Cyanosis

Cyanosis is a blue coloration of the skin and mucous membranes due to the presence of deoxygenated hemoglobin in blood vessels near the skin surface. It occurs when the oxygen saturation of arterial blood falls below 85-90% (1.5g/dl deoxyhemoglobin). The name is derived from the color cyan, the Greek word for blue.

Although human blood is always a shade of red (except in rare cases of hemoglobin-related disease), the optical properties of skin distort the dark red color of deoxygenated blood to make it appear blueish.

The elementary principle behind cyanosis is that deoxygenated hemoglobin is more prone to the optical bluish discoloration, and also produces vasoconstriction that makes it more evident. The scattering of color that produces the blue hue of veins and cyanosis is similar to the process that makes the sky and large bodies of water appear blue: some colors are refracted and absorbed more than others. During cyanosis, tissues are uncharacteristically low on oxygen, and therefore tissues that would normally be filled with bright oxygenated blood are instead filled with darker, deoxygenated blood. Darker blood is much more prone to the blue-shifting optical effects, and thus oxygen deficiency - hypoxia - leads to blue discoloration of the lips and other mucous membranes.

Types:
Cyanosis can occur in the fingers, including underneath the fingernails, as well as other extremities (called peripheral cyanosis), or in the lips and tongue (central cyanosis).

Central cyanosis is often due to a circulatory or ventilatory problem that leads to poorer blood oxygenation in the lungs or greater oxygen extraction due to slowing down of blood circulation in the skin's blood vessels.

Acute cyanosis can be a result of asphyxiation or choking, and is one of the surest signs that respiration is being blocked.

Peripheral cyanosis is the blue tint in fingers or extremities, due to inadequate circulation. The blood reaching the extremities is not oxygen rich and when viewed through the skin a combination of factors can lead to the appearance of a blue color. All factors contributing to central cyanosis can also cause peripheral symptoms to appear, however peripheral cyanosis can be observed without there being heart or lung failures. Small blood vessels may be restricted and can be treated by increasing the normal oxygenation level of the blood.

Causes:
Common causes of central cyanosis- Abnormal hemoglobin levels, Congenital heart disease, Heart failure, Heart valve disease, High altitude, Hypothermia, Hypoventilation, Lung disease, Myocardial infarction, Polycythaemia, Pulmonary embolism, COPD (Emphysema and Chronic Bronchitis), Asthma, Methemoglobinemia, Tetralogy of Fallot (heart defect).

Common causes of acute cyanosis- Choking, Inhaled foreign body, Cold exposure, Drug overdose, Shock, Asthma, Pneumothorax, Heart failure, Left ventricular failure.

Common causes of peripheral cyanosis- All common causes of central cyanosis, Arterial obstruction, Cold exposure (due to vasoconstriction), Raynaud's phenomenon (vasoconstriction), Reduced cardiac output (e.g. heart failure, hypovolaemia), Vasoconstriction, Venous obstruction (e.g. deep vein thrombosis).

Symptoms:
Adult respiratory distress syndrome, Asphyxia, Asthma, Blue baby, Bronchopulmonary dysplasia, Chemical pneumonia, Chronic Bronchitis, Chronic Obstructive Pulmonary Disease, Congenital heart defects, Dermatomyositis, Drowning, Emphysema, Epiglotitis, Erythromelalgia, Familial emphysema, Heart attack, Immune Thrombocytopenic Purpura, Kaposi's Sarcoma,
Melioidosis, Methahemoglobinemia, Mountain sickness, Necrotizing fasciitis, Neonatal Respiratory Distress Syndrome, Pneumoconiosis, Pneumonia, Primary pulmonary hypertension, Pulmonary edema, Pulmonary embolism, Raynaud's phenomenon, Sarcoidosis, Shaken Baby Syndrome, Shock, Whooping Cough.

Diagnosis:

Treatment:

Cushing's Syndrome

Cushing's syndrome is a condition that occurs when your body is exposed to high levels of the hormone cortisol for a prolonged period of time. Sometimes called hypercortisolism, Cushing's syndrome can occur when your adrenal glands, located above your kidneys, make too much cortisol. It may also develop if you're taking high doses of cortisol-like medications (corticosteroids) for a prolonged period.

Too much cortisol can produce some of the hallmark signs of Cushing's syndrome — a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. It can also result in high blood pressure, bone loss and, on occasion, diabetes.

The most common cause of Cushing's syndrome is the use of oral corticosteroid medication. By contrast, it's rare for the cause to be excess cortisol production by your body. The syndrome is named after Harvey Cushing, an American surgeon who first identified the condition in 1932.

Treatments for Cushing's syndrome are designed to return your body's cortisol production to normal. By normalizing or even markedly lowering cortisol levels, you'll experience noticeable improvements in your signs and symptoms. Left untreated, however, Cushing's syndrome can eventually lead to death.

Causes:
Your endocrine system consists of glands that produce hormones, which regulate processes throughout your body. These glands include the adrenal glands, pituitary gland, thyroid gland, parathyroid glands, pancreas, ovaries (in females) and testicles (in men).

Your adrenal glands produce a number of hormones, including cortisol. Cortisol plays a variety of roles in your body. For example, cortisol helps regulate your blood pressure and keeps your cardiovascular system functioning normally. It also helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy. However, when the level of cortisol is too high in your body, you may develop Cushing's syndrome.

Cushing's syndrome can develop from a cause that originates outside of your body (Exogenous Cushing's syndrome). Taking corticosteroid medications in high doses over an extended period of time may result in Cushing's syndrome. These medications, such as prednisone, dexamethasone (Decadron) and methylprednisolone (Medrol), have the same effects as does the cortisol produced by your body. People can also develop Cushing's from injectable corticosteroids — for example, repeated injections for joint pain, bursitis and back pain. While certain inhaled steroid medicines (taken for asthma) and steroid skin creams (for skin disorders such as eczema) are in the same general category of drugs, they're generally not implicated in Cushing's syndrome unless taken in very high doses.

The condition may also be due to your body's own overproduction of cortisol (Endogenous Cushing's syndrome). This may occur from excess production by one or both adrenal glands, or overproduction of the adrenocorticotropic hormone (ACTH), which normally regulates cortisol production. In these cases, Cushing's syndrome may be related to:
* A pituitary gland tumor- A noncancerous (benign) tumor of the pituitary gland, located at the base of the brain, secretes an excess amount of ACTH, which in turn stimulates the adrenal glands to make more cortisol. When this form of the syndrome develops, it's called Cushing's disease. It occurs five times as often in women as in men and is the most common form of endogenous Cushing's syndrome.
* An ectopic ACTH-secreting tumor- Rarely, when a tumor develops in an organ that normally does not produce ACTH, the tumor will begin to secrete this hormone in excess, resulting in Cushing's syndrome. These tumors, which can be benign or cancerous (malignant), are usually found in the lung, pancreas, thyroid or thymus gland.
* A primary adrenal gland disease- In some people, the cause of Cushing's syndrome is excess cortisol secretion that doesn't depend on stimulation from ACTH and is associated with disorders of the adrenal glands. The most common of these disorders is a noncancerous tumor of the adrenal cortex, called an adrenal adenoma. Cancerous tumors of the adrenal cortex are rare, but they can cause Cushing's syndrome as well. Occasionally, benign, nodular enlargement of both adrenal glands can result in Cushing's syndrome.

Symptoms:
Common signs and symptoms of Cushing's syndrome include:
* Weight gain, particularly around your midsection and upper back
* Fatigue.
* Muscle weakness.
* Rounding of your face (moon face).
* Facial flushing.
* Fatty pad or hump between your shoulders (buffalo hump).
* Pink or purple stretch marks (striae) on the skin of your abdomen, thighs, breasts and arms.
* Thin and fragile skin that bruises easily.
* Slow healing of cuts, insect bites and infections.
* Depression, anxiety and irritability.
* Thicker or more visible body and facial hair (hirsutism).
* Acne.
* Irregular or absent menstrual periods in females.
* Erectile dysfunction in males.
* High blood pressure.

Diagnosis:
Cushing's syndrome can be difficult to diagnose, particularly endogenous Cushing's, because other conditions share the same signs and symptoms.

Your doctor will conduct a physical exam, looking for signs of Cushing's syndrome. He or she may suspect Cushing's syndrome if you have signs such as rounding of the face (moon face), a pad of fatty tissue at the shoulders and neck (buffalo hump), and thin skin with bruises and stretch marks. Your doctor may ask you about signs and symptoms such as fatigue, depression and weight change.

If you've been taking a corticosteroid medication long term, your doctor may suspect that you've developed Cushing's syndrome as a result of this drug. If you haven't been using a corticosteroid medication, these diagnostic tests may help pinpoint the cause:

Urine and blood tests- These tests measure hormone levels in your urine and blood and show whether your body is producing excessive cortisol. For the urine test, you may be asked to collect a sample of your urine over a 24-hour period. Both the urine and blood samples will be sent to a laboratory to be analyzed for cortisol levels.

Saliva test- Cortisol levels normally rise and fall throughout the day. In people without Cushing's syndrome, levels of cortisol drop significantly overnight. By analyzing cortisol levels from a small sample of saliva collected between 11 p.m. and midnight, doctors can see if cortisol levels are too high, indicating a diagnosis of Cushing's.

Imaging tests- Computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans can provide images of your pituitary and adrenal glands to locate abnormalities, such as tumors.

As these tests help your doctor diagnose Cushing's syndrome, they may also rule out medical conditions with similar signs and symptoms. For example, polycystic ovary syndrome — a hormone disorder in women with enlarged ovaries — shares some of the same signs and symptoms as Cushing's has, such as excessive hair growth and irregular menstrual periods. Depression, eating disorders and alcoholism also can partially mimic Cushing's syndrome.

Treatment:
Treatments for Cushing's syndrome are designed to lower the high level of cortisol in your body. The best treatment for you depends on the cause of the syndrome. Treatment options include:

Reducing corticosteroid use- If the cause of Cushing's syndrome is long-term use of corticosteroid medications, your doctor may be able to keep your Cushing's signs and symptoms under control by reducing the dosage of the drug over a period of time, while still adequately managing your asthma, arthritis or other condition. For many of these medical problems, your doctor can prescribe noncorticosteroid drugs, which will allow him or her to reduce the dosage or eliminate the use of corticosteroids altogether.

Surgery- If the cause of Cushing's syndrome is a tumor, your doctor may recommend complete surgical removal. Pituitary tumors are typically removed by a neurosurgeon, who may perform the procedure through your nose. If a tumor is present in the adrenal glands, lung or pancreas, the surgeon can remove it through a standard operation or in some cases by using minimally invasive surgical techniques, with smaller incisions.

Radiation therapy- If the surgeon can't totally remove the pituitary tumor, he or she will usually prescribe radiation therapy to be used in conjunction with the operation. Additionally, radiation may be used for people who aren't suitable candidates for surgery. Radiation can be given in small doses over a six-week period, or by a technique called stereotactic radiosurgery or gamma-knife radiation.

Medical therapy- In some situations, when surgery and radiation don't produce a normalization of cortisol production, your doctor may advise medical therapy. Medications to control excessive production of cortisol include ketoconazole (Nizoral), mitotane (Lysodren) and metyrapone (Metopirone). Medical therapy is also sometimes used before surgery for people who are very sick. Doing so may improve their signs and symptoms and minimize their surgical risk.

In some cases, the tumor or its treatment will cause other hormones produced by the pituitary or adrenal gland to become deficient and your doctor will recommend hormone replacement medications.

Left untreated, Cushing's syndrome can lead to death. However, most often, treatments improve signs and symptoms and normalize cortisol levels.

Crohns Disease

Crohn's disease, a type of inflammatory bowel disease (IBD), is a condition in which the lining of your digestive tract becomes inflamed, causing severe diarrhea and abdominal pain. The inflammation often spreads deep into the layers of affected tissue. Like ulcerative colitis, another common IBD, Crohn's disease can be both painful and debilitating and sometimes may lead to life-threatening complication.

While there's no known medical cure for Crohn's disease, therapies can greatly reduce the signs and symptoms of Crohn's disease and even bring about a long-term remission. With these therapies, many people afflicted with Crohn's disease are able to function normally in their everyday lives.

Causes:
The exact cause of Crohn's disease is unknown. However, genetic and environmental factors have been invoked in the pathogenesis of the disease. Research has indicated that Crohn's disease has a strong genetic link. The disease runs in families and those with a sibling with the disease are 30 times more likely to develop it than the normal population. Ethnic background is also a risk factor. Until very recently, whites and European Jews accounted for the vast majority of the cases in the United States, and in most industrialized countries, this demographic is still true.

Mutations in the CARD15 gene (also known as the NOD2 gene) are associated with Crohn's disease and with susceptibility to certain phenotypes of disease location and activity. In earlier studies, only two genes were linked to Crohn's, but scientists now believe there are over eight genes that show genetics play a crucial role in the disease.

It's possible that a virus or bacterium may cause Crohn's disease. When your immune system tries to fight off the invading microorganism, the digestive tract becomes inflamed. One microorganism that may be involved in the development of Crohn's is Mycobacterium avium subspecies paratuberculosis (MAP), a bacterium that causes intestinal disease in cattle. Researchers have found MAP in the blood and intestinal tissue of many people with Crohn's disease, but only rarely in people with ulcerative colitis.

There's no clear evidence that MAP causes Crohn's disease. Some researchers believe that a genetic susceptibility may trigger an abnormal response to the bacterium in some people. Currently, most investigators believe that some people with the disease develop it because of an abnormal immune response to bacteria that normally live in the intestine.

Symptoms:
Signs and symptoms of Crohn's disease can range from mild to severe and may develop gradually or come on suddenly, without warning. They include:

Diarrhea- The inflammation that occurs in Crohn's disease causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can't completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping also can contribute to loose stools. In mild cases, stools may simply be looser or more frequent than usual. But people with severe disease may have dozens of bowel movements a day, affecting both sleep and ordinary activities.
Abdominal pain and cramping- Inflammation and ulceration may cause the walls of portions of your bowel to swell and eventually thicken with scar tissue. This affects the normal movement of intestinal tract contents through your digestive tract and may lead to pain and cramping. Mild Crohn's disease usually causes slight to moderate intestinal discomfort, but in more serious cases, the pain may be severe and occur with nausea and vomiting.
Blood in your stool- Food moving through your digestive tract can cause inflamed tissue to bleed, or your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. You can also have bleeding you don't see (occult blood). In severe disease, bleeding is often serious and ongoing.
Ulcers- Crohn's disease begins as small, scattered sores on the surface of the intestine. Eventually these sores may become large ulcers that penetrate deep into — and sometimes through — the intestinal walls. You may also have ulcers in your mouth similar to canker sores.
Reduced appetite and weight loss- Abdominal pain and cramping and the inflammatory reaction in the wall of your bowel can affect both your appetite and your ability to digest and absorb food.
Fistula or abscess- Inflammation from Crohn's disease may tunnel through the wall of the bowel into adjacent organs, such as the bladder or vagina, creating an abnormal connection called a fistula. This can also lead to an abscess, a swollen, pus-filled sore. The fistula may also tunnel out through your skin. A common place for this type of fistula is in the area around the anus. When this occurs, it's called perianal fistula.

Diagnosis:
Blood tests- Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection. Two tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but not everyone with Crohn's disease or ulcerative colitis has these antibodies.
Colonoscopy- This test allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis.
Flexible sigmoidoscopy- In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last 2 feet of your colon. The test usually takes just a few minutes. It's somewhat uncomfortable, and there's a slight risk of perforating the colon wall. It may also miss problems higher up in your colon or in your small intestine.
Barium enema- This diagnostic test allows your doctor to evaluate your large intestine with an X-ray. Before the test, barium, a contrast dye, is placed into your bowel in an enema form. Sometimes, air also is added. The barium fills and coats the lining of the bowel, creating a silhouette of your rectum, colon and a portion of your small intestine.
Small bowel X-ray- This test looks at the part of the small bowel that can't be seen by colonoscopy. After you drink barium, X-ray pictures are taken of your small intestine. The test can help locate areas of narrowing or inflammation in the small bowel that are seen in Crohn's disease.
Computerized tomography (CT)- Sometimes you may have a CT scan, a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel that can't be seen with other tests. Your doctor may order this scan to better understand the location and extent of your disease or to check for complications such as a partial blockages, abscesses or fistulas. Although not invasive, a CT scan exposes you to more radiation than a conventional X-ray does.

Capsule endoscopy- If you have signs and symptoms that suggest Crohn's disease but the usual diagnostic tests are negative, your doctor may perform capsule endoscopy. For this test you swallow a capsule that has a camera in it. The camera takes pictures, which are transmitted to a computer that you wear on your belt. The images are then downloaded, displayed on a monitor and checked for signs of Crohn's disease. Once it's made the trip through your digestive system, the camera exits your body painlessly in your stool.

Capsule endoscopy is generally very safe, but if you have a partial blockage in the bowel, there's a slight chance the capsule may become lodged in your intestine. Your doctor will try to minimize the chance of this by performing other diagnostic tests to look for a partial blockage before you have this procedure. If the camera does become lodged in the bowel, it may need to be surgically removed.

Treatment:
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

Sulfasalazine (Azulfidine)- Doctors have used this drug for many years to treat Crohn's disease. Although it can be effective in reducing symptoms of the disease, it has a number of side effects, including nausea, vomiting, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
Mesalamine (Asacol, Rowasa)- This medication tends to have fewer side effects than sulfasalazine has. You take it in tablet form or use it rectally in the form of an enema or suppository, depending on which part of your colon is affected.
Corticosteroids- Corticosteroids can help reduce inflammation anywhere in your body, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More serious side effects include high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts and an increased susceptibility to infections. Long-term use of corticosteroids in children can lead to stunted growth.

Immune system suppressors are drugs which reduce inflammation, but they target your immune system rather than treating inflammation itself.
Azathioprine (Imuran) and mercaptopurine (Purinethol)- These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Although it can take up to three months for these medications to begin to work, they help reduce signs and symptoms of IBD in general and can heal fistulas from Crohn's disease in particular. If you're taking either of these medications, you'll need to follow up closely with your doctor and have your blood checked regularly to look for side effects.
Infliximab (Remicade)- This drug is specifically for adults and children with moderate to severe Crohn's disease who don't respond to or can't tolerate other treatments. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract and contributes to the formation of fistulas.
Methotrexate (Rheumatrex)- This drug, normally used to treat cancer, is sometimes used for people with Crohn's disease who don't respond well to other medications. It starts working in about eight to 10 weeks. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause allergic pneumonia.
Cyclosporine (Neoral, Sandimmune)- This potent drug, which is most often used to help heal Crohn's-related fistulas, is normally reserved for people who don't respond well to other medications. Cyclosporine begins working in one to two weeks — more quickly than less toxic drugs — but it has the potential for serious side effects, such as kidney and liver damage, high blood pressure, seizures, fatal infections and an increased risk of lymphoma.

Antibiotics can heal fistulas and abscesses in people with Crohn's disease. Researchers also believe antibiotics help reduce harmful intestinal bacteria and directly suppress the intestine's immune system, which can trigger symptoms. Frequently prescribed antibiotics include:
Metronidazole (Flagyl)- Once the most commonly used antibiotic for Crohn's disease, metronidazole can sometimes cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness. If these effects occur, stop the medication and call your doctor. Other side effects include nausea, a metallic taste in your mouth, headache, dizziness and loss of appetite. Avoid alcoholic beverages while taking this medication because a severe reaction may result.
Ciprofloxacin (Cipro)- This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole. Ciprofloxacin may cause fainting, an irregular heartbeat, abdominal pain, diarrhea, fatigue and, rarely, tendon problems.

Coronary heart disease

Coronary heart disease (CHD), also called coronary artery disease (CAD), ischaemic heart disease, atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the muscle of the heart) with oxygen and nutrients. It is the leading cause of death in the U.S. While the symptoms and signs of coronary heart disease are noted in the advanced state of disease, most individuals with coronary heart disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms, often a "sudden" heart attack, finally arise. After decades of progression, some of these atheromatous plaques may rupture and (along with the activation of the blood clotting system) start limiting blood flow to the heart muscle. The disease is the most common cause of sudden death, and is also the most common reason for death of men and women over 20 years of age.

Overview:
Atherosclerotic heart disease can be thought of as a wide spectrum of disease of the heart. At one end of the spectrum is the asymptomatic individual with atheromatous streaks within the walls of the coronary arteries (the arteries of the heart). These streaks represent the early stage of atherosclerotic heart disease and do not obstruct the flow of blood. A coronary angiogram performed during this stage of diseases may not show any evidence of coronary artery disease, because the lumen of the coronary artery has not decreased in calibre.

Atheromatous plaques that cause obstruction of less than 70 percent of the diameter of the vessel rarely cause symptoms of obstructive coronary artery disease. As the plaques grow in thickness and obstruct more than 70 percent of the diameter of the vessel, the individual develops symptoms of obstructive coronary artery disease. At this stage of the disease process, the patient can be said to have ischemic heart disease. The symptoms of ischemic heart disease are often first noted during times of increased workload of the heart. For instance, the first symptoms include exertional angina or decreased exercise tolerance.

As the degree of coronary artery disease progresses, there may be near-complete obstruction of the lumen of the coronary artery, severely restricting the flow of oxygen-carrying blood to the myocardium. Individuals with this degree of coronary heart disease typically have suffered from one or more myocardial infarctions (heart attacks), and may have signs and symptoms of chronic coronary ischemia, including symptoms of angina at rest and flash pulmonary edema.

Causes:
Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:

* Smoking
* High amounts of certain fats and cholesterol in the blood
* High blood pressure
* High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged.

The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle.

Plaque also can crack, which causes blood cells called platelets (PLATE-lets) to clump together and form blood clots at the site of the cracks. This narrows the arteries more and worsens angina or causes a heart attack.

Symptoms:
There are often no typical symptoms as they are well known for coronary heart disease; Cardiac Syndrome X often is a diagnosis of exclusion. However, the following list may be helpful in diagnosing the disease:

* Chest pain or Angina, quite often at rest; the pain may spread to the left arm or the neck, back, throat, or jaw. There might be present a numbness (paresthesia) or a loss of feeling in the arms, shoulders, or wrists. Patients with female-pattern coronary artery disease often have chest pain after they exercise and a very variable duration of angina episodes.
* Coronary angiography demonstrates “normal” coronary arteries, i. e. no blockages or stenoses can be detected in the larger epicardial vessels.
* No inducible coronary artery spasm present during cardiac catheterization.
* Characteristic ischemic ECG changes during exercise testing.
* ST segment depression and angina in the absence of left ventricular wall motion abnormalities during pharmacological stress test.
* Reduction of platelet aggregation after exercise (aggregation time 10 seconds).
* Inconstant or partial response to sublingual nitrates.
* Absence of cardiac or systemic diseases potentially associated with microvascular dysfunction.
* Postmenopausal or menopausal status.
* Impaired quality of life.

The diagnosis of “Cardiac Syndrome W” - female-pattern coronary artery disease often is, as mentioned, an “exclusion” diagnosis. Therefore, usually the same tests are used as in any patient with the suspicion of coronary heart disease:

* Baseline ECG
* Exercise ECG – Stress test
* Exercise radioisotope test (nuclear stress test, myocardial scintigraphy).
* Echocardiography (including stress echocardiography).
* Coronary angiography.
* Intravascular ultrasound.
* MRI scan.

Diagnosis:
EKG (Electrocardiogram)- An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack.

Echocardiography- This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

Chest X Ray- A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Blood Tests- Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD.
Coronary Angiography and Cardiac Catheterization- Your doctor may ask you to have coronary angiography if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries.
To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.
Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

Treatment:
Making lifestyle changes can often help prevent or treat CAD. For some people, these changes may be the only treatment needed:

* Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight
* Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you.
* Lose weight, if you're overweight or obese.
* Quit smoking, if you smoke. Avoid exposure to secondhand smoke.
* Learn to cope with and reduce stress.

You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label.

Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

* Whole grain cereals such as oatmeal and oat bran.
* Fruits such as apples, bananas, oranges, pears, and prunes.
* Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans.

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber.

Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel.

You also should try to limit the amount of sodium (salt) that you eat. This means choosing low-sodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item.

Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day.

Regular physical activity can lower many CAD risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the "good" cholesterol that helps prevent CAD).

Therapeutic options for coronary heart disease today are based on three principles:

1. Medical treatment- drugs, e.g. nitroglycerin, beta-blockers, calcium antagonists, etc.
2. Coronary interventions as angioplasty and stent-implantation.
3. Coronary artery bypass grafting (CABG - coronary artery bypass surgery). Recent research efforts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem cell therapies.

Convulsions

Convulsions are when a person's body shakes rapidly and uncontrollably. During convulsions, the person's muscles contract and relax repeatedly.

The term "convulsion" is often used interchangeably with "seizure," although there are many types of seizure, some of which have subtle or mild symptoms instead of convulsions. Seizures of all types are caused by disorganized and sudden electrical activity in the brain.

Causes:
Epilepsy, Alcohol use, Barbiturates, intoxication or withdrawal, Brain illness or injury, Brain tumor (rare), Choking, Drug abuse, Electric shock, Fever (particularly in young children),
Head injury, Heart disease, Heat illness, Malignant hypertension (very high blood pressure),
Meningitis, Poisoning, Stroke, Toxemia of pregnancy, Uremia related to kidney failure,
Venomous bites and stings, Withdrawal from benzodiazepines (such as Valium), Low blood sugar, etc.

Considerations:

Convulsions can be unsettling to watch. Despite their appearance, most seizures are relatively harmless. They usually last from 30 seconds to 2 minutes. However, if a seizure is prolonged, or if multiple seizures happen and the person doesn't awaken in between, this is a medical emergency.

If a person has recurring seizures, and there are no underlying causes that can be identified, that person is said to have epilepsy. Epilepsy can usually be controlled well with medication.

Pay attention to which arms or legs are shaking, whether there is any change in consciousness, whether there is loss of urine or stool, and whether the eyes deviate in any direction.

Symptoms:
Brief blackout followed by period of confusion, Sudden falling, Drooling or frothing at the mouth,
Grunting and snorting, Breathing stops temporarily, Uncontrollable muscle spasms with twitching and jerking limbs, Loss of bladder or bowel control, Eye movements, Teeth clenching, Unusual behavior like sudden anger, sudden laughter, or picking at one's clothing, The person may have warning symptoms prior to the attack, which may consist of fear or anxiety, nausea, visual symptoms, or vertigo.

First Aid:
1. When a seizure occurs, the main goal is to protect the person from injury. Try to prevent a fall. Lay the person on the ground in a safe area. Clear the area of furniture or other sharp objects.
2. Cushion the person's head.
3. Loosen tight clothing, especially around the person's neck.
4. Turn the person on his or her side. If vomiting occurs, this helps make sure that the vomit is not inhaled into the lungs.
5. Look for a medical I.D. bracelet with seizure instructions.
6. Stay with the person until recovery or until you have professional medical help. Meanwhile, monitor the person's vital signs (pulse, rate of breathing).

In an infant or child, if the seizure occurs with a high fever, cool the child gradually with tepid water. You can give the child acetaminophen (Tylenol), especially if the child has had fever convulsions before. DO NOT immerse the child in a cold bath.

Do Not:
* DO NOT restrain the person.
* DO NOT place anything between the person's teeth during a seizure (including your fingers).
* DO NOT move the person unless he or she is in danger or near something hazardous.
* DO NOT try to make the person stop convulsing. He or she has no control over the seizure and is not aware of what is happening at the time.
* DO NOT give the person anything by mouth until the convulsions have stopped and the person is fully awake and alert.

Constipation

Constipation, costiveness, or irregularity, is a condition of the digestive system where a person (or animal) experiences hard feces that are difficult to egest. It may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction. The term obstipation is used for severe constipation that prevents passage of both stools and gas. Causes of constipation may be dietary, hormonal, anatomical, a side effect of medications (e.g. some painkillers), or an illness or disorder. Treatments consist of changes in dietary and exercise habits, the use of laxatives, and other medical interventions depending on the underlying cause.

Causes:
The main causes of constipation include:

* Hardening of the feces
Improper mastication (chewing) of food.
Insufficient intake of dietary fiber.
Dehydration from any cause or inadequate fluid intake.
Medication, e.g. diuretics and those containing iron, calcium, aluminum.
Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along.
Hypothyroidism (slow-acting thyroid gland).
Hypokalemia.
Injured anal sphincter (patulous anus).
Medications, such as loperamide, opioids (e.g. codeine & morphine) and certain tricyclic antidepressants.
* Severe illness due to other causes
Acute porphyria (a rare inherited condition).
Lead poisoning.
* Dyschezia (usually the result of suppressing defecation).
* Constriction, where part of the intestine or rectum is narrowed or blocked, not allowing feces to pass
Stenosis (Strictures).
Diverticula.
Tumors, either of the bowel or surrounding tissues.
Retained foreign body or a bezoar.
* Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings.
Functional constipation.
Constipation-predominant irritable bowel syndrome, characterized by a combination of constipation and abdominal discomfort and/or pain.
* Smoking cessation (nicotine has a laxative effect).
* Abdominal surgery, other types of surgery, childbirth.

Symptoms:
Following are the major constipation symptoms:

1. Difficulty in elimination of the hard faecal matter.
2. Cramping in a lower abdomen.
3. Mouth ulcer.
4. Bad breath.
5. Nausea.
6. Headache.
7. Coated tongue.
8. Dullness on skin.

Diagnosis:
The diagnosis is essentially made from the patient's description of the symptoms। Bowel movements that are difficult to pass, very firm, or made up of small rabbit-like pellets qualify as constipation, even if they occur every day. Other symptoms related to constipation can include bloating, distention, abdominal pain, or a sense of incomplete emptying.

During physical examination, scybala (manually palpable lumps of stool) may be detected on palpation of the abdomen. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not; if so, then suppositories or enemas may be considered. Otherwise, oral medication may be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, admixture of blood and whether any tumors or abnormalities are present.

X-rays of the abdomen, generally only performed on hospitalized patients or if bowel obstruction is suspected, may reveal impacted fecal matter in the colon, and confirm or rule out other causes of similar symptoms।

Colonic propagating pressure wave sequences (PSs) are responsible for discrete movements of content and are vital for normal defaecation. Deficiencies in PS frequency, amplitude and extent of propagation are all implicated in severe defecatory dysfunction. Mechanisms that can normalise these aberrant motor patterns may help rectify the problem. Recently the novel therapy of sacral nerve stimulation (SNS) has been utilized for the treatment of severe constipation।

Treatment:
In people without medical problems, the main intervention is to increase the intake of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation. However, enemas are generally useful only for stool in the rectum, not in the intestinal tract.

Lactulose, a non absorbable synthetic sugar that keeps sodium and water inside the intestinal lumen, relieves constipation. It can be used for months together. Among the other safe remedies, fiber supplements, lactitiol, sorbitol, milk of magnesia, lubricants etc. may be of value. Electrolyte imbalance e.g. hyponatremia may occur in some cases especially in diabetics.

In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation. The mechanism of the herbal, enema, and colonic irrigation treatments often include the breakdown of impacted and hardened fecal matter.

Laxatives may be necessary in people in whom dietary intervention is not effective or is inappropriate. Most laxatives can be safely used long-term, although some are associated with cramping and bloatedness and can cause the phenomenon of melanosis coli.

Conjunctivitis

Conjunctivitis, commonly called "Pink Eye" and "Red Eye" in the UK, and "Madras Eye" in India is an inflammation of the conjunctiva (the outermost layer of the eye and the inner surface of the eyelids), most commonly due to an allergic reaction or an infection (usually bacterial, or viral).

Pink eye may make you feel as if you've got something in one or both of your eyes that you just can't remove. When you wake up in the morning, your eyes may seem to be pasted shut from the discharge coming from your eyes. The whites of your eyes may begin to have a pink discoloration, and you may not see as clearly as you did before.
Inflammation causes small blood vessels in the conjunctiva to become more prominent, resulting in a pink or red cast to the whites of your eyes. Pink eye and red eye are terms commonly used to refer to all types of conjunctivitis. Though the inflammation of pink eye makes it an irritating condition, it rarely affects your sight. If you suspect pink eye, you can take steps to ease your discomfort. But because pink eye can be contagious, it should be diagnosed and treated early. This is especially important for preschool-age children, who commonly develop both viral and bacterial conjunctivitis.


Types:

Blepharoconjunctivitis is a combination of conjunctivitis with blepharitis (inflammation of the eyelids).
Keratoconjunctivitis is a combination of conjunctivitis and keratitis (corneal inflammation).
Episcleritis is an inflammatory condition that produces a similar appearance to conjunctivitis, but without discharge or tearing.

Causes:
Causes of pink eye include:

* Viruses.
* Bacteria.
* Allergies.
* A chemical splash in the eye.
* A foreign object in the eye.

Most cases of pink eye are caused by viruses. In newborns, pink eye may result from an incompletely opened tear duct.

Viral and bacterial conjunctivitis may affect one or both eyes. Viral conjunctivitis usually produces a watery or mucous discharge.
Bacterial conjunctivitis often produces a thicker, yellow-green discharge and may be associated with a respiratory infection or with a sore throat. Both viral and bacterial conjunctivitis are associated with colds. Both viral and bacterial types are very contagious. Adults and children alike can develop both of these types of pink eye. However, bacterial conjunctivitis is more common in children than it is in adults.

Allergic conjunctivitis affects both eyes and is a response to an allergy-causing substance such as pollen. In response to allergens, your body produces an antibody called immunoglobulin E (IgE). This antibody triggers special cells called mast cells in the mucous lining of your eyes and airways to release inflammatory substances, including histamines. Your body's release of histamine can produce a number of allergy symptoms, including red or pink eyes. If you have allergic conjunctivitis, you may experience intense itching, tearing and inflammation of the eyes — as well as itching, sneezing and watery nasal discharge. You may also experience swelling of the membrane (conjunctiva) that lines your eyelids and part of your eyeballs, resulting in what may look like clear blisters on the whites of your eyes.

Irritation from a chemical splash or foreign object in your eye is also associated with conjunctivitis. Discharge tends to be mucus, not pus. Sometimes, flushing and cleaning the eye to rid it of the chemical or object causes redness and irritation. Signs and symptoms usually clear up on their own within about a day.

Symptoms:
The most common signs and symptoms of pink eye include:

* Redness in one or both eyes
* Itchiness in one or both eyes
* Blurred vision and sensitivity to light
* A gritty feeling in one or both eyes
* A discharge in one or both eyes that forms a crust during the night
* Tearing

Acute allergic conjunctivitis is typically itchy. Sometimes distressingly so, and the patient often complains of some lid swelling. Chronic allergy often causes just itch or irritation, and often much frustration because the absence of redness or discharge can lead to accusations of hypochondria.
Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Its symptoms include watery discharge and variable itch. The infection usually begins with one eye, but may spread easily to the fellow eye.
Bacterial conjunctivitis due to the common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, grey or yellowish mucopurulent discharge that may cause the lids to stick together (matting), especially after sleeping.
Irritant or toxic conjunctivitis is irritable or painful when the infected eye is pointed far down or far up. Discharge and itch are usually absent. This is the only group in which severe pain may occur.

Diagnosis:
Conjunctivitis symptoms and signs are relatively non-specific. Even after biomicroscopy, laboratory tests are often necessary if proof of aetiology is needed.
A purulent discharge strongly suggests bacterial cause, unless there is known exposure to toxins. Infection with Neisseria gonorrhoeae should be suspected if the discharge is particularly thick and copious.
A diffuse, less "injected" conjunctivitis (looking pink rather than red) suggests a viral cause, especially if numerous follicles are present on the lower tarsal conjunctiva on biomicroscopy.
Scarring of the tarsal conjunctiva suggests trachoma, especially if seen in endemic areas, if the scarring is linear (von Arlt's line), or if there is also corneal vascularisation.
Clinical tests for lagophthalmos, dry eye (Schirmer test) and unstable tear film may help distinguish the various types of dry eye.
Other symptoms including pain, blurring of vision and photophobia should not be prominent in conjunctivitis. Fluctuating blurring is common, due to tearing and mucoid discharge. Mild photophobia is common. However, if any of these symptoms are prominent, it is important to exclude other diseases such as glaucoma, uveitis, keratitis and even meningitis or caroticocavernous fistula.

Treatment:
Conjunctivitis sometimes requires medical attention. The appropriate treatment depends on the cause of the problem. For the allergic type, cool water constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, non-steroidal anti-inflammatory medications and antihistamines may be prescribed. Some patients with persistent allergic conjunctivitis may also require topical steroid drops.
Your doctor may prescribe antibiotic eyedrops if the infection is bacterial, and the infection should clear within several days of starting treatment. Antibiotic eye ointment, in place of eyedrops, is sometimes prescribed for treating bacterial pink eye in children. An ointment is often easier to administer to an infant or young child than are eyedrops.