III.

PATIENT AND HIS ILLNESS

A. Review of Anatomy and Physiology

Cardiovascular System
The heart and circulatory system make up
the cardiovascular system. The heart works as a
pump that pushes blood to the organs, tissues,
and cells of the body. Blood delivers oxygen and
nutrients to every cell and removes the carbon
dioxide and waste products made by those cells.
Blood is carried from the heart to the rest of the
body through a complex network of arteries,
arterioles, and capillaries. Blood is returned to
the heart through venules and veins.

The one-way circulatory system carries blood to all parts of the

body. This process of blood flow within the body is called circulation.
Arteries carry oxygen-rich blood away from the heart, and veins carry
oxygen-poor blood back to the heart. In pulmonary circulation, though,
the roles are switched. It is the pulmonary artery that brings oxygen-poor
blood into the lungs and the pulmonary vein that brings oxygen-rich
blood back to the heart.

Twenty major arteries make a path through the tissues, where they
branch into smaller vessels called arterioles. Arterioles further branch
into capillaries, the true deliverers of oxygen and nutrients to the cells.
Most capillaries are thinner than a hair. In fact, many are so tiny, only
one blood cell can move through them at a time. Once the capillaries
deliver oxygen and nutrients and pick up carbon dioxide and other
waste, they move the blood back through wider vessels called venules.
Venules eventually join to form veins, which deliver the blood back to the
heart to pick up oxygen.
53
 Vasoconstriction or the spasm of smooth muscles around the blood
vessels causes and decrease in blood flow but an increase in pressure.
In vasodilation, the lumen of the blood vessel increase in diameter
thereby allowing increase in blood flow. There is no tension on the walls
of the vessels therefore, there is lower pressure.

Various external factors also cause changes in blood pressure and

pulse rate. An elevation or decline may be detrimental to health.
Changes may also be caused or aggravated by other disease conditions
existing in other parts of the body.

The blood is part of the circulatory system. Whole blood contains

three types of blood cells, including: red blood cells, white blood cells
and platelets.

These three types of blood cells are mostly manufactured in the

bone marrow of the vertebrae, ribs, pelvis, skull, and sternum. These
cells travel through the circulatory system suspended in a yellowish fluid
called plasma. Plasma is 90% water and contains nutrients, proteins,
hormones, and waste products. Whole blood is a mixture of blood cells
and plasma.

Red blood cells (also called erythrocytes) are shaped like slightly
indented, flattened disks. Red blood cells contain an iron-rich protein
called hemoglobin. Blood gets its bright red color when hemoglobin in
red blood cells picks up oxygen in the lungs. As the blood travels
through the body, the hemoglobin releases oxygen to the tissues. The
body contains more red blood cells than any other type of cell, and each
red blood cell has a life span of about 4 months. Each day, the body
produces new red blood cells to replace those that die or are lost from
the body.

White blood cells (also called leukocytes) are a key part of the
body's system for defending itself against infection. They can move in
54
and out of the bloodstream to reach affected tissues. The blood contains
far fewer white blood cells than red cells, although the body can increase
production of white blood cells to fight infection. There are several types
of white blood cells, and their life spans vary from a few days to months.
New cells are constantly being formed in the bone marrow.

Several different parts of blood are involved in fighting infection.

White blood cells called granulocytes and lymphocytes travel along the
walls of blood vessels. They fight bacteria and viruses and may also
attempt to destroy cells that have become infected or have changed into
cancer cells.

Certain types of white blood cells produce antibodies, special

proteins that recognize foreign materials and help the body destroy or
neutralize them. When a person has an infection, his or her white cell
count often is higher than when he or she is well because more white
blood cells are being produced or are entering the bloodstream to battle
the infection. After the body has been challenged by some infections,
lymphocytes remember how to make the specific antibodies that will
quickly attack the same germ if it enters the body again.

Platelets (also called thrombocytes) are tiny oval-shaped cells

made in the bone marrow. They help in the clotting process. When a
blood vessel breaks, platelets gather in the area and help seal off the
leak. Platelets survive only about 9 days in the bloodstream and are
constantly being replaced by new cells.

Blood also contains important proteins called clotting factors, which

are critical to the clotting process. Although platelets alone can plug
small blood vessel leaks and temporarily stop or slow bleeding, the
action of clotting factors is needed to produce a strong, stable clot.

Platelets and clotting factors work together to form solid lumps to

seal leaks, wounds, cuts, and scratches and to prevent bleeding inside
55
and on the surfaces of our bodies. The process of clotting is like a puzzle
with interlocking parts. When the last part is in place, the clot is formed.

When large blood vessels are cut the body may not be able to
repair itself through clotting alone. In these cases, dressings or stitches
are used to help control bleeding.

In addition to the cells and clotting factors, blood contains other

important substances, such as nutrients from the food that has been
processed by the digestive system. Blood also carries hormones
released by the endocrine glands and carries them to the body parts that
need them.

Blood is essential for good

health because the body
depends on a steady supply of
fuel and oxygen to reach its
billions of cells. Even the heart
couldn't survive without blood
flowing through the vessels that
bring nourishment to its muscular
walls. Blood also carries carbon
dioxide and other waste materials to the lungs, kidneys, and digestive
system, from where they are removed from the body.

The heart is a hollow, muscular organ that is divided into four

chambers. The right and left atria (atrium is the singular form) receive
venous blood from the veins, while the right and left ventricles pump
blood into the arteries. Although the heart is a single organ, it functions
as 2 separate pumps. The right half pumps blood into the pulmonary
circuit, while the left half pumps blood into the systemic circuit. A
muscular wall called the septum separates the two halves of the heart.
The atria are separated from the ventricles by a sheet of tough

56
connective tissue called the fibrous skeleton of the heart. Imbedded
within this sheet of tissue are the heart valves.

Endocrine system
The endocrine system is
made up of glands that
produce and secrete
hormones. These hormones
regulate the body’s growth,
metabolism (the physical and
chemical processes of the
body), and sexual
development and function.
The hormones are released
into the bloodstream and may
affect one or several organs
throughout the body.

The role of the endocrine system is to maintain the body in

balance through the release of hormones which transfer information and
instructions from one set of cells to another. Many different hormones
move through the bloodstream, but each type of hormone is designed to
affect only certain cells.

Hormones are chemical messengers created by the body. They

transfer information from one set of cells to another to coordinate the
functions of different parts of the body. Hormones can act on some
specific cells because they themselves do not actually cause an effect. It
is only through binding with a receptor (part of the cell specifically
designed to recognize the hormone) like a key into a lock - that causes a
chain reaction to occur, changing the activity of the cells. If a cell does
not have a receptor for a hormone then there will be no effect. Also,

57
there can be different receptors for the same hormone, and so the same
hormone can have different effects on different cells.

The major glands of the endocrine system are the pituitary,

thyroid, parathyroids, adrenals, pineal body, thymus, and the
reproductive organs (ovaries and testes). The pancreas is also a part of
this system; it has a role in hormone production as well as in digestion. A
gland is a group of cells that produces and secretes chemicals. A gland
selects and removes materials from the blood, processes them, and
secretes the finished chemical product for use somewhere in the body.
The endocrine gland cells release a hormone into the blood stream for
distribution throughout the entire body. These hormones act as chemical
messengers and can alter the activity of many organs at once.

The hypothalamus controls all the processes undergone by

the anterior and posterior pituitary glands. It initiates the production of
hormones by the APG. The APG is controlled by releasing hormones
which are chemical signals produced by the nerve cells of the
hypothalamus, causing either stimulation or inhibition of hormone
production. Secretion of hormones by the PPG is controlled by nervous
system stimulation of nerve cells in the hypothalamus. Parathyroid
glands secrete parathyroid hormone which is essential for the regulation
of blood calcium levels. Adrenal glands produce epinephrine and
norepinephrine which are fight-or-flight hormones that prepare the body
for vigorous physical activity. Testes and ovaries produce hormones that
are responsible for secondary sex characteristics, spermatogenesis, and
oogenesis. The thymus gland secretes thymosin which aids in the
synthesis of WBC for fighting infection. This gland decreases in size in
some older adults. The pineal body releases melatonin that is thought to
decrease the secretion of LSH & FSH by decreasing the release of
hypothalamic-releasing hormones. The thyroid gland, located on either
side of the trachea, is controlled by the thyroid stimulating hormone

58
releases by the anterior pituitary gland, which was initially stimulated by
the TSH releasing hormone from the hypothalamus.

The pancreas is also part of the body's hormone-secreting system,

even though it is also associated with the digestive system because it
produces and secretes digestive enzymes. The pancreas produces two
important hormones, insulin and glucagon. They work together to
maintain a steady level of glucose, or sugar, in the blood and to keep the
body supplied with fuel to produce and maintain stores of energy. The
pancreas completes the job of breaking down protein, carbohydrates,
and fats using digestive juices of pancreas combined with juices from the
intestines, secretes hormones that affect the level of sugar in the blood,
and produces chemicals that neutralize stomach acids that pass from
the stomach into the small intestine by using substances in pancreatic
juice. It contains Islets of Langerhans, which are tiny groups of
specialized cells that are scattered throughout the organ.

In humans, the pancreas is a 15-25 cm (6-10 inch) elongated

organ in the abdomen adjacent to the small intestine and lies toward the
back. It has three regions: a head (abuts a part of the duodenum), body
(at the level of L2 of the spine) and tail (extends toward the spleen).

The pancreatic duct (also called the duct of Wirsung) runs the
length of the pancreas and empties into the second part of the
duodenum at the ampulla of Vater. The common bile duct usually joins
the pancreatic duct at or near this point. Many people also have a small
accessory duct, the duct of Santorini, which extends from the main duct
more upstream (towards the tail) to the duodenum, joining it more
proximal than the ampulla of Vater.

The pancreas is supplied arterially by the Pancreaticoduodenal

arteries and the splenic artery: the splenic artery supplies the neck,
body, and tail of the pancreas; the superior mesenteric artery provides

59
 the inferior pancreaticoduodenal artery; and the gastroduodenal artery
provides the superior pancreaticoduodenal artery.

Venous drainage is via the pancreaticoduodenal veins which end

up in the portal vein. The splenic vein passes posterior to the pancreas
but is said to not drain the pancreas itself. The portal vein is formed by
the union of the superior mesenteric vein and splenic vein posterior to
the neck of the pancreas. In some people (some books say 40% of
people); the inferior mesenteric vein also joins with the splenic vein
behind the pancreas (in others it simply joins with the superior
mesenteric vein instead).

The pancreas is a compound gland in the sense that it is

composed of both exocrine and endocrine tissues. The exocrine function
of the pancreas involves the synthesis and secretion of pancreatic
juices. The endocrine function resides in the million or so cellular islands
(the islets of Langerhans) embedded between the exocrine units of the
pancreas. Beta cells of the islands secrete insulin, which helps control
carbohydrate metabolism. Alpha cells of the islets secrete glucagon that
counters the action of insulin.

There are four main types of cells in the islets of Langerhans. They
are relatively difficult to distinguish using standard staining techniques,
but they can be classified by their secretion:

Name of cells Endocrine product % of islet cells Representative function

beta cells Insulin and Amylin 50-80% lower blood sugar
alpha cells Glucagon 15-20% raise blood sugar
delta cells Somatostatin 3-10% inhibit endocrine pancreas
PP cells Pancreatic polypeptide 1% inhibit exocrine pancreas
The islets are a compact collection of endocrine cells arranged in
clusters and cords and are crisscrossed by a dense network of
capillaries. The capillaries of the islets are lined by layers of endocrine
cells in direct contact with vessels, and most endocrine cells are in direct

60
 contact with blood vessels, by either cytoplasmic processes or by direct
apposition. There are two main types of exocrine pancreatic cells,
responsible for two main classes of secretions.

Name of cells Exocrine secretion Primary signal

Centroacinar
bicarbonate ions Secretin
cells
digestive enzymes
Basophilic cells (pancreatic amylase, Pancreatic lipase, CCK
trypsinogen, chymotrypsinogen, etc.)

Respiratory System

The respiratory system generally includes tubes, such as the

bronchi, used to carry air to the lungs, where gas exchange takes place.
A diaphragm pulls air in and pushes it out. Respiratory systems of
various types are found in a wide variety of organisms. Even trees have
respiratory systems.

In humans, the respiratory system consists of the airways, the

lungs, and the respiratory muscles that mediate the movement of air into
and out of the body. Within the alveolar system of the lungs, molecules
of oxygen and carbon dioxide are passively exchanged, by diffusion,
between the gaseous environment and the blood. Thus, the respiratory
system facilitates oxygenation of the blood with a concomitant removal
of carbon dioxide and other gaseous metabolic wastes from the
circulation. The system also helps to maintain the acid-base balance of
the body through the efficient removal of carbon dioxide from the blood.

1. The Sinuses (frontal, maxillary, and sphenoidal) are hollow

spaces in the bones of the head. Small openings connect them to the
nose. The functions they serve include helping to regulate the
temperature and humidity of air breathed in, as well as to lighten the
bone structure of the head and to give resonance to the voice.

61
 2. The Nose (nasal cavity) is the preferred entrance for outside air
into the respiratory system. The hairs that line the wall are part of the air-
cleaning system.

3. Air also enters through the Mouth (oral cavity), especially in

people who have a mouth-breathing habit or whose nasal passages may
be temporarily obstructed, as by a cold or during heavy exercise.

4. The Adenoids are lymph tissue at the top of the throat. When
they enlarge and interfere with breathing, they may be removed. The
lymph system, consisting of nodes (knots of cells) and connecting
vessels, carries fluid throughout the body. This system helps to resist
body infection by filtering out foreign matter, including germs, and
producing cells (lymphocytes) to fight them.

5. The Tonsils are lymph nodes in the wall of the throat (pharynx)
that often become infected. They are part of the germ-fighting system of
the body.

6. The Throat (pharynx) collects incoming air from the nose and
mouth and passes it downward to the windpipe (trachea).

7. The Epiglottis is a flap of tissue that guards the entrance to the

windpipe (trachea), closing when anything is swallowed that should go
into the esophagus and stomach.

8. The Voice Box (larynx) contains the vocal chords. It is the place
where moving air being breathed in and out creates voice sounds.

9. The Esophagus is the passage leading from the mouth and

throat to the stomach.

10. The Windpipe (trachea) is the passage leading from the throat
(pharynx) to the lungs.

62
 11. The Lymph nodes of the lungs are found against the walls of
the bronchial tubes and windpipe.

12. The rib cages are bones supporting and protecting the chest
cavity. They move to a limited degree, helping the lungs to expand and
contract.

13. The windpipe divides into the two main Bronchial tubes, one
for each lung, which subdivide into each lobe of the lungs. These, in
turn, subdivide further.

14. The right lung is divided into three Lobes, or sections. Each
lobe is like a balloon filled with sponge-like tissue. Air moves in and out
through one opening -- a branch of the bronchial tube.

15. The left lung is divided into two Lobes.

16. The Pleura are the two membranes, actually one continuous
one folded on it, that surround each lobe of the lungs and separate the
lungs from the chest wall.

17. The bronchial tubes are lines with Cilia (like very small hairs)
that have a wave-like motion. This motion carried Mucus (sticky phlegm
or liquid) upward and out into the throat, where it is either coughed up or
swallowed. The mucus catches and holds much of the dust, germs, and
other unwanted matte that has invaded the lungs. You get rid of this
matter when you cough, sneeze, clear your throat or swallow.

18. The Diaphraghm is the strong wall of muscle that separates

the chest cavity from the abdominal cavity. By moving downward, it
creates suction in the chest to draw in air and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called

Bronchioles, at the ends of which are the air sacs or alveoli (plural of
alveolus).

63
 20. The Alveoli are the very small air sacs that are the destination
of air breathed in. The Capillaries are blood vessels that are imbedded in
the walls of the alveoli. Blood passes through the capillaries, brought to
them by the Pulmonary artery and taken away by the Pulmonary vein.
While in the capillaries the blood gives off carbon dioxide through the
capillary wall into the alveoli and takes up oxygen from the air in the
alveoli.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract,

moving the ribcage up and out. The diaphragm moves down at the same
time, creating negative pressure within the thorax. The lungs are held to
the thoracic wall by the pleural membranes, and so expand outwards as
well. This creates negative pressure within the lungs, and so air rushes
in through the upper and lower airways.
Expiration is mainly due to the natural elasticity
of the lungs

Physiology of Gas Exchange

Each branch of the bronchial tree

eventually sub-divides to form very narrow
terminal bronchioles, which terminate in the
alveoli. There are many millions of alveoli in
each lung, and these are the areas
responsible for gaseous exchange, presenting a massive surface area
for exchange to occur over.

Each alveolus is very closely associated with a network of

capillaries containing deoxygenated blood from the pulmonary artery.
The capillary and alveolar walls are very thin, allowing rapid exchange of

64
gases by passive diffusion along concentration gradients. CO2 moves
into the alveolus as the concentration is much lower in the alveolus than
in the blood, and O2 moves out of the alveolus as the continuous flow of
blood through the capillaries prevents saturation of the blood with O 2 and
allows maximal transfer across the membrane.

65