Richard Wendel MD, MBA Moderator

An 8 week Fall OLLI online course

Thursdays from 11am-12pm starting
September 23rd.
Email address: [email protected]
Each week we will focus on one of the body’s systems:
1. September 23:Nervous System
2. September 30: Endocrine glands
3. October 7: Skeletal, Muscles, Skin
4. October 14: Digestive System
5. October 21:Immune system
6. October 28:Pulmonary system
7. November 4:Cardiovascular system
8. November18:GenitoUrinary tract
 Brain and Central Nervous System
Gross Anatomy

Functional MRI and PET scanning as

Research Tool
Arterial Blood Supply to the Brain

bruits
 Neurotransmitters; carry impulses
across synapses
❖ Dopamine (reward-motivation)Parkinson’s
❖Serotonin (SSRIs) Depression
❖Acetylcholine (alpha adrenergic-parasympathetic)
❖Norepinephrine (blood pressure) (Beta
adrenergic)
❖Epinephrine/adrenalin(Beta adrenergic)
❖GABA-(gamma-aminobutyric acid) and Glutamine
(epilepsy and seizures)
Cranial Nerve Diagram: 12 altogether
Cursory Neurologic Exam when you go
to see you Primary Care Physician
• Sensorium and memory
• Pupils (R&R&RLA)
• Funduscopic exam
• Eyes movements
• Check Reflexes with reflex hammer
• Strength evaluation and proprioception
• Balance
Optic Chiasm
 Right Brain versus Left Brain
• Right brain more adept at spatial and nonverbal
concepts and being more creative and
emotional (a scientist or musician) imagination,
holistic thinking
• Left Brain are more analytical and methodical.
They are better at things like reading, writing, and
computations. (an accountant or author) logic
No proof that one is dominant but the differences
do appear to be real between the two sides.
 Autonomic Nervous System or Involuntary
nervous system

❖ Sympathetic nervous system: the ‘fight or flight’ response to stress

mediated by adrenaline/epinephrine or nor-epinephrine. The response to
stress includes pupil dilation, increased sweating, increased heart rate, and
increased blood pressure. The adrenal gland and solar plexus secretes
adrenalin.
❖ Parasympathetic nervous system; involuntary functions of the body such as
peristalsis, slowing of the heart, constriction of the pupil. Mediated by
acetylcholine. TheVagus nerve, the tenth cranial nerve, is a parasympathetic
nerve trunk.
 Medical Conditions of the CNS
• Demyelinating Disorders; Multiple Sclerosis,
Amyotrophic lateral sclerosis (ALS), Guillain-
Barre Syndrome
• Brain Cancer: (meningioma, glioblastomas,
gliomas, acoustical neuroma)
• Psychosis and Neurosis
 Amyotrophic Lateral Sclerosis/Lou
Gehrig’s Disease
• Slowly progressive (5-8 years) but uniformly fatal
demyelinating disorder (neural sheaths) of both
upper and lower motor neurons with about
13,000 deaths per year. Retain cognitive function
• Onset between age 50 and 70: mean 55 and
more common in men and 10 percent familial
• Progressive Respiratory symptoms most
devastating
• No known treatment; Riluzole a glutamate
inhibitor can be given.
 Multiple Sclerosis; an autoimmune inflammatory
demyelinating disease three to four time more common in
females than males

• Variable symptoms beginning between the ages

of 20 and 40: slurred speech, fatigue, dizziness,
tingling, altered sexual, bowel and bladder
function, cognitive
• Common disorder about 720,000 cases in US with
variable course and no diagnostic lab test (MRI)
• FDA has approved 15 plus drugs for treatment
(average cost per year 80,000)-these drugs alter
the immune response of lymphocytes.
 Meningitis, Encephalitis, and Brain
Abscess
• Viral meningitis is fairly common due to
enteroviruses (85-95% and seasonal)
Presents with stiff neck or nuchal rigidity
• Encephalitis can be caused by the Herpes simplex
virus and is treated with acyclovir and
dexamethasone.
• Lumbar puncture with examination of
cerebrospinal fluid is diagnostic
• MRI is better than CT scan for diagnostic
purposes.
 Parkinson’s and Parkinsonism that has a broad
range of presentations
• Cause: Due to loss of Dopamine producing cells in the basal
ganglia at the base of the brain
• Symptoms: tremors, rigidity, gait, mask face, mood change,
hallucinations
• Early symptoms of anosmia, sleep disorders, constipation,
depression, restlessness, anxiety, orthostatic hypotension
(may occur many years before)
• Treatment: directed at increasing dopamine. Levodopa the
mainstay but a whole array of meds prescribed by
neurologists. Deep brains stimulation of basal ganglia can be
used and is often effective-do not know why this works.
 Dementias
1) Alzheimer's disease: 60% of patients (Beta-amyloid and Tau
Protein with tangles)—cause unknown (APOE-e4 genetic link). No
effective treatment although there is a new blood test for Tau
protein that is 96% accurate in diagnosing Alzheimer’s:
anticholinergics and NMDA receptor antagonists may temporarily
delay the need for NH placement but no long term benefits.
2) Arteriosclerotic; multiple mini-strokes, Transient Ischemic Attacks
(TIAs)
3) Temporal Frontal Lobe Dementia; usually starts with difficult in
speech and behavioral problems. More rapidly progressive.
4) Lewy Body Dementia; more behavioral problems and shorter
course and hallucinations
5) TDP- 23 deposition dementia in ¼ over the age of 90
For all dementias try to avoid too many meds; less is more and
antipsychotics are not well tolerated.
 Strokes; two types--ischemic and
hemorrhagic
• Unlike heart attach do not give aspirin because of possible
intracranial bleeding
• Cincinnati Criteria: Facial droop, Arm drift, Slurred Speech:
All three present = 87% chance of stroke.
• Emergency CT scan to differentiate
• Window of 3-4.5 hours from when symptoms first started
(with new angiography techniques can estimate amount of
viable brain beyond stroke (flair and penumbra) and
possible large vessel disease and in some cases extract the
clot to retrain maximal function up to 24 hours.)
• IV anticoagulant and fibrinolytic: plasminogen activator
(tPA) and Alteplase. Cannot give after 4.5 hours.
• Carotid bruit
Migraine; 40 million Americans and second most
disabling condition worldwide
A disorder with many treatments; none curative
• 1. Tryptans (effect on serotonin) and NSAIDS--moderately effective,
mainstay of treatment
• 2. Calcitonin gene-related peptide receptor antagonists (vasodilator)—
moderate to high effectiveness.
• 3. Dihydroergotamine (blocks vasospasm)—(traditional treatment)
moderate to high effectiveness.
• 4. Acetaminophen-moderate effectiveness
• 5. Remote electric neuromodulaion (stimulates upper arm peripheral
nerves to modulate pain especially in adolescence)—moderate
effectiveness
• 7. Noninvasive vagal nerve stimulation (mainly cluster headaches)-
moderate
• 8. Botox (15 or more headaches per month, 31 injections) Costy? And lasts
several months.
 Benefits of Sleep
• Critical role in immune function, metabolism, memory,
learning, (retain information better right before sleep) and
other vital functions
• The 5 or 6 sleep cycles each night lasts about 90 minutes
• Dream sleep or rapid eye movement
(REM) sleep consumes about 90 minutes on an average
night; heart rate and breathing increase and your limbs
may even become paralyzed
• Need between 7 and 9 hours of sleep per night and people
over 65 should also get 7 to 8 hours per night
• Why do we sleep? No definitive answer; but brain shrinks
and may open the blood–cerebrospinal fluid barrier
(BCSFB) for excretion of waste products.
 BRAIN DEATH IN ORGAN DONATION
1. Comatose and unresponsive
2. EEG for brain wave activity
3. Now have a nuclear scan that reveals total
brain blackout. No longer need to rely on clinical
findings and expert opinions, but still by law
need multiple expert opinions.
 Obstructive Sleep Apnea (OSA) and
Central Sleep Apnea(CSA)
• An epidemic due in large part due to increasing BMIs
(weight in kilograms divided by height in meters
squared with normal range of 18.5 – 24.9 with 30 and
above equaling morbid obesity)
• As high as 37% of men and 50% of women being
afflicted
• Symptoms of snoring, gaps in breathing with
intercostal attempts, HPT, drowsiness and stroke.
• Treatment CPAP (Continuous positive airway pressure)
• Opioids greatly exacerbate the complications of OSA
(sudden death)
Peripheral Segmental Nerves
Cervical 1-7, Thoracic 1-12, Lumbar 1-5
 Peripheral Nerve Testing
• Tendon Reflexes: ankle, knee, elbow
• Sensory for vibration with a tuning fork
• Pain pin prick
• Hot, Cold and light touch
• Proprioception: finger to nose with eyes
closed
• EMG
 Medical conditions of peripheral
nerves
• Peripheral neuritis (age, diabetes, alcohol risk
factors)
• Carpal Tunnel syndrome
• Sciatica (most commonly occurs when a
herniated disk, bone spur on the spine or
narrowing of the spine (spinal stenosis)
compresses part of the nerve.
• Herniated disc disease
• Paraplegia and Quadriplegia
• Herpes Zoster
 The Endocrine System: Glands that produce
chemical messengers called hormones.
• Pituitary gland
• Hypothalamus
• Pineal (melatonin)
• Thyroid glands
• Parathyroid glands
• Adrenal glands
• Pancreas
• Testicles and ovaries
The Pituitary Gland; Master Gland; size
of a pea or one-half gram

Feedback Loops
 Pituitary Hormones
Anterior Pituitary
• Growth Hormone (GH)
• Thyroid stimulating hormone (TSH)
• Adrenocorticotrophic hormone (ACTH)
• Gonadotropic hormones; Luteinizing hormone (LH), ICSH,
Follicle Stimulating hormone (FSH)
• Melanocyte Stimulating Hormone (MSH)
________________________________________
Posterior Pituitary
• Anti-Diuretic hormone or vasopressin (ADH)
• Oxytocin (love and uterine contractions)
• Prolactin (lactation)
 Pituitary Dysfunction
• Acromegaly, Gigantism, Dwarfism(GH)
• Hyperthyroidism (Graves Disease),
Hypothyroidism
• Cushing’s disease or Addison’s disease
• Hypogonadism
• Infertility
Thyroid and Parathyroid Glands
Feedback Regulatory Mechanisms
 Thyroid and Parathyroid Glands

Parathormone has
Opposite effect
The Adrenal Glands: total weight combined
10 grams or 1/3rd of an ounce
Adrenal Gland Locations
 The Effects of Prednisone
Short courses of Cortisone safe; chronic use has many
side effects
ACTH

Moon Facies
Cushionoid
 Addison's and Cushing's Disease
• Adrenal Insufficiency is usually caused by autoimmune
adrenalitis (many other causes as well) and gives
symptoms related to the three hormones the adrenal
gland secretes—ADH, Cortisone and Sex Hormones.
These include weakness, fatigue, low BP, weight loss.
Treatment is hormone replacement
• Cushing’s Disease is due to an excess of steroids often
due to pituitary adenoma or long term corticosteroid
treatment. Symptoms of diabetes, HPT, moon facies,
obesity, buffalo hump
 Parathyroid Disease
• Four pea sized glands in the neck behind the
thyroid gland that secrete Parathormone, a
hormone, that regulates calcium levels through
bone resorption, GI absorption and renal
excretion.
• Adenomas of the parathyroid glands and
paraneoplastic syndromes may cause
hypercalcemia and HPT. Extreme elevations of
Ca+ can be life threatening (mental and cardiac
arrhythmias)
The Pancreas
Functions of the Pancreas (Diabetes is cause by a lack
of insulin (Juvenile Diabetes) or insulin resistance
(Adult onset of Diabetes)
• Secretion of insulin, which acts to lower blood
sugar, and glucagon, which acts to raise blood
sugar.
• Digestive enzymes Lipase, Amylase, Trypsin
 Diabetes Mellitus: Juvenile and Adult Onset Diabetes
(13.8 percent of Cincinnatians have the latter)
• In the Juvenile variety the B cells in the pancreas are unable to produce
insulin; possibly an autoimmune response? And no genetic factors
have been identified with 90 % with no relative with the disorder.
• Adult Onset Diabetes: an epidemic with a number of risk factors; (no
identifiable gene seems to predispose to its occurrence but it does
seem to occur more frequently in some families). Insulin resistance
seems to be a factor.
Risk Factors:
• Obesity
• Age and inactivity
• African-Americans
• Smoking
• Obesity
• Hyperglycemia
• Low socioeconomic statis
• Inactivity
Organs effected by Diabetes: sugar is a
toxin
• The Kidney with albuminuria (prognosis and
diagnosismmm), decrease GFR. 50 percent of
dialysis patients with End Stage Renal Disease
have diabetes.
• Strict glucose control has greater benefit for Type
1/Juvenile as opposed to Type 2 diabetes.
• Diabetes is the primary cause of blindness in
adults ages 20 to 74.
• Associated with The Metabolic Syndrome with
arteriosclerosis disease.
 Diagnosing Diabetes
• FBS--overnight fasting generally and normal value
is up to 100 mg/dl. Values of 100 to 125 mg/dL
suggest you are prediabetic, and 126 mg/dL or
higher indicates you probably have diabetes.
• Glucose Tolerance Test
• Gestational diabetes
• Hgb A1C the gold standard to diagnose and
regulate diabetes; on an annual physical if the
FBS is over 100, a Hgb A1C is performed.
 Overview of Treatment
Medications to Treat Diabetes
• Metformin (Glucophage). Generally, metformin is
the first medication prescribed for type 2
diabetes. (increases sensitivity to insulin,
decreases sugar absorption and lowers sugar
production)..survival benefits?
• Sulfonylureas. Least expensive; activate B cells
• Insulin-many forms and ways to control blood
sugar levels.
Newer Medications for the Treatment
of Diabetes
• SGLT2 inhibitors: (Farxiga/Jardiance and many
more) prevents reabsorption of glucose in
proximal tubule in the kidney, osmotic
diuresis; it lowers Aic levels
• GLP-1 receptor (Trulicity) (glucagon-like
peptide agonists)associated with some weight
loss, slows emptying of stomach and by
injection.
 Skeletal System

206 bones
Joints most commonly involved in
disease states
 Terminology
• Tendon
• Ligament
• Vertebrae and Inter-Vertebral Discs
• Cartilage
• Synovia and synovial Fluid
• Structure of bones: cortical bone and
cancellous bone, bone marrow, periosteum
24 Vertebrae

Our height decreases as we age

Cross Section of a long bone

B CELLS AND
OTHER BLOOD CELLS
 Types of Joints
Various types of synovial joints:
1.Hinge joints as in knees, elbows and ankles
2.Ball and socket joints as in the hip and
shoulder (which is multiaxial)
3. Pivotal or rotational as in the spine, elbow
 “Aging is the process of wearing out gradually”

• Degenerative arthritis/osteoarthritis
• Many causes like RA, psoriasis, inflammatory bowel
disease, reactive arthritis
• Falls/hip fractures
• Spinal Stenosis
The Bionic Man comes to the rescue
• Joint replacements from easiest to hardest in terms of
rehabilitation and satisfactory outcomes:
Hips< Knee< Shoulder (others ankle, elbows, finger,
vertebrae)
Conservative Treatments(surgical replacement a
final solution after all else fails)
• In the morning you have more stiffness and pain that usually decreases after you
are active.
• Neuropathic pain often chronic pain-can have regional pain syndrome
• Physical therapy: range of motion and strengthening exercises
• Pain medication: mainly NSAIDS like Advil or Celebrex
• Ultrasound
• Lidocaine patches
• Injections of joints: lidocaine, steroids, hyaluronic acid derivatives and ?stem cells
• Arthroscopic evaluation and trimming up cartilage.
If in doubt, get a second opinions when surgery
is offered is often worthwhile. But joint
replacement can be a Lifestyle issue and
replacements are very successful; how much
functionality do you want?
The Rehab Process: no fun

Most important
question; how
much and for how
long will I have
pain?
 Athletic Injuries and Cancer
• Anterior Cruciate Ligament (ACL) and PCL tears
• Torn Cartilage in knee (surgery or not?) Quadriceps exercises
• Plantar fasciitis (calf stretching)
• Tendon tears (biceps, quadriceps)
• Dislocated shoulder

Cancers:
• Osteosarcoma, Chondrosarcoma (rare)
• Multiple Myeloma and Leukemia (bone marrow biopsies)
• Metastatic Cancer (Prostate, breast, and lung most common)
Plantar Fasciitis
 Rheumatoid Arthritis: A Chronic
Disorder with a variable course
• 0.24 to 1 percent incidence with 2 to1 women
• RA is an autoimmune disorder. It occurs when
your body’s immune system attacks the synovium
of the joint that produces joint fluid that
nourishes the cartilage and lubricates the joints.
• If left untreated it can invade and destroy a joint
and surrounding bony tissue.
• The exact cause of the immune system’s attacks is
unknown
Joints involved with RA
 Treatment of Rheumatoid Arthritis (immune
suppressants) very effective with good outcomes

• Methotrexate (alone or in combination with

hydroxychloroquine and sulfasalazine)
• Many new and expensive drugs such as
Leflunomide
 Gout; Podagra; the Devils Grip
▪ 50 percent of 1st episodes in foot but can involve many joints
▪ Elevated serum uric acid >6 as a marker
▪ Uric acid kidney stones (low purine diet, allopurinol and
alkalization of urine with sodium bicarb.)
▪ Prevention; lower purine diet, alkalinize the urine
▪ Acute episodes; NSAIDS, steroids, Colchicine, and titrate uric
acid level with Allopurinol (A xanthine oxidase inhibitor) to
less than 6
▪ Acute attacks 5-7 days
▪ Low purine diet (alcohol)
 What is osteopenia and osteoporosis
• Decreased density and mineralization of the bone
predisposing to fractures.
• Mainly post-menopausal women(testosterone is
protective)
• The meaning of T scores on the DEXA scan----T-0
is the mean or average. Osteoporosis is minus 2.5
or greater, osteopenia is minus 1 to minus 2.5.
• When to treat with bisphosphonates, Vitamin D
and Ca supplementation? Ask your PCP
Muscular system
Chewing Muscles

Temporalis Muscle

Masseter Muscle
 Muscular Disorders
• ALS, Muscular dystrophy and Myasthenia
gravis can directly effect the muscles and
many illnesses cause secondary muscular
weakness but most muscular disorders relate
to trauma of one sort or another.
Sarcopenia
The Rotator Cuff (external rotation)
 Shoulder Replacement

Joint Replacement a lifestyle decision?

 Muscle Evaluation
• A physical exam, tendon reflexes,
• Muscle strength tests: muscle atrophy
• Electromyography (EMG)
• A muscle biopsy (muscular dystrophy,
dermatomyositis, trichinosis, ALS and a few
others)
Skin; largest organ in the body.
 Common Disorders of the Skin
• Actinic keratosis/sun exposure related-atrophy, thinning,
atypical cells that are precursors to Basal Cell and
Squamous Cell cancers (this disorder makes the
dermatologists a high income specialist)
• Seborrheic Keratosis and Liver Spots
• Wrinkles (genetic and farmer’s skin)
• Psoriasis is a papulosquamous eruption: extensor surfaces,
scalp, T cell malfunction
• Eczema and atopic dermatitis (asthma & hay fever)
• Acne
• Hives
• Furuncle and Carbuncle
 Images of Psoriasis

Commonly on extensor On the scalp presents as reddish welts

surfaces of extremities And ridges with excessive ‘dandruff’
 More Disorders of the Skin
• Vitiligo
• Alopecia
• Contact Dermatitis and Poison Ivy
• Warts (HPV-venereal warts) Need for vaccination
for both women and men!
• Ringworm and Tinea Versicolor (fungi)
• Melanoma (cure rates dependent upon stage and
early detection—any change in black mole needs
evaluation)
• Sebaceous Cysts
Burns: 1st, 2nd, 3rd and 4th Degree
 Burn Management
• With a 3rd degree burn about a 2cm defect will
close/heal spontaneously over time.
• Split and full thickness grafts
• Skin substitutes; cadaver, pig, synthetic
The Digestive System
 Names of the upper GI organs and
Terminology
• Salivary Glands (parotids gland largest secrete
ptyalin (alpha-amylase) .5-1 liter per day.
• Esophagus (cardiac sphincter) peristalsis
• Stomach (hiatal hernia) hydrochloric acid and
pepsin that digest proteins
• Duodenum (4 parts with common bile duct and
pancreatic duct connect at the ampulla of vater.
• Ilium and Jejunum (small intestine 22 feet long
and need about 5 feet to maintain nutrition)
 The Stomach

There are four

main regions in
the stomach: the
cardia, fundus,
body, and
pylorus.
 Gastro-esophageal Reflex Disease
(GERD) and Hiatal Hernia
Old fashion gastro indigestion, heart burn.
Rx:
1. Weight Loss, stop smoking, decrease
drinking, overeating, earlier dining
2. Antacids
3. H-2-receptor blockers — to decrease acid
production (Tagamet HB)
4. PPI (protein pump inhibitors) that
suppress stomach acid. Frequently
prescribed but chronic use can have long
term side effects such as changes in
microbiome (c. difficil), osteoporosis,
macrocytic anemia, low Mg
(In unconscious patients can cause
aspiration pneumonia due to gastric reflux.)
 Gastric and Duodenal Ulcers
• A person has a higher risk of developing a peptic ulcer
(mainly duodenal) if they have an overgrowth
of Helicobacter pylori (H. pylori) bacteria in the
digestive tract. A few are due to malignancy
• Some medication such as steroids, NSAIDS and aspirin
(anticoagulants) can cause (alcohol not associated)
• Treatment of H. pylori with two antibiotics is very
effective and test for cure with blood, breathe or stool
tests
• Proton pump inhibitors (PPIs)
• Histamine H2-receptor antagonists
• Protectants, such as sucralfate
• Antacids
 Medical Marijuana; effective in treating nausea: not
legalized nationally but 50 % have tried it by age 20:
excellent safety profile for recreational use
• Seventy Cannabinoids but main active ingredient is
THC and CBD.(newer plants genetically engineered to
increase THC and the product comes in many forms)
• It is both an inhibitor and stimulant.
• Approved medical uses mainly for nausea and vomiting
and pain associated with cancer chemotherapy.
• Many other medical uses including epilepsy, mental
illness, PTSD, muscle spasms
• Half life 20-30 hours, eliminated 60% in stool, 30% in
urine.
• Chronic Use can cause Cannabinoid Hyperemesis
Syndrome (CHS)
 The Lower GI Track--Colon and
Omentum/mesentery
• Caecum
• Appendix (vestigial organ with no known function (RLQ pain as opposed to
diverticulitis that is usually LLQ)
• Ascending Colon
• Transverse Colon
• Descending Colon
• Sigmoid Colon
• Rectum
• Anus
• Peritoneal and retroperitoneal space
• Greater and lesser omentum: The greater omentum attaches the stomach
to the transverse colon. The lesser omentum attaches the stomach and
the duodenum to the liver.
• The mesentery attaches your intestines to the wall of your abdomen
Lower GI Tract
 The Peritoneal Cavity
The omentum is a fatty
blanket that hangs down in
front of all of the
intestines.
 Acute Appendicitis
Declining incidence for no known reason and
just 1 in 20 develop it.
• Signs and Symptoms
RLQ pain and tenderness (rebound if appendix ruptured) If pain is on left it is
more commonly related to diverticulitis), nausea, vomiting, low grade fever and
elevated white blood cell counts (polys).

• Rx: surgical removal usually laparoscopic, if

ruptured treat with antibiotics and later
removal.
Liver, Gall Bladder, Duodenum and
Pancreas
Arterial Blood Supply to upper GI track
The Portal System: carries nutrients from digestion to
the liver to store and metabolize, after a meal
 Functions of the Liver: a Thousand
Metabolic Processes occur in the Liver
• Produces most of the proteins the body needs
(albumin/oncotic pressure)
• Prevents shortages of nutrients by storing certain vitamins,
minerals, and sugar (glycogen)
• Produces bile, a substance that helps digest fat and absorb
fat soluble vitamins A, D, E, and K
• Produces substances that help with the blood clotting
cascade (Prothrombin, Fibrinogen, Factors V, VII, VIII, IX,
X, XI, XII, XIII)
• Helps your body fight infection by removing bacteria from
the blood
• Metabolizes and removes potentially harmful substances
from medications and foods
 Types of Liver Disease and
Terminology
• Hepatitis: Inflammation of the liver, usually caused by viruses like
hepatitis A, B, and C. (B&C through blood sharing)
• Cirrhosis: Long-term damage to the liver from any cause can lead to
permanent scarring, called cirrhosis. (Alcohol, Hepatiti and
Malnutrition)
• Fatty Liver
• Cancer: The most common type of primary liver cancer, Hepatoma,
is uncommon and usually occurs in patients with cirrhosis.
• Metastatic Cancer
• Ascites: Increase pressure in the Portal System, some cancers
(ovarian), heart failure, peritonitis and anasarca.
 Symptoms of Liver Failure: Yellowing of your skin and
eyeballs(jaundice): Abdominal swelling (ascites): Nausea &
Vomiting: malaise: disorientation and confusion.

Reason to treat
Hepatitis C?
 Why is pancreatic cancer so difficult to cure? The
location of the pancreas and the late onset of
symptoms
• 60,000 new cases each year with a 5 year survival rate
of 10 percent.
• 50 percent of patient present with metastatic disease,
30 percent with locally invasive disease.
• 10th leading cause of cancer and the 3rd leading cause
of cancer related mortality.
• Few are surgical candidates; mainly heavy duty chemo
that increases life expectancy by 2-6 months
• Risk factors; smoking, obesity, alcoholism and
pancreatitis.
• Host of genetic risk factors.
 The Gall Bladder
• Stores bile that digests fats and colors the stool brown
• Gall stone; 6% of men and 9% of women (may
predispose to cholecystitis)
• Most asymptomatic; but recurrence of biliary colic
common if you have had one attack
• Cholecystitis, Pancreatitis and Common Duct stones
more serious
• Laparoscopic removal of gall bladder (minimally
invasive)
• Diagnostic tool now used Endoscopic Ultrasound (EUS)
 Factors Influencing Weight
• Leptin is a hormone, made by fat cells, that
decreases your appetite.
• Ghrelin is a hormone released primarily in
the stomach that increases appetite, and also
plays a role in body weight.
• Microbiome (intestinal flora in the gut, mainly
large intestine)
• Hypothalamus in the Central Nervous System
• Of course: Diet, Mood, Good Food and Exercise play
a significant role
 Bariatric Surgery for Morbid Obesity
(BMI > 40)
• When all else fails:
 Disorders of the GI tract
• Celiac disease (gluten in wheat, rye, and barley)
genetic immune disorder with one percent incidence
with majority undiagnosed.
Diagnosis antibody testing and biopsy
• Irritable Bowel syndrome (IBS)
• Ulcerative Colitis-superficial and confined to colon
(relapses but 20 % go on to colectomy)
• Regional ileitis (Crohnes Disease) penetrating and can
involve entire GI tract—fistulae, abscesses, strictures,
treatment similar to UC. Follow with fecal calprotectin)
• C difficile bacteria and other ‘super bugs’
• Hemorrhoids
 Colon Cancer

• Colon Cancer-3rd or 4th most common cancer

with 150,000 new cases each year (1 in 23
(4.4%) for men and 1 in 25 (4.1%) for women)
with about 56,000 deaths annually.
• Most often involve the left side of the colon
and rectum.
 Colonoscopy Screening
• The American College of Surgeons recommends that
people at average risk of colorectal cancer start regular
screening at age 45 usually with colonoscopy
(sedation, anesthesia? And bowel prep) Average cost is
$2,750. Routine screening every 10 years without
pathology.
• Stool Guaiac
• Cologuard, a stool test that shows altered DNA and/or
blood in stool. Cologuard can detect 92% of
cancers but only 42% of large precancerous polyp with
12% false-positive rates. Average cost $500.
 GI Diagnostic Studies
• EGD (Esophago-gastro-duodenoscopy)
• Colonoscopy
• Cologard
• CT and MRI
• PET scan
• Stool guaiac
• Serum Direct and Indirect Bilirubin, ALP
(alkaline phosphatase) ALT, AST, GGT
Immune System
Lymphatic and Hematopoietic Systems
related to the Immune Response
Lymphatic System/lymphoid tissue

T-cells

B-cells
Peripheral Blood Smear
CBC and Differential Blood Cell Count
Neutrophils Relative 37.0 % bacterial infections
Lymphocytes Relative 53.0 % immune system, leukemia

Monocytes Relative 7.0 % immune system,

globulins, mature into
macrophages
Eosinophils Relative 2.0 % Allergic reactions,
parasitic diseases
Basophils Relative 1.0 % inflammation
Neutrophils Absolute 3.3 10*3/uL 1.5 - 7.8 10*3/uL

Lymphocytes Absolute 4.7 10*3/uL 0.8 - 3.9 10*3/uL

Monocytes Absolute 0.6 10*3/uL 0.2 - 0.9 10*3/uL

Eosinophils Absolute 0.2 10*3/uL 0.0 - 0.5 10*3/uL

Basophils Absolute 0.1 10*3/uL 0.0 - 0.2 10*3/uL

The immune response to antigens and
injury
• Cytokines are secreted by immune cells and
act as signaling proteins. They include
Interferons (some20 or so), Interleukins (30 or
more), Growth factor, Tumor Necrosis factor.
• Prostaglandins (response to injury) and
leukotrienes (response to allergy) are involved
in numerous homeostatic biological functions
and inflammation.
Blood Cell Formation

Myeloid Lymphoid
NK cells are best known for killing
virally infected cells, and
detecting and controlling early
signs of cancer.
The Immune System; Lymphoid System
B cells T cells
Cytotoxic T Cells (CD8 T Cells)
Cytotoxic T cells kill their target cells, primarily by releasing cytotoxic granules into the cell to be killed.
These cells recognizejju their specific antigen (such as fragments of viruses) when presented by MHC
(Hyman leukocyte antigens (HLA) Class I molecules that are present on the surface of all nucleated
cells.
MHC Class I molecules interact with a protein called CD8 on the cytotoxic T cells, which helps to
identify this cell type. Cytotoxic T cells require several signals from other cells to be activated, such as
from dendritic cells and T helper cells.
Their main function is to kill virally infected cells, but they also kill cells with intracellular bacteria or
tumorous cells.
T-Helper Cells (Th) (CD4 T Cells)
T helper cells have a wider range of effector functions than CD8 T cells and can differentiate into many
different subtypes, such as Th1, Th2, Th17 and regulatory T cells.
They become activated when they are presented with peptide antigens by MHC Class II molecules, which
are expressed on the surface of APCs. MHC Class II molecules interact with a protein called CD4 on the T
helper cells, which helps to identify this cell type.
The roles of a CD4 T cell may include activating other immune cells, releasing cytokines, and helping B cells
to produce antibodies. They help to shape, activate and regulate the adaptive immune response.
Memory T Cells
Following an infection, antigen-specific, long-lived memory T cells are formed. Memory
T cells are important because they can quickly expand to large numbers of effector T
cells upon re-exposure to the antigen and have a low threshold for activation.
They provide the immune system with memory against previously encountered
antigens. Memory T cells may either be CD4+ or CD8+.
 Immunoglobulins
• Immunoglobulins, also known as antibodies,
are glycoprotein molecules produced mainly
by plasma cells and initiate the immune
response by specifically recognizing and
binding to particular antigens, such as bacteria
or viruses, and aiding in their destruction.
 Classes of Immunoglobulins
The five major antibody classes are:
• Immunoglobulin G (IgG), 80%, is found in all body fluids and
protects against bacterial and viral infections.
• Immunoglobulin M (IgM), is the first antibody to be released by B
cells during primary response
• Immunoglobulin D (IgD, important in B cell activation
• Immunoglobulin A (IgA), which is found in high concentrations in
the mucous membranes, particularly those lining the respiratory
passages and gastrointestinal tract, and prevent attachment of
pathogens to epithelial surfaces.
• Immunoglobulin E (IgE), found on mast cells and basophils and
triggers release of histamine which is associated mainly with allergic
reactions (when the immune system overreacts to environmental
antigens such as pollen or pet dander). It is found in the lungs, skin,
and mucous membranes.
Immunizations
 Adult Immunizations

Almost 1 our of every 3 people in the US will develop shingles

in their lifetime
• Shingles vaccine, which protects against shingles and the
complications from the disease (recommended for healthy
adults 50 years and older) Two Shots/Expensive!
• Pneumococcal polysaccharide vaccine (PPSV23), which
protects against serious pneumococcal disease, including
meningitis and bloodstream infections (recommended for
all adults 65 years or older, and for adults younger than 65
years who have certain health conditions)
 Leukemias and Lymphomas
• Acute Lymphocytic Leukemia (ALL)
• Acute Myeloid Leukemia (AML)
• Chronic Lymphocytic Leukemia (CLL)
• Chronic Myeloid Leukemia (CML) translocation of chromosome 9 &22
(Philadelphia chromosome) diagnosed with Karyotype, FISH, and PCR.
New Rx. With tyrosine kinase inhibitors, good outcomes
• Chronic Myelomonocytic Leukemia (CMML)
• Polycythemia Vera-too many RBCS; JAK2 pathway, Dx. PCR and increase
EPO. Thrombosis main issue. Phlebotomy, and Hydroxyurea.
• Essential thrombocytosis: JAK2, CALR and MPL mutations, too may
platelets, usually asymptomatic
• Myelofibrosis; nasty disease, burned out bone marrow, allogenic stem cell
transplant with 18 month survival or less.
• Multiple Myeloma
 Autoimmune Diseases
• Rheumatoid Arthritis
• Psoriasis
• Multiple Sclerosis
• Crohn’s Disease
• Ulcerative Colitis
• Type I diabetes/juvenile
• Addison’s Disease
• Graves Disease
• Scleroderma
• Lupus Erythematosus
• Pernicious Anemia
• Polyarthritis Nodosa
• Myasthenia Gravis
SLE-SYSTEMIC LUPUS ERYTHEMATOSIS
• Rare (140/100,000) but more common in
minorities and young women with a strong
genetic predisposition.
• Treatment with Hydroxychloroquine
• Symptoms; butterfly rash, Reynaud's
phenomena, alopecia and depression
• Delay in diagnosis due to wide range of
symptoms than mimic other disorders.
 DRESS-Drug Reaction with Eosinophilia and Systemic
Symptoms (take drugs sparingly with definite
indications)
• Rare but anti-seizure drugs, allopurinol, sulfa,
vancomycin, minocycline
• HLA (haplotype) cause CD4 AND CD8
lymphocytes to upregulate to make TNF and
Interferon plus activate Herpes and CMV viruses.
• Rashes of all kinds, fever, adenopathy, liver, heart
and kidney impairment. (2-10% mortality)
• Patch testing
 HIV-the virus; Aids-the syndrome
• A retro virus that infects CD4-T cells causing a decline in their
numbers. Less than 200 is critical level. (susceptible to opportunistic
infection)
• 1.1 million infected in US, more men than women and 1/7th are
unaware they are infected.
• No longer considered a death warrant but a chronic disease with no
complete cure and need for lifelong medication. ($3000 cost per
month. Undetectable viral counts=untransmissable
• Screening of high risk individuals (after 45 days from inoculation
this detects 99% of cases).
• Three classes of new drugs for treatment; mainstay Truvada and
Descovy (15,000/yr ). Problems with compliance.
• In high risk individuals move toward prophylaxis (PrEP) with one pill
a week with Truvada or Descovy.
 Tests
• Antinuclear antibody (ANA)
• Rheumatoid factor
• CBC
• C-reactive protein (CRP)
• Erythrocyte sedimentation rate (ESR)
• Urinalysis
• Complement (part of immune system)
Genetics and Cellular Anatomy

Amino Acids
 What is a chromosome?
• Chromosomes are the things that make
organisms what they are. They carry all of the
information used to help a cell grow, thrive,
and reproduce. Chromosomes are made up of
DNA. Segments of DNA in specific patterns are
called genes. ... You will find
the chromosomes and genetic material in the
nucleus of a cell and mitochondria.
A chromosome contains hundreds to
thousands of genes.
Genes and Chromosomes
 Difference between DNA & RNA
• DNA is a long polymer with deoxyribose (a sugar) and
phosphate backbone. Having four different
nitrogenous bases: adenine, guanine, cytosine and
thymine.
• RNA is a polymer with a ribose (a sugar) and phosphate
backbone. Four different nitrogenous bases: adenine,
guanine, cytosine, and uracil.
Differences between DNA & RNA: Thymine is the pyrimidine base of
the DNA, whereas Uracil is the pyrimidine base of the RNA. The
occurrence of thymine and uracil is a crucial difference as thymine is
only found in DNA and uracil is only found in RNA. Methyl group is
absent in uracil whereas present in thymine at the C-5 position.
 What is the chemistry of cytosine,
adenine, thymine and guanine made
• As a nitrogenous base, cytosine is full of
nitrogen atoms (it has three). It also has one
ring of carbon, which makes it a pyrimidine. A
purine, on the other hand, has two rings of
carbon. There are two
pyrimidines, cytosine and thymine, and two
purines, adenine and guanine, in DNA.
Basic structure of DNA
 What is an amino acid?
• An amino acid is an organic molecule that is
made up of a basic amino group (−NH2), an
acidic carboxyl group (−COOH), and an organic
R group (or side chain) that is unique to each
amino acid. The term amino acid is short for
α-amino [alpha-amino] carboxylic acid
 Amino acids
• ESSENTIAL AMINO ACIDS
• Essential amino acids cannot be made by the
body. As a result, they must come from food.
• The 9 essential amino acids are: histidine,
isoleucine, leucine, lysine, methionine,
phenylalanine, threonine, tryptophan, and valine.
• Nonessential amino acids
include: alanine, arginine, asparagine, aspartic
acid, cysteine, glutamic
acid, glutamine, glycine, proline, serine,
and tyrosine.
 General Knowledge
• In humans, each cell normally contains 23
pairs of chromosomes, for a total of 46.
Twenty-two of these pairs, called autosomes,
look the same in both males and females. The
23rd pair, the sex chromosomes, differ
between males and females.
Karyotyping
 Difference between Meiosis and
Mitosis
• Sperm and ova; they fuse to form a zygote

In mature organs cell division is infrequent

When Should Someone have a Genetic
test?
• At birth? Pregnancy?
• When they come down with a disease/cancer for
precision medical care?
• Wait for genetics to advance more?

Arguments to get it in the newborn period

• 1. Uncover repairable genetic defects (CRISPR-cas9 or
gene replacement therapy.
• 2. Predict predisposition for various illnesses
• 3. Genetic profile for eugenics/descendants.
• Social, emotional and societal consquences
Common Genetic Disorders that relate
to an identifiable gene
• Cystic Fibrosis
• Hemophilia
• Huntington’s Chorea
• Neurofibromatosis
• Thalassemia
• Tourette syndrome
• Von Willenbrands
• Sickle Cell
• Down’s
 Designer Babies and Curative
Technique for genetic disorders?
• Gene Splicing techniques/problems (Crispr-
Cas9)
• Eugenics/ethical considerations
• Role inheritance plays; nature vs. nurture
• Crack babies, smoking, need for prenatal care
The Cell; basic unit of you body with
some 60 trillion individual cells
The Cell Structure
 The basic cell ingredients; organelles
• The nucleus contains the hereditary DNA of the cell
• Ribosomes are granules that are the site of protein synthesis(contained in the
rough endoplasmic reticulum)
• The mitochondrion is the power plant that form ATP and converts glucose, fats
and protein to energy
• The rough endoplasmic reticulum manufactures proteins
• Smooth endoplasmic reticulum chemically modifies proteins, lipid and other
molecules
• The Golgi apparatus processes and packages proteins and targets them
• The centrioles are associated with cell division
• A cytoskeleton composed of microtubules and microfilaments support the cell and
is involved in cell movement and organelle movement.
• The plasma membrane regulates traffic of materials into and out of the cell
• The nucleolus begins the assembly of ribosomes from proteins and RNA
• Lysosome digests particles like food taken into the cell by phagocytosis.
• Peroxisome collect toxic materials
• Telomeres are repeated DNA sequences at the end of
chromosomes. Telomeres get shorter each time a cell
copies itself, but the important DNA stays intact.
Eventually, telomeres get too short to do their job, causing
our cells to age and stop functioning properly.
Therefore, telomeres act as the aging clock in every cell.
• Messenger RNA (mRNA) is a single-stranded RNA molecule
that is complementary to one of the DNA strands of a gene.
The mRNA is an RNA version of the gene that leaves the cell
nucleus and moves to the cytoplasm where proteins are
made. During protein synthesis, an organelle called a
ribosome moves along the mRNA, reads its base sequence,
and uses the genetic code to translate each three-base
triplet, or codon, into its corresponding amino acid.
Apoptosis; programmed cell death or
injury (necrosis)
A Neuron; are new brain cells created in the adult and
what is neuroplasticity (growth and reorganization)

The Importance of stem cells as mature neurons and cardiac

muscle cells probably do not exhibit mitosis
 Types of Viruses/phage particles:
Lytic/virulent and lysogenic
• DNA: single stranded (Covid-19) or double
stranded
• RNA: single stranded or double stranded
More than two-thirds of human viruses can also
infect non-human hosts, mainly mammals, and
sometimes birds.
There are 219 virus species that are known to be
able to infect humans
Only a small part of the total diversity of
viruses has been studied. As of 2019, 4
realms, 9 kingdoms, 16 phyla, 2 subphyla,
36 classes, 55 orders, 8 suborders, 168
families, 103 subfamilies, 1,422 genera,
68 subgenera, and 6,589 species of
viruses have been defined by the ICTV.
Coronaviruses are a large family of
viruses found in both animals and
humans, and are known to cause
the common cold to more severe
diseases such as Middle East
Respiratory Syndrome (MERS),
Severe Acute Respiratory Syndrome
(SARS), and Novel Coronavirus
(COVID-19). The COVID-19 virus
attacks angiotensin 2 receptors
present in virtually all human cells
and thus attacks multiple organ
systems as well as the lungs
 The Pandemic
• Novel Corona or Covid-19 is a single stranded
RNA virus that mutates at a high rate, which
results in the emergence of new variants such
as the Delta strain that is now prevalent in the
U.S. The current vaccines are still effective
against the Delta strain which is more easily
transmitted than the initial strains.
Viruses are entirely dependent on the host
for replication and they are roughly one-
hundredth the size of a bacteria
They consist of two or three distinct parts:
1. genetic material, either DNA or RNA
2. a protein coat, or capsid, which protects
the genetic information
3. a lipid envelope is sometimes present
around the protein coat when the virus is
outside of the cell
 Corona Virus

M, E, N proteins are
envelope proteins

Hemagglutinin-
esterase destroys
receptors
 Covid-19 and the Pandemic
A multisystem disease since every blood vessel in the body
has Angiotension 2 receptors. It is more lethal than the flu
with ‘long haul’ symptoms lingering in more than 30 percent
of patients with shortness of breath, chronic fatigue, renal
failure, brain fogginess to name a few. These may last
months/years and be irreversible. At this time over 700,000
Americans have died and a sizable proportion could have
been saved with high vaccination rates and government policy
that dealt with it as a medical issue and not a political one.
Misinformation and anti-vaxxer push back remains a serious
problem. Age and compromised immune systems are major
risk factors. If you recover from Covid within 2 weeks your
outlook of have any long-haul consequences decreases
dramatically.
Covid-19; therapy; still no magic bullets or
even curative remedies in the pipeline
Therapy
• Ventilation with PO2 of greater than 60% not SOB, CPAP,
Intubation and other assisted ventilation as late as possible.
• The prone position improves breathing
• Antiviral treatment Remdesivir, Baricitinib, Tocilizumab
when given early and usually with steroids may be
beneficial.
• Steroids (hydroxydexamethasone) 10% reduction in
mortality (no standardization of dose)
• Convalescent Serum is no longer recommended
• Anticoagulation with LMWH (Low Molecular Weight
Heparin) to prevent DVT and strokes due to clotting.
Pulmonary System
Pulmonary System
Lungs in Detail
The Pleural Space
 Functions of the Lungs
• Exchange of CO2 (hypercapnia) and O2 (hypoxia)
Use pulse oximeter to gage blood oxygen levels
• Acid and Base Balance (Respiratory Acidosis) with
hyperventilation you can produce respiratory
alkalosis and dizziness.
• Pulmonary arteries (deoxygenated blood) come
from the right ventricle of the heart and
pulmonary veins (oxygenated blood) returned
blood to the left atrium of the heart.
• Filtering and removal of bacteria and small
particles in the air (tracheal elevator)
 Pulmonary Studies
• Chest x-ray (not a screening test)
• Pulse Oximetry (will become part of the fitbit?)
• Serum CO2 and arterial blood gases (acidosis or
alkalosis) Low CO2 suggests acidosis or
ketoacidosis, a complication of diabetes; high
CO2 may indicate pulmonary alkalosis.
• Spiral CT with Calcium index
• Sputum Culture
• Lung Biopsy
 Electrolytes
Normal Blood Ph. is 7.4: below is acidosis, above
alkalosis

Sodium 138 mmol/L 135 - 146 mmol/L

Potassium 4.5 mmol/L 3.5 - 5.1 mmol/L

Chloride 102 mmol/L 98 - 110 mmol/L

CO2 25 mmol/L 22 - 29 mmol/L

Anion Gap (high equals 11 mmol/L 5 - 13 mmol/L

acidosis)
 Obstructive Sleep Apnea; with periods of hypoxia
(low oxygen levels) mainly during REM sleep
Signs & Symptoms: Snoring,
daytime drowsiness,
hypertension, heart disease,
stroke, diabetes,

Evaluation in Sleep Lab

Treatment of OSA:
Lose weight
Sleep on your side
CPAP
Dental Prosthesis
Surgery (controversial
The mechanics of Intubation and being
on the ventilator
Pulmonary Function Tests; spirometry
 Normal Pulmonary Function
• The normal one second value for the (Forced
Expiratory Volume) FEV1/FVC (Forced Volume
Capacity) ratio is 70% (and 65% in persons
older than age 65).
 Pneumonia
• Bacterial (community acquired and hospital
acquired) Just like MRSA
• Viral
• Aspiration
• Pneumocystis Pneumonia and unusual bacterial
in Immune compromised patients of any sort. HIV
especially
• Procalcitonin responds to tissue injury: New lab
test to differentiate between bacterial and viral
pneumonia and meningitis.
 Idiopathic Pulmonary Fibrosis.
• Most have no known cause; 3-5 year course. Newer
treatments with nintedanib and pirfenidone, ground
glass appearance on x-ray, pulmonary hypertension.
• 40,000 deaths per year and often goes undiagnosed
because of non-specific symptoms.
• Life expectancy after diagnosis 8-12 years.
• Anything that damages the lung like irradiation, certain
drugs, pneumonia, pneumoconiosis,
• Rare diseases like connective tissue disease, Systemic
lupus erythematosus, Rheumatoid arthritis,
Sarcoidosis, Scleroderma
 Medical Conditions
• Tuberculosis (declining incidence in US)
• Histoplasmosis (high incidence in Ohio valley,
but rarely causes serious disease)
• Pulmonary embolus
• CHF
• Atelectasis
 COPD/ Emphysema( 3rd leading cause
of death)
1% with COPD have genetic Alpha-1-antitrypsin deficiency ,
• Cigarette smoking (1/3RD nonsmokers), asthma, chronic bronchitis, fumes
and industrial irritants.
Acute-or-chronic respiratory failure that predispose to pulmonary infection,
pulmonary embolism, cardiac arrhythmia and lung cancer
Treatment:
1. Stop smoking and avoid air pollutants
2. Rx active infections/ sputum liquefiers
3. LAMA (long acting muscarinic antagonists/anti-parasympathetic drugs
like atropine
4. LABA (long acting beta2 agonists) like adrenalin
5. Long acting steroids—effective if eosinophil count elevate
6. O2 if needed based on pulse oximeter (<88-90%)
7. Some new anti-inflammatory drugs (Monoclonal antibodies-Triple Rx.)
More on COPD/ slowly progressive; no
predictive tests
• FEV peaks at age 20.
• Asthmatics have better prognosis
• CT diagnostic insight (multistage loss of tissue
leads to increase cancer risk
• O2 bronchitis phenotype leads to metabolic
syndrome
• 6 minute walk--<350 meters
• Stress test
 Leading causes of death in US
• Heart disease: 647,457.
• Cancer: 599,108.
• Accidents (unintentional injuries): 169,936.
• Chronic lower respiratory diseases: 160,201.
• Stroke (cerebrovascular diseases): 146,383.
• Alzheimer's disease: 121,404. (5.5 million people
are affected)
• Diabetes: 83,564.
• Influenza and pneumonia: 55,672
• Where will Covid 19 Fit?
 The Pleural Spaces
• Asbestosis and Mesothelioma (of the pleura)
• Pleural Effusions; Transudate or Exudate
• Congestive Heart Failure most common cause
but many others such as Cirrhosis, Cancer,
Pneumonia, Nephrotic syndrome, Drugs
• Empyema
• Hemothorax mainly due to trauma
• Chest Tubes
 Occupational Exposures
• Silicosis
• Black lung disease
• Asbestosis
• Talcosis
• Hyperimmune pulmonitis
• All of these conditions you can multiply by 10
in heavy smokers.
 Lung Cancer: Number one Killer (116,000
cases with 72,000 deaths in 2019
Americans). Five year survival rate 20.5%

• Tobacco responsible for about 90 percent and with 40 pack

year history have 20 times the incidence; currently sixty
percent are diagnosed with advanced disease.
• Therapy Improving with detection at earlier stages:
Surgery; X-ray, Targeted therapy—sequencing and
mutations and Immunotherapy.
• Low dose CT for screening (1 preventable death for every
150 persons screened)
Criteria for screening with LDCT: Smokers age 55-80, 30 pk year history, quite
just within past 15 years.
 Pulmonary Emboli and DVT
• Hypercoagulable states and genetic
predisposition
• Vascular damage or trauma
• Circulatory stasis and dependency
 Emergencies in Oncology
• Hypercalcemia—in 30 % Multiple Myeloma-
bisphophonates, hydration, QT on EKG
• Cord compression-lung, breast, prostate
• Tumor lysis syndrome-increase K and Uric Acid
• Hyponatremia-120-135 mEq-CNS symptoms
• Hyper-viscosity syndrome-increase Igm
• Leukostasis—WBC greater than 100,000
• Febrile neutropenia—WBC 1500-500
• Superior vena cava syndrome
• Related to therapy be it Monoclonal antibodies,
Immunotherapy or Chemotherapy
 Vaping; Electronic Nicotine Device
System (ENDS)
• 25 percent of high school students are
experimenting with vaping
• JUUL
• Addicting and can cause lung damage due to
ingredients such as propylene glycol, THC,
Flavorants, Vitamine E acetate, and heavy
metals such as zinc and manganese.
• Some deaths and permanent pulmonary
fibrosis.
Global Health Disorders
Cardiovascular System
CARDIOVASCULAR SYSTEM
Human Heart with four chambers
Overview of Circulation
The Arch of the Aorta
Cardiac Electrical System
Electrocardio physiologist
Abdominal Aorta and Vena Cava
 Heart Conditions
• Arrhythmias (atrial fib, atrial flutter, heart
blocks, ventricular tachycardia, and
fibrillation)
• CHF (two types)
• HPT
• Congenital defects, atrial septal defects
common (patent fossa ovalus)
Myocardial Infarction/Acute Coronary
Syndromes and Angina
1. One and a half million cases in US yearly (STEMI vs Non STEMI)
Often the cause of SCD (sudden cardiac death) (ECD)
2. Usually presents with crushing central chest pain that can radiate
into the neck and down the arm with profuse sweating, dizziness,
hypotension. Some atypical presentations.
3. A true emergency; 1.Call 911-and EMS squads have monitoring
equipment, medications, means to treat cardiac arrest,
arrhythmias, hypotension, and can alert ER to prepare for PCI in
the cardiac cath lab (85 percent of cases)2. Give aspirin.
4. PCI (window of several hours) and TPA very effective in reversing
coronary artery occlusion.
5. Need to go to hospital with 24/7 cardiac lab for PCI
6. Acute MI due to unstable plaque disruption that causes
inflammation and clot formation. (control of cholesterol may
reverse)
 Atrial Fibrillation
• Irregular irregularity of the pulse; often intermittent
but if persists needs to be treated.
• Fast heart rate generally in the range from 100 to 175
beats a minute
• Why is it serious; less efficiency of the heart, clots in
atrial appendage can migrate causing strokes and
emboli to other organs.
• Risk Factors: age (about ¼ will develop—an epidemic),
hypertension, European ancestry, Diabetes, heart
failure, Ischemic heart disease, Hyperthyroidism, open
heart surgery, moderate to heavy alcohol use
 Treatment of Atrial Fibrillation
• Cardioversion if sustained (within 48 hours) (AED)
• Anticoagulation
• Antiarrhythmic drugs (several classifications)
Main objective is to slow the heart rate and make
the myocardium less irritable.
• Atrial ablations (destroys aberrant pacemakers in
the pulmonary veins)
The Watchman device or tying off the left atrial
appendage where most emboli originate.
 Heart Failure
• An Epidemic due to an aging population;
• Two types of Left Ventricular Heart Failure: Normal and Low
Ejection Fraction Failure: One is a large heart with
ventricular hypertrophy and low EF, the other is normal EF
with normal heart size and wall rigidity.
• Symptoms of SOB, Dyspnea on exertion, orthopnea,
peripheral edema. Possibly coronary syndrome pain.

• Pulmonary Hypertension: (>25 mm Hg/cor pulmonale) due

to hereditary, COPD and other pulmonary diseases, Left
sided heart failure, multiple pulmonary emboli, Obstructive
Sleep Apnea.
Improvements in Treatment of CHF
• Beta Blockers
• ACE inhibitors
• ARB
• ARNI
• SGLT2
• Diuretics relieve symptoms but no survival benefit
• Digoxin—no long term benefit
• Better fluid regulation through device tele-monitoring;
Jugular vein pressure, orthopnea and bendopnea (SOB
within 30 seconds bending over. (decreases
hospitalizations)
 Anti-coagulants: Some Indications
DVT, atrial fib, heart valves, prevent stroke, emboli, massive obesity, cancer
and renal failure

• Warfarin or Coumadin with INR to regulate with 2-3

range effective in patients taking warfarin ($39 per
month) Monthly blood test to regulate
• Factor Xa inhibitors or DOAC (direct oral anticoagulants
such as Eliquis, Pradaxa and Xarelto (average cost per
month $235)
• Aspirin
• Plavix
• NSAIDS
• Heparin
• Low Molecular Weight Heparin (lovenox)
 Tests and Interventions for Acute
Myocardial Infarction, Angina and CHF
• PCI (Percutaneous Cardiac Interventions) and
Atrial Ablations
• Chest X-ray
• Echocardiogram (TEE)
• Stress Test
• Blood Tests for Myocardial Damage
Troponin (now High Sensitivity)
CPK
Natriuretic peptide BNP.
 CT angiography (CTA) of the Heart
• With advanced equipment (64 t 128 detectors)
can visualize coronary vessels 1.5 mm and above.
• If normal, there is 99% negative predictive value
and 10 year warranty that you will not die of a
cardiac event.
• Indications: Chest pain, Equivocal Stress test,
screening before valvular surgery, new onset of
CHF and cardiomyopathy, coronary anomalies,
bypass surgery, stint patency.
 Subacute and Acute Bacterial Endocarditis (infections/vegitations on the
valve leaflets) commonly due to staph aureus and enterococcus in acute and
strep viridans and enterococcus in SBE

• Risk Factors: Mitral value prolapse (20 % of young women), congenital

defects, enlarged hearts, rheumatic fever, prosthetic heart valves, bicuspid
aortic valves and stenosis in older men, HIV and most common today IV
Drug use.
These predisposing conditions are one of the reasons for
prophylactic antibiotics prior to some surgeries such as dental procedures and
bowel surgery.
• Diagnosis via blood cultures and ECHO cardiogram (Transesophageal ECHO
85-90 percent diagnostic)
• SBE is generally slow in onset whereas Acute progresses quickly.
• Treatment; need high doses of bactericidal antibiotics such as Ceftriaxone
and Vancomycin
• One very concerning complication is mycotic emboli to the brain causing
stroke.
 Cardiac Valvular Disease
• Mitral regurgitation common (10 percent over the age of
75) Rx if EF is less than 50% and even between 50 and 50%.
Can cause pulmonary hypertension.
Two types; valvular abnormalities (Mitral Valve
Prolapse), and secondary to LVH or ventricular abn. The
former treat with replacements or mitral clips
• Aortic stenosis due to arteriosclerosis. Bicuspid aortic valve
present serious problem and symptomatic individuals have
low survival rates. Open permanent surgical replacement in
young and percutaneous dilatation and prosthesis in poorer
surgical risk patients.
• Need for anticoagulation and prophylactic antibiotics with
dental procedures.
 Giant Cell Arteritis/Temporal Arteritis
• Headache and fever of unknown origin in
older folks
• Jaw claudication, tenderness over temporal
region and visual loss
• Can involve all large arteries and .5 to 1
percent of population.
• Effective treatment with steroids and new
monoclonal antibodies.
 The Metabolic Syndrome
The Epidemic Complex of
• a. Obesity
• b. Hypertension
• c. Hypercholesterolemia
• d. Hyperlipidemia
• e. Adult Onset of Diabetes Mellitus (Hgb A1C
>6 or 6.5.)
 Major Classifications of
Antihypertensive Medications
• ACE (angiotensin converting enzyme
inhibitors)
• ARBs (Angiotensin II receptor blockers)
• Calcium Channel Blockers
• Beta-blockers
• Diuretics (Thiazides, Loop Diuretics, K+
sparing)
Genitourinary System
The Genitourinary System
Renal Collecting System
Renal Blood Supply and Anatomy

20 Percent of Cardiac output goes to the

Kidney
 Diagram of Renal Tubule/Nephron

Creatinine and Bun

Values
lasix
 Functions of the Kidney
❖Water and electrolyte balance (Na & K)
❖Acid-base balance (Hydronium ion)
❖Elimination of metabolic waste like urea,
creatinine, drugs and toxins
❖Blood pressure regulation with angiotensin
❖Erythropoietin hormone that stimulates RBC
production
 Affliction of Genitourinary System
• Pyelonephritis and Cystitis
• Kidney Stones
• Urinary Incontinence
• Renal Cell Carcinoma and Transitional cell
bladder cancer
• Uremia due to ESRD
• Glomerulonephritis
• Congenital disorders
 The Nephrotic Syndrome; a disorder
effecting the glomeruli of the Kidney
• Massive proteinuria; greater than 3.5 gms
• Hypoalbuminemia less than 2.5 grams per dl
• Hyperlipidemia
• Edema-osmotic pressure

• Many Causes but some idiopathic due to an

unknown factor circulating in the blood.
Male Reproductive System
 Male Problems
• BPH
• Cancer of the prostate
• Prostatitis (acute and chronic)
• Epididymitis
• STD (sexually transmitted disease)
• ED (erectile dysfunction)(Viagra, Cialis, Levitra)
• Peronei's Disease
Cancer of the Prostate; most common
cancer in men;
• 11 percent of men develop with 33,000 deaths
annually
• Usually diagnosed with PSA (and DRE) followed by
trans rectal biopsy and Gleason Score and staging with
bone scan and CT.
• High risk with family history, African-Americans, BRAC-
2 gene.
• Rx: Radical prostatectomy, x-ray therapy,
Brachytherapy, and LHRH and anti androgens like
Flutaminde, and in hormonal resistant disease
Docetaxel or androgen receptor inhibitors like
Enzalutamide
Female Reproductive System
 Overactive Bladder Disorder (OBD) and Urinary
Stress Incontinence (Pelvic Relaxation)
OBD treatments:
▪ Timed Voiding
▪ Anticholinergics
▪ Sacral and tibial nerve stimulation
▪ Botox injections
Urinary Stress Incontinence:
▪ Pessary and perineal exercises
▪ Estrogen vaginal cream
▪ Sling procedures
 More Female Conditions
• Cancer of the Cervix (HPV)
• STD
• Uterine fibroids
• Infertility
• Need for C section?
 Cervical Cancer—13,000 cases a year
• HPV (types 16 & 18) responsible for 70
percent of cases.
• HPV vaccination (females and males?) with
Gardasil 9 at age 11 or 12.
• Pap smears and HPV Testing on cervical
smears
• Colposcopy
• Why don’t PCPs do pelvic examinations?
 Spring Quarter Class
• Sight/ The Eye
• Hearing/The Ear
• Skin/Dermatology
• The Cell and Immunity
• Genetics
• Palliative Pain Management
• Managing Healthcare Costs
• Changes in Medicine in past 50 years.
 Palliative Pain Management
• Overriding issues and goals
• Quality of life
• The emotions of dying as a normal process
• Relief of pain
• Integrate the psychological and spiritual
• Live as active as possible

• Pain as distress: physical, psyche, social,

emotional spiritual
 Nociceptive versus Neuropathic Pain
• Nociceptive pain is the body’s response to
actual damage or stretching like physical
trauma that is divided into two categories:
Somatic pain usually related to trauma that is localized
to the injury or stimulus and often is aching, sharp,
increases with movement
Visceral pain that relates to body organs (usually
obstruction of a viscera) that is often poorly localized,
colicky and frequently radiates.
 Neuropathic Pain
Pain originating with the nerve that represents an
abnormal processing of sensory imputes.
• Allodynia—pain due to a stimulus that does not
normally provoke pain
• Hyperalgesia-- increased pain from a stimulus that
usually provokes pain
• Hyperesthesia-- is an increase in the sensitivity of any
of your senses, such as sight, sound, touch, and smell
• Neuralgia--extreme shooting or stabbing pain that
follows the path of a damaged or irritated nerve
unrelated to the stimulus.
 Assess Pain
• Perception-what makes it worse or better; get
the story from the patient.
• Quality-what it feels like
• Radiation
• Site-severity and relation to movement or
static
• Temporary and timing
• What is impact of pain in your life
 Goals; comfort and functionality
Mild Pain
• Non Pharmacological: massage, PT/OT,
ice/heat, ultrasound, meditation, cognitive,
prayer
• Non-Opioid: NSAIDS (Selective COX 2 like
Celebrex), Acetaminophen, Steroids, Capsaicin
creams, Lidocaine patches
•
 Moderate Pain
• Codeine-usually in cough medicine
• Tramadol-opioid effect, muscle relaxant.
• Hydromorphone-long acting opioid
• Methadone-less addicting, cheap
• Morphine, oxycodone
• Fentanyl patch—long acting
• Buprenorphine patches (in combo with
naloxone used to treat addiction)
 Other Modalities
• Variety of nerve blocks (agents--glycerin,
hypertonic saline, phenol, thermal)
• PCA pump that patient controls
• Pain point injections with lidocaine, steroids
• Epidurals with steroids
• Intrathecal ad epidural pumps
• Vertebralplasty (bone cement), Kyphoplasty to
restore height.
 Pain Pathways

medial lemniscus, also

known as Reil's band or
Reil's ribbon, is a large
ascending bundle of
heavily myelinated axons
that decussate in the
brainstem, specifically in
the medulla oblongata.
Vision/The Eye
Uvea-choroid, ciliary body
and iris
The Sixth Cranial nerve, the
Abducens, the Third, Oculomotor
nerve, and the Fourth, the Trochlear
supply the movements of the eye
 Diseases of the Eye
• Age-Related Macular Degeneration (wet and
dry).
• Cataract.
• Diabetic Retinopathy.
• Glaucoma.
• Amblyopia/strabismus: lazy eye is an
imbalance in the muscles, common and can
result in loss of vision in weak eye. Good
treatment.
 Glasses and
• A nearsighted/myopic person sees near
objects clearly, while objects in the distance
are blurred.
• A farsighted/hyperopia person sees faraway
objects clearly, while objects that are near are
blurred.
• Still another defect of vision is known as
presbyopia or farsightedness due to old age.
 Tests for sight
• Routine exam; eye movements, pupils round and
regular and react to light and accommodation,
nystagmus
• A refraction assessment determines if you have vision
problems such as nearsightedness or farsightedness,
astigmatism (evenly) , or presbyopia
• Tonometry: A standard eye test that is done to
determine the fluid pressure inside the eye.
normal pressure range is 12 to 22 mm Hg
• Visual fields
• Funduscopic examination
The External, Middle and Internal Ear
The Internal Ear
 The vestibulocochlear nerve (auditory vestibular nerve), known as
the eighth cranial nerve transmits sound and equilibrium (balance)
information

• There are four types of hearing loss:

• Auditory Processing Disorders.
• Conductive.
• Sensorineural.
• Mixed.
Types of hearing loss
 The aging ear
• Presbycusis (a type of hearing loss known as
sensorineural) is the loss of hearing that
gradually occurs in most individuals as they
grow older. Hearing loss is a common disorder
associated with aging. About 30-35 percent of
adults age 65 and older have a hearing loss. It
is estimated that 40-50 percent of people 75
and older have a hearing loss.
 Tests for Hearing Loss
• Physical exam; otoscope
• Tuning fork to differentiate between bone and
air conduction.
• Audiometry
 Audiometer Testing
• There are a few tests involved in audiometry. A
pure tone test measures the quietest sound you
can hear at different pitches. It involves using an
audiometer, which is a machine that plays sounds
via headphones. Your audiologist or an assistant
will play a variety of sounds, such as tones and
speech, at different intervals into one ear at a
time, to determine your range of hearing. The
audiologist will give you instructions for each
sound. Most likely, they’ll ask you to raise your
hand when a sound becomes audible.
Every increase of 10 dB on the decibel scale is equal to a 10-fold
increase in sound pressure level (SPL).

Short list of common sounds and how they measure up:

• Normal conversation – 60 dB
• Heavy city traffic – 85 dB
• Lawn mower – 90 dB
• MP3 player at maximum volume – 105 dB
• Sirens – 120 dB
• Concerts – 120 dB
• Sporting events – 105 to 130 dB (depending upon the
stadium)
• Firearms – 150 dB
Quantification of hearing loss
Before you buy
When looking for a hearing aid, explore your options to understand what type of hearing aid will
work best for you. Also:
Get a checkup. See your doctor to rule out correctable causes of hearing loss, such as earwax or
an infection. And have your hearing tested by a hearing specialist (audiologist).
Seek a referral to a reputable audiologist. If you don't know a good audiologist, ask your doctor
for a referral. An audiologist will assess your hearing, help you choose the most appropriate
hearing aid and adjust the device to meet your needs. If you have hearing loss in both ears, you
will get best results with two hearing aids.
Ask about a trial period. You can usually get a hearing aid with a trial period. It may take you a
while to get used to the device and decide if it's right for you. Have the dispenser put in writing
the cost of a trial, whether this amount is credited toward the final cost of the hearing aid and
how much is refundable if you return the hearing aid during the trial period.
Think about future needs. Ask whether the hearing aid you've chosen is capable of increased
power so that it will still be useful if your hearing loss gets worse. Hearing aids do not function
indefinitely, but they should last about five years.
Check for a warranty. Make sure the hearing aid includes a warranty that covers parts and labor
for a specified period. Some dispensers may include office visits or professional services in the
warranty.
Beware of misleading claims. Hearing aids can't restore normal hearing or eliminate all
background noise. Beware of advertisements or dispensers who claim otherwise.
Plan for the expense. The cost of hearing aids varies widely — from about $1,500 to more than
a few thousand dollars each. Professional fees, remote controls, hearing aid accessories and
other hearing aid options may cost extra. Talk to your audiologist about your needs and
expectations.
 Types of Hearing Aids
• In-the-ear (ITE) hearing aids (custom fit)
half-shell designs that fill half the bowl of the outer ear to full-
shell designs that fill almost the entire outer ear bowl,
directional microphones and manual controls
• Invisible in the canal (IIC) small, manual dexterity,
invisible, with string
Completely in the canal (CIC) larger, longer battery life,

• Behind-the-ear (BTE) hearing aids (does not occlude entire

canal) Receiver in the ear (RITE) rechargeable
battery option , telecoil options fits all degrees of hearing
loss, including profound hearing los
Things to Consider
• Analog and digital hearing aids
• Directional microphone
• T-coil (Telephone switch) allows you to switch from the
normal microphone setting to a "T-coil" setting in order
to hear better on the telephone. The voice of the
speaker, who can be some distance away, is amplified
significantly more than any background noise
• Direct audio input
• Feedback suppression helps suppress squeals when a
hearing aid gets too close to the phone or has a loose-
fitting earmold.
• What is a cochlear implant?
• Cochlear implants are complex medical devices that work
differently than hearing aids. Rather than amplifying sound—which
helps a person with residual hearing ability—a cochlear implant
provides the sense of sound by stimulating the auditory nerve
directly.

• Adult candidates are generally eligible for an implant if they:

• Have severe or profound hearing loss in both ears.
• Get little or no benefit from hearing aids.
• Have no medical problems that could put them at risk during
surgery.
• Have a strong desire to be part of the hearing world and
communicate through listening, speaking and speechreading.
 Cost
• The average cost of a hearing aid is $1,000 to $4,000.
• The average price of a single hearing aid is $2,300, according to a 2015 report from
the President's Council of Advisors on Science and Technology. And most people
need two.
• The average price of a single hearing aid is $2,300, according to a 2015 report from
the President's Council of Advisors on Science and Technology. And most people
need two. (Six global manufacturers control 90 percent of the market.)
• According to the website Exposing Hearing Aids, a provider information portal that
also connects patients with providers, a typical hearing aid pricing model breaks
down as follows:
Total patient price: $4,600
Manufacturer costs (materials and research): $1,400
Retailer costs (operating costs, salaries, marketing, continuing education): $2,236
Service costs for the life of the hearing aids (adjustments, cleaning, repairs, batteries):
$574
Potential pretax profit: $350