during stress, causing the intestines to be more
sensitive and squeeze (contract) more. For some people, symptoms are disabling and reduce
the ability to work, travel, and attend social events.

Symptoms:
Symptoms range from mild to severe and are different from person to person.
Most people have mild symptoms. The main symptoms of IBS are abdominal pain,
fullness, gas, and bloating that have been present for at least 3 days a month for the last
3 months. The pain and other symptoms will often:
 Be reduced or go away after a bowel movement
Occur when there is a change in how often you have bowel movements

People with IBS may switch between constipation and diarrhea, or mostly have one or
the other.
People with diarrhea will have frequent, loose, watery stools. They will often have
an urgent need to have a bowel movement, which may be hard to control.
Those with constipation will have a hard time passing stool, as well as fewer
bowel movements. They will often need to strain and will feel cramps with a
bowel movement. Often, they do not release any stool, or only a small amount.

For some people, the symptoms may get worse for a few weeks or a month, and then
decrease for a while. For other people, symptoms are present most of the time.

People with IBS may also lose their appetite.

Signs and Tests: There is no test to diagnose IBS. Tests may be done to rule out other
problems:
Blood tests to see if you have celiac disease or a low blood count (anemia)
Stool cultures to check for an infection
Some patients will have a colonoscopy.

Treatment: The goal of treatment is to relieve symptoms. Lifestyle changes can help in
some cases of IBS. For example, regular exercise and improved sleep habits may
reduce anxiety and help relieve bowel symptoms. Dietary changes can be helpful.
However, no specific diet can be recommended for IBS, because the condition differs
from one person to another. Avoiding caffeine and large meals, and increasing fiber
may help. Therapy may help in cases of severe anxiety or depression.

Medications may include:

Anticholinergic medications (dicyclomine, propantheline, belladonna, and
hyoscyamine) taken to control intestine muscle spasms
Bisacodyl to treat constipation
Loperamide to treat diarrhea
Low doses of tricyclic antidepressants to help relieve intestinal pain
Lubiprostone for constipation symptoms
Rifaximin, an antibiotic

Gastroesophageal reflux disease (GERD)

A condition in which the stomach contents (food or liquid) leak backwards from the stomach into
the esophagus. This action can irritate the esophagus, causing heartburn and other symptoms.

The risk factors for reflux include:

 Alcohol (possibly)
Hiatal hernia (a condition in which part of the stomach moves above the
diaphragm, which is the muscle that separates the chest and abdominal cavities)
Obesity
Pregnancy
Scleroderma
Smoking
Reflux can be brought on or made worse by many different medications. Such drugs
include:
Anticholinergics (e.g., for seasickness)
Betablockers for high blood pressure or heart disease
Bronchodilators for asthma
Calcium channel blockers for high blood pressure
Dopamineactive drugs for Parkinson's disease
Progestin for abnormal menstrual bleeding or birth control
Sedatives for insomnia or anxiety
Tricyclic antidepressants

Symptoms:
Feeling that food is stuck behind the breastbone
Heartburn or a burning pain in the chest (under the breastbone)
Increased by bending, stooping, lying down, or eating
More likely or worse at night
Relieved by antacids
Nausea after eating
Less common symptoms are:
Bringing food back up (regurgitation)
Cough or wheezing
Difficulty swallowing
Hiccups
Hoarseness or change in voice
Sore throat

Signs and Tests:

Esophagogastroduodenoscopy (EGD)
Barium swallow
Continuous esophageal pH monitoring
Esophageal manometry
A positive stool occult blood test may diagnose bleeding that is coming from the
irritation in the esophagus, stomach, or intestines

Treatment:
 Medicine: overthecounter antacids, although they do not last very long. Common side
effects of antacids include diarrhea or constipation. Other overthecounter and
prescription drugs can treat GERD. They work more slowly than antacids but provide
longer relief:
Proton pump inhibitors (PPIs) decrease the amount of acid produced in your
stomach
H2 blockers (antagonists) lower the amount of acid released in the stomach

Surgery: Antireflux operations (fundoplication and others) may be an option for patients
whose symptoms do not go away with lifestyle changes and drugs. Heartburn and other
symptoms should improve after surgery, drugs may still be needed.

Pancreatitis
Inflammation of the pancreas. It may be acute or chronic, and may involve a pancreatic
abscess or pseudocyst. Acute pancreatitis is sudden swelling and inflammation of the
pancreas. Chronic pancreatitis is inflammation of the pancreas that does not heal or improve,
gets worse over time, and leads to permanent damage.

When inflammation and scarring of the pancreas occur, the organ is no longer able to make the
right amount of these enzymes. As a result, your body may be unable to digest fat and other
important parts of food.

Damage to the portions of the pancreas that make insulin may lead to diabetes. The condition is
often caused by alcohol abuse over many years. Repeat episodes of acute pancreatitis can lead
to chronic pancreatitis. Genetics may be a factor in some cases. Sometimes the cause is not
known.

Other conditions that have been linked to chronic pancreatitis:

Autoimmune problems (when the immune system attacks the body)
Blockage of the pancreatic duct or the common bile duct, the tubes that drain
enzymes from the pancreas
Complications of cystic fibrosis
High levels of a fat called triglycerides in the blood (hypertriglyceridemia)
Hyperparathyroidism
Use of certain medicationss (especially estrogens, corticosteroids, thiazide
diuretics, and azathioprine)

Symptoms:
Abdominal pain
Greatest in the upper abdomen
May last from hours to days
Eventually may be continuous
May get worse from eating or drinking
 May get worse from drinking alcohol
May also be felt in the back
Digestive problems
Chronic weight loss, even when eating habits and amounts are normal
Diarrhea, nausea, and vomiting
Fatty or oily stools
Pale or claycolored stools

Signs and Tests:

Tests for pancreatitis include:
Fecal fat test
Serum amylase
Serum IgG4 (for diagnosing autoimmune pancreatitis)
Serum lipase
Serum trypsinogen
Inflammation or calcium deposits of the pancreas, or changes to the ducts of the
pancreas may be seen on:
Abdominal CT scan
Abdominal ultrasound
Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic ultrasound (EUS)
Magnetic resonance cholangiopancreatography (MRCP)
An exploratory laparotomy may be done to confirm the diagnosis, but this is
usually done for acute pancreatitis.

Treatment: People with severe pain or who are losing weight may need to stay in the
hospital for:
Pain medicines
Fluids given through a vein (IV)
Stopping food or fluid by mouth to limit the activity of the pancreas, and then
slowly starting an oral diet
Inserting a tube through the nose or mouth to remove the contents of the
stomach (nasogastric suctioning) may sometimes be done. The tube may stay in
for 1 2 days, or sometimes for 1 2 weeks.
Pancreatic enzymes may be prescribed
Smoking and drinking must be avoided

Surgery: Surgery may be recommended if a blockage is found. In severe cases, part or

all of the pancreas may be removed.
Resection of the pancreatic head
Pancreaticojejunostomy drains the pancreatic duct directly into a loop of
jejunum

1001
0010
 Other possible complications:
Ascites (accumulation of fluid in the peritoneal cavity)
Blockage (obstruction) of the small intestine or bile ducts
Blood clot in the vein of the spleen
Fluid collections in the pancreas (pancreatic pseudocysts) that may become
infected
Poor function of the pancreas
Diabetes
Fat or other nutrient malabsorption
Vitamin malabsorption (most often the fatsoluble vitamins, A, D, E, or K)

Cirrhosis of the liver

Cirrhosis is scarring of the liver and poor liver function. It is the final phase of chronic liver
disease.

Common causes of chronic liver disease include:

Hepatitis C infection (longterm infection)
Longterm alcohol abuse (see alcoholic liver disease)
Other causes of cirrhosis include:
Autoimmune inflammation of the liver
Disorders of the drainage system of the liver (the biliary system), such as primary
biliary cirrhosis and primary sclerosing cholangitis
Hepatitis B (longterm infection)
Medications
Metabolic disorders of iron and copper (hemochromatosis and Wilson's disease)
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis
(NASH)

Symptoms: Symptoms may develop gradually, or there may be no symptoms. When

symptoms do occur, they can include:
Confusion or problems thinking
Impotence, loss of interest in sex, and breast development (gynecomastia) in
men
Loss of appetite
Nausea and vomiting
Nosebleeds or bleeding gums
Pale or claycolored stools
Small, red spiderlike blood vessels on the skin
Swelling or fluid buildup of the legs (edema) and in the abdomen (ascites)
Vomiting blood or blood in stools
Weakness
Weight loss
Yellow color in the skin, mucus membranes, or eyes (jaundice)
Signs and Tests:
During a physical examination the health care provider may find:
An enlarged liver or spleen
Excess breast tissue
Expanded (distended) abdomen, as a result of too much fluid
Reddened palms
Red spiderlike blood vessels on the skin
Small testicles
Widened (dilated) veins in the abdomen wall
Yellow eyes or skin (jaundice) Tests
can reveal liver problems including:
Anemia (detected on a complete blood count test)
Clotting problems
Liver function problems (detected on liver function tests)
Low blood albumin
The following tests may be used to evaluate the liver:
Computed tomography (CT) of the abdomen
Magnetic resonance imaging (MRI) of the abdomen
Endoscopy to check for abnormal veins in the esophagus or stomach
Ultrasound of the abdomen
A liver biopsy confirms cirrhosis.

Complications: Once cirrhosis develops, it is not possible to heal the liver or return its
function to normal. It is a serious condition that can lead to many complications.
Bleeding disorders (coagulopathy)
Buildup of fluid in the abdomen (ascites) and infection of the fluid (bacterial
peritonitis)
Enlarged veins in the esophagus, stomach, or intestines that bleed easily
(esophageal varices)
Increased pressure in the blood vessels of the liver (portal hypertension)
Kidney failure (hepatorenal syndrome)
Liver cancer (hepatocellular carcinoma)
Mental confusion, change in the level of consciousness, or coma (hepatic
encephalopathy)

Treatment: Treatment options are available for the complications of cirrhosis:

Bleeding varices upper endoscopy with banding and sclerosis
Excess abdominal fluid (ascites) take diuretics, restrict fluid and salt, and
remove fluid (paracentesis)
Coagulopathy blood products or vitamin K
Confusion or encephalopathy lactulose medication and antibiotics
Infections antibiotics
 Surgery: A procedure called transjugular intrahepatic portosystemic shunt (TIPS) is
sometimes needed for bleeding varices or ascites.

When cirrhosis progresses to endstage liver disease, patients may be candidates for a
liver transplant.

Hepatitis C (Hep C)
A viral disease that leads to swelling (inflammation) of the liver. Hepatitis C infection is caused
by the hepatitis C virus (HCV).

People who may be at risk for hepatitis C are those who:

Have been on longterm kidney dialysis
Have regular contact with blood at work (for instance, as a health care worker)
Have unprotected sexual contact with a person who has hepatitis C
Inject street drugs or share a needle with someone who has hepatitis C
Received a blood transfusion before July 1992
Received a tattoo or acupuncture with contaminated instruments
Received blood, blood products, or solid organs from a donor who has hepatitis C
Share personal items such as toothbrushes and razors with someone who has hepatitis
C
Were born to a hepatitis Cinfected mother

Symptoms: Most people who were recently infected with hepatitis C do not have
symptoms. About 1 in 10 have yellowing of the skin (jaundice) that gets better. Of
people who get infected with hepatitis C, most develop a chronic infection. Usually there
are no symptoms. If the infection has been present for many years, the liver may be
permanently scarred. This is called cirrhosis. In many cases, there may be no symptoms
of the disease until cirrhosis has developed.

The following symptoms could occur with hepatitis C infection:

Abdominal pain (right upper abdomen)
Abdominal swelling (due to fluid called ascites)
Claycolored or pale stools
Dark urine
Fatigue
Fever
Itching
Jaundice
Loss of appetite
Nausea
Vomiting
Signs and Tests:
Blood tests are done to check for hepatitis C:
EIA assay to detect hepatitis C antibody
Hepatitis C RNA assays to measure virus levels (viral load)
Genetic testing is done to check for the hepatitis C genotype. Six genotypes exist. Test
results can help your doctor better choose your treatment.
Most Americans have genotype 1 infection, which is the hardest to treat.
Genotypes 2 and 3 are also common, and respond better to treatment.
The following tests are done to identify and monitor liver damage from hepatitis C:
Albumin level
Liver function tests
Prothrombin time
Liver biopsy can show how much damage has been done to the liver.

Treatment: The goals of HCV treatment are to remove the virus from the blood and
reduce the risk of cirrhosis and liver cancer that can result from longterm HCV infection.
Many patients with hepatitis C benefit from treatment with medications. The most
common medications are a combination of pegylated interferon alfa and ribavirin, an
antiviral medication.
Most patients receive weekly injections of pegylated interferon alfa.
Ribavirin is a capsule taken twice daily. Ribavirin can cause birth defects.
Treatment is given for 24 48 weeks.
Telaprevir and boceprevir are newer drugs which may be used for patients with
genotype 1.
These medications have a number of side effects, and patients must be watched closely.

Side effects from the combination of ribavirin and interferon (or peginterferon) are
common and so severe in some people that they interfere with treatment. Since Ribavirin
can't be used alone as a hepatitis C treatment, the side effects are actually from the
combination of ribavirin and an interferon. Here is a list of the most common side effects:
Anemia a blood disorder involving a lack of red blood cells to carry oxygen,
resulting in fatigue. After about two weeks of Ribavirin treatment, about 10% of
people develop a severe form of anemia.
Headache
Irritability and anxiety
Depression. Sometimes people taking ribavirin develop irritability, severe
depression, and even suicidal thoughts. For most people, these side effects can
be controlled with antidepressants or other medicines. Some people may not be
able to start treatment of hepatitis C due to mental health problems.
Alopecia
Itchiness
Insomnia
Arthralgia
 Myalgia
Anorexia
Neutropenia a blood disorder caused by a loss of neutrophils, a type of white
blood cell that destroys bacteria. Neutropenia is probably the result of decreased
bone marrow function, which the combination therapy suppresses..
Nausea and vomiting
Fever
Chills
Fatigue

Even moderate amounts of alcohol speed up the progression of hepatitis C, and alcohol
reduces the effectiveness of treatment.

Hepatitis C usually comes back after a liver transplant, which can lead to cirrhosis of the
new liver.

Hepatitis B (Hep B)
Hepatitis B is irritation and swelling (inflammation) of the liver due to infection with the hepatitis
B virus (HBV). The acute illness usually goes away after 2 3 weeks. The liver usually returns
to normal within 4 6 months in almost all patients who are infected. Some people develop
chronic hepatitis. Complications may include chronic persistent hepatitis, cirrhosis, or fulminant
(occurs suddenly and with great severity) hepatitis, which can lead to liver failure and possibly
death.

Hepatitis B infection can be spread through having contact with the blood, semen, vaginal fluids,
and other body fluids of someone who already has a hepatitis B infection.
Infection can be spread through:
Blood transfusions
Direct contact with blood in health care settings
Sexual contact with an infected person
Tattoo or acupuncture with unclean needles or instruments
Shared needles during drug use
Shared personal items with an infected person
The hepatitis B virus can be passed to an infant during childbirth if the mother is infected.

Symptoms: After first becoming infected with the hepatitis B virus, a patient may:
Have no symptoms
Feel sick for a period of days or weeks
Become very ill (called fulminant hepatitis)
If the body is able to fight off the hepatitis B infection, any symptoms should go away
over a period of weeks to months. Some people's bodies are not able to completely get
rid of the hepatitis B infection. This is called chronic hepatitis B.
 Many people who have chronic hepatitis B have few or no symptoms. Symptoms may
not appear for up to 6 months after the time of infection. Early symptoms may include:
Appetite loss
Fatigue
Fever, lowgrade
Muscle and joint aches
Nausea and vomiting
Yellow skin and dark urine due to jaundice

People with chronic hepatitis may have no symptoms, even though gradual liver damage
may be occurring. Over time, some people may develop symptoms of chronic liver
damage and cirrhosis of the liver.

Signs and Tests:

The following tests are done to identify and monitor liver damage from hepatitis B:
Albumin level
Liver function tests
Prothrombin time
The following tests are done to help diagnose and monitor people with hepatitis B:
Antibody to HBsAg (AntiHBs) a positive result means the person has had
hepatitis B in the past, or has received a hepatitis B vaccine
Antibody to hepatitis B core antigen (AntiHBc) a positive result means there
was a recent infection or an infection in the past
Hepatitis B surface antigen (HBsAg) a positive result means there is an active
infection
Hepatitis E surface antigen (HBeAg) a positive result means there is a hepatitis
B infection and the person is more likely to spread the infection to others through
sexual contact or sharing needles
Patients with chronic hepatitis will need ongoing blood tests to monitor their status.

Treatment:
Acute hepatitis B needs no treatment other than careful monitoring of liver and other
body functions with blood tests. In the rare case that liver failure develops, a liver
transplant may be needed. Liver transplantation is used to treat severe, chronic hepatitis
B liver disease. A liver transplant is the only cure in some cases of liver failure.

Some patients with chronic hepatitis B may be treated with antiviral medications or a
medication called peginterferon. These medications can decrease or remove hepatitis B
from the blood and reduce the risk of cirrhosis and liver cancer. Patients with chronic
hepatitis should avoid alcohol.

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http://www.mayoclinic.com/health/esophagealvarices/DS00820
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001301/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001268/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002129/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001292/
http://biology.clc.uc.edu/courses/bio105/digestiv.htm
http://www.johnshopkinshealthalerts.com/alerts_index/digestive_health/191.html
http://en.wikipedia.org/wiki/Human_gastrointestinal_tract
http://www.enchantedlearning.com/subjects/anatomy/digestive/
http://en.wikipedia.org/wiki/File:Gut_wall.svg
http://en.wikipedia.org/wiki/Intestine http://en.wikipedia.org/wiki/Muscularis_mucosa
http://www.bio.davidson.edu/people/kabernd/BerndCV/Lab/EpithelialInfoWeb/index.html
http://en.wikipedia.org/wiki/Lamina_propria
http://en.wikipedia.org/wiki/Peritoneum
http://www.nlm.nih.gov/medlineplus/ency/article/002942.htm
http://en.wikipedia.org/wiki/Submucosa
http://en.wikipedia.org/wiki/Vermiform_appendix
http://www.mayoclinic.com/health/endoscopy/MY00138
http://www.roswellpark.org/patients/jejunostomytube
http://www.mayoclinic.com/health/ostomy/SA00072
http://www.umm.edu/ency/article/002943.htm
http://www.mayoclinic.com/health/crohnsdisease/DS00104
http://womenshealth.gov/publications/ourpublications/factsheet/inflammatoryboweldisease.cf m
http://www.nlm.nih.gov/medlineplus/ency/article/003885.htm
http://www.mayoclinic.org/ileoanalanastomosis/about.html
http://hepatitis.about.com/od/treatment/f/RibavirinReact.htm
http://www.mayoclinic.org/ulcerativecolitis/treatment.html
http://ibdcrohns.about.com/od/cdbeyondbasics/a/strictureplasty.htm
GenitoUrinary System (Urogenital System)
The organ system of the reproductive organs and the urinary system. These are grouped
together because of their proximity to each other, their common origin and the use of common
pathways, like the male urethra. Also, because of their proximity, the systems are sometimes
imaged together.

The main organs of the urinary system are the kidneys, which form urine. The other parts of the
systemthe ureters, the urinary bladder, and the urethraneither form urine nor change its
composition. They are merely structures that transport urine from the kidneys to the outside of
the body.

Usual treatment providers: Nephrologist, urologist, urogynecologist

Key terms and components:

Kidneys
Organs located on either side of the vertebral column or spine near the small of the back. The
left kidney usually sits slightly higher than the right one. The size of an adult kidney is
approximately 4 inches (10 centimeters) long, 2.5 inches (6 centimeters) wide, and 1 inch (2.5
centimeters) thick. The upper portions of the kidneys rest on the lower surface of the diaphragm,
a membrane of muscle separating the thoracic or chest cavity from the abdominal cavity. The
lower portion of the rib cage encloses and protects the kidneys. The kidneys are held in place
by the abdominal lining and supporting connective tissue.

On the side of each kidney facing the vertebral column is an indentation called the hilus.
Through the hilus the renal artery enters and the renal vein and ureter exit. The renal artery
brings blood to the kidneys.

Renal
Pertaining to the kidney(s).
Urine
Fluid formed by the kidneys from blood plasma.

Renal cortex
Outermost layer of the kidney.

Renal medulla
Middle layer of a kidney.

Renal pyramids
Triangular or pieshaped segments of the renal medulla in which urine production occurs.

Nephrons
Urineforming structures in the kidneys.

Glomerulus (plural: glomeruli)

Capillaries enclosed by a Bowman's capsule.

Bowman's capsule
Cupshaped end of a nephron that encloses a glomerulus.

Renal corpuscle
Part of a nephron that consists of a glomerulus enclosed by a Bowman's capsule.

Renal pelvis
A cavity at the innermost area of a kidney that connects to the ureter.

Calyces
Cupshaped extensions of the renal pelvis that enclose the tips of the renal pyramids and collect
urine.

Renal tubule
Twisting, narrow tube leading from the Bowman's capsule in a nephron.

Henle's loop
Looped portion of a renal tubule.

Hilus
Indentation or depression on the surface of an organ such as a kidney.

Urinary bladder
Hollow, collapsible, muscular sac that stores urine temporarily.
Ureter
Muscular tube that carries urine from the renal pelvis in a kidney to the urinary bladder.

Urethra
Thinwalled tube that carries urine from the urinary bladder to the outside of the body.

Micturition
Urination, or the elimination or voiding of urine from the urinary bladder.

Uric acid
Waste product in urine formed by the breakdown of nucleic acids.

Urea
Main nitrogencontaining waste excreted in the urine, produced when the liver combines
ammonia and carbon dioxide.

Renin
Enzyme secreted by the cells of renal tubules that helps to raise blood pressure.

Filtration
Movement of water and dissolved materials through a membrane from an area of higher
pressure to an area of lower pressure.

Renal filtrate
Fluid formed in a Bowman's capsule from blood plasma by the process of filtration in the renal
corpuscle.

Peristalsis
Series of wavelike muscular contractions that move material in one direction through a hollow
organ.

Creatinine
A normal product of muscle metabolism.

Creatinine clearance test

A test for renal function based on the rate at which creatinine is excreted by the kidney.

Serum albumin
A major plasma protein that is responsible for much of the plasma colloidal osmotic pressure
and serves as a transport protein.

Serum creatinine

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The amount of creatinine in the blood and is measured to evaluate kidney function.

Aldosterone
Hormone secreted by the adrenal cortex that controls the salt and water balance in the body.

Antidiuretic hormone
Hormone produced by the hypothalamus and stored in the posterior pituitary that increases the
absorption of water by the kidneys.

Glomerular disease
Can be classified into two broad categories, nephrotic and nephritic. Nephrotic conditions are
associated with increased urinary protein excretion and nephritic conditions are associated with
inflammation of the internal structures of the kidneys.

Nephritis
Inflammation of the nephrons in the kidneys.

Nephropathy
Damage to or disease of a kidney.

Nephrosis
Noninflammatory nephropathy.

Anasarca
Generalized massive edema (swelling).

Diastolic hypertension
Elevated diastolic blood pressure.

Fluid overload syndrome

Associated with renal disease, it occurs when there is excessive sodium and water retention in
the body that cannot be adequately removed by the diseased kidneys. Symptoms and signs of
vascular congestion may include fatigue, shortness of breath, hypertension, congestive heart
failure, accumulation of fluid in the abdomen (ascites) or chest (pleural effusions), and
peripheral edema.

Nephrotic syndrome
A general name for a group of diseases involving defective kidney glomeruli, characterized by
heavy proteinuria, hypoalbuminemia, hyperlipidemia, and varying degrees of edema.

Peritoneal dialysis
A method of hemodialysis in which the dialyzing solution is introduced into and removed from
the peritoneal cavity either continuously or intermittently.
Dialysate
The fluid and solutes in a dialysis process that flow through the dialyzer, do not pass through
the membrane, and are discarded along with removed toxic substances after leaving the
dialyzer.

Proteinuria
Excess protein in the urine.

Renal osteodystrophy
Refers to a variety of bone disorders usually caused by chronic kidney failure.

Hemodialysis (dialysis)
The removal of toxic metabolic byproducts from the blood by diffusion in an artificial kidney
machine.

Testes (testicles)
Two oval organs located inside the scrotum, the loose sac of skin that hangs behind the penis.
The testicles make the male hormones, including testosterone, and produce sperm, the male
reproductive cells. Disorders of the testes can lead to serious complications, including hormonal
imbalances, sexual dysfunction and infertility.

Vas deferens
Tubes that carry sperm out of the testes.

Epididymis
The tube that connects the testicle with the vas deferens.

Prostate gland
As part of the male reproductive system, the prostate glands primary function is to secrete a
slightly alkaline fluid that forms part of the seminal fluid, a fluid that carries sperm. The prostate
gland is about the size of a walnut and surrounds the neck of a mans bladder and urethra the
tube that carries urine from the bladder. It is partly muscular and partly glandular, with ducts
opening into the prostatic portion of the urethra. It is made up of three lobes: a center lobe with
one lobe on each side.

Ovaries
Two ovum (egg) producing reproductive organs, which are part of the female reproductive
system. Ovaries in female individuals are analogous to testes in male individuals, in that they
are both gonads and endocrine glands. The ovaries are attached to the outer layer of the
uterus via the ovarian ligaments. Ovaries secrete both estrogen and progesterone. Estrogen is
responsible for the appearance of secondary sex characteristics of female people at puberty
and for the maturation and maintenance of the reproductive organs in their mature functional
state. Progesterone functions with estrogen by promoting menstrual cycle changes in the
endometrium.

Uterus
A major female hormoneresponsive reproductive organ. It is within the uterus that the fetus
develops during gestation. One end, the cervix, opens into the vagina the other is connected
on both sides to the Fallopian tubes. The uterus provides structural integrity and support to the
bladder, bowel, pelvic bones and organs. The uterus helps separate and keep the bladder in its
natural position above the pubic bone and the bowel in its natural configuration behind the
uterus.

Fallopian tubes
Two very fine tubes leading from the ovaries into the uterus. The tubes allow passage of the
egg from the ovary to the uterus.

Cervix
The lower, narrow portion of the uterus where it joins with the top end of the vagina. It is
cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.

Hormones
Chemicals that travel through the bloodstream to tissues or organs. They work slowly, over time,
and affect many different processes, including: growth and development, metabolism (how the
body gets energy from food), sexual function, reproduction, and mood. Men produce hormones
in their testes and women produce them in their ovaries.

Diuretic
An agent that increases the rate of urine formation.

Common conditions:

Chronic kidney disease (CKD) and end stage renal disease (ESRD)
The slow loss of kidney function over time. Chronic kidney disease (CKD) slowly gets worse
over time. In the early stages, there may be no symptoms. The loss of function usually takes
months or years to occur. It may be so slow that symptoms do not appear until kidney function is
less than onetenth of normal.

The final stage of chronic kidney disease is called endstage renal disease (ESRD). At this
stage, the kidneys are no longer able to remove enough wastes and excess fluids from the
body. The patient needs dialysis or a kidney transplant.

Diabetes and high blood pressure are the two most common causes and account for most
cases. Many other diseases and conditions can damage the kidneys, including:
Autoimmune disorders (such as systemic lupus erythematosus and scleroderma)
 Birth defects of the kidneys (such as polycystic kidney disease)
Certain toxic chemicals
Glomerulonephritis
Injury or trauma
Kidney stones and infection
Problems with the arteries leading to or inside the kidneys
Some pain medications and other drugs (such as cancer drugs)
Reflux nephropathy (in which the kidneys are damaged by the backward flow of
urine into the kidneys)
Other kidney diseases

Chronic kidney disease leads to a buildup of fluid and waste products in the body. This
condition affects most body systems and functions, including:
Blood pressure control
Red blood cell production
Vitamin D and bone health

Symptoms:
The early symptoms of chronic kidney disease are also symptoms of other illnesses.
These symptoms may be the only signs of kidney disease until the condition is more
advanced. Symptoms may include:
Appetite loss
General ill feeling and fatigue
Headaches
Itching (pruritus) and dry skin
Nausea
Weight loss without trying to lose weight
Other symptoms that may develop, especially when kidney function has gotten worse,
include:
Abnormally dark or light skin
Bone pain
Brain and nervous system symptoms:
Drowsiness and confusion
Problems concentrating or thinking
Numbness in the hands, feet, or other areas
Muscle twitching or cramps
Breath odor
Easy bruising, bleeding, or blood in the stool
Excessive thirst
Frequent hiccups
Low level of sexual interest and impotence
Menstrual periods stop (amenorrhea)
Shortness of breath
 Sleep problems, such as insomnia, restless leg syndrome, and obstructive sleep
apnea
Swelling of the feet and hands (edema)
Vomiting, typically in the morning

Signs and Tests:

High blood pressure is almost always present during all stages of chronic kidney
disease. A nervous system exam may show signs of nerve damage. The health care
provider may hear abnormal heart or lung sounds when listening with a stethoscope.
A urinalysis may show protein or other changes. These changes may appear 6 months
to 10 or more years before symptoms appear.

Tests that check how well the kidneys are working include:
Creatinine clearance
Creatinine levels
BUN
Chronic kidney disease changes the results of several other tests. Every patient needs
to have the following checked regularly, as often as every 2 3 months when kidney
disease gets worse:
Albumin
Calcium
Cholesterol
Complete blood count (CBC)
Electrolytes
Magnesium
Phosphorous
Potassium
Sodium
Causes of chronic kidney disease may be seen on:
Abdominal CT scan
Abdominal MRI
Abdominal ultrasound
Kidney biopsy
Kidney scan
Kidney ultrasound
This disease may also change the results of the following tests:
Erythropoietin
PTH
Bone density test
Vitamin D

Treatment:
Controlling blood pressure will slow further kidney damage.
 Angiotensinconverting enzyme (ACE) inhibitors or angiotensin receptor blockers
(ARBs) are used most often.
The goal is to keep blood pressure at or below 130/80 mmHg

People with CKD should not smoke, should keep blood sugar in control, and should
avoid eating too much salt or potassium.

Other treatments may include:

Special medicines called phosphate binders, to help prevent phosphorous levels
from becoming too high
Treatment for anemia, such as extra iron in the diet, iron pills, iron through a vein
(intravenous iron) special shots of a medicine called erythropoietin, and blood
transfusions
Extra calcium and vitamin D

When the loss of kidney function becomes more severe, dialysis or a kidney transplant
will be needed.

Dialysis is a treatment that does some of the things done by healthy kidneys. It is
needed once end stage kidney failure develops usually when there is about 85 to 90
percent loss of kidney function. Dialysis can be done in a hospital, in a dialysis unit that
is not part of a hospital, or at home. There are two types of dialysis hemodialysis and
peritoneal dialysis.

In hemodialysis, an artificial kidney (hemodialyzer) is used to remove waste and extra

chemicals and fluid from the blood. To get the blood into the artificial kidney, the doctor
needs to make an access into the blood vessels. This is done by minor surgery to your
arm or leg. Occasionally, an access is made by means of a narrow plastic tube, called a
catheter, which is inserted into a large vein in the neck. This type of access may be
temporary, but is sometimes used for longterm treatment.

The time needed for your dialysis depends on:

how well the kidneys work
how much fluid weight is gained between treatments
how much waste is in the body
the size of the person
the type of artificial kidney used

Usually, each hemodialysis treatment lasts about four hours and is done three times per
week.

In peritoneal dialysis, the blood is cleaned inside the body. The doctor will do surgery to
place a plastic tube called a catheter into the abdomen to make an access. During the
treatment, the peritoneal cavity is slowly filled with dialysate through the catheter. The
blood stays in the arteries and veins that line the peritoneal cavity. Extra fluid and waste
products are drawn out of your blood and into the dialysate. There are several kinds of
peritoneal dialysis but two major ones are Continuous Ambulatory Peritoneal Dialysis
(CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD).

Continuous Ambulatory Peritoneal Dialysis (CAPD) is the only type of peritoneal dialysis
that is done without machines. It is done by the patient, usually four or five times a day.
A bag of dialysate (about two quarts) is put into the peritoneal cavity through the
catheter. The dialysate stays there for about four or five hours before it is drained back
into the bag and thrown away. This is called an exchange. While the dialysate is in the
peritoneal cavity.

Continuous Cycling Peritoneal Dialysis (CCPD) usually is done at home using a special
machine called a cycler. This is similar to CAPD except that a number of cycles
(exchanges) occur. Each cycle usually lasts 11/2 hours and exchanges are done
throughout the night.

Dialysis does some of the work of healthy kidneys, but it does not cure CKD. Dialysis
treatments are needed for the remainder of the patients life, unless a kidney transplant
is available.

Other complications of CKD and ESRD:

Anemia
Bleeding from the stomach or intestines
Bone, joint, and muscle pain
Changes in blood sugar
Damage to nerves of the legs and arms (peripheral neuropathy)
Dementia
Fluid buildup around the lungs (pleural effusion)
Heart and blood vessel complications
Congestive heart failure
Coronary artery disease
High blood pressure
Pericarditis
Stroke
High phosphorous levels
High potassium levels
Hyperparathyroidism
Increased risk of infections
Liver damage or failure
Malnutrition
Miscarriages and infertility
 Seizures
Swelling (edema)
Weakening of the bones and increased risk of fractures

Renal vascular disease

Renal vascular disease is the name given to a variety of complications that affect the arteries
and veins of the kidneys. These complications affect the blood circulation of the kidneys, and
may cause damage to the tissues of the kidneys, kidney failure, and/or high blood pressure.

Vascular conditions affecting the renal arteries and veins include the following:
Renal artery stenosis a blockage of an artery to the kidneys. It may cause kidney failure
and hypertension
Renal artery thrombosis the formation of a clot in a renal artery. A thrombosis of a
renal artery may cause kidney failure because of blocked blood flow to the kidney.
Renal artery aneurysm a bulging, weakened area in the wall of an artery to the kidney.
Most of these aneurysms are small (less than two centimeters, or about threequarters of
an inch) and without symptoms. Renal artery aneurysms are uncommon and are
generally discovered during diagnostic procedures performed in relation to other
conditions.
Atheroembolic renal disease when a piece of plaque from the aorta and/or other large
arteries breaks off and travels through the bloodstream, blocking small arteries such as
the renal arteries. Atheroembolic renal disease is becoming a common cause of renal
insufficiency (poor kidney function) in the elderly.
Renal vein thrombosis the formation of a clot in a vein to the kidney.

Renal vascular disease is often associated with hypertension (high blood pressure). Hormones
which influence blood pressure are affected by kidney function. Decreased blood flow to the
kidney(s) as a result of renal vascular disease may cause an excessive amount of renin to be
produced. Renin is a powerful hormone that increases blood pressure.

Symptoms:

Renal artery stenosis

sudden onset of hypertension before age 50 suggests fibromuscular
dysplasiarelated stenosis
sudden onset of hypertension at or after age 50 suggests stenosis caused by
atherosclerosis
hypertension not responsive to three or more blood pressure medications
increased urea (a waste product excreted by the kidneys) in the blood
unexplained kidney failure
sudden kidney failure when first taking an angiotensinconverting enzyme (ACE)
inhibitor medication for blood pressure and/or heart treatment
Renal artery thrombosis
Acute (sudden) complete blockage
sudden onset of flank (between the ribs and the upper border of the hip bone)
pain and tenderness
fever
blood in the urine
nausea and/or vomiting
sudden decrease in kidney function
hypertension
More gradual or incomplete blockages:
may be asymptomatic (without symptoms) and go undetected

Renal artery aneurysm

generally asymptomatic
hypertension may be present in up to 90 percent of persons with a renal artery
aneurysm
dissecting aneurysms (caused by a tear in the inner layer of the artery wall) may
cause flank pain and blood in the urine

Atheroembolic renal disease

skin lesions such as purpura (a type of rash in which blood cells leak into the skin
or mucous membranes)
mottling (discolored areas) of the toes and feet
kidney failure (either sudden or occurring over a longer period of time)
abdominal pain
diarrhea
confusion
weight loss
fever
muscle aches

Renal vein thrombosis

Chronic (over a period of time) onset:
most often asymptomatic
Acute (sudden) onset:
persistent severe flank pain that may be spasmodic (with spasms) at times
soreness in the area over the kidney, between the ribs and the backbone
decreased kidney function

Tests:
Angiogram
Duplex ultrasound
Renography a specialized radiology procedure used to assess the function and
 structure of the kidneys
Magnetic resonance angiography (MRA)

Treatment: Depends on type of renal vascular disease that is present. For thrombosis,
anticoagulant (anticlotting) medication may be used. Surgery to remove the clot may be
performed for renal artery thrombosis. Endovascular and open surgical procedures may
be used to place a stent or for bypass surgery, in atheroembolic renal disease. Renal
artery aneurysms will often be treated surgically. For renal artery stenosis, angioplasty,
stent placement, or bypass surgery may be performed.

Antihypertensive medication, including angiotensinconverting enzyme (ACE) inhibitor

medication, may be used to treat high blood pressure.

Diabetic nephropathy
Kidney disease or damage that occurs in people with diabetes. In people with diabetes, the
nephrons thicken and slowly become scarred over time. The kidneys begin to leak and protein
(albumin) passes into the urine. The exact cause is unknown. Poor control of blood sugar is
thought to lead to kidney damage. If the person also has high blood pressure, kidney damage is
even more likely.

Signs and Tests:

When someone has diabetes, a urine test should be done, at least once a year, for too
much protein. It looks for a protein called albumin. Because the test looks for small
amounts of albumin, it is sometimes called a test for microalbuminuria. Too much
protein is often a sign of kidney damage.

High blood pressure often goes along with diabetic nephropathy. There may be high
blood pressure that begins quickly or is hard to control.

Doctors will also check kidney function with the following blood tests every year:
BUN
Serum creatinine
Other lab tests that may be done include:
24hour urine protein
Blood levels of phosphorus, calcium, bicarbonate, PTH, and potassium
Hemoglobin
Hematocrit
Protein electrophoresis urine
A kidney biopsy confirms the diagnosis. However, doctors can often diagnose the
condition without a biopsy.

Diabetic kidney disease is a major cause of sickness and death in people with diabetes.
When it is caught in the early stages, kidney damage may be slowed with treatment.

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 Once larger amounts of protein appear in the urine, kidney damage will slowly get worse.
Often, it will lead to the need for dialysis or a kidney transplant. People with diabetic
kidney disease often also have problems with high blood pressure, heart disease, and
eye damage.

Interstitial cystitis (IC)

A painful condition due to chronic inflammation of the bladder wall. The cause is unknown. The
condition is usually diagnosed by ruling out other conditions (such as sexually transmitted
disease, bladder cancer, and bladder infections). IC is frequently misdiagnosed as a urinary
tract infection. Patients often go years without a correct diagnosis. On average, there is about a
4year delay between the time the first symptoms occur and the diagnosis is made.

Symptoms:
Pain during intercourse
Pelvic pain
Urinary discomfort
Urinary frequency (up to 60 times a day in severe cases)
Urinary urgency

Signs and Tests:

Diagnosis is made by ruling out other causes. Tests include:
Bladder biopsy
Cystoscopy (endoscopy of bladder)
Urine analysis
Urine culture
Urine cytology
Video urodynamics (shows how much urine must be in the bladder before you
feel the need to urinate)

Treatment:
There is no cure for IC, and there are no standard or consistently effective treatments.
Results vary from person to person. As long as the cause is unknown, treatment is
based on trial and error until you find relief.

Elmiron is the only medication taken by mouth that is specifically approved for treating
IC. This medicine coats the bladder like PeptoBismol coats the stomach.
Other medicines may include:
Opioid painkillers for severe pain
Tricyclic antidepressants such as Elavil (amitriptyline) to relieve pain and urinary
frequency
Vistaril (hydroxyzine pamoate), an antihistamine that causes sedation, helps
reduce urinary frequency
Other therapies include:
 Bladder hydrodistention (overfilling the bladder with fluid while under general
anesthesia)
Bladder training (using relaxation techniques to train the bladder to go only at
specific times)
Instilled medications medicines are placed directly into the bladder. Medicines
that are given this way include dimethyl sulfoxide (DMS), heparin, Clorpactin,
lidocaine, doxorubicin, or bacillus CalmetteGuerin (BCG) vaccine.
Physical therapy and biofeedback (may help relieve pelvic floor muscle spasms)
Surgery, ranging from cystoscopic manipulation to bladder removal (cystectomy)

Other complications:
Chronic depression
Chronic pain that may cause a change in lifestyle
Emotional trauma
Side effects of treatments (depending on the treatment)

Sources: http://ghr.nlm.nih.gov/condition/congenitalbilateralabsenceofthevasdeferens
http://www.nlm.nih.gov/medlineplus/ency/article/001279.htm http://www.faqs.org/health/Bodyby-
DesignV2/TheUrinarySystemDesignpartsoftheurinary system.html
http://www.socialsecurity.gov/disability/professionals/bluebook/6.00GenitoUrinaryAdult.htm
http://en.wikipedia.org/wiki/Male_reproductive_system_%28human%29
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001508/
http://en.wikipedia.org/wiki/Female_reproductive_system
http://www.nlm.nih.gov/medlineplus/hormones.html
http://en.wikipedia.org/wiki/Cervix
http://my.clevelandclinic.org/disorders/testicular_cancer/hic_disorders_of_the_testes.aspx
http://en.wikipedia.org/wiki/Fallopian_tube
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001529/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001503/
http://www.kidney.org/atoz/content/dialysisinfo.cfm http://www.uchospitals.edu/online-
library/content=P08261 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001524/
Hematological Disorders
Hematologic diseases are disorders which primarily affect the blood.

Usual treatment provider: hematologist

Key terms and components:

Bone marrow
The flexible tissue found in the interior of bones. Red blood cells are produced in the heads of
long bones, in a process known as hematopoesis. The hematopoietic compartment of bone
marrow produces approximately 500 billion blood cells per day, which use the bone marrow
vasculature as a conduit to the body's systemic circulation. Bone marrow is also a key
component of the lymphatic system, producing the lymphocytes that support the body's immune
system.

Leukocytes (white blood cells or WBCs)

There are five types: lymphocytes, monocytes, neutrophils, eosinophils, and basophils. They
are broken into two classifications: granulocytes (with granules) and agranulocytes (without
granules). Neutrophils, eosinophils, and basophils are granulocytes. Monocytes and
lymphocytes are agranulocytes.

Lymphocytes
A type of white blood cells which are part of the immune system. There are three major types,
namely: Natural Killer (NK) cells, Tcells (Thymus cells) and Bcells (Bone cells).

Monocytes
White blood cells that consume bacteria.

Neutrophils
White blood cells that ingest foreign contaminants in the body. They are the most common
W.B.C.s.

Basophils
White blood cells that promote inflammation. Basophils contain anticoagulant heparin, which
prevents blood from clotting too quickly. They also contain the vasodilator histamine, which
promotes blood flow to tissues.

Eosinophil
White blood cells that moderate allergic reactions.

Erythrocytes
Red blood cells. They are the principal means of delivering oxygen (O2) to the body tissues via
the blood flow through the circulatory system. The cells develop in the bone marrow and
circulate for about 100120 days in the body before their components are recycled.

Platelets
Platelets are the smallest of the three major types of blood cells. The normal platelet count is
150,000350,000 per microliter of blood. The principal function of platelets is to prevent
bleeding

Coagulation
The process by which blood forms clots. It is an important part of hemostasis, the cessation of
blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a
platelet and fibrincontaining clot to stop bleeding and begin repair of the damaged vessel.
Disorders of coagulation can lead to an increased risk of bleeding (hemorrhage) or obstructive
clotting (thrombosis).

Hemoglobin (Hb or Hgb)

A protein in red blood cells that carries oxygen.

Plasma cell
White blood cells which produce large volumes of antibodies. They are transported by the blood
plasma and the lymphatic system. Like all blood cells, plasma cells ultimately originate in the
bone marrow however, these cells leave the bone marrow as B cells, before differentiation into
plasma cells, normally in lymph nodes.

Antibody (immunoglobulin)
A large Yshaped protein produced by Bcells that is used by the immune system to identify and
neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part
of the foreign target, called an antigen. Antibodies are produced by a type of white blood cell
called a plasma cell.

Bilirubin
A yellowish pigment found in bile, a fluid made by the liver. A small amount of older red blood
cells are replaced by new blood cells every day. Bilirubin is left after these older blood cells are
removed. The liver helps break down bilirubin so that it can be removed by the body in the stool.

Spleen
Similar in structure to a large lymph node, the spleen acts primarily as a blood filter. As such, it
is a nonvital organ, with a healthy life possible after removal. It removes old red blood cells and
holds a reserve of blood in case of hemorrhagic shock while also recycling iron. It metabolizes
hemoglobin removed from aging erythrocytes. The globin portion of hemoglobin is degraded to
its constitutive amino acids, and the heme portion is metabolized to bilirubin, which is
subsequently shuttled to the liver for removal. It synthesizes antibodies in its white pulp and
removes antibodycoated bacteria along with antibodycoated blood cells by way of blood and
lymph node circulation.

Myeloid
Pertaining to, derived from, or resembling bone marrow or the spinal cord.

Hemoglobinopathies
Hemoglobinopathy is a group of disorders passed down through families (inherited) in which
there is abnormal production or structure of the hemoglobin molecule. Such disorders include
hemoglobin C disease, hemoglobin SC disease, sickle cell anemia, and various types of
thalassemia.

Myeloproliferative disorders
A group of conditions that cause blood cells platelets, white blood cells, and red blood cells
to grow abnormally in the bone marrow.

Coagulopathies
Bleeding disorders. A group of conditions in which there is a problem with the body's blood
clotting process. These disorders can lead to heavy and prolonged bleeding after an injury.
Bleeding can also begin on its own.

Hemorrhage
Loss of blood or blood escape from the circulatory system. Bleeding can occur internally, where
blood leaks from blood vessels inside the body, or externally, either through a natural opening
such as the vagina, mouth, nose, ear or anus, or through a break in the skin.

Subarachnoid Hemorrhage
Bleeding in the area between the brain and the thin tissues that cover the brain. This area is
called the subarachnoid space.

Transfusion
A common procedure in which a person receives blood through an intravenous (IV) line inserted
into one of the blood vessels. Blood transfusions are used to replace blood lost during surgery
or a serious injury. A transfusion also might be done if the body can't make blood properly
because of an illness.

Common Conditions:

Anemia
A condition in which the body does not have enough healthy red blood cells. Red blood cells
provide oxygen to body tissues.

Types of Anemia:
Anemia due to B12 deficiency
Anemia due to folate deficiency
Anemia due to iron deficiency
Anemia of chronic disease
Hemolytic anemia
Idiopathic aplastic anemia
Megaloblastic anemia
Pernicious anemia
Secondary aplastic anemia
Sickle cell anemia
Thalassemia

Although many parts of the body help make red blood cells, most of this is done in the bone

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marrow. Bone marrow is the soft tissue in the center of bones that helps form blood cells.
Healthy red blood cells last between 90 and 120 days. Parts of the body then remove old blood
cells. A hormone called erythropoietin made in the kidneys signals the bone marrow to make
more red blood cells.

Hemoglobin is the oxygencarrying protein inside red blood cells. It gives red blood cells their
red color. People with anemia do not have enough hemoglobin.

The body needs certain vitamins, minerals, and nutrients to make enough red blood cells. Iron,
vitamin B12, and folic acid are three of the most important ones. The body may not have
enough of these nutrients because:
Changes in the lining of the stomach or intestines affect how well nutrients are absorbed
(for example, celiac disease)
Poor diet
Slow blood loss (for example, from heavy menstrual periods or stomach ulcers)
Surgery that removes part of the stomach or intestines
Possible causes of anemia include:
Certain medications
Destruction of red blood cells earlier than normal (which may be caused by immune
system problems)
Longterm (chronic) diseases such as chronic kidney disease, cancer, ulcerative colitis,
or rheumatoid arthritis
Some forms of anemia, such as thalassemia or sickle cell anemia, which can be
inherited
Pregnancy
Problems with bone marrow such as lymphoma, leukemia, multiple myeloma, or aplastic
anemia

Symptoms: If the problem develops slowly, symptoms that may occur first include:
Feeling grumpy
Feeling weak or tired more often than usual, or with exercise
Headaches
Problems concentrating or thinking
If the anemia gets worse, symptoms may include:
Blue color to the whites of the eyes
Brittle nails
Lightheadedness when you stand up
Pale skin color
Shortness of breath
Sore tongue
Some types of anemia may have other symptoms.
 Signs and Tests: On examination, the following may be found:
Low blood pressure, especially when you stand up
Heart murmur
Pale skin
Rapid heart rate
Some types of anemia may cause other findings on a physical exam.
Blood tests used to diagnose some common types of anemia may include:
Blood levels of iron, vitamin B12, folic acid, and other vitamins and minerals
Red blood count and hemoglobin level
Reticulocyte (immature red blood cell) count
Other tests may be done to find medical problems that can cause anemia.

Treatment:
Treatment is directed at the cause of the anemia, and may include:
Blood transfusions
Corticosteroids or other medicines that suppress the immune system
Erythropoietin, a medicine that helps bone marrow make more blood cells
Supplements of iron, vitamin B12, folic acid, or other vitamins and minerals

Sickle cell disease

A type of anemia, passed down through families, in which red blood cells form an abnormal
sickle or crescent shape. Red blood cells carry oxygen to the body and are normally shaped like
a disc.

Sickle cell anemia is caused by an abnormal type of hemoglobin called hemoglobin S.

Hemoglobin is a protein inside red blood cells that carries oxygen.
Hemoglobin S changes the shape of red blood cells. The red blood cells become shaped
like crescents or sickles.
The fragile, sickleshaped cells deliver less oxygen to the body's tissues.
They can also get stuck more easily in small blood vessels, as well as break into pieces
that can interrupt healthy blood flow. These problems decrease the amount of oxygen
flowing to body tissues even more.

Sickle cell anemia is inherited from both parents. If you inherit the sickle cell gene from only one
parent, you will have sickle cell trait. People with sickle cell trait do not have the symptoms of
sickle cell anemia.

Sickle cell disease is much more common in people of African and Mediterranean descent. It is
also seen in people from South and Central America, the Caribbean, and the Middle East.

Symptoms: Almost all patients with sickle cell anemia have painful episodes (called
crises), which can last from hours to days. These crises can cause pain in the bones of
the back, the long bones, and the chest.
Some patients have one episode every few years. Others have many episodes per year.
The crises can be severe enough to require a hospital stay.
When the anemia becomes more severe, symptoms may include:
Fatigue
Paleness
Rapid heart rate
Shortness of breath
Yellowing of the eyes and skin (jaundice)
Younger children with sickle cell anemia have attacks of abdominal pain.
The following symptoms may occur because small blood vessels may become blocked
by the abnormal cells:
Painful and prolonged erection (priapism)
Poor eyesight or blindness
Problems thinking or confusion caused by small storkes
Ulcers on the lower legs (in adolescents and adults)
Over time, the spleen no longer works. As a result, people with sickle cell anemia may
have symptoms of infections such as:
Bone infection (osteomyelitis)
Gallbladder infection (cholecystitis)
Lung infection (pneumonia)
Urinary tract infection
Other symptoms include:
Delayed growth and puberty
Painful joints caused by arthritis

Signs and Tests:

Bilirubin
Blood oxygen
Complete blood count (CBC)
Hemoglobin electrophoresis
Serum creatinine
Serum potassium
Sickle cell test

Treatment:
The goal of treatment is to manage and control symptoms, and to limit the number of
crises. Patients with sickle cell disease need ongoing treatment, even when they are not
having a painful crisis.

Folic acid supplements should be taken. Folic acid is needed to make new red blood
cells.
 Treatment for a sickle cell crisis includes:
Blood transfusions (may also be given regularly to prevent stroke)
Pain medicines
Plenty of fluids
Other treatments for sickle cell anemia may include:
Hydroxyurea (Hydrea), a medicine that may help reduce the number of pain
episodes (including chest pain and difficulty breathing) in some people
Antibiotics to prevent bacterial infections, which are common in children with
sickle cell disease
Treatments that may be needed to manage complications of sickle cell anemia include:
Dialysis or kidney transplant for kidney disease
Counseling for psychological complications
Gallbladder removal in people with gallstone disease
Hip replacement for avascular necrosis of the hip
Surgery for eye problems
Treatment for overuse or abuse of narcotic pain medicines
Wound care for leg ulcers
Bone marrow or stem cell transplants can cure sickle cell anemia. However, they are
currently not an option for most patients. Sickle cell anemia patients are often unable to
find wellmatched stem cell donors.

Prognosis:
In the past, sickle cell patients often died between ages 20 and 40. Today patients can
live into their 50s or beyond. Causes of death include organ failure and infection.

Thrombocytopenia
A relative decrease of platelets in blood. Platelets (thrombocytes) are colorless blood cells that
play an important role in blood clotting. Platelets stop blood loss by clumping and forming plugs
in blood vessel holes.

Thrombocytopenia often occurs as a result of a separate disorder, such as leukemia or an

immune system problem, or as a medication side effect. Thrombocytopenia may be mild and
cause few signs or symptoms. In rare cases, the number of platelets may be so low that
dangerous internal bleeding can occur.

A normal platelet count is 150,000 to 450,000 platelets per microliter of blood. A count of less
than 150,000 platelets per microliter is lower than normal. But the risk for serious bleeding
doesn't occur until the count becomes very lowless than 10,000 or 20,000 platelets per
microliter. Milder bleeding sometimes occurs when the count is less than 50,000 platelets per
microliter.

Many factors can cause a low platelet count, such as:

The body's bone marrow doesn't make enough platelets.

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 The bone marrow makes enough platelets, but the body destroys them or uses them up.
The spleen holds on to too many platelets.
A combination of the above factors.

How long thrombocytopenia lasts depends on its cause. It can range from days to years.

Thrombocytopenia usually improves when the underlying cause is treated. Sometimes

medications, surgery or a blood or platelet transfusion can help treat chronic thrombocytopenia.

Hemophilia
A group of bleeding disorders in which it takes a long time for the blood to clot. When you
bleed, the body launches a series of reactions that help the blood clot. This is called the
coagulation cascade. The process involves special proteins called coagulation factors. When
one or more of these clotting factors are missing, there is usually a higher chance of bleeding.
Hemophilia is caused by a lack of enough factor VIII or IX. In most cases, hemophilia is passed
down through families (inherited). It most often affects males.

The main symptom of hemophilia is bleeding. Mild cases may go unnoticed until later in life,
when they occur during surgery or after trauma. In more severe cases, serious bleeding may
occur without any cause. Internal bleeding may occur anywhere. Bleeding into joints is common.

Most often, hemophilia is diagnosed after a person has an abnormal bleeding episode or when
there is a known family history of the condition.

Standard treatment involves replacing the missing clotting factor through a vein (intravenous
infusions).

Neutropenia (type of granulocytopenia)

Neutropenia indicates a deficiency of neutrophils (the most common granulocyte cell) only.

Neutropenia is an abnormally low count of neutrophils, white blood cells that help your immune
system fight off infections, particularly of bacteria and fungi. You have several types of white
blood cells, and between 45 and 70 percent of all white blood cells are neutrophils.

The threshold for defining neutropenia varies slightly from one medical practice to another.
Neutropenia in adults is generally defined as a count of 1,700 or fewer neutrophils per microliter
of blood.

The lower your neutrophil count, the more vulnerable you are to infectious diseases. If you have
severe neutropenia fewer than about 500 cells per microliter of blood bacteria normally
present in your mouth and digestive tract can cause infections.

Treatment:
 The two primary treatments for neutropenia are antibiotics to fight infection and drugs
that help the bone marrow make neutrophils. In some cases, a bone marrow transplant
may be an option.

Sources:
http://www.mayoclinic.com/health/neutropenia/MY00110
http://www.nlm.nih.gov/medlineplus/ency/article/001291.htm
http://en.wikipedia.org/wiki/Spleen
http://en.wikipedia.org/wiki/Bone_marrow
http://www.nlm.nih.gov/medlineplus/ency/article/003479.htm
http://www.differencebetween.net/science/differencebetweenlymphocytesandleukocytes/
http://www.nlm.nih.gov/medlineplus/ency/article/003645.htm
http://en.wikipedia.org/wiki/Plasma_cell
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001586/
http://www.umm.edu/altmed/articles/myeloproliferativedisorders000114.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002281/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001586/
http://www.sicklecelldisease.org/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001554/
http://www.mayoclinic.com/health/thrombocytopenia/DS00691
http://www.ucsfbenioffchildrens.org/conditions/neutropenia/treatment.html
http://www.nhlbi.nih.gov/health/healthtopics/topics/thcp/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001564/
Skin Disorders
The skin is the largest organ of the integumentary system (the system that protects the body
from damage), which guards the underlying muscles, bones, ligaments and internal organs.
The skin is important because it interfaces with the environment and is the first defense from
,external factors. The skin protects the body against pathogens and excessive water loss. Its
other functions are insulation, temperature regulation, sensation, and the production of vitamin
D folates. Severely damaged skin may heal by forming scar tissue.

Usual treatment provider: Dermatologist

Key terms and components:

Cutaneous
Of, relating to, or affecting the skin.

Epidermis
The outer layer of skin. The thickness of the epidermis varies in different types of skin. It is
thinnest on the eyelids at .05 mm and thickest on the palms and soles at 1.5 mm.
The epidermis contains 5 layers. From bottom to top, the layers are named stratum basale,
stratum spinosum, stratum granulosum, stratum licidum, and stratum corneum. The bottom
layer, the stratum basale, has cells that are shaped like columns. In this layer the cells divide
and push already formed cells into higher layers. As the cells move into the higher layers, they
flatten and eventually die. The top layer of the epidermis, the stratum corneum, is made of dead,
flat skin cells that shed about every 2 weeks.

There are three types of specialized cells in the epidermis. The melanocyte produces pigment
(melanin), the Langerhans' cell is the first defense of the immune system in the skin, and the
Merkels cells function is not yet known.

Dermis
A layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous
tissues, that consists of connective tissue and cushions the body from stress and strain. It is
divided into two layers, the superficial area adjacent to the epidermis called the papillary region
and a deep, thicker area known as the reticular dermis. The dermis is tightly connected to the
epidermis through a basement membrane.

Subcutaneous layer
The subcutaneous layer is composed primarily of fatty (adipose tissue), and acts as a shock
absorber. It contains sensory nerves, gives contour and shape to the body, serves as an energy
source, and gives skin independence of movement.

Touch receptor
The skin is sensitive to many different kinds of "stimuli," such as touch, pressure, and
temperature. Within the skin, there are different types of "receptors" that are activated by
different stimuli. When a receptor is activated, it triggers a series of nerve impulses. For a
person to "feel" the stimulus, the nerve impulses must make their way up to brain.

Photosensitivity
Abnormal light sensitivity. A skin rash as a result of an unusual reaction to sunlight.

Graft
A patch of skin that is removed by surgery from one area of the body and transplanted, or
attached, to another area.

Dermatitis
Dermatitis is a general term that describes an inflammation of the skin. There are different types
of dermatitis, including seborrheic dermatitis and atopic dermatitis (eczema). Although the
disorder can have many causes and occur in many forms, it usually involves swollen, reddened
and itchy skin.

Lesion
A superficial growth or patch of the skin that does not resemble the area surrounding it. Skin
lesions can be caused by a wide variety of conditions and diseases.

Skin lesions can be grouped into two categories: primary and secondary. Primary skin lesions
are variations in color or texture that may be present at birth, such as moles or birthmarks, or
that may be acquired during a person's lifetime, such as those associated with infectious
diseases (e.g. warts, acne, or psoriasis), allergic reactions (e.g. hives or contact dermatitis), or
environmental agents (e.g. sunburn, pressure, or temperature extremes). Secondary skin
lesions are those changes in the skin that result from primary skin lesions, either as a natural
progression or as a result of a person manipulating (e.g. scratching or picking at) a primary
lesion.

The major types of primary lesions are:

Macule
A small, circular, flat spot less than 2/5 in (1 cm) in diameter. The color of a macule is not the
same as that of nearby skin. Examples of macules include freckles and flat moles.

Vesicle

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A raised lesion less than 1/5 in (5 mm) across and filled with a clear fluid. Vesicles that are more
than 1/5 in (5 mm) across are called bullae or blisters. These lesions may may be the result of
sunburns, insect bites, chemical irritation, or certain viral infections, such as herpes.

Pustule
A raised lesion filled with pus. A pustule is usually the result of an infection, such as acne,
imptigeo, or boils.

Papule
A solid, raised lesion less than 2/5 in (1 cm) across. A patch of closely grouped papules more
than 2/5 in (1 cm) across is called a plaque. Papules and plaques can be rough in texture and
red, pink, or brown in color. Papules are associated with such conditions as warts, syphilis,
psoriasis, seborrheic and actinic keratoses, lichen planus, and skin cancer.

Nodule
A solid lesion that has distinct edges and that is usually more deeply rooted than a papule.
Doctors often describe a nodule as "palpable," meaning that, when examined by touch, it can be
felt as a hard mass distinct from the tissue surrounding it. A nodule more than 2 cm in diameter
is called a tumor. Nodules are associated with, among other conditions, keratinous cysts,
lipomas, fibromas, and some types of lymphomas.

Wheal
A skin elevation caused by swelling that can be itchy and usually disappears soon after
erupting. Wheals are generally associated with an allergic reaction, such as to a drug or an
insect bite.

Telangiectasia
Small, dilated blood vessels that appear close to the surface of the skin. Telangiectasia is often
a symptom of such diseases as rosacea or scleroderma.

The major types of secondary skin lesions are:

Ulcer
Lesion that involves loss of the upper portion of the skin (epidermis) and part of the lower
portion (dermis). Ulcers can result from acute conditions such as bacterial infection or trauma, or
from more chronic conditions, such as scleroderma or disorders involving peripheral veins and
arteries. An ulcer that appears as a deep crack that extends to the dermis is called a fissure.

Scale
A dry buildup of dead skin cells that often flakes off the surface of the skin. Diseases that
promote scale include fungal infections, psoriasis, and seborrheic dermatitis.

Crust

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A dried collection of blood, serum, or pus. Also called a scab, a crust is often part of the normal
healing process of many infectious lesions.

Erosion
Lesion that involves loss of the epidermis.

Excoriation
A hollow, crusted area caused by scratching or picking at a primary lesion.

Scar
Discolored, fibrous tissue that permanently replaces normal skin after destruction of the dermis.
A very thick and raised scar is called a keloid.

Lichenification
Rough, thick epidermis with exaggerated skin lines. This is often a characteristic of scratch
dermatitis and atopic dermatitis.

Atrophy
An area of skin that has become very thin and wrinkled. Normally seen in older individuals and
people who are using very strong topical corticosteroid medication.

Common conditions:

Burns
injury to flesh caused by heat, electricity, chemicals, light, radiation or friction. There are three
burn classifications.

1stdegree burn
The least serious burns are those in which only the outer layer of skin is burned, but not
all the way through.
The skin is usually red
Often there is swelling
Pain sometimes is present

2nddegree burn
When the first layer of skin has been burned through and the second layer of skin
(dermis) also is burned, the injury is called a seconddegree burn.
Blisters develop
Skin takes on an intensely reddened, splotchy appearance
There is severe pain and swelling.

3rddegree burn
The most serious burns involve all layers of the skin and cause permanent tissue
 damage. Fat, muscle and even bone may be affected. Areas may be charred black or
appear dry and white.

Psoriasis
Psoriasis is a common skin condition that causes skin redness and irritation. Most people with
psoriasis have thick, red skin with flaky, silverwhite patches called scales.

Some people with psoriasis may also have arthritis, a condition known as psoriatic arthritis.

See Psoriatic Arthritis section, above.

Complications of Psoriasis:
Arthritis
Pain
Severe itching
Secondary skin infections
Side effects from medicines used to treat psoriasis
Skin cancer from light therapy

Decubitus ulcer (pressure ulcer, bed sore)

A pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing
against the skin. Pressure on the skin reduces blood flow to the area. Without enough blood,
the skin can die. An ulcer may form. You are more likely to get a pressure ulcer if you:
Use a wheelchair or stay in bed for a long time
Are an older adult
Cannot move certain parts of your body without help because of a spine or brain injury or
disease such as multiple sclerosis
Have a disease that affects blood flow, including diabetes or vascular disease
Have Alzheimer's disease or another condition that affects your mental status
Have fragile skin
Have urinary incontinence or bowel incontinence
Do not get enough nutrition (malnourishment)

Symptoms
Red skin that gets worse over time
The area forms a blister, then an open sore
Pressure sores most commonly occur on the
Elbow
Hips
Heels
Ankles
 Shoulders
Back
Back of head
Pressure sores are grouped by their severity. Stage I is the earliest stage. Stage IV is
the worst.
Stage I: A reddened area on the skin that, when pressed, does not turn white.
This is a sign that a pressure ulcer is starting to develop.
Stage II: The skin blisters or forms an open sore. The area around the sore may
be red and irritated.
Stage III: The skin now develops an open, sunken hole called a crater. There is
damage to the tissue below the skin.
Stage IV: The pressure ulcer has become so deep that there is damage to the
muscle and bone, and sometimes to tendons and joints.

Sources: http://en.wikipedia.org/wiki/Skin
http://dermatology.about.com/cs/skinanatomy/g/epidermis.htm
http://skinipedia.org/skinessentials/skinphysiology101part4.html
http://faculty.washington.edu/chudler/chtouch.html
http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutdiagnosis.aspx?articleid
=94&zoneid=15 http://www.nlm.nih.gov/medlineplus/scars.html
http://www.nlm.nih.gov/medlineplus/ency/article/002982.htm
http://www.mayoclinic.com/health/firstaidburns/FA00022
http://www.mayoclinic.com/health/dermatitiseczema/DS00339
http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470/

Endocrine System
The endocrine system is a collection of glands that produce hormones that regulate the body's
growth, metabolism, and sexual development and function. The hormones are released into the
bloodstream and transported to tissues and organs throughout the body.

When an endocrine gland functions abnormally, producing either too much of a specific
hormone (hyperfunction) or too little (hypofunction), the hormonal imbalance can cause various
complications in the body. The major glands of the endocrine system are the pituitary, thyroid,
parathyroid, adrenal, and pancreas.
Usual treatment provider: endocrinologist other relevant treatment providers, especially for
people with diabetes: dietitian, eye doctor, foot doctor, and dentist.

Key terms and components:

Hormones
The body's chemical messengers, which travel through the bloodstream. They work slowly,
over time, and affect many different processes, including
Growth and development
Metabolism how the body gets energy from the food
Sexual function
Reproduction
Mood
Hormones are made by the endocrine glands. It takes only a tiny amount to cause significant
changes in cells or even the entire body. Therefore, too much or too little of a certain hormone
can be a serious problem. Laboratory tests can measure the hormone levels in blood, urine or
saliva.

Prohormone
A committed intraglandular precursor of a hormone, usually having minimal hormonal effect by
itself. The term has been used in medical science since the middle of the 20th century. The
primary function of a prohormone is to enhance the strength of the hormone that already occurs
in the body.

Metabolism
All of the physical and chemical processes in the body that convert or use energy, such as:
Breathing
Circulating blood
Controlling body temperature
Contracting muscles
Digesting food and nutrients
Eliminating waste through urine and feces
Functioning of the brain and nerves

Adrenal glands
Divided into 2 regions secrete hormones that influence the body's metabolism, blood
chemicals, and body characteristics, as well as influence the part of the nervous system that is
involved in the response and defense against stress. Adrenal glands produce hormones such
as estrogen, progesterone, steroids, cortisol, and cortisone, and chemicals such as adrenalin
(epinephrine), norepinephrine, and dopamine. When the glands produce more or less hormones
than required by the body, disease conditions may occur.
Hypothalamus
Activates and controls the part of the nervous system that controls involuntary body functions,
the hormonal system, and many body functions. The hormones produced by the hypothalamus
control body temperature, hunger, moods, thirst, sex drive, and sleep.

Ovaries and testicles

Secrete hormones that influence female and male characteristics, respectively.

Pancreas
Secretes a hormone (insulin) that controls the use of glucose by the body.

Parathyroid glands
Secrete parathyroid hormone, which maintains the calcium level in the blood.

Pineal body
Involved with daily biological cycles. It produces the serotonin derivative melatonin, a hormone
that affects the modulation of wake/sleep patterns and seasonal functions.

Pituitary gland
Produces a number of different hormones that influence various other endocrine glands. The
pituitary gland secretes nine hormones that regulate homeostasis. These include growth
hormone, thyroidstimulating hormone, adrenocorticotropic hormone, betaendorphin, prolactin,
luteinizing hormone, folliclestimulating hormone, and melanocytestimulating hormones.

Posterior pituitary gland

Stores and secretes important endocrine hormones: oxytocin and antidiuretic hormone (ADH,
also known as vasopressin and AVP, arginine vasopressin).

Thymus gland
A gland needed early in life for normal immune function. It is very large just after a child is born
and weighs its greatest when a child reaches puberty. Then its tissue is replaced by fat. The
thymus gland secretes hormones called humoral factors. These hormones help to develop the
lymphoid system, which is a system throughout the body that help it to reach a mature immune
response in cells to protect them from invading bodies, like bacteria.

Thyroid gland
Produces hormones that stimulate body heat production, bone growth, and the body's
metabolism. It controls how quickly the body uses energy, makes proteins, and controls how
sensitive the body is to other hormones. It participates in these processes by producing thyroid
hormones, the principal ones being triiodothyronine (T3) and thyroxine which is sometimes
referred to as tetraiodothyronine (T4). These hormones regulate the rate of metabolism and
affect the growth and rate of function of many other systems in the body. T3 and T4 are
synthesized from both iodine and tyrosine. The thyroid also produces calcitonin, which plays a

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role in calcium homeostasis.

Hormonal output from the thyroid is regulated by thyroidstimulating hormone (TSH) produced
by the anterior pituitary, which itself is regulated by thyrotropinreleasing hormone (TRH)
produced by the hypothalamus.

Estrogen
A group of compounds which are the primary female sex hormones. Natural estrogens are
steroid hormones, while some synthetic ones are nonsteroidal. While estrogens are present in
both men and women, they are usually present at significantly higher levels in women of
reproductive age. Estrogen has several other functions, including, but not limited to:
accelerating metabolism, increasing fat stores, reducing bone resorption, increasing bone
formation, increasing hepatic production of binding proteins, increasing platelet adhesiveness,
increasing HDL and triglycerides, salt and water retention, and reducing bowel motility.

Progesterone
A steroid hormone involved in the female menstrual cycle, pregnancy (supports gestation) and
embryogenesis of humans. Progesterone belongs to a class of hormones called progestogens,
and is the major naturally occurring human progestogen.

Steroids
A type of organic compound that contains a characteristic arrangement of four cycloalkane rings
that are joined to each other. Examples of steroids include the dietary fat cholesterol, the sex
hormones estradiol and testosterone, and the antiinflammatory drug dexamethasone.

Steroid hormone (sterone)

A steroid that acts as a hormone. Steroid hormones can be grouped into five groups by the
receptors to which they bind: glucocorticoids, mineralocorticoids, androgens, estrogens, and
progestogens. Steroid hormones help control metabolism, inflammation, immune functions, salt
and water balance, development of sexual characteristics, and the ability to withstand illness
and injury.

Cortisol
A steroid hormone produced by the adrenal gland. It plays a role in the metabolism of proteins,
lipids, and carbohydrates. It affects blood glucose levels, helps maintain blood pressure, and
helps regulate the immune system. Most cortisol in the blood is bound to a protein only a small
percentage is "free" and biologically active. Free cortisol is excreted into the urine and is present
in the saliva.

Cortisone
A steroid hormone. It is one of the main hormones released by the adrenal gland in response to
stress. In chemical structure, it is a corticosteroid closely related to corticosterone. It is used to
treat a variety of ailments and can be administered intravenously, orally, intraarticularly, or
transcutaneously. Cortisone suppresses the immune system, thus reducing inflammation and
attendant pain and swelling at the site of the injury.

Cortisone is one of several endproducts of a process called steroidogenesis. This process

starts with the synthesis of cholesterol, which then proceeds through a series of modifications in
the adrenal gland (suprarenal) to become any one of many steroid hormones.

Catecholamines
Hormones produced by the adrenal glands. They are released into the blood during times of
physical or emotional stress. The major catecholamines are dopamine, norepinephrine, and
epinephrine (which used to be called adrenalin). Catecholamines are more often measured with
a urine test than with a blood test.

Higherthannormal levels of blood catecholamines may suggest: acute anxiety,

ganglioblastoma (very rare), ganglioneuroma (very rare), neuroblastoma (rare),
pheochromocytoma (rare), or severe stress.

Normal results:
Epinephrine: 0900 picograms/milliliter (pg/ml)
Norepinephrine: 0600 pg/ml

Adrenalin (epinephrine)
A hormone and a neurotransmitter. Epinephrine has many functions in the body, regulating
heart rate, blood vessel and air passage diameters, and metabolic shifts epinephrine release is
a crucial component of the fightorflight response of the sympathetic nervous system.

Norepinephrine (norepi or NE)

A catecholamine with multiple roles including as a hormone and a neurotransmitter. Areas of
the body that produce or are affected by norepinephrine are described as noradrenergic. One
of the most important functions of norepinephrine is its role as a neurotransmitter. An increase
in norepinephrine from the sympathetic nervous system increases the rate of heart contractions.

As a stress hormone, norepinephrine affects parts of the brain, such as the amygdala, where
attention and responses are controlled. Along with epinephrine, norepinephrine also underlies
the fightorflight response, directly increasing heart rate, triggering the release of glucose from
energy stores, and increasing blood flow to skeletal muscle. It increases the brain's oxygen
supply. Norepinephrine can also suppress neuroinflammation when released diffusely in the
brain from the locus coeruleus. When norepinephrine acts as a drug, it increases blood
pressure by increasing vascular tone (tension of vascular smooth muscle).

Dopamine
Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.
Dopamine also helps regulate movement and emotional responses, and it enables us not only
to see rewards, but to take action to move toward them. Dopamine deficiency results in
Parkinson's Disease, and people with low dopamine activity may be more prone to addiction.
The presence of a certain kind of dopamine receptor is also associated with sensationseeking.

Thyrotropinreleasing hormone
Also called thyrotropinreleasing factor (TRF), thyroliberin or protirelin, is a hormone that
stimulates the release of TSH (thyroidstimulating hormone) and prolactin from the anterior
pituitary. TRH has been used clinically for the treatment of spinocerebellar degeneration and
disturbance of consciousness in humans.

Growth hormone
A hormone that stimulates growth, cell reproduction and regeneration..

Somatostatin (growth hormoneinhibiting hormone (GHIH))

A hormone that regulates the endocrine system and affects neurotransmission and cell
proliferation.

Vasopressin
A hormone responsible for increasing water absorption in the collecting ducts of the kidney
nephron. It also increases peripheral vascular resistance, which in turn increases arterial blood
pressure. It plays a key role in homeostasis, by the regulation of water, glucose, and salts in the
blood.

Triiodothyronine
A thyroid hormone that affects almost every physiological process in the body, including growth
and development, metabolism, body temperature, and heart rate. Production of T3 and its
prohormone, thyroxine (T4), is activated by thyroidstimulating hormone (TSH).

Serotonin
Primarily found in the gastrointestinal tract, platelets, and in the central nervous system (CNS). It
is popularly thought to be a contributor to feelings of wellbeing and happiness. Approximately
90% of the human body's total serotonin is located in the enterochromaffin cells in the
alimentary canal, where it is used to regulate intestinal movements. The remainder is
synthesized in serotonergic neurons of the CNS, where it has various functions. These include
the regulation of mood, appetite, and sleep. Serotonin also has some cognitive functions,
including memory and learning. Modulation of serotonin at synapses is thought to be a major
action of several classes of pharmacological antidepressants.

Melatonin
A hormone found naturally in the body. Melatonin can be made synthetically and is also used,
as medicine, to adjust the bodys internal clock. It is used for adjusting sleepwake cycles in
people whose daily work schedule changes (shiftwork disorder), and for helping blind people
establish a day and night cycle.
Melatonin is also used for the inability to fall asleep (insomnia) delayed sleep phase syndrome
(DSPS) insomnia associated with attention deficithyperactivity disorder (ADHD) insomnia due
to certain high blood pressure medications called betablockers and sleep problems in children
with developmental disorders including autism, cerebral palsy, and mental retardation. It is also
used as a sleep aid after discontinuing the use of benzodiazepine drugs and to reduce the side
effects of stopping smoking.

Some people use melatonin for Alzheimers disease, ringing in the ears, depression, chronic
fatigue syndrome (CFS), fibromyalgia, migraine and other headaches, irritable bowel syndrome
(IBS), bone loss (osteoporosis), a movement disorder called tardive dyskinesia (TD), epilepsy,
as an antiaging agent, for menopause, and for birth control.

Other uses include breast cancer, brain cancer, lung cancer, prostate cancer, head cancer,
neck cancer, and gastrointestinal cancer. Melatonin is also used for some of the side effects of
cancer treatment (chemotherapy) including weight loss, nerve pain, weakness, and a lowered
number of clotforming cells (thrombocytopenia).

Antidiuretic hormone (arginine vasopressin)

A hormone secreted from the posterior pituitary. The most important effect of antidiuretic
hormone is to conserve body water by reducing the loss of water in urine.

Thyroidstimulating hormone
A hormone that stimulates the thyroid gland to produce thyroxine (T4), and then triiodothyronine
(T3) which stimulates the metabolism of almost every tissue in the body. It is a glycoprotein
hormone synthesized and secreted by thyrotrope cells in the anterior pituitary gland, which
regulates the endocrine function of the thyroid gland.

Adrenocorticotropic hormone (ACTH)

A hormone produced and secreted by the anterior pituitary gland. It is often produced in
response to biological stress (along with its precursor corticotropinreleasing hormone from the
hypothalamus). Its principal effects are increased production and release of corticosteroids. A
deficiency of ACTH is a cause of secondary adrenal insufficiency and an excess of it is a cause
of Cushings syndrome.

Insulin
A hormone, produced by the pancreas, which is central to regulating carbohydrate and fat
metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up
glucose from the blood, storing it as glycogen inside these tissues.

Insulin stops the use of fat as an energy source by inhibiting the release of glucagon. With the
exception of the metabolic disorder diabetes mellitus and metabolic syndrome, insulin is
provided within the body in a constant proportion to remove excess glucose from the blood,
which otherwise would be toxic. When blood glucose levels fall below a certain level, the body
begins to use stored sugar as an energy source through glycogenolysis, which breaks down the
glycogen stored in the liver and muscles into glucose, which can then be utilized as an energy
source. As a central metabolic control mechanism, its status is also used as a control signal to
other body systems (such as amino acid uptake by body cells). In addition, it has several other
anabolic effects throughout the body.

When control of insulin levels fails, diabetes mellitus will result. As a consequence, insulin is
used medically to treat some forms of diabetes mellitus. Patients with type 1 diabetes depend
on external insulin (most commonly injected subcutaneously) for their survival because the
hormone is no longer produced internally. Patients with type 2 diabetes are often insulin
resistant and, because of such resistance, may suffer from a "relative" insulin deficiency. Some
patients with type 2 diabetes may eventually require insulin if other medications fail to control
blood glucose levels adequately. Over 40% of those with Type 2 diabetes require insulin as part
of their diabetes management plan.

Insulin also influences other body functions, such as vascular compliance and cognition. Once
insulin enters the human brain, it enhances learning and memory and benefits verbal memory in
particular.

Blood glucose (BG or blood sugar)

Glucose is a carbohydrate, and is the most important simple sugar in human metabolism.
Glucose is one of the primary molecules which serve as energy sources for plants and animals.
It is found in the human bloodstream where it is referred to as "blood sugar." The normal
concentration of glucose in the blood is about 0.1%, but it becomes much higher in persons
suffering from diabetes.

Blood glucose monitoring refers to the ongoing measurement of blood sugar. Monitoring can be
done at any time using a portable device called a glucometer.

Glycolysis
The first step in the breakdown of glucose in all cells.

Glycemia
The presence, or the level of concentration, of glucose in one's blood.

Ketosis
A state of elevated levels of ketone bodies. It is almost always generalized throughout the
body, with hyperketonemia, that is, an elevated level of ketone bodies in the blood. Ketone
bodies are formed by ketogenesis when the liver glycogen stores are depleted. The ketone
bodies acetoacetate and hydroxybutyrate are used for energy.

Hemoglobin A1c test (HbA1c)

The A1C test is a common blood test used to diagnose type 1 and type 2 diabetes. It also helps
to gauge how wellcontrolled an individuals diabetes is. The A1C test goes by many other
names, including glycated hemoglobin, glycosylated hemoglobin, hemoglobin A1C and HbA1c.

The A1C test result reflects the average blood sugar level for the preceding two to three
months. Specifically, the A1C test measures what percentage of your hemoglobin is coated with
sugar (glycated). The higher the A1C level, the poorer the blood sugar control. Also, if there is
already a diagnosis of diabetes, the higher the A1C level, the higher the risk of diabetes
complications.

Common conditions:

Hypothyroidism
A condition in which the thyroid gland does not make enough thyroid hormone. The most
common cause of hypothyroidism is inflammation of the thyroid gland, which damages the
gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the
thyroid gland, is the most common example of this. Some women develop hypothyroidism after
pregnancy (often referred to as "postpartum thyroiditis").

Other common causes of hypothyroidism include:

Congenital (birth) defects
Radiation treatments to the neck to treat different cancers, which may also
damage the thyroid gland
Radioactive iodine used to treat an overactive thyroid (hyperthyroidism)
Surgical removal of part or all of the thyroid gland, done to treat other thyroid
problems
Viral thyroiditis, which may cause hyperthyroidism and is often followed by
temporary or permanent hypothyroidism
Certain drugs can cause hypothyroidism, including:
Amiodarone
Drugs used for hyperthyroidism (overactive thyroid), such as propylthiouracil
(PTU) and methimazole
Lithium
Radiation to the brain
Sheehan syndrome, a condition that may occur in a woman who bleeds severely
during pregnancy or childbirth and causes destruction of the pituitary gland
Risk factors include:
Age over 50 years
Being female

Symptoms:
Early symptoms:
Being more sensitive to cold
 Constipation
Depression
Fatigue or feeling slowed down
Heavier menstrual periods
Joint or muscle pain
Paleness or dry skin
Thin, brittle hair or fingernails
Weakness
Weight gain (unintentional)
Late symptoms, if left untreated:
Decreased taste and smell
Hoarseness
Puffy face, hands, and feet
Slow speech
Thickening of the skin
Thinning of eyebrows

Signs and Tests:

A physical examination may reveal a smaller than normal thyroid gland, although
sometimes the gland is normal size or even enlarged (goiter). The examination may also
reveal:
Brittle nails
Coarse facial features
Pale or dry skin, which may be cool to the touch
Swelling of the arms and legs
Thin and brittle hair
A chest xray may show an enlarged heart.
Laboratory tests to determine thyroid function include:
TSH test
T4 test
Lab tests may also reveal:
Anemia on a complete blood count (CBC)
Increased cholesterol levels
Increased liver enzymes
Increased prolactin
Low sodium

Treatment:
The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine
is the most commonly used medication. Doctors will prescribe the lowest dose possible
that effectively relieves symptoms and brings the TSH level to a normal range. Lifelong
therapy is required unless the hypothyroidism is caused by a condition called transient
viral thyroiditis.
 Expectations:
In most cases, thyroid levels return to normal with proper treatment. However, thyroid
hormone replacement must be taken for the rest of your life.

Complications:
Myxedema coma (a medical emergency that occurs when the body's level of thyroid
hormones becomes extremely low) can result in death.

Hyperthyroidism
A condition in which the thyroid gland makes too much thyroid hormone. The condition is often
referred to as an "overactive thyroid."

Hyperthyroidism occurs when the thyroid releases too much of its hormones over a short (acute)
or long (chronic) period of time. Many diseases and conditions can cause this problem,
including:
Getting too much iodine
Graves disease (accounts for most cases of hyperthyroidism)
Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
Noncancerous growths of the thyroid gland or pituitary gland
Taking large amounts of thyroid hormone
Tumors of the testes or ovaries

Symptoms:
Difficulty concentrating
Fatigue
Frequent bowel movements
Goiter (visibly enlarged thyroid gland) or thyroid nodules
Heat intolerance
Increased appetite
Increased sweating
Irregular menstrual periods in women
Nervousness
Restlessness
Weight loss (rarely, weight gain)
Other symptoms that can occur with this disease:
Breast development in men
Clammy skin
Diarrhea
Hair loss
Hand tremor
Weakness
High blood pressure
 Itching overall
Lack of menstrual periods in women
Nausea and vomiting
Pounding, rapid, or irregular pulse
Protruding eyes (exophthalmos)
Rapid, forceful, or irregular heartbeat (palpitations)
Skin blushing or flushing
Sleeping difficulty

Signs and Tests:

Physical examination may reveal thyroid enlargement, tremor, hyperactive reflexes, or
an increased heart rate. Systolic blood pressure may be high.

Blood tests are also done to measure levels of thyroid hormones.

TSH (thyroid stimulating hormone) level is usually low
T3 and free T4 levels are usually high
This disease may also affect the results of the following tests:
Cholesterol test
Glucose test
Radioactive iodine uptake
T3RU
Triglycerides
Vitamin B12 (in rare cases)

Treatment: Depends on the cause and the severity of symptoms. Hyperthyroidism is

usually treated with one or more of the following:
Antithyroid medications
Betablockers such as propranolol are used to treat some of the symptoms,
including rapid heart rate, sweating, and anxiety until the hyperthyroidism can be
controlled.
Radioactive iodine (which destroys the thyroid and stops the excess production
of hormones)
Surgery to remove the thyroid. If the thyroid must be removed with surgery or
destroyed with radiation, hormone replacement pills must be taken after the
procedure, indefinitely.

Expectations:
Hyperthyroidism is generally treatable and only rarely is life threatening. Some of its
causes may go away without treatment.

Hyperthyroidism caused by Graves disease usually gets worse over time. It has many
complications, some of which are severe and affect quality of life.
 Complications:
Thyroid crisis (storm), also called thyrotoxicosis, is a sudden worsening of
hyperthyroidism symptoms that may occur with infection or stress. Fever, decreased
mental alertness, and abdominal pain may occur. Immediate hospitalization is needed.

Other complications related to hyperthyroidism include:

Heartrelated complications including:
Rapid heart rate
Congestive heart failure
Atrial fibrillation
Increased risk for osteoporosis, if hyperthyroidism is present for a long time
Surgeryrelated complications, including:
Scarring of the neck
Hoarseness due to nerve damage to the voice box
Low calcium level due to damage to the parathyroid glands (located near
the thyroid gland)

Diabetes mellitus, Type 1 (Type 1 diabetes, T1DM,, or, formerly, juvenile diabetes)
A condition in which blood glucose (blood sugar), is too high. With type 1 diabetes, the pancreas
does not make insulin. This results from autoimmune destruction of insulinproducing beta cells
of the pancreas. Without insulin, too much glucose stays in the blood and urine. Over time,
high blood glucose can lead to serious problems with the heart, eyes, kidneys, nerves, and
gums and teeth. Although the cause of type 1 diabetes is still not fully understood, it is believed
to be of immunological origin. Type 1 diabetes is a polygenic disease, meaning many different
genes contribute to its onset.

Type 1 diabetes happens most often in children and young adults but can appear at any age.

Symptoms:
Excessive thirst (polydipsia)
Frequent urination (polyuria)
Feeling very hungry (polyphagia)
Feeling tired
Unintended weight loss
Sores that heal slowly
Dry, itchy skin
Loss of feeling in the feet or tingling in the feet
Blurry eyesight

Untreated type 1 diabetes commonly leads to coma, often from diabetic ketoacidosis
(DKA a type of metabolic acidosis which is caused by high concentrations of ketone
bodies, formed by the breakdown of fatty acids and the deamination of amino acids),
which is fatal if untreated. Ketoacidosis causes cerebral edema (accumulation of liquid

1501
5015
in the brain). This complication is lifethreatening.

Diagnosis:
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is
diagnosed by demonstrating any one of the following:
Fasting plasma glucose level at or above 7.0 mmol/L (126 mg/dL).
Plasma glucose at or above 11.1 mmol/L (200 mg/dL) two hours after a 75 g oral
glucose load as in a glucose tolerance test.
Symptoms of hyperglycemia and casual plasma glucose at or above 11.1 mmol/L
(200 mg/dL).
Glycated hemoglobin (hemoglobin A1C) at or above 6.5 (This criterion was
recommended by the American Diabetes Association in 2010).

Type 1 can be distinguished from type 2 diabetes via a Cpeptide assay, which
measures endogenous insulin production.

About a quarter of people with new type 1 diabetes have developed some degree of
diabetic ketoacidosis by the time the diabetes is recognized. The diagnosis of other
types of diabetes is usually made in other ways. These include ordinary health
screening, detection of hyperglycemia during other medical investigations, and
secondary symptoms such as vision changes or unexplainable fatigue. Diabetes is often
detected when a person suffers a problem that may be caused by diabetes, such as a
heart attack, stroke, neuropathy, poor wound healing or a foot ulcer, certain eye
problems, certain fungal infections, or delivering a baby with macrosomia or
hypoglycemia.

Abnormal test results, in the absence of unequivocal hyperglycemia, should be

confirmed by a repeat test on a different day. Most physicians prefer to measure a
fasting glucose level because of the ease of measurement and the considerable time
commitment of formal glucose tolerance testing, which takes two hours to complete and
offers no prognostic advantage over the fasting test. According to the current definition,
two fasting glucose measurements above 126 mg/dL (7.0 mmol/L) is considered
diagnostic for diabetes mellitus.

Patients with fasting glucose levels from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) are
considered to have impaired fasting glucose. Patients with plasma glucose at or above
140 mg/dL (7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hours after a 75 g
oral glucose load are considered to have impaired glucose tolerance. Of these two
prediabetic states, the latter, in particular, is a major risk factor for progression to full-
blown diabetes mellitus and cardiovascular disease.
 Condition 2 hour glucose Fasting glucose HbA1c

mmol/l(mg/dl) mmol/l(mg/dl) %

Normal <7.8 (<140) <6.1 (<110) <6.0

Impaired <7.8 (<140) 6.1(110) & 6.06.4

fasting <7.0(<126)
glycaemia

Impaired 7.8 (140) <7.0 (<126) 6.06.4

glucose
tolerance

Diabetes 11.1 (200) 7.0 (126) 6.5

mellitus

Treatment:
Eventually, type 1 diabetes is fatal unless treated with insulin. Injection is the most
common method of administering insulin other methods are insulin pumps and inhaled
insulin. Pancreatic transplants have been used. Pancreatic islet cell transplantation is
experimental, though growing.

Type 1 treatment must be continued indefinitely in all cases. Treatment should not
significantly impair normal activities, and can be done adequately if sufficient patient
training, awareness, appropriate care, discipline in testing and dosing of insulin is taken.
However, treatment remains quite burdensome for many people.

Treatment of diabetes focuses on lowering blood sugar or glucose (BG) to the near
normal range, approximately 80140 mg/dl (4.47.8 mmol/L). The ultimate goal of
normalizing BG is to avoid longterm complications that affect the nervous system (e.g.
peripheral neuropathy leading to pain and/or loss of feeling in the extremities), and the
cardiovascular system (e.g. heart attacks, vision loss).

Complications:
High blood sugar (hyperglycemia) may lead to increased fatigue and chronic
hyperglycemia can also result in longterm damage to organs.

People with type 1 diabetes always need to use insulin, but treatment can lead to low
BG (hypoglycemia), i.e. BG less than 70 mg/dl (3.9 mmol/l). Hypoglycemia is a very
common occurrence in people with diabetes, usually the result of a mismatch in the
balance among insulin, food and physical activity, although the nonphysiological method
 of delivery also plays a role. Hypoglycemia may lead to seizures or episodes of
unconsciousness, and requires emergency treatment.

Complications of poorly managed type 1 diabetes mellitus may include cardiovascular

disease, diabetic neuropathy, and diabetic retinopathy, among others.

Diabetes Mellitus, Type 2

A lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2
diabetes is the most common form of diabetes.

In type 2 diabetes, the bodys fat, liver, and muscle cells do not respond correctly to insulin
(insulin resistance). As a result, blood sugar does not get into these cells to be stored for
energy. When sugar cannot enter cells, high levels of sugar build up in the blood. This is called
hyperglycemia.

Type 2 diabetes usually occurs slowly over time. Most people with the disease are overweight
when they are diagnosed. Increased fat makes it harder for your body to use insulin the correct
way. However, type 2 diabetes can also develop in people who are thin. This is more common
in the elderly.

Family history and genes play a large role in type 2 diabetes. Low activity level, poor diet, and
excess body weight around the waist increase your risk.

Symptoms:
Often, people with type 2 diabetes have no symptoms at first. They may not have
symptoms for many years.

The early symptoms of diabetes may include:

Bladder, kidney, skin, or other infections that are more frequent or heal slowly
Fatigue
Hunger
Increased thirst
Increased urination
The first symptom may also be:
Blurred vision
Erectile dysfunction
Pain or numbness in the feet or hands

Exams and Tests:

Diabetes may be suspected if blood sugar level is higher than 200 mg/dL. To confirm the
diagnosis, one or more of the following tests must be done.
Diabetes blood tests:
Fasting blood glucose level diabetes is diagnosed if it is higher than 126 mg/dL
 two times
Hemoglobin A1c test
Normal: Less than 5.7%
Prediabetes: 5.7% 6.4%
Diabetes: 6.5% or higher
Oral glucose tolerance test diabetes is diagnosed if glucose level is higher than
200 mg/dL after 2 hours

Monitoring: People with diabetes should see their health care providers every 3 months,
in order to:
Check blood pressure (ideal is 130/80 mm/Hg or lower).
Check the skin and bones on the feet and legs
Check to see if the feet are becoming numb
Examine the eyes/retina

Other Regular Tests:

Hemoglobin A1c test (HbA1c) every 6 months if diabetes is well controlled
otherwise every 3 months.
Cholesterol and triglyceride levels tested yearly (LDL levels below 70100 mg/dL
are ideal).
Yearly tests to make sure the kidneys are working well (microalbuminuria and
serum creatinine).
Eye doctor visits at least once a year, or more often if there are signs of diabetic
eye disease.
Dental exam every 6 months

Treatment: The goal of treatment at first is to lower high blood glucose levels. The
longterm goals of treatment are to prevent problems from diabetes.

The main treatment for type 2 diabetes is exercise and diet. Regular exercise is
important for people with diabetes.

The doctor will help set blood sugar goals. Most people with type 2 diabetes only need
to check their blood sugar once or twice a day.

Managing body weight and eating a wellbalanced diet are important. Some people with
type 2 diabetes can stop taking medications after losing weight (although they still have
diabetes).

Medication: If diet and exercise are not enough to control blood sugar at normal or
nearnormal levels, medication may be prescribed.

Some of the most common types of medication are listed below. They are taken by
 mouth or injection:
Alphaglucosidase inhibitors (such as acarbose)
Biguanides (Metformin)
Injectable medicines (including exenatide, mitiglinide, pramlintide, sitagliptin, and
saxagliptin)
Meglitinides (including repaglinide and nateglinide)
Sulfonylureas (like glimepiride, glyburide, and tolazamide)
Thiazolidinediones (such as rosiglitazone and pioglitazone). (Rosiglitazone may
increase the risk of heart problems. Talk to your doctor.)

These drugs may be given with insulin, or insulin may be used alone. Insulin may be
needed for poor blood glucose control.

Complications
After many years, diabetes can lead to serious problems with the eyes, kidneys, nerves,
heart, blood vessels, or other areas of the body.

People with diabetes are more likely to have foot problems. It can become harder for
blood to flow to the legs and feet.

Diabetes also decreases the body's ability to fight infection. Small infections can quickly
get worse and cause the death of skin and other tissues. Infections of the skin, female
genital tract, and urinary tract are also more common.

High blood sugar levels can damage nerves (diabetic neuropathy), which means you
may not feel an injury to the foot until you get a large sore or infection. Nerve damage
may cause pain, tingling, and a loss of feeling. Because of nerve damage, there may be
problems with digestion, weakness, and trouble going to the bathroom.

For someone with diabetes, the risk of a heart attack is the same as that of someone
who has already had a heart attack. Both women and men with diabetes are at risk.
They may not have the normal signs of a heart attack. Controlling blood sugar and
blood pressure can reduce the risk of death, stroke, heart failure, and other diabetes
problems.

Eye problems may include trouble seeing (especially at night), light sensitivity and
blindness.

Diabetic neuropathy
Nerve injuries are caused by decreased blood flow and high blood sugar levels. They are more
likely to develop if blood sugar levels are not well controlled.
About half of people with diabetes will develop nerve damage. Most of the time symptoms do
not begin until 10 to 20 years after diabetes has been diagnosed. Nerve injuries may affect:
 Nerves in the skull (cranial nerves)
Nerves from the spinal column and their branches
Nerves that help your body manage vital organs, such as the heart, bladder,
stomach, and intestines (called autonomic neuropathy)

Symptoms:
Symptoms often develop slowly over several years. They can vary depending on the
nerves that are affected:
People with diabetes may have trouble digesting food. These problems can make
diabetes harder to control. Symptoms of this problem are:
Feeling full after eating only a small amount of food
Heartburn and bloating
Nausea, constipation, or diarrhea
Swallowing problems
Throwing up food a few hours after a meal
Tingling or burning in the arms and legs may be an early sign of nerve damage. These
feelings often start in the toes and feet. there may be deep pain, often in the feet and
legs. Nerve damage may cause loss of feeling in the arms and legs. Because of this, a
diabetes patient may:
Not notice when stepping on something sharp
Not notice a blister or small cut
Not notice when touching something that is too hot or cold
Damage to nerves in the heart and blood vessels may cause:
Feeling lightheaded when standing up (orthostatic hypotension)
Fast heart rate
Failure to notice angina, the chest pain that warns of heart disease and heart
attack
Other symptoms of nerve damage are:
Sexual problems
Not being able to tell when blood sugar gets too low
Bladder problems: leaking urine and not being able to tell when bladder is full.
Some people are not able to empty their bladder.
Sweating too much when the temperature is cool, when at rest, or at other
unusual times

Signs and Tests:

A physical exam may show:
A lack of reflexes in the ankle
A loss of feeling in the feet (checked with a brushlike instrument called a
monofilament)
Changes in the skin
Drop in blood pressure when standing up after sitting or lying down
Tests that may be done include:
 Electromyogram (EMG) a recording of electrical activity in muscles
Nerve conduction velocity tests (NCV) a recording of the speed at which
signals travel along nerves

Medication:
The following medications may be used to reduce symptoms in the feet, legs, and arms:
Certain drugs that are also used to treat depression, such as amitriptyline (Elavil),
doxepin (Sinequan), or duloxetine (Cymbalta)
Certain drugs that are also used to treat seizures, such as gabapentin
(Neurontin), pregabalin (Lyrica), carbamazepine (Tegretol), and valproate
(Depakote)
Pain medicines
Treatments for nausea and vomiting may include:
Taking medicines that help food move more quickly through your stomach and
intestines
Sleeping with your head raised
Eating smaller, more frequent meals
Diarrhea, constipation, bladder problems, and other symptoms are treated as needed.

Expectations: Treatment relieves pain and can control some symptoms, but the disease
generally continues to get worse.

Complications:
Bladder and kidney infections
Injury to the feet due to loss of feeling
Muscle damage
Poor blood sugar control due to nausea and vomiting
Skin and soft tissue damage and risk of amputation
Neuropathy may also hide angina, the warning chest pain for heart disease and
heart attack.

Diabetic retinopathy
Diabetic retinopathy is caused by damage to blood vessels of the retina. The retina is the layer
of tissue at the back of the inner eye. It changes light and images that enter the eye into nerve
signals that are sent to the brain.

There are two types, or stages of diabetic retinopathy:

Nonproliferative develops first
Proliferative is the more advanced and severe form of the disease

Diabetic retinopathy is the leading cause of blindness in workingage Americans. People with
type 1 diabetes and type 2 diabetes are at risk for this condition.
Having more severe diabetes for a longer period of time increases the chance of getting
retinopathy. Retinopathy is also more likely to occur earlier and be more severe if your diabetes
has been poorly controlled.

Almost everyone who has had diabetes for more than 30 years will show signs of diabetic
retinopathy.

Symptoms:
Most often, diabetic retinopathy has no symptoms until the damage to your eyes is
severe. Symptoms of diabetic retinopathy include:
Blurred vision and slow vision loss over time
Floaters
Shadows or missing areas of vision
Trouble seeing at night
Many people with early diabetic retinopathy have no symptoms before major bleeding
occurs in the eye.

Treatment:
People with the earlier form (nonproliferative) of diabetic retinopathy may not need
treatment. However, they should be closely followed by an eye doctor who is trained to
treat diabetic retinopathy.

Treatment usually does not reverse damage that has already occurred. However, it can
help keep the disease from getting worse. Once an eye doctor notices new blood
vessels growing in the retina (neovascularization) or macular edema develops, treatment
is usually needed.

Several procedures or surgeries are the main treatment for diabetic retinopathy. Laser
eye surgery creates small burns in the retina where there are abnormal blood vessels.
This process is called photocoagulation. It is used to keep vessels from leaking or to get
rid of abnormal, fragile vessels.
Focal laser photocoagulation is used to treat macular edema.
Scatter laser treatment or panretinal photocoagulation treats a large area of the
retina. Often two or more sessions are needed.

A surgical procedure called vitrectomy is used when there is bleeding (hemorrhage) into
the eye. It may also be used to repair retinal detachment.

Drugs that prevent abnormal blood vessels from growing, and corticosteroids injected
into the eyeball are being investigated as new treatments for diabetic retinopathy.

Complications: Other problems that may develop are:

Cataracts
 Glaucoma increased pressure in the eye that can lead to blindness
Macular edema if fluid leaks into the area of the retina that provides sharp
vision straight in front of you, vision becomes more blurry
Retinal detachment scarring may cause part of the retina to pull away from the
back of your eyeball

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Nervous System

The nervous system is the control and communication system of the body. It sends and
receives messages, controlling all thoughts and movements. It contains a network of
specialized cells called neurons that coordinate a persons actions and transmit signals between
different parts of its body. The nervous system is divided into the central nervous system (CNS)
and peripheral nervous system (PNS). It is made up of the brain, spinal cord, retina, cranial
nerves, and spinal nerves.

Neurology is a medical specialty dealing with disorders of the nervous system. It deals with the
diagnosis and treatment of all categories of disease involving the central, peripheral, and
autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,
such as muscle.

Usual treatment providers: neurologist neurosurgeon

Key terms and components:

Neuron
An electrically excitable cell that processes and transmits information by electrical and chemical
signaling. Chemical signaling occurs via synapses, specialized connections with other cells.
Neurons connect to each other to form neural networks. Neurons are the core components of
the nervous system, including the brain, spinal cord, and peripheral ganglia. A number of
specialized types of neurons exist: sensory neurons respond to touch, sound, light and
numerous other stimuli affecting cells of the sensory organs that then send signals to the spinal
cord and brain. Motor neurons receive signals from the brain and spinal cord, cause muscle
contractions, and affect glands. Interneurons connect neurons to other neurons within the same
region of the brain or spinal cord.

Brain
The center of the human nervous system. It contains approximately 80 to 120 billion neurons
(nerve cells). The brain is very soft, having a consistency similar to soft gelatin. The brain
consists of three main structures: the cerebrum, the cerebellum and the brainstem.

Cerebrum
Divided into two hemispheres (left and right), which consist of four lobes (frontal, parietal,
occipital and temporal). The outer layer of the brain is known as the cerebral cortex or
the grey matter. It covers the nuclei deep within the cerebral hemisphere, e.g. the

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basal ganglia the structure called the thalamus, and the white matter, which consists
mostly of myelinated axons.

Cerebral cortex
The outer layer of gray matter of the cerebral hemispheres. It is largely responsible for
higher brain functions, including sensation, voluntary muscle movement, thought,
reasoning, and memory.

Grey matter
Closely packed neuron cell bodies form the grey matter of the brain. The grey matter
contains specialized regions of the brain involved in muscle control, sensory perceptions,
such as seeing and hearing, memory, emotions and speech.

White matter
Neuronal tissue containing mainly long, myelinated axons, is known as white matter or
the diencephalon. Situated between the brainstem and cerebellum, the white matter
contains structures at the core of the brain such as the thalamus and hypothalamus. The
nuclei of the white matter are involved in the relay of sensory information from the rest of
the body to the cerebral cortex, as well as in the regulation of autonomic (unconscious)
functions such as body temperature, heart rate and blood pressure. Certain nuclei within
the white matter are involved in the expression of emotions, the release of hormones
from the pituitary gland, and in the regulation of food and water intake.

Frontal lobe
Contains most of the dopaminesensitive neurons in the cerebral cortex. The dopamine
system is associated with reward, attention, shortterm memory tasks, planning, and
motivation. The executive functions of the frontal lobes involve the ability to recognize
future consequences resulting from current actions, to choose between good and bad
actions (or better and best), override and suppress unacceptable social responses, and
determine similarities and differences between things or events. Therefore, it is involved
in higher mental functions.

The frontal lobes also play an important part in retaining longer term memories which are
not taskbased. These are often memories associated with emotions derived from input
from the brain's limbic system. The frontal lobe modifies those emotions to generally fit
socially acceptable norms.

Parietal lobe
The parietal lobe plays important roles in integrating sensory information from various
parts of the body, knowledge of numbers and their relations, and in the manipulation of
objects. Portions of the parietal lobe are involved with visuospatial processing.

Temporal lobe
Involved in auditory perception and is home to the primary auditory cortex. It is also
important for the processing of semantics in both speech and vision. The temporal lobe
contains the hippocampus and plays a key role in the formation of longterm memory.

Occipital lobe
The visual processing center of the brain. A significant functional aspect of the occipital
lobe is that it contains the primary visual cortex. If one occipital lobe is damaged, the
result can be homonomous vision loss from similarly positioned "field cuts" in each eye.
Occipital lesions can cause visual hallucinations. Lesions in the parietaltemporal-
occipital association area are associated with color agnosia (color blindness),
movement agnosia (motion blindness or inability to perceive motion), and agraphia
(inability to write). Damage to the primary visual cortex which is located on the surface
of the posterior occipital lobe, can cause blindness due to the holes in the visual map on
the surface of the visual cortex that resulted from the lesions.

Cortical layers
The human cerebral cortex is composed of 6 somewhat distinct layers each layer
identified by the nerve cell type and the destination of these nerve cell's axons (within
the brain). The human cortex is a roughly 2.4 mm thick sheet of neuronal cell bodies that
forms the external surface of the telencephalon.

Cerebellum
Responsible for psychomotor function, the cerebellum coordinates sensory input from
the inner ear and the muscles to provide accurate control of position and movement.

Brain stem
Found at the base of the brain, it forms the link between the cerebral cortex, white matter
and the spinal cord. The brainstem contributes to the control of breathing, sleep and
circulation.

Basal ganglia
Collectively, the caudate nucleus, putamen and globus pallidus form the basal ganglia,
and are involved in movement control. These highly specialised clusters of cells/nuclei
are found within the white matter, beneath the cerebral cortex.

Limbic system
The limbic system is not a structure, but a series of nerve pathways incorporating
structures deep within the temporal lobes, such as the hippocampus and the amygdala.
Forming connections with the cerebral cortex, white matter and brainstem, the limbic
system is involved in the control and expression of mood and emotion, in the processing
and storage of recent memory, and in the control of appetite and emotional responses to
food. All these functions are frequently affected in depression and the limbic system has
been implicated in the pathogenesis of depression. The limbic system is also linked with
parts of the neuroendocrine and autonomic nervous systems, and some psychiatric
disorders, such as anxiety, are associated with both hormonal and autonomic changes.

Thalamus and Hypothalamus

The thalamus and hypothalamus are prominent internal structures. The thalamus has
wideranging connections with the cortex and many other parts of the brain, such as the
basal ganglia, hypothalamus and brainstem. It is capable of perceiving pain but not of
accurately locating it. The hypothalamus has several important functions, including
control of appetite, sleep patterns, sexual drive and response to anxiety.

Cerebrospinal fluid (CSF) and Ventricles

Within the brain, there are a number of cavities called ventricles. Ventricles are filled with
cerebrospinal fluid (CSF), which is produced within the ventricle wall. The CSF also
surrounds the outer surfaces of the brain and cushions the brain against trauma,
maintains and controls the extracellular environment, and circulates endocrine
hormones. during a lumbar puncture (LP), the CSF is collected from the spinal canal of
the patient. Laboratory analyses of the CSF (e.g. glucose and electrolyte concentrations)
can show whether there is an infection in or around the brain.

Reticular activating system

At the core of the brainstem is a collection of nuclei called the reticular formation.These
nuclei receive input from most of the bodys sensory systems (e.g. sight, smell, taste,
etc) and other parts of the brain, such as the cerebellum and cerebral hemispheres.

Some neurons from the reticular formation project to meet motor neurons of the spinal
cord and influence functions such as cardiovascular and respiratory control. In addition,
there are also neurons projecting into most of the rest of the brain. The ascending fibers
of the reticular formation form a network called the reticular activating system, which
influence wakefulness, overall degree of arousal and consciousness all factors which
may be disturbed in depressed patients.

Brain cells
Although extremely complex, the brain is largely made up of only two principal cell types:
neurons and glial cells. There are over 100,000 million neurons in the brain and an
even greater number of glial cells. It is estimated that there are more than 10,000 million
cells in the cerebral cortex alone.

Neurons
Neurons are involved in information transmission receiving, processing and
transmitting information through their highly specialized structure. Neurons
consist of a cell body and two types of projections the dendrites and an axon.
Most neurons have many dendrites, but only one axon.
The majority of neurons are unable to undergo cell division or repair. This
 limitation results in irreversible damage to the nervous system after trauma,
intoxication, oxygen deficiency or stroke.

Neurons use their highly specialised structure to both send and receive signals.
Individual neurons receive information from thousands of other neurons, and in
turn send information to thousands more. Information is passed from one neuron
to another via neurotransmission. This is an indirect process that takes place in
the area between the nerve ending (nerve terminal) and the next cell body. This
area is called the synaptic cleft or synapse.

Glia
Glial cells do not have a direct role in neurotransmission, but they play a
supporting role that helps define synaptic contacts and maintain the signalling
abilities of neurons. Various types of glial cells can be found in the brain (or
CNS) including astrocytes, oligodendroglia and microglia.

Glial cells are responsible for: modulating the rate of nerve impulse propagation
controlling the uptake of neurotransmitters and playing a pivotal role during
development and adulthood.

Axon
A long, slender projection of a nerve cell, or neuron, that typically conducts electrical impulses
away from the neuron's cell body. In certain sensory neurons (pseudounipolar neurons), such
as those for touch and warmth, the electrical impulse travels along an axon from the periphery
to the cell body, and from the cell body to the spinal cord along another branch of the same
axon. Axon dysfunction causes many inherited and acquired neurological disorders which can
affect both the peripheral and central neurons.
Synapse
A structure that permits a neuron to pass an electrical or chemical signal to another cell (neural
or otherwise).

Neurotransmitter
Chemicals that transmit signals from a neuron to a target cell across a synapse. The only direct
action of a neurotransmitter is to activate a receptor. Therefore, the effects of a neurotransmitter
system depend on the connections of the neurons that use the transmitter, and the chemical
properties of the receptors that the transmitter binds to. Major neurotransmitters are:
Amino acids: glutamate, aspartate, Dserine, aminobutyric acid (GABA), glycine
Monoamines and other biogenic amines: dopamine (DA), norepinephrine
(noradrenaline NE, NA), epinephrine (adrenaline), histamine, serotonin (SE,
5HT)
Others: acetylcholine (ACh), adenosine, anandamide, nitric oxide

Myelin
A dielectric (electrically insulating) material that forms a layer, the myelin sheath, usually around
only the axon of a neuron. It is essential for the proper functioning of the nervous system. Myelin
is an outgrowth of a type of glial cell. The production of the myelin sheath is called myelination.

Arachnoid mater, dura mater, pia mater, and subarachnoid space

One of the three meninges, the protective membranes that cover the brain and spinal cord. It is
interposed between the two other meninges, the more superficial dura mater and the deeper pia
mater, from which it is separated by the subarachnoid space. The delicate arachnoid layer is
attached to the inside of the dura and surrounds the brain and spinal cord.

Spinal cord
The main pathway for information, connecting the brain and peripheral nervous system. The
spinal cord is located in the vertebral foramen and is made up of 31 segments: 8 cervical, 12
thoracic, 5 lumbar, 5 sacral and 1 coccygeal. A pair of spinal nerves exits from each segment of
the spinal cord.

The spinal cord is about 45 cm long in men and 43 cm long in women. The length of the spinal
cord is much shorter than the length of the bony spinal column. In fact, the spinal cord extends
down to only the last of the thoracic vertebrae. Therefore, nerves that branch from the spinal
cord from the lumbar and sacral levels must run in the vertebral canal for a distance before they
exit the vertebral column. This collection of nerves in the vertebral canal is called the cauda
equina (which means "horse tail").

Receptors in the skin send information to the spinal cord through the spinal nerves. The cell
bodies for these nerve fibers are located in the dorsal root ganglion. The nerve fibers enter the
spinal cord through the dorsal root. Some fibers make synapses with other neurons in the dorsal
horn, while others continue up to the brain. Many cell bodies in the ventral horn of the spinal
cord send axons through the ventral root to muscles to control movement.

The nerves within the spinal cord are grouped together in different bundles called ascending
and descending tracts. Ascending tracts within the spinal cord carry sensory information from
the body, upwards to the brain, such as touch, skin temperature, pain and joint position.
Descending tracts within the spinal cord carry information from the brain downwards to initiate
movement and control body functions.

Nerve
An enclosed, cablelike bundle of axons (the long, slender projections of neurons) in the
peripheral nervous system. A nerve provides a common pathway for the electrochemical nerve
impulses that are transmitted along each of the axons to peripheral organs.

Within a nerve, each axon is surrounded by a layer of connective tissue called the endoneurium.
The axons are bundled together into groups called fascicles, and each fascicle is wrapped in a
layer of connective tissue called the perineurium. Finally, the entire nerve is wrapped in a layer
of connective tissue called the epineurium.

Spinal nerves
The spinal nerves branch off from the spinal cord and pass out through a hole in each of the
vertebrae called the foramen. These nerves carry information from the spinal cord to the rest of
the body, and from the body back up to the brain.

There are four main groups of spinal nerves, which exit different levels of the spinal cord.
These are in descending order down the vertebral column:

Cervical Nerves ("C") : (nerves in the neck) supply movement and feeling to the arms,
neck and upper trunk. Also control breathing.

Thoracic Nerves ("T") : (nerves in the upper back) supply the trunk and abdomen.

Lumbar Nerves ("L") and Sacral Nerves ("S") : (nerves in the lower back) supply the
legs, the bladder, bowel and sexual organs.

Dorsal root (posterior root) and ventral root

The dorsal root of a spinal nerve passes posteriorly to the spinal cord, separating the
posterior and lateral funiculi. It consists of sensory fibers. The ventral root (motor root)
of each spinal nerve consists of axons from motor neurons whose cell bodies are found
within the gray matter of the spinal cord.

A ventral root and a dorsal root unite to form a spinal nerve, which passes outward from
the vertebral canal through an intervertebral foramen. A posterior branch (posterior
ramus) of each spinal nerve turns toward the posterior to innervate muscles and skin of
the back. The main portion of the nerve, the anterior branch (anterior ramus), continues
forward to supply muscles and skin on the front and sides of the trunk and limbs. The
spinal nerves in the thoracic and lumbar regions have a fourth or visceral branch, which
is part of the autonomic nervous system.

Cranial nerves
Nerves that emerge directly from the brain, in contrast to spinal nerves, which emerge from
segments of the spinal cord. There are traditionally twelve pairs of cranial nerves. Only the first
and the second pair emerge from the cerebrum the remaining ten pairs emerge from the
brainstem.

Vagus nerve (pneumogastric nerve or cranial nerve X)

The tenth of twelve (excluding CN0) paired cranial nerves. Upon leaving the medulla between
the medullary pyramid and the inferior cerebellar peduncle, it extends through the jugular
foramen, then passing into the carotid sheath between the internal carotid artery and the
internal jugular vein down below the head, to the neck, chest and abdomen, where it contributes
to the innervation of the viscera. Besides output to the various organs in the body, the vagus
nerve conveys sensory information about the state of the body's organs to the central nervous
system. Eighty to ninety percent of the nerve fibers in the vagus nerve are afferent (sensory)
nerves communicating the state of the viscera to the brain.

Ganglion
A biological tissue mass, most commonly a mass of nerve cell bodies. Ganglia often
interconnect with other ganglia to form a complex system of ganglia known as a nerve plexus.
Ganglia provide relay points and intermediary connections between different neurological
structures in the body, such as the peripheral and central nervous systems.

There are two major groups of ganglia:

Dorsal root ganglia (also known as the spinal ganglia) contain the cell bodies of
sensory (afferent) nerves.
Autonomic ganglia contain the cell bodies of autonomic nerves.

In the autonomic nervous system, fibers from the central nervous system to the ganglia are
known as preganglionic fibers, while those from the ganglia to the effector organ are called
postganglionic fibers.

Central nervous system (CNS)

The central nervous system is composed of the brain and spinal cord. The brain and spinal cord
serve as the main "processing center" for the entire nervous system, and control all the
workings of the body.

Peripheral nervous system (PNS)

The PNS consists of sensory neurons running from stimulus receptors that inform the CNS of
the stimuli, and motor neurons running from the CNS to the muscles and glands called
effectors that take action. It is subdivided into the sensorysomatic nervous system and the
autonomic nervous system.

Sensory division
The sensory division of the PNS carries all types of sensory information to the CNS,
including that from the "special senses" of touch, smell, taste, hearing, and sight, as well
pain, body position (proprioception), and a variety of visceral sensory information. The
information from the viscera (internal organs) includes some of which the body is aware
(bladder fullness and stomach aches, for example), as well as much of which the body is
not aware, including blood pressure, concentration of substances in the blood, and many
other bits of sensory information used to regulate the internal environment.

Motor division
The motor division of the PNS is subdivided into several branches. The somatic motor
branch carries voluntary (willed) commands to the skeletal muscles, allowing a person to
perform physical actions. The autonomic motor branch carries autonomic (automatic, or
unwilled) commands to a variety of muscles and glands throughout the body, allowing
the brain to control heart rate, blood pressure, breathing rate, sweat production, and
hormone release, among other functions.

Somatic nervous system (SoNS or voluntary nervous system)

The part of the peripheral nervous system associated with the voluntary control of
body movements via skeletal muscles. The SoNS consists of efferent nerves
responsible for stimulating muscle contraction, including all the non sensory
neurons connected with skeletal muscles and skin.

Autonomic nervous system (ANS or visceral nervous system or involuntary

nervous system)
The part of the peripheral nervous system that acts as a control system
functioning largely below the level of consciousness, and controls visceral
functions. The ANS affects heart rate, digestion, respiratory rate, salivation,
perspiration, pupillary dilation, micturition (urination), and sexual arousal. While
most of its actions are involuntary, some, such as breathing, work along with the
conscious mind. It is divided into two main complementary subsystems: the
parasympathetic nervous system (PSNS) and sympathetic nervous system
(SNS).

Sympathetic nervous system (SNS)

Its general action is to mobilize the body's nervous system fightorflight
response. It is also constantly active at a basic level to control most of
the bodys internal organs and maintain homeostasis.

Sympathetic nerves originate inside the vertebral column, toward the

middle of the spinal cord in the intermediolateral cell column (or lateral
horn), beginning at the first thoracic segment of the spinal cord and are
thought to extend to the second or third lumbar segments. Because its
cells begin in the thoracic and lumbar regions of the spinal cord, the SNS
is said to have a thoracolumbar outflow.

Parasympathetic nervous system (PSNS)

Responsible for stimulation of "restanddigest" activities that occur when
the body is at rest, including sexual arousal, salivation, lacrimation (tears),
urination, digestion, and defecation. Its action is described as being
complementary to that of one of the other main branches of the ANS.

Parasympathetic nerve fibers arise from the central nervous system with
the S2, S3, and S4 spinal nerves and from the third, seventh, ninth, and
tenth cranial nerves. Because of its location, the parasympathetic system
 is commonly referred to as having "craniosacral outflow. The
parasympathetic nerves that arise from the S2, S3, and S4 spinal nerves
are commonly referred to as the pelvic splanchnic nerves or the "nervi
erigentes".

Enteric nervous system (ENS)

A subdivision of the autonomic nervous system (ANS) that directly controls the
gastrointestinal system.

Hemiplegia and Hemiparesis

Total paralysis of the arm, leg, and trunk on the same side of the body. Hemiplegia is more
severe than hemiparesis, which is weakness on one side of the body. Hemiplegia may be
congenital or acquired from an illness or stroke.

Common conditions:

Peripheral neuropathy (See Diabetic Neuropathy)

Damage to peripheral nerves. There are many types and causes. Often, no cause can be
found. Diabetes is the most common cause. Other medical problems that may cause
neuropathy are:
Autoimmune disorders rheumatoid arthritis or lupus
Chronic kidney disease
Infections such as HIV and liver infections
Low levels of vitamin B12 or other problems with your diet
Poor blood flow to the legs
Underactive thyroid gland

Drugs and toxins may damage nerves. One example is heavy alcohol use. Glue, lead,
mercury, and solvents may damage nerves. Drugs that treat infections, cancer, seizures,
and high blood pressure may cause nerve damage.

Pressure on a nerve near a body part may be a cause. An example is carpal tunnel
syndrome.

A bone fracture or other trauma may damage a nerve. Being exposed to cold
temperatures for a long period of time may too. Pressure from badfitting casts, splints, a
brace, or crutches can damage a nerve.

Symptoms, Tests, and Treatment:

See diabetic neuropathy

Epilepsy
A brain disorder in which a person has repeated seizures (convulsions) over time. Seizures are
episodes of abnormal electrical disturbances in the brain that cause changes in attention or
behavior.

Epilepsy occurs when permanent changes in brain tissue cause the brain to be too excitable or
jumpy. The brain sends out abnormal signals. This results in repeated, unpredictable seizures.
(A single seizure that does not happen again is not epilepsy.) Epilepsy may be due to a medical
condition or injury that affects the brain, or the cause may be unknown (idiopathic). Epilepsy
seizures usually begin between ages 5 and 20, but they can happen at any age.
Common causes of epilepsy include:
Stroke or transient ischemic attack (TIA)
Dementia, such as Alzheimer's disease
Traumatic brain injury
Infections, including brain abscess, meningitis, encephalitis, and AIDS
Brain problems that are present at birth (congenital brain defect)
Brain injury that occurs during or near birth
Metabolism disorders present at birth (such as phenylketonuria)
Brain tumor
Abnormal blood vessels in the brain
Other illness that damage or destroy brain tissue
Use of certain medications, including antidepressants, tramadol, cocaine, and
amphetamines

Symptoms vary from person to person. Some people may have simple staring spells, while
others have violent shaking and loss of alertness. The type of seizure depends on the part of
the brain affected and cause of epilepsy.

Most of the time, the seizure is similar to the previous one. Some people with epilepsy have a
strange sensation (such as tingling, smelling an odor that isn't actually there, or emotional
changes) before each seizure. This is called an aura.

Symptoms also vary, depending on the type of seizure:

Absence seizures (petit mal)

The term commonly given to a staring spell, most commonly called an "absence
seizure." It is a brief (usually less than 15 seconds) disturbance of brain function due to
abnormal electrical activity in the brain. Atypical petit mal seizures begin slower and last
longer. Symptoms are similar but muscle activity changes may be more noticeable.

They may occur with other types of seizures, such as generalized tonicclonic seizures
(grand mal seizures), twitches or jerks (myoclonus), or sudden loss of muscle strength
(atonic seizures).

Symptoms:

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 Most petit mal seizures last only a few seconds. Most commonly they involve
staring episodes or "absence spells." The episodes may:
Occur many times a day
Occur for weeks to months before being noticed
Interfere with school and learning
Be mistaken for lack of attention or other misbehavior
Unexplained difficulties in school and learning difficulties may be the first
sign of petit mal seizures.
During the seizure, the person may:
Stop walking and start again a few seconds later
Stop talking in midsentence and start again a few seconds later
The person usually does not fall during the seizure.
Immediately after the seizure, the person is usually:
Wide awake
Thinking clearly
Unaware of the seizure
Specific symptoms of typical petit mal seizures may include:
Changes in muscle activity, such as:
No movement
Hand fumbling
Fluttering eyelids
Lip smacking
Chewing
Changes in alertness (consciousness), such as:
Staring episodes
Lack of awareness of surroundings
Sudden halt in movement, talking, and other awake activities
May be triggered by hyperventilation or flashing lights, in some
cases

Generalized tonicclonic seizures (grand mal)

A generalized tonicclonic seizure is a seizure involving the entire body. It is also called a
grand mal seizure. The terms seizure, convulsion, or epilepsy are most often associated
with generalized tonicclonic seizures.

Generalized tonicclonic seizures may occur in people of any age. They may occur once
(single episode), or as part of a repeated, chronic condition (epilepsy).

Symptoms:
Many patients with generalized tonicclonic seizures have vision, taste, smell, or
sensory changes, hallucinations, or dizziness before the seizure. This is called an
aura.
The seizures usually involve muscle rigidity, followed by violent muscle
 contractions, and loss of alertness (consciousness).Other symptoms that occur
during the seizure may include:
Biting the cheek or tongue
Clenched teeth or jaw
Loss of urine or stool control (incontinence)
Stopped breathing or difficulty breathing
Blue skin color
After the seizure, the person may have:
Normal breathing
Sleepiness that lasts for 1 hour or longer
Loss of memory (amnesia) regarding events surrounding the seizure
episode
Headache
Drowsiness
Confusion
Weakness of one side of the body for a few minutes to a few hours
following seizure (called Todd's paralysis)

Clonic seizure
Consist of rhythmic jerking movements of the arms and legs, sometimes on both sides of
the body. "Clonus" means rapidly alternating contraction and relaxation of a muscle in
other words, repeated jerking. The movements cannot be stopped by restraining or
repositioning the arms or legs. Clonic seizures are rare, however. Much more common
are tonicclonic seizures, in which the jerking is preceded by stiffening (the "tonic" part).
Sometimes tonicclonic seizures start with jerking alone. These are called clonictonic-
clonic seizures.

Atonic seizure
Atonic seizures cause the muscles to go limp. The patients body may slump or crumple
to the ground, possibly causing injury. The areas of the brain stem responsible for
increasing and decreasing muscle tone are close together, which means atonic and
myoclonic seizures (which cause the muscles to tense) probably begin in the same
place. Patients experiencing sudden dramatic changes in muscle tone will often suffer
from either or both types of seizures.

Partial seizure (focal seizure)

All seizures are caused by abnormal electrical disturbances in the brain. Partial (focal)
seizures occur when this electrical activity remains in a limited area of the brain. The
seizures may sometimes turn into generalized seizures, which affect the whole brain.
This is called secondary generalization. Partial seizures can be further characterized as:
Simple not affecting awareness or memory
Complex affecting awareness or memory of events before, during, and
immediately after the seizure, and affecting behavior
 Symptoms:
Patients with focal seizures can have any of the symptoms below, depending on
where in the brain the seizure starts. Patients with simple focal seizures do not
lose consciousness. They will be aware of and remember the events that occur
at the time. Patients with complex partial seizures may or may not remember
any or all of the symptoms or events during the seizure.
Abnormal muscle contraction
Muscle contraction/relaxation (clonic activity) common
Affects one side of the body (leg, part of the face, or other area)
Abnormal head movements
Forced turning of the head
Staring spells, with or without complex, repetitive movements (such as
picking at clothes) these are called automatisms and include:
Abnormal mouth movements
Lip smacking
Behaviors that seem to be a habit
Chewing/swallowing without cause
Forced turning of the eyes
Abnormal sensations
Numbness, tingling, crawling sensation (like ants crawling on the
skin)
May occur in only one part of the body, or may spread
May occur with or without motor symptoms
Hallucinations
Abdominal pain or discomfort
Nausea
Sweating
Flushed face
Dilated pupils
Rapid heart rate/pulse
Other symptoms include:
Blackout spells periods of time lost from memory
Changes in vision
Sensation of deja vu
Changes in mood or emotion

Signs and Tests:

A physical exam will include a detailed look at the brain and nervous system.

An EEG (electroencephalogram) will be done to check the electrical activity in the brain.
People with epilepsy will often have abnormal electrical activity seen on this test. In
some cases, the test may show the area in the brain where the seizures start. The brain
 may appear normal after a seizure or between seizures.

To diagnose epilepsy or plan for epilepsy surgery, a person may be required to:
Wear an EEG recorder for days or weeks while you go about your everyday life.
Stay in the hospital where brain activity can be be observed on video. This is
called video EEG.

Tests that may be done include:

Blood chemistry
Blood sugar
CBC (complete blood count)
Kidney function tests
Liver function tests
Lumbar puncture (spinal tap)
Tests for infectious diseases
Head CT or MRI scan often done to find the cause and location of the problem in
the brain.

Treatment:
Treatment for epilepsy may involve surgery or medication. If epilepsy seizures are due
to a tumor, abnormal blood vessels, or bleeding in the brain, surgery to treat these
disorders may make the seizures stop.

Medication to prevent seizures, called anticonvulsants, may reduce the number of future
seizures.
These drugs are taken by mouth. The type prescribed depends on the type of
seizures the person has.
Regular blood tests may be needed to check for side effects.
Missing a dose of medication can cause a seizure.
Many epilepsy medications cause birth defects.

Epilepsy that does not get better after two or three antiseizure drugs have been tried is
called "medically refractory epilepsy."
Surgery to remove the abnormal brain cells causing the seizures may be helpful
for some patients.
Surgery to place a vagus nerve stimulator (VNS) may be recommended. This
device is similar to a heart pacemaker. It can help reduce the number of seizures.

Lifestyle or medical changes can increase the risk for a seizure in a person with
epilepsy.

Other considerations:
Persons with poorly controlled epilepsy should not drive. Each state has a
 different law about which people with a history of seizures are allowed to drive.
Persons with poorly controlled epilepsy should also avoid machinery or activities
where loss of awareness would cause great danger, such as climbing to high
places.

Expectations:
Some people with epilepsy may be able to reduce or even stop their antiseizure
medicines after having no seizures for several years. Certain types of childhood epilepsy
go away or improve with age, usually in the late teens or 20s.

For many people, epilepsy is a lifelong condition. In these cases, the antiseizure drugs
need to be continued. There is a very low risk of sudden death with epilepsy. However,
serious injury can occur if a seizure occurs during driving or when operating equipment.

Complications:
Difficulty learning
Breathing in food or saliva into the lungs during a seizure, which can cause
aspiration pneumonia
Injury from falls, bumps, selfinflicted bites, driving or operating machinery during
a seizure
Permanent brain damage (stroke or other damage)
Side effects of medications

Prevention:
Generally, there is no known way to prevent epilepsy. However, proper diet and sleep,
and staying away from illegal drugs and alcohol, may decrease the likelihood of
triggering seizures in people with epilepsy.

Cerebrovascular accident (CVA or stroke)

The rapid loss of brain function due to disturbance in the blood supply to the brain. This can be
due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a
hemorrhage (leakage of blood). As a result, the affected area of the brain cannot function,
which might result in an inability to move one or more limbs on one side of the body, inability to
understand or formulate speech, or an inability to see one side of the visual field. A stroke is a
medical emergency and can cause permanent neurological damage, complications, and death.

Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or
transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial
fibrillation. High blood pressure is the most important modifiable risk factor of stroke.

Ischemic
Cerebral infarction is an ischemic stroke resulting from a disturbance in the blood
vessels supplying blood to the brain. Stroke caused by cerebral infarction should be
distinguished from two other kinds of stroke: cerebral hemorrhage and subarachnoid
hemorrhage. A cerebral infarction occurs when a blood vessel that supplies a part of the
brain becomes blocked or leakage occurs outside the vessel walls. This loss of blood
supply results in the death of that area of tissue. Cerebral infarctions vary in their
severity with one third of the cases resulting in death.

In an ischemic stroke, blood supply to part of the brain is decreased, leading to

dysfunction of the brain tissue in that area. There are four reasons why this might
happen:
1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)
2. Embolism (obstruction due to an embolus from elsewhere in the body),
3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)
4. Venous thrombosis.

Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin) this
constitutes 3040% of all ischemic strokes.

There are various classification systems for acute ischemic stroke. The Oxford
Community Stroke Project classification (OCSP, also known as the Bamford or Oxford
classification) relies primarily on the initial symptoms based on the extent of the
symptoms, the stroke episode is classified as total anterior circulation infarct (TACI),
partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation
infarct (POCI).

An ischemic stroke is sometimes treated in a hospital with thrombolysis (also known as a

"clot buster"), and some hemorrhagic strokes benefit from neurosurgery. Treatment to
recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and
involving health professions such as speech and language therapy, physical therapy and
occupational therapy. Prevention of recurrence may involve the administration of
antiplatelet drugs such as aspirin and dipyridamole, control and reduction of
hypertension, and the use of statins.

Hemorrhagic
Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A
distinction is made between intraaxial hemorrhage (blood inside the brain) and extra-
axial hemorrhage (blood inside the skull but outside the brain). Intraaxial hemorrhage is
due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the
ventricular system). The main types of extraaxial hemorrhage are epidural hematoma
(bleeding between the dura mater and the skull), subdural hematoma (in the subdural
space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater).
Most of the hemorrhagic stroke syndromes have specific symptoms (e.g., headache,
previous head injury).
Stroke Signs and Symptoms:
Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not
progress further. The symptoms depend on the area of the brain affected. The more extensive
the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can
cause additional symptoms. For example, in intracranial hemorrhage, the affected area may
compress other structures. Most forms of stroke are not associated with headache, apart from
subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral
hemorrhage.

Symptoms of stroke subtypes:

If the area of the brain affected contains one of the three prominent central nervous
system pathwaysthe spinothalamic tract, corticospinal tract, and dorsal column (medial
lemniscus), symptoms may include:
hemiplegia and muscle weakness of the face
numbness
reduction in sensory or vibratory sensation
initial flaccidity (hypotonicity), replaced by spasticity (hypertonicity), hyperreflexia,
and obligatory synergies.
In most cases, the symptoms affect only one side of the body (unilateral). Depending on
the part of the brain affected, the defect in the brain is usually on the opposite side of the
body. However, since these pathways also travel in the spinal cord and any lesion there
can also produce these symptoms, the presence of any one of these symptoms does not
necessarily indicate a stroke.

In addition to the above CNS pathways, the brainstem gives rise to most of the twelve
cranial nerves. A stroke affecting the brain stem and brain therefore can produce
symptoms relating to deficits in these cranial nerves:
altered smell, taste, hearing, or vision (total or partial)
drooping of eyelid (ptosis) and weakness of ocular muscles
decreased reflexes: gag, swallow, pupil reactivity to light
decreased sensation and muscle weakness of the face
balance problems and nystagmus
altered breathing and heart rate
weakness in sternocleidomastoid muscle with inability to turn head to one side
weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can
produce the following symptoms:
aphasia (difficulty with verbal expression, auditory comprehension, reading
and/or writing)
dysarthria (motor speech disorder resulting from neurological injury)
apraxia (altered voluntary movements)
 visual field defect
memory deficits (involvement of temporal lobe)
hemineglect (involvement of parietal lobe)
disorganized thinking, confusion, hypersexual gestures (with involvement of
frontal lobe)
lack of insight of his or her, usually strokerelated, disability

If the cerebellum is involved, the patient may have the following:

altered walking gait
altered movement coordination
vertigo and or disequilibrium

Loss of consciousness, headache, and vomiting usually occurs more often in

hemorrhagic stroke than in thrombosis because of the increased intracranial pressure
from the leaking blood compressing the brain.

If symptoms are maximal at onset, the cause is more likely to be a subarachnoid

hemorrhage or an embolic stroke.

Silent stroke
A stroke that does not have any outward symptoms, and the patients are typically
unaware they have suffered a stroke. Despite not causing identifiable symptoms, a silent
stroke still causes damage to the brain, and places the patient at increased risk for both
transient ischemic attack and major stroke in the future. Conversely, those who have
suffered a major stroke are at risk of having silent strokes.

Silent strokes typically cause lesions which are detected via the use of neuroimaging
such as MRI. Silent strokes are estimated to occur at five times the rate of symptomatic
strokes. The risk of silent stroke increases with age, but may also affect younger adults
and children, especially those with acute anemia.

Recognizing strokes:
Various systems have been proposed to increase recognition of stroke by patients, relatives and
emergency first responders. A systematic review, updating a previous systematic review from
1994, looked at a number of trials to evaluate how well different physical examination findings
are able to predict the presence or absence of stroke. It was found that suddenonset face
weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm
drift downward) and abnormal speech are the findings most likely to lead to the correct
identification of a case of stroke. Similarly, when all three of these are absent, the likelihood of
stroke is significantly decreased. While these findings are not perfect for diagnosing stroke, the
fact that they can be evaluated relatively rapidly and easily make them very valuable in the
acute setting.
Proposed systems include FAST (stroke) (face, arm, speech, and time), as advocated by the
Department of Health (United Kingdom) and The Stroke Association, the American Stroke
Association (www.strokeassociation.org), National Stroke Association (US www.stroke.org), the
Los Angeles Prehospital Stroke Screen (LAPSS) and the Cincinnati Prehospital Stroke Scale
(CPSS).

For people referred to the emergency room, early recognition of stroke is deemed important as
this can expedite diagnostic tests and treatments. A scoring system called ROSIER (recognition
of stroke in the emergency room) is recommended for this purpose it is based on features from
the medical history and physical examination.

Diagnosis:
Stroke is diagnosed through several techniques: a neurological examination (such as the
Nihss), CT scans (most often without contrast enhancements) or MRI scans, Doppler
ultrasound, and arteriography. The diagnosis of stroke itself is clinical, with assistance
from the imaging techniques. Imaging techniques also assist in determining the subtypes
and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis
itself, though blood tests may be of help in finding out the likely cause of stroke.

Imaging:
For diagnosing ischemic stroke in the emergency setting:
CT scans (without contrast enhancements)
MRI scan

For diagnosing hemorrhagic stroke in the emergency setting:

CT scans (without contrast enhancements)
MRI scan

For detecting chronic hemorrhages, MRI scan is more sensitive.

For the assessment of stable stroke, nuclear medicine scans SPECT and PET/CT may
be helpful. SPECT documents cerebral blood flow and PET with FDG isotope the
metabolic activity of the neurons.

Tests for underlying cause:

When a stroke has been diagnosed, various other studies may be performed to
determine the underlying cause. With the current treatment and diagnosis options
available, it is of particular importance to determine whether there is a peripheral source
of emboli. Test selection may vary, since the cause of stroke varies with age,
comorbidity and the clinical presentation. Commonly used techniques include:
an ultrasound/doppler study of the carotid arteries (to detect carotid stenosis) or
dissection of the precerebral arteries
an electrocardiogram (ECG) and echocardiogram (to identify arrhythmias and
 resultant clots in the heart which may spread to the brain vessels through the
bloodstream)
a Holter monitor study to identify intermittent arrhythmias
an angiogram of the cerebral vasculature (if a bleed is thought to have originated
from an aneurysm or arteriovenous malformation)
blood tests to determine hypercholesterolemia, bleeding diathesis and some
rarer causes such as homocysteinuria.

When an acute stroke is suspected by history and physical examination, the goal of early
assessment is to determine the cause. Treatment varies according to the underlying
cause of the stroke, thromboembolic (ischemic) or hemorrhagic. A noncontrast head CT
scan can rapidly identify a hemorrhagic stroke by imaging bleeding in or around the
brain. If no bleeding is seen, a presumptive diagnosis of ischemic stroke is made.

Treatment and management

Stroke unit
People who have had a stroke are often admitted to a "stroke unit", a ward or dedicated
area in hospital staffed by nurses and therapists with experience in stroke treatment. It
has been shown that people admitted to a stroke unit have a higher chance of surviving
than those admitted elsewhere in hospital, even if they are being cared for by doctors
without experience in stroke.

Procedures:
Surgical procedures such as carotid endarterectomy or carotid angioplasty can be used
to remove significant atherosclerotic narrowing (stenosis) of the carotid artery, which
supplies blood to the brain. Carotid artery stenting has not been shown to be equally
useful. Patients are selected for surgery based on age, gender, degree of stenosis, time
since symptoms and patients' preferences. Surgery is most efficient when not delayed
too long the risk of recurrent stroke in a patient who has a 50% or greater stenosis is
up to 20% after 5 years, but endarterectomy reduces this risk to around 5%. The number
of procedures needed to cure one patient was 5 for early surgery (within two weeks after
the initial stroke), but 125 if delayed longer than 12 weeks.

Thrombolysis
In an increasing number of primary stroke centers, pharmacologic thrombolysis ("clot
busting") with the drug tissue plasminogen activator (tPA), is used to dissolve the clot
and unblock the artery. However, the use of tPA in acute stroke is controversial.

Mechanical thrombectomy
Another intervention for acute ischemic stroke is removal of the offending thrombus
directly. This is accomplished by inserting a catheter into the femoral artery, directing it
into the cerebral circulation, and deploying a corkscrewlike device to ensnare the clot,
which is then withdrawn from the body. Mechanical embolectomy devices have been

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demonstrated effective at restoring blood flow in patients who were unable to receive
thrombolytic drugs or for whom the drugs were ineffective.

Angioplasty and Stenting

Angioplasty and stenting are starting to be considered as possible viable options in
treatment of acute ischemic stroke.

Hemicraniectomy
Large territory strokes can cause significant edema of the brain with secondary brain
injury in surrounding tissue. This phenomenon is mainly encountered in strokes of the
middle cerebral artery territory, and is also called "malignant cerebral infaction" because
it carries a dismal prognosis. Relief of the pressure may be attempted with medication,
but some require hemicraniectomy, the temporary surgical removal of the skull on one
side of the head.

Secondary prevention of ischemic stroke

Anticoagulation can prevent recurrent stroke. Among patients with nonvalvular atrial
fibrillation, anticoagulation can reduce stroke by 60% while antiplatelet agents can
reduce stroke by 20%.

If studies show carotid stenosis, and the patient has residual function in the affected
side, carotid endarterectomy (surgical removal of the stenosis) may decrease the risk of
recurrence if performed rapidly after stroke.

Expectations:
Disability affects 75% of stroke survivors enough to decrease their employability. Stroke
can affect patients physically, mentally, emotionally, or a combination of the three. The
results of stroke vary widely depending on size and location of the lesion. Dysfunctions
correspond to areas in the brain that have been damaged.

Some of the physical disabilities that can result from stroke include muscle weakness,
numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform
learned movements), difficulties carrying out daily activities, appetite loss, speech loss,
vision loss, and pain. If the stroke is severe enough, or in a certain location such as parts
of the brainstem, coma or death can result.

Emotional problems resulting from stroke can result from direct damage to emotional
centers in the brain or from frustration and difficulty adapting to new limitations. Post-
stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to
express emotions), mania, apathy, and psychosis. Thirty to fifty percent of stroke
survivors suffer post stroke depression, which is characterized by lethargy, irritability,
sleep disturbances, lowered self esteem, and withdrawal. Depression can reduce
motivation and worsen outcome, but can be treated with antidepressants.
 Emotional lability, another consequence of stroke, causes the patient to switch quickly
between emotional highs and lows and to express emotions inappropriately, for instance
with an excess of laughing or crying with little or no provocation. While these
expressions of emotion usually correspond to the patient's actual emotions, a more
severe form of emotional lability causes patients to laugh and cry pathologically, without
regard to context or emotion. Some patients show the opposite of what they feel, for
example crying when they are happy. Emotional lability occurs in about 20% of stroke
patients.

Cognitive deficits resulting from stroke include perceptual disorders, aphasia, dementia,
and problems with attention and memory. A stroke sufferer may be unaware of his or her
own disabilities, a condition called anosognosia. In a condition called hemispatial
neglect, a patient is unable to attend to anything on the side of space opposite to the
damaged hemisphere.

Up to 10% of all stroke patients develop seizures, most commonly in the week
subsequent to the event the severity of the stroke increases the likelihood of a seizure.

Transient ischemic attack (TIA or mini stroke or warning stroke)

While transient ischemic attack (TIA) is often labeled ministroke, it is more accurately
characterized as a warning stroke.

TIA is caused by a clot the only difference between a stroke and TIA is that with TIA the
blockage is transient (temporary). TIA symptoms occur rapidly and last a relatively short time.
Most TIAs last less than five minutes the average is about a minute. Unlike a stroke, when a
TIA is over, theres no permanent injury to the brain.

The warning signs of a TIA are exactly the same as for a stroke. While the vast majority of
strokes are not preceded by TIA, about a third of people who experience TIA go on to have a
stroke within a year. Although a TIA resolves itself before there is damage, there is no way to
predict which clots will dissolve on their own.

Traumatic brain injury (TBI)

Also known as intracranial injury, occurs when an external force traumatically injures the brain.
TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other
features (e.g., occurring in a specific location or over a widespread area). Head injury usually
refers to TBI, but is a broader category because it can involve damage to structures other than
the brain, such as the scalp and skull. Causes include falls, vehicle accidents, and violence.

Brain trauma can be caused by a direct impact or by acceleration alone. In addition to the
damage caused at the moment of injury, brain trauma causes secondary injury, a variety of
events that take place in the minutes and days following the injury. These processes, which
include alterations in cerebral blood flow and the pressure within the skull, contribute
substantially to the damage from the initial injury.

TBI can cause a host of physical, cognitive, social, emotional, and behavioral effects, and
outcome can range from complete recovery to permanent disability or death. Some of the
current imaging techniques used for diagnosis and treatment include CT scans computed
tomography and MRIs magnetic resonance imaging.

Depending on the injury, treatment required may be minimal or may include interventions such
as medications, emergency surgery or surgery years later. Physical therapy, speech therapy,
recreation therapy, and occupational therapy may be employed for rehabilitation.

Multiple sclerosis (demyelinating disease)

An autoimmune disease that affects the brain and spinal cord (central nervous system).

Multiple sclerosis (MS) affects women more than men. The disorder is most commonly
diagnosed between ages 20 and 40, but can be seen at any age.

MS is caused by damage to the myelin sheath, the protective covering that surrounds nerve
cells. When this nerve covering is damaged, nerve signals slow down or stop.
The nerve damage is caused by inflammation. Inflammation occurs when the body's own
immune cells attack the nervous system. This can occur along any area of the brain, optic
nerve, and spinal cord.

It is unknown what exactly causes this to happen. The most common thought is that a virus or
gene defect, or both, are to blame. Environmental factors may play a role.
You are slightly more likely to get this condition if you have a family history of MS or live in an
part of the world where MS is more common.

Symptoms:
Symptoms vary, because the location and severity of each attack can be different.
Episodes can last for days, weeks, or months. These episodes alternate with periods of
reduced or no symptoms (remissions).

Fever, hot baths, sun exposure, and stress can trigger or worsen attacks.
It is common for the disease to return (relapse). However, the disease may continue to
get worse without periods of remission.

Because nerves in any part of the brain or spinal cord may be damaged, patients with
multiple sclerosis can have symptoms in many parts of the body.

Muscle symptoms:
 Loss of balance
Muscle spasms
Numbness or abnormal sensation in any area
Problems moving arms or legs
Problems walking
Problems with coordination and making small movements
Tremor in one or more arms or legs
Weakness in one or more arms or legs
Bowel and bladder symptoms:
Constipation and stool leakage
Difficulty beginning to urinate
Frequent need to urinate
Strong urge to urinate
Urine leakage (incontinence)
Eye symptoms:
Double vision
Eye discomfort
Uncontrollable rapid eye movements
Vision loss (usually affects one eye at a time)
Numbness, tingling, or pain
Facial pain
Painful muscle spasms
Tingling, crawling, or burning feeling in the arms and legs
Other brain and nerve symptoms:
Decreased attention span, poor judgment, and memory loss
Difficulty reasoning and solving problems
Depression or feelings of sadness
Dizziness and balance problems
Hearing loss
Sexual symptoms:
Problems with erections
Problems with vaginal lubrication
Speech and swallowing symptoms:
Slurred or difficulttounderstand speech
Trouble chewing and swallowing
Fatigue is a common and bothersome symptoms as MS progresses. It is often worse in
the late afternoon.

Signs and Tests:

Symptoms of MS may mimic those of many other nervous system disorders. The
disease is diagnosed by ruling out other conditions. People who have a form of MS
called relapsingremitting may have a history of at least two attacks, separated by a
period of reduced or no symptoms.
The health care provider may suspect MS if there are decreases in the function of two
different parts of the central nervous system (such as abnormal reflexes) at two different
times.

A neurological exam may show reduced nerve function in one area of the body, or
spread over many parts of the body. This may include:
Abnormal nerve reflexes
Decreased ability to move a part of the body
Decreased or abnormal sensation
Other loss of nervous system functions
An eye examination may show:
Abnormal pupil responses
Changes in the visual fields or eye movements
Decreased visual acuity
Problems with the inside parts of the eye
Rapid eye movements triggered when the eye moves
Tests to diagnose multiple sclerosis include:
Lumbar puncture (spinal tap) for cerebrospinal fluid tests, including CSF
oligoclonal banding
MRI scan of the brain and MRI scan of the spine are important to help diagnose
and follow MS
Nerve function study (evoked potential test)

Treatment:
There is no known cure for multiple sclerosis at this time. However, there are therapies
that may slow the disease. The goal of treatment is to control symptoms and help you
maintain a normal quality of life.

Medications used to slow the progression of multiple sclerosis are taken on a longterm
basis, they include:
Interferons (Avonex, Betaseron, or Rebif), glatiramer acetate (Copaxone),
mitoxantrone (Novantrone), and natalizumab (Tysabri)
Fingolimod (Gilenya )
Methotrexate, azathioprine (Imuran), intravenous immunoglobulin (IVIg) and
cyclophosphamide (Cytoxan) may also be used if the above drugs are not
working well

Steroids may be used to decrease the severity of attacks.

Medications to control symptoms may include:

Medicines to reduce muscle spasms such as Lioresal (Baclofen), tizanidine
(Zanaflex), or a benzodiazepine
 Cholinergic medications to reduce urinary problems
Antidepressants for mood or behavior symptoms
Amantadine for fatigue

Expectations:
The amount of disability and discomfort depends on:
Frequency of attacks
How severe they are
The part of the central nervous system that is affected by each attack

Most people return to normal or nearnormal function between attacks. Slowly, there is
greater loss of function with less improvement between attacks. Over time, many require
a wheelchair to get around and have a more difficult time transferring out of the
wheelchair.

Complications:
Depression
Difficulty swallowing
Difficulty thinking
Less and less ability to care for self
Need for indwelling catheter
Osteoporosis or thinning of the bones
Pressure sores
Side effects of medications used to treat the disorder
Urinary tract infections

Sources: http://www.dartmouth.edu/~rswenson/NeuroSci/chapter_11.html
http://www.innerbody.com/image_skel04/nerv93.html#anatomytermbottom
http://en.wikipedia.org/wiki/Somatic_nervous_system
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001717/
http://en.wikipedia.org/wiki/Autonomic_nervous_system
http://www.biologyreference.com/OcPh/PeripheralNervousSystem.html
http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/P/PNS.html
http://en.wikipedia.org/wiki/Neurotransmitter
http://en.wikipedia.org/wiki/Cortical_column
http://www.nlm.nih.gov/medlineplus/ency/article/002311.htm
http://en.wikipedia.org/wiki/Neurology
http://hes.ucfsd.org/gclaypo/nervoussys.html
http://en.wikipedia.org/wiki/File:Brain_human_normal_inferior_view_with_labels_en2.svg
http://en.wikipedia.org/wiki/Nervous_system
http://faculty.washington.edu/chudler/spinal.html
http://en.wikipedia.org/wiki/Spinal_nerves
http://www.brainexplorer.org/brain_atlas/Brainatlas_index.shtml
http://en.wikipedia.org/wiki/Frontal_lobe
http://en.wikipedia.org/wiki/Neuron
http://en.wikipedia.org/wiki/Vagus_nerve
http://www.apparelyzed.com/spinalcord.html
http://en.wikipedia.org/wiki/Ganglia
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001619/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/
http://en.wikipedia.org/wiki/Traumatic_brain_injury
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001715/
http://www.epilepsy.com/EPILEPSY/SEIZURE_CLONIC
http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/epilepsy/seizures/typ
es/dropattackatonicseizures.html
http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/TIA/TIATransientI
schemicAttack_UCM_310942_Article.jsp
http://en.wikipedia.org/wiki/Stroke
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001747/
Immune System

The immune system is made up of a number of interdependent cell types which collectively
protect the body from various harmful substances, parasitic, fungal, bacterial and viral
infections, and from the growth of tumor cells.

Immunodeficiency is a state in which the immune system's ability to fight infectious disease is
compromised or entirely absent. Immunodeficiency may also decrease cancer
immunosurveillance. Most cases of immunodeficiency are acquired ("secondary") but some
people are born with defects in their immune system, or primary immunodeficiency. A person
who has an immunodeficiency of any kind is said to be immunocompromised. An
immunocompromised person may be particularly vulnerable to opportunistic infections, in
addition to normal infections that could affect everyone.

Sometimes, the immune system mistakenly attacks and destroys healthy body tissue, due to an
autoimmune disease.

Usual treatment providers: infectious disease specialist, rheumatologist, neurologist, and many
other types of specialist, depending on the body systems affected.

Key terms and components:

Lymph
Lymph is a fluid that is usually clear, colorless fluid composed of white blood cells, especially
lymphocytes (the cells that attack bacteria in the blood), and chyle (fluid from the intestines
which contains proteins and fats). It flows through the lymphatic vessels. There are no RBCs in
lymph and it has a lower protein content than blood.

Lymph system (lymphatic system)

The lymph system is a network of organs, lymph nodes, lymph ducts, and lymph vessels that
produce and transport lymph from tissues to the bloodstream. The lymph system is a major
component of the body's immune system.

The lymph flows from the interstitial fluid (the fluid which lies in the interstices or fluid
compartments) of all body tissues through lymphatic vessels, up to either the thoracic duct or
right lymph duct, which terminate in the subclavian veins, where lymph is mixed into the blood
(the right lymph duct drains the right sides of the thorax, neck, and head, whereas the thoracic
duct drains the rest of the body). Lymph carries lipids and lipidsoluble vitamins absorbed from
the GI tract. The lymphatic vessels, like veins, have oneway valves that prevent backflow.

Additionally, along these vessels, there are small, round or beanshaped lymph nodes. Lymph
nodes produce immune cells that help the body fight infection. They also filter the lymph fluid
and remove foreign material such as bacteria and cancer cells. When bacteria are recognized in
the lymph fluid, the lymph nodes produce more infectionfighting white blood cells, which causes
the nodes to swell. They are located in clusters in various parts of the body, such as the neck,
armpit, groin, and inside the center of the chest and abdomen. The lymph that leaves a lymph
node is richer in lymphocytes.

The lymphatic system includes the tonsils, adenoids, spleen, and thymus.

Bone marrow
The flexible tissue found in the interior of bones. Bone marrow is a key component of the
lymphatic system, producing the lymphocytes that support the immune system.

Pathogen
Infectious agent in colloquial terms, a germ such as a virus, bacterium, prion, or fungus,
that causes disease.

Antigen
Any substance that elicits an immune response. An antigen may be a foreign substance from
the environment such as chemicals, bacteria, viruses, or pollen. An antigen may also be formed
within the body, as with bacterial toxins or tissue cells.

Antibody (immunoglobulin)
A large Yshaped protein produced by Bcells that is used by the immune system to identify and
neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part
of the foreign target, called an antigen. Antibodies are produced by a type of white blood cell
called a plasma cell.

Major Histocompatibility Complex (MHC)

A set of molecules displayed on cell surfaces that are responsible for lymphocyte recognition
and "antigen presentation." The MHC molecules control the immune response through
recognition of "self" and "nonself."
Leukocytes (white blood cells or WBCs)
There are five types: lymphocytes, monocytes, neutrophils, eosinophils, and basophils. They
are broken into two classifications: granulocytes (with granules) and agranulocytes (without
granules). Neutrophils, eosinophils, and basophils are granulocytes. Monocytes and
lymphocytes are agranulocytes.

Monocytes
White blood cells that consume bacteria.

Neutrophils
White blood cells that ingest foreign contaminants in the body. They are the most common
WBCs.

Basophils
White blood cells that promote inflammation. Basophils contain anticoagulant heparin, which
prevents blood from clotting too quickly. They also contain the vasodilator histamine, which
promotes blood flow to tissues.

Eosinophils
White blood cells that moderate allergic reactions.

Lymphocytes
A type of white blood cells which are part of the immune system. There are three major types,
namely: Natural Killer (NK) cells, Tcells (Thymus cells) and Bcells (Bone cells).

T lymphocytes (T cells)
A type of lymphocyte that play a central role in immunity. They can be distinguished from other
lymphocytes, such as B cells and natural killer cells (NK cells), by the presence of a T cell
receptor (TCR) on the cell surface. They are called T cells because they mature in the thymus.
There are several subsets of T cells, each with a distinct function. These include T helper cells,
cytotoxic T cells, memory T cells, regulatory T cells, and natural killer T cells (NKT cells not to
be confused with natural killer (NK) cells).

T helper cells
Assist other white blood cells in immunologic processes, including maturation of B cells
into plasma cells and memory B cells, and activation of cytotoxic T cells and
macrophages. These cells are also known as CD4+ T cells because they express the
CD4 protein on their surface. Helper T cells become activated when they are presented
with peptide antigens by MHC class II molecules, which are expressed on the surface of
antigen presenting cells (APCs). Once activated, they divide rapidly and secrete small
proteins called cytokines that regulate or assist in the active immune response.

CD4 test

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 Individuals who have HIV infection or other disorders of the immune system may have
tests showing a reduction of either the absolute count or the percentage of their Thelper
lymphocytes (CD4 cells). The extent of immune suppression correlates with the level or
rate of decline of the CD4 count. Generally, when the CD4 count is below 200/mm3 (or
below 14 percent of the total lymphocyte count) the susceptibility to opportunistic
infection is greatly increased. Although a reduced CD4 count alone does not establish a
definitive diagnosis of HIV infection, a CD4 count below 200 does offer supportive
evidence when there are clinical findings, but not a definitive diagnosis of an
opportunistic infection(s). However, a reduced CD4 count alone does not document the
severity or functional consequences of HIV infection.

CD8 test
CD8 cells are lymphocytes that are sometimes called Tsuppressor cells or cytotoxic T
cells. CD8 cells identify and kill cells that have been infected with viruses or that have
been affected by cancer.

They play an important role in the immune response to HIV by killing cells infected with
the virus and by producing substances that block HIV replication.

These tests measure the number of CD4 and CD8 cells in the blood and, in conjunction
with an HIV viral load test, assess the status of the immune system of someone who has
been diagnosed with HIV. As the disease progresses, the number of CD4 cells will
decrease in relation to the number of total lymphocytes and CD8 cells. To provide a
clearer picture of the condition of the immune system, the results of these tests may be
expressed as a ratio of CD4 to total lymphocytes (percentage) or as a ratio of CD4 cells
to CD8 cells.

These tests are most often used to help monitor disease progression in HIV but may
also be used occasionally in other conditions, such as lymphomas and organ
transplantation.

Natural killer cells

Provide rapid responses to virally infected cells and respond to tumor formation, acting at
around 3 days after infection. NK cells are unique, however, as they have the ability to
recognize stressed cells in the absence of antibodies and MHC, allowing for a much faster
immune reaction.

Bone cells (B cells)

The primary function of B cells is to produce antibodies in response to foreign proteins such as
viruses, bacteria and tumor cells.

Macrophages
Cells produced by the differentiation of monocytes in tissues. Macrophages are important due
to their function in the regulation of immune responses. Macrophages are many times referred
to as scavengers, or 'AntigenPresenting Cells (APC's),' because they both pick up and
ingest foreign materials, and then present these antigens to other cells in a person's immune
system like B cells and T cells. The process is one of the steps involved in initiating an immune
response.

Spleen
Similar in structure to a large lymph node, the spleen acts primarily as a blood filter. As such, it
is a nonvital organ, with a healthy life possible after removal. It removes old red blood cells and
holds a reserve of blood in case of hemorrhagic shock while also recycling iron. It metabolizes
hemoglobin removed from aging erythrocytes. The globin portion of hemoglobin is degraded to
its constitutive amino acids, and the heme portion is metabolized to bilirubin, which is
subsequently shuttled to the liver for removal. It synthesizes antibodies in its white pulp and
removes antibodycoated bacteria along with antibodycoated blood cells by way of blood and
lymph node circulation.

Tonsils
The term tonsils most commonly means the palatine tonsils, which can be seen in the back of
the human throat. The palatine tonsils and the nasopharyngeal tonsil are lymphoepithelial
tissues. These tissues are the immune system's first line of defense against ingested or inhaled
foreign pathogens. However, the fundamental immunological roles of tonsils have yet to be
understood.

Adenoids (nasopharyngeal tonsil)

A mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx,
where the nose blends into the throat.

Thymus
A specialized organ of the immune system. The thymus "educates" Tlymphocytes (T cells),
which are critical cells of the immune system.

Viral load (VL)

A measure of the severity of a viral infection, and can be calculated by estimating the amount of
virus in an involved body fluid. For example, it can be given in RNA (ribonucleic acid) copies per
milliliter of blood plasma. Tracking viral load is used to monitor therapy during chronic viral
infections, and in immunocompromised patients such as those recovering from bone marrow or
solid organ transplantation. Currently, routine testing is available for HIV1, cytomegalovirus,
hepatitis B virus, and hepatitis C virus.

Common conditions:

Inflammatory arthritis see Musculoskeletal System, above, for:

 Rheumatoid arthritis

Psoriatic arthritis

Ankylosing spondylitis

Autoimmune disorders
In patients with an autoimmune disorder, the immune system can't tell the difference between
healthy body tissue and antigens. The result is an immune response that destroys normal body
tissues. This response is a hypersensitivity reaction similar to the response in allergic
conditions.

What causes the immune system to no longer tell the difference between healthy body tissues
and antigens is unknown. One theory is that some microorganisms (such as bacteria or viruses)
or drugs may trigger some of these changes, especially in people who have genes that make
them more likely to get autoimmune disorders.

An autoimmune disorder may result in:

The destruction of one or more types of body tissue
Abnormal growth of an organ
Changes in organ function
An autoimmune disorder may affect one or more organ or tissue types. Organs and
tissues commonly affected by autoimmune disorders include:
Blood vessels
Connective tissues
Endocrine glands such as the thyroid or pancreas
Joints
Muscles
Red blood cells
Skin
A person may have more than one autoimmune disorder at the same time. Examples of
autoimmune (or autoimmunerelated) disorders include:
Addison's disease
Celiac disease sprue (glutensensitive enteropathy)
Dermatomyositis
Graves disease
Hashimoto's thyroiditis
Multiple sclerosis (see Nervous System, above)
Myasthenia gravis
Pernicious anemia
Reactive arthritis
Rheumatoid arthritis (see Musculoskeletal System, above)
Sjogren syndrome (see below)
 Systemic lupus erythematosus (see below)
Type I diabetes (see Endocrine System, above)

Symptoms of an autoimmune disease vary based on the disease and location of the
abnormal immune response.

Symptoms that often occur with autoimmune diseases include:

Fatigue
Fever
General illfeeling (malaise)

Exams and Tests:

The health care provider will do a physical exam. Signs depend on the type of disease.
Tests that may be done to diagnose an autoimmune disorder may include:
Antinuclear antibody tests
Autoantibody tests
CBC
Creactive protein (CRP)
Erythrocyte sedimentation rate (ESR)

Treatment depends on the specific disease. Medicines are often prescribed to control or
reduce the immune system's response. They are often called immunosuppressive
medicines. Such medicines may include corticosteroids (such as prednisone) and
nonsteroid drugs such as azathioprine, cyclophosphamide, mycophenolate, sirolimus, or
tacrolimus.

Systemic lupus erythematosus (SLE or lupus)

Lupus is a longterm autoimmune disorder that leads to longterm (chronic) inflammation and
may affect the skin, joints, kidneys, brain, and other organs.

Symptoms:
Symptoms vary from person to person, and may come and go. Almost everyone with
SLE has joint pain and swelling. Some develop arthritis. Frequently affected joints are
the fingers, hands, wrists, and knees.

Other common symptoms include:

Chest pain when taking a deep breath
Fatigue
Fever with no other cause
General discomfort, uneasiness, or ill feeling (malaise)
Hair loss
Mouth sores
Sensitivity to sunlight
 Skin rash a "butterfly" rash over the cheeks and bridge of the nose affects
about half of people with SLE. The rash gets worse in sunlight. The rash may
also be widespread.
Swollen lymph nodes
Anemia

Other symptoms depend on what part of the body is affected:

Brain and nervous system: headaches, numbness, tingling, seizures, vision
problems, personality changes
Digestive tract: abdominal pain, nausea, and vomiting
Heart: abnormal heart rhythms (arrhythmias)
Lung: coughing up blood and difficulty breathing
Skin: patchy skin color, fingers that change color when cold (Raynaud's
phenomenon)

Some patients only have skin symptoms. This is called discoid lupus.

Signs and Tests:

To be diagnosed with lupus, you must have 4 out of 11 typical signs of the disease.
A nervous system exam will also be done. An abnormal sound called a heart friction rub
or pleural friction rub may be heard.

Tests used to diagnose SLE may include:

Antibody tests, including antinuclear antibody (ANA) panel
CBC
Chest xray
Kidney biopsy
Urinalysis

This disease may also alter the results of the following tests:
Antithyroglobulin antibody
Antithyroid microsomal antibody
Complement components (C3 and C4)
Coombs' test direct
Cryoglobulins
ESR
Kidney function blood tests
Liver function blood tests
Rheumatoid factor

Treatment:
There is no cure for SLE. The goal of treatment is to control symptoms.
 Mild disease may be treated with:
Nonsteroidal antiinflammatory medications (NSAIDs) treat arthritis and pleurisy
Corticosteroid creams to treat skin rashes
An antimalaria drug (hydroxychloroquine) and lowdose corticosteroids for skin
and arthritis symptoms

People with SLE should wear protective clothing, sunglasses, and sunscreen when in
the sun.

Severe or lifethreatening symptoms (such as hemolytic anemia, extensive heart or lung

involvement, kidney disease, or central nervous system involvement) often require more
aggressive treatment by specialists.

Treatment for more severe lupus may include:

Highdose corticosteroids or medications to decrease the immune system
response
Cytotoxic drugs (drugs that block cell growth) if corticosteroids dont work, or if
symptoms get worse when corticosteroids are stopped. These medicine have
serious, severe side effects.

Talk therapy and support groups may help relieve depression and mood changes that
may occur in patients with this disease.

Complications:
Some people with SLE have abnormal deposits in the kidney cells. This leads to a
condition called lupus nephritis. Patients with this condition may eventually develop
kidney failure and need dialysis or a kidney transplant.

SLE causes damage to many different parts of the body, including:

Blood clots in the legs (deep vein thrombosis) or lungs (pulmonary embolism)
Destruction of red blood cells (hemolytic anemia) or anemia of chronic disease
Fluid around the heart (pericarditis), endocarditis, or inflammation of the heart
(myocarditis)
Fluid around the lungs (pleural effusions) and damage to lung tissue
Pregnancy complications, including miscarriage
Stroke
Severely low blood platelets (thrombocytopenia)
Inflammation of the blood vessels

Sjogrens syndrome
Sjogren's (SHOWgrins) syndrome is an autoimmune disorder identified by its two most
common symptoms dry eyes and a dry mouth.
Sjogren's syndrome often accompanies other immunesystem disorders, such as rheumatoid
arthritis and lupus. In Sjogren's syndrome, the mucous membranes and moisturesecreting
glands of your eyes and mouth are usually affected first resulting in decreased production of
tears and saliva.

Although you can develop Sjogren's syndrome at any age, most people are older than 40 at the
time of diagnosis. The condition is much more common in women. Treatment focuses on
relieving symptoms, which often subside with time.

It is common for people who have Sjogren's syndrome to also have a rheumatic disease
such as rheumatoid arthritis or lupus.

Other symptoms:
Some people with Sjogren's syndrome also experience one or more of the following:
Joint pain, swelling and stiffness
Swollen salivary glands particularly the set located behind your jaw
and in front of your ears
Skin rashes or dry skin
Persistent dry cough
Prolonged fatigue

Certain genes put people at higher risk for the disorder, but it appears that a triggering
mechanism such as infection with a particular virus or strain of bacteria is also
necessary.

In Sjogren's syndrome, your immune system first targets the moisturesecreting glands
of the eyes and mouth, but it can also damage other parts of the body, such as:
Joints
Thyroid
Kidneys
Liver
Lungs
Skin
Nerves

Complications:
Dental cavities. Because saliva helps protect the teeth from the bacteria that
cause cavities, you're more prone to developing cavities if your mouth is dry.
Yeast infections. People with Sjogren's syndrome are much more likely to
develop oral thrush, a yeast infection in the mouth.
Vision problems. Dry eyes can lead to light sensitivity, blurred vision and corneal
ulcers.
Less common complications may affect:
 Lungs, kidneys or liver. Inflammation may cause pneumonia, bronchitis or other
problems in the lungs may lead to problems with kidney function and may cause
hepatitis or cirrhosis of the liver.
Lymph nodes. A small percentage of people with Sjogren's syndrome develop
cancer of the lymph nodes (lymphoma).
Peripheral neuropathy

Diagnosis:
There is no single test that will confirm diagnosis. Rheumatologists have primary
responsibility for diagnosing and managing Sjgrens and can conduct a series of tests
and ask about symptoms. Classification criteria for Sjgrens help doctors arrive at a
diagnosis. These criteria consider dryness symptoms, changes in salivary (mouth) and
lacrimal (eye) gland function, and systemic (whole body) findings.

Blood tests:
ANA (AntiNuclear Antibody)
ANAs are a group of antibodies that react against normal components of
a cell nucleus. About 70% of Sjgrens patients have a positive ANA test
result.
RF (Rheumatoid Factor)
This antibody test is indicative of a most often performed for the diagnosis
of rheumatoid arthritis (RA) but is positive in many rheumatic diseases. In
Sjgrens patients, 6070% have a positive RF.
SSA (or Ro) and SSB (or La)
These are the marker antibodies for Sjgren's. Seventy percent of
Sjgrens patients are positive for SSA and 40% are positive for SSB
(these may also found in lupus patients).
ESR (Erythrocyte Sedimentation Rate)
This test measures inflammation. An elevated ESR indicates the
presence of an inflammatory disorder, including Sjgrens.
IGs (Immunoglobulins)
These are normal blood proteins that participate in immune reactions and
are usually elevated in Sjgrens patients.

Ophthalmologic (eye) tests:

Schirmer Test
Measures tear production.
Rose Bengal and Lissamine Green
Eyedrops containing dyes that an eye care specialist uses to examine the
surface of the eye for dry spots.

Dental/mouth tests:
Salivary Flow
 Measures the amount of saliva produced over a certain period of time.
Salivary scintigraphy
A nuclear medicine test that measures salivary gland function.
Salivary gland biopsy (usually in the lower lip)
Confirms inflammatory cell (lymphocytic) infiltration of the minor salivary
glands.

Treatment:
Currently, there is no cure for Sjgrens syndrome. However, treatments may
improve various symptoms and prevent complications. In addition to over the
counter (OTC) eye drops and mouth preparations, prescription products for dry
eyes and dry mouth are available. They include Evoxac (cevimeline), Salagen
(pilocarpine hydrochloride) and Numoisyn for dry mouth and Restasis
(cyclosporine ophthalmic emulsion) and Lacrisert (hydroxypropyl cellulose
ophthalmic insert) for dry eye.

Some patients are prescribed immunosuppressive medications to treat their

internal organ manifestations. Physicians may also prescribe other medications
for systemic manifestations or severe flares.

NSAIDs may be used to treat musculoskeletal symptoms. For individuals with

severe complications, corticosteroids or immunosuppressive drugs may be
prescribed, and sometimes IVIG (intravenous immunoglobulin). Also, disease-
modifying antirheumatic drugs (DMARDs) such as methotrexate may be helpful.
Hydroxychloroquine (Plaquenil) is another option and is generally considered
safer than methotrexate.

Expectations:
Sjgren's can damage vital organs of the body with symptoms that may plateau
or worsen, or go into remission as with other autoimmune diseases. Some
people may experience only the mild symptoms of dry eyes and mouth, while
others have symptoms of severe disease. Many patients are able to treat
problems symptomatically. Others are forced to cope with blurred vision, constant
eye discomfort, recurrent mouth infections, swollen parotid glands, hoarseness,
and difficulty in swallowing and eating. Debilitating fatigue and joint pain can
seriously impair quality of life. Some patients can develop renal involvement
(autoimmune tubulointerstitial nephritis) leading to proteinuria, urinary
concentrating defect and distal renal tubular acidosis.

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS)

AIDS is a chronic, potentially lifethreatening condition caused by the human immunodeficiency
virus (HIV). By damaging the immune system, HIV interferes with the body's ability to fight the
organisms that cause disease.
HIV is a sexually transmitted disease. It can also be spread by contact with infected blood, or
from mother to child during pregnancy, childbirth or breastfeeding. It can take years before HIV
weakens the immune system to the point where the person has AIDS.

Symptoms:
The symptoms of HIV and AIDS vary, depending on the phase of infection:

Primary infection
The majority people infected by HIV develop a flulike illness within a month or two after
the virus enters the body. This illness, known as primary or acute HIV infection, may last
for a few weeks. Possible symptoms include:
Fever
Muscle soreness
Rash
Headache
Sore throat
Mouth or genital ulcers
Swollen lymph glands, mainly on the neck
Joint pain
Night sweats
Diarrhea
Although the symptoms of primary HIV infection may be mild enough to go unnoticed,
the amount of virus in the blood stream (viral load) is particularly high at this time. As a
result, HIV infection spreads more efficiently during primary infection than during the next
stage of infection.

Clinical latent infection

In some people, persistent swelling of lymph nodes occurs during clinical latent HIV.
Otherwise, there are no specific signs and symptoms. HIV remains in the body, however,
as free virus and in infected white blood cells.

Clinical latent infection typically lasts 8 to 10 years. A few people stay in this stage even
longer, but others progress to moresevere disease much sooner.

Early symptomatic HIV infection

As the virus continues to multiply and destroy immune cells, the person may develop
mild infections or chronic symptoms such as:
Fever
Fatigue
Swollen lymph nodes
Diarrhea
Weight loss

2002
0020
 Cough and shortness of breath

Progression to AIDS
Without treatment for HIV infection, the disease typically progresses to AIDS in about 10
years. By the time AIDS develops, the immune system has been severely damaged,
making a person susceptible to opportunistic infections diseases that wouldn't trouble
a person with a healthy immune system. The signs and symptoms of some of these
infections may include:
Soaking night sweats
Shaking chills or fever higher than 100 F (38 C) for several weeks
Cough and shortness of breath
Chronic diarrhea
Persistent white spots or unusual lesions on the tongue or in the mouth
Headaches
Persistent, unexplained fatigue
Blurred and distorted vision
Weight loss
Skin rashes or bumps

HIV destroys CD4 cells a specific type of white blood cell that plays a large role in
helping the body fight disease. The immune system weakens as more CD4 cells are
killed. A person can have an HIV infection for years before it progresses to AIDS.

To be diagnosed with AIDS, you must have a CD4 count under 200 or experience an
AIDSdefining complication, such as:
Pneumocystis jiroveci pneumonia
Cytomegalovirus
Tuberculosis
Toxoplasmosis
Cryptosporidiosis

Infections common to HIV/AIDS:

Tuberculosis (TB).
Salmonellosis. Bacterial infection from contaminated food or water. Symptoms
include severe diarrhea, fever, chills, abdominal pain and, occasionally, vomiting.
Although anyone exposed to salmonella bacteria can become sick, salmonellosis
is far more common in people who are HIVpositive.
Cytomegalovirus (CMV). This common herpes virus is transmitted in body fluids
such as saliva, blood, urine, semen and breast milk. A healthy immune system
inactivates the virus, and it remains dormant in the body. If the immune system
weakens, the virus resurfaces causing damage to the eyes, digestive tract,
lungs or other organs.
Candidiasis. Candidiasis is a common HIVrelated infection. It causes
 inflammation and a thick white coating on the mucous membranes of the mouth,
tongue, esophagus or vagina.
Cryptococcal meningitis. Meningitis is an inflammation of the membranes and
fluid surrounding the brain and spinal cord (meninges). Cryptococcal meningitis is
a common central nervous system infection associated with HIV, caused by a
fungus that is present in soil. It may also be associated with bird or bat droppings.
Toxoplasmosis. This potentially deadly infection is caused by Toxoplasma
gondii, a parasite spread primarily by cats. Infected cats pass the parasites in
their stools, and the parasites may then spread to other animals.
Cryptosporidiosis. This infection is caused by an intestinal parasite that's
commonly found in animals. You contract cryptosporidiosis when you ingest
contaminated food or water. The parasite grows in your intestines and bile ducts,
leading to severe, chronic diarrhea in people with AIDS.

Cancers common to HIV/AIDS:

Kaposi's sarcoma. Kaposi's sarcoma is a tumor of the blood vessel walls.
Although rare in people not infected with HIV, it's common in HIVpositive people.
Kaposi's sarcoma usually appears as pink, red or purple lesions on the skin and
mouth. In people with darker skin, the lesions may look dark brown or black.
Kaposi's sarcoma can also affect the internal organs, including the digestive tract
and lungs.
Lymphomas. This type of cancer originates in your white blood cells.
Lymphomas usually begin in your lymph nodes. The most common early sign is
painless swelling of the lymph nodes in your neck, armpit or groin.

Other complications:
Wasting syndrome. Aggressive treatment regimens have reduced the number
of cases of wasting syndrome, but it does still affect many people with AIDS. It is
defined as a loss of at least 10 percent of body weight and is often accompanied
by diarrhea, chronic weakness and fever.
Neurological complications. Although AIDS doesn't appear to infect the nerve
cells, it can still cause neurological symptoms such as confusion, forgetfulness,
depression, anxiety and trouble walking. One of the most common neurological
complications is AIDS dementia complex, which leads to behavioral changes and
diminished mental functioning.

Tests:
HIV is most commonly diagnosed by testing your blood or saliva for the presence of
antibodies to the virus. Unfortunately, these types of HIV tests aren't accurate
immediately after infection because it takes time for your body to develop these
antibodies usually up to 12 weeks. In rare cases, it can take up to six months for an
HIV antibody test to become positive.
A newer type of test checks for HIV antigen, a protein produced by the virus immediately
after infection. This test can confirm a diagnosis within days of infection.

Several types of tests can help to determine what stage of the disease. These tests
include:
CD4 count. CD4 cells are a type of white blood cell that's specifically targeted
and destroyed by HIV. A healthy person's CD4 count can vary from 500 to more
than 1,000. Even if a person has no symptoms, HIV infection progresses to AIDS
when his or her CD4 count becomes less than 200.
Viral load. This test measures the amount of virus in the blood. Studies have
shown that people with higher viral loads generally fare more poorly than do
those with a lower viral load.
Drug resistance. This type of test determines if the strain of HIV is resistant to
any antiHIV medications.

Tests for complications

Lab tests to check for other infections or complications, include:
Tuberculosis
Hepatitis
Toxoplasmosis
Sexually transmitted diseases
Liver or kidney damage
Urinary tract infections

Treatment:
There is no cure for HIV/AIDS, but a variety of drugs can be used in combination to
control the virus. Each of the classes of antiHIV drugs blocks the virus in different ways.
It's best to combine at least three drugs from two different classes to avoid creating
strains of HIV that are immune to single drugs. The classes of antiHIV drugs include:
Nonnucleoside reverse transcriptase inhibitors (NNRTIs). NNRTIs disable a
protein needed by HIV to make copies of itself. Examples include efavirenz
(Sustiva), etravirine (Intelence) and nevirapine (Viramune).
Nucleoside reverse transcriptase inhibitors (NRTIs). NRTIs are faulty
versions of building blocks that HIV needs to make copies of itself. Examples
include Abacavir (Ziagen), and the combination drugs emtricitabine and tenofovir
(Truvada), and lamivudine and zidovudine (Combivir).
Protease inhibitors (PIs). PIs disable protease, another protein that HIV needs
to make copies of itself. Examples include atazanavir (Reyataz), darunavir
(Prezista), fosamprenavir (Lexiva) and ritonavir (Norvir).
Entry or fusion inhibitors. These drugs block HIV's entry into CD4 cells.
Examples include enfuvirtide (Fuzeon) and maraviroc (Selzentry).
Integrase inhibitors. Raltegravir (Isentress) works by disabling integrase, a
protein that HIV uses to insert its genetic material into CD4 cells.
 Current guidelines indicate that treatment should begin if a person:
has severe symptoms
has CD4 count under 500
is pregnant
has HIVrelated kidney disease
is being treated for hepatitis B

HIV treatment regimens may involve taking multiple pills at specific times every day for
the rest of the persons life. Side effects can include:
Nausea, vomiting or diarrhea
Abnormal heartbeats
Shortness of breath
Skin rash
Weakened bones
Bone death, particularly in the hip joints

Treatment response
A persons response to any treatment is measured by the viral load and CD4 counts.
Viral load should be tested at the start of treatment and then every three to four months
while undergoing therapy. CD4 counts should be checked every three to six months.

HIV treatment should reduce the viral load to the point that it's undetectable. That
doesn't mean the HIV is gone. It just means that the test is not sensitive enough to
detect it.

Sources:

http://uhaweb.hartford.edu/bugl/immune.htm
http://www.nlm.nih.gov/medlineplus/ency/article/002247.htm
http://en.wikipedia.org/wiki/Lymph
http://en.wikipedia.org/wiki/Tonsil
http://www.socialsecurity.gov/disability/professionals/bluebook/14.00ImmuneAdult.htm#14_08
http://www.disabledworld.com/health/autoimmunediseases/immunesystem.php
http://www.nlm.nih.gov/medlineplus/ency/article/002224.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000816.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001471/
http://www.mayoclinic.com/health/sjogrenssyndrome/DS00147
http://www.mayoclinic.com/health/sjogrenssyndrome/DS00147/DSECTION=complications
http://www.sjogrens.org/home/aboutsjogrenssyndrome/diagnosis
http://www.sjogrens.org/home/aboutsjogrenssyndrome/treatments
http://www.mayoclinic.com/health/hivaids/DS00005
http://www.mayoclinic.com/health/hivaids/DS00005/DSECTION=symptoms
http://www.mayoclinic.com/health/hivaids/DS00005/DSECTION=treatmentsanddrugs