MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
Biomedical Science II (BMS2) – Summary
Table of content
1 – Cardiovascular pathology .......................................................................................................................................................................................................................................................................... 3
1.1 Cardiovascular diseases..................................................................................................................................................................................................................................................................... 3
1.1.1 Hypertension .......................................................................................................................................................................................................................................................................... 4
1.1.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 5
1.1.3 Ischaemic heart disease .......................................................................................................................................................................................................................................................... 5
1.1.4 Heart failure ........................................................................................................................................................................................................................................................................... 7
1.2 Risk factors ....................................................................................................................................................................................................................................................................................... 7
1.2.1 Hypertension .......................................................................................................................................................................................................................................................................... 8
1.2.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 8
1.2.3 Ischaemic heart disease .......................................................................................................................................................................................................................................................... 8
1.3 Pathogenesis..................................................................................................................................................................................................................................................................................... 8
1.3.1 Hypertension .......................................................................................................................................................................................................................................................................... 8
1.3.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 9
1.3.3 Ischaemic heart disease ........................................................................................................................................................................................................................................................ 11
1.3.4 Heart failure ......................................................................................................................................................................................................................................................................... 12
1.4 Treatment strategies ....................................................................................................................................................................................................................................................................... 13
1.4.1 Hypertension ........................................................................................................................................................................................................................................................................ 13
1.4.2 Atherosclerosis ..................................................................................................................................................................................................................................................................... 15
1.4.3 Ischaemic heart disease ........................................................................................................................................................................................................................................................ 16
1.4.4 Heart failure ......................................................................................................................................................................................................................................................................... 17
2 – Obesity ................................................................................................................................................................................................................................................................................................... 18
2.1 Pathogenesis of obesity .................................................................................................................................................................................................................................................................. 18
2.2 Pathological effects (complications) of obesity ................................................................................................................................................................................................................................ 19
2.3 Metabolic syndrome in obesity ....................................................................................................................................................................................................................................................... 21
2.4 Obesity treatment options .............................................................................................................................................................................................................................................................. 21
2.4.1 Conservative treatment ........................................................................................................................................................................................................................................................ 21
2.4.2 Pharmacological interventions.............................................................................................................................................................................................................................................. 21
2.4.3 Surgical interventions ........................................................................................................................................................................................................................................................... 22
3 – Diabetes ................................................................................................................................................................................................................................................................................................. 23
3.1 Pathogenesis of diabetes ................................................................................................................................................................................................................................................................ 24
3.2 Complications of diabetes ............................................................................................................................................................................................................................................................... 25
3.2.1 Diabetic Ketoacidosis (DKA) .................................................................................................................................................................................................................................................. 26
3.2.2 Hyperosmolar hyperglycaemic state (HHS) ........................................................................................................................................................................................................................... 26
3.3 Diabetes treatment options ............................................................................................................................................................................................................................................................ 26
3.3.1 Oral hypoglycaemic agents ................................................................................................................................................................................................................................................... 27
3.3.2 Insulin therapy...................................................................................................................................................................................................................................................................... 27
4 – Respiratory pathology ............................................................................................................................................................................................................................................................................. 28
4.1 Basic respiratory pathology classification ........................................................................................................................................................................................................................................ 28
4.2 Mechanism of asthma & COPD........................................................................................................................................................................................................................................................ 29
4.3 Drugs used in treatment of respiratory conditions .......................................................................................................................................................................................................................... 30
4.3.1 Asthma drug treatment ........................................................................................................................................................................................................................................................ 30
4.3.2 COPD drug treatment ........................................................................................................................................................................................................................................................... 31
4.4 Overview lung cancers & developmental diseases ........................................................................................................................................................................................................................... 32
4.5 Asthma & COPD .............................................................................................................................................................................................................................................................................. 33
4.5.1 Differentiation ...................................................................................................................................................................................................................................................................... 35
5 - GI tract pathology & pharmacology ......................................................................................................................................................................................................................................................... 36
5.1 Classifications of GIT disease ........................................................................................................................................................................................................................................................... 36
5.2 Infection & inflammatory disorders ................................................................................................................................................................................................................................................. 36
5.2.1 GORD & Barret’s oesophagus ............................................................................................................................................................................................................................................... 36
5.2.2 Peptic disease ....................................................................................................................................................................................................................................................................... 37
5.3 Inflammatory bowel diseases .......................................................................................................................................................................................................................................................... 39
5.3.1 Ulcerative Colitis & Crohn’s Disease (!) ................................................................................................................................................................................................................................. 39
5.3.2 Diverticular disease .............................................................................................................................................................................................................................................................. 41
Page 1 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
5.4 Hepatobiliary disease ...................................................................................................................................................................................................................................................................... 41
5.4.1 Jaundice (!) ........................................................................................................................................................................................................................................................................... 41
5.4.2 Hepatitis (liver inflammation) ............................................................................................................................................................................................................................................... 41
5.4.3 Pancreatitis (pancreas inflammation) ................................................................................................................................................................................................................................... 42
5.5 Treatment strategies....................................................................................................................................................................................................................................................................... 43
5.5.1 GORD ................................................................................................................................................................................................................................................................................... 43
5.5.2 Peptic disease ....................................................................................................................................................................................................................................................................... 43
5.5.3 IBD ....................................................................................................................................................................................................................................................................................... 44
6 – Renal & GU pathology ............................................................................................................................................................................................................................................................................. 45
6.1 Classification of renal disease .......................................................................................................................................................................................................................................................... 45
6.2 Mechanisms of acute & chronic renal failure ................................................................................................................................................................................................................................... 45
6.2.1 AKI pathogenesis .................................................................................................................................................................................................................................................................. 45
6.2.2 CKD pathogenesis ................................................................................................................................................................................................................................................................. 48
6.3 Complications of chronic renal failure ............................................................................................................................................................................................................................................. 49
6.4 Major forms of GU disease .............................................................................................................................................................................................................................................................. 49
6.4.1 CIN ....................................................................................................................................................................................................................................................................................... 49
6.5 Treatment strategies ....................................................................................................................................................................................................................................................................... 50
6.5.1 AKI........................................................................................................................................................................................................................................................................................ 50
6.5.2 CKD ...................................................................................................................................................................................................................................................................................... 51
7 – Bone & joint pathology ........................................................................................................................................................................................................................................................................... 52
7.1 Assessment of bone disease............................................................................................................................................................................................................................................................ 52
7.2 Classification of common bone pathology ....................................................................................................................................................................................................................................... 52
7.3 Mechanisms of major metabolic bone diseases ............................................................................................................................................................................................................................... 53
7.3.1 Osteoporosis ........................................................................................................................................................................................................................................................................ 53
7.3.2 Osteopenia ........................................................................................................................................................................................................................................................................... 54
7.3.3 Osteomalacia / Rickets disease ............................................................................................................................................................................................................................................. 54
7.3.4 Hyperparathyroidism ............................................................................................................................................................................................................................................................ 54
7.3.5 Renal osteodystrophy ........................................................................................................................................................................................................................................................... 54
7.3.6 Paget’s disease (less important) ............................................................................................................................................................................................................................................ 55
7.4 Differentiation of joint diseases ...................................................................................................................................................................................................................................................... 55
7.4.1 Osteoarthritis (OA) ............................................................................................................................................................................................................................................................... 56
7.4.2 Rheumatoid arthritis (RA) ..................................................................................................................................................................................................................................................... 57
7.4.3 OA vs RA ............................................................................................................................................................................................................................................................................... 57
7.4.4 Septic arthritis (less important) ............................................................................................................................................................................................................................................. 57
7.4.5 Gout ..................................................................................................................................................................................................................................................................................... 58
7.5 Treatment strategies ....................................................................................................................................................................................................................................................................... 58
7.5.1 Metabolic bone disease ........................................................................................................................................................................................................................................................ 58
7.5.2 Joint diseases ....................................................................................................................................................................................................................................................................... 59
8 – Endocrine pathology ............................................................................................................................................................................................................................................................................... 61
8.1 Scope of common endocrine diseases ............................................................................................................................................................................................................................................. 61
8.2 Clinical features of major endocrine disorders................................................................................................................................................................................................................................. 62
8.2.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 62
8.2.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 63
8.2.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 63
8.2.4 Reproductive management (only MCQ) ................................................................................................................................................................................................................................ 65
8.3 Laboratory investigations for (differential) diagnosis ....................................................................................................................................................................................................................... 66
8.3.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 66
8.3.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 66
8.3.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 66
8.4 Treatment strategies ....................................................................................................................................................................................................................................................................... 67
8.4.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 67
8.4.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 67
8.4.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 68
Page 2 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
1 – Cardiovascular pathology
Stroke = disruption in blood supply to brain ➔ 3 types:
1) Ischaemia = blockage of an artery
o Response = infarction = necrosis
2) Haemorrhage = bleeding from a ruptured blood vessel
3) Transient ischaemic attack (TIA) = mini stroke due to temporary disruption in blood supply
to brain
Aneurysm = ballooning at weak spot in an artery wall ➔ increases stroke/haemorrhage risk
1.1 Cardiovascular diseases
Cardiovascular disease (CVD) = interlinked group of diseases that affect the structure & function of
the heart and/or blood vessels:
• Major forms:
o Hypertension = persistently high BP in the arteries
o Atherosclerosis = build-up of fats, cholesterol & other substances in/on artery walls
(plaques) which can restrict BF ➔ arterial wall thickening & loss of elasticity
o Ischaemic heart disease (IHD) = inadequate BF to myocardium ➔ ischaemia ➔
▪ Angina = chest pain or pressure due to insufficient blood flow to the heart
muscle (myocardium)
▪ Myocardial infarction (MI) / heart attack = decrease/halt in BF to a part of
the heart ➔ permanent damage to the heart muscle
o Heart/cardiac failure = inability of the heart to balance supply & demand for BF ➔
reduced cardiac output ➔ inadequate tissue perfusion
• Stroke (cerebrovascular disease)
• Miscellaneous conditions ➔ rheumatic heart disease, cardiomyopathy, heart arrhythmia,
congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery
disease & thromboembolic disease
Page 3 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
1.1.1 Hypertension
• Commonest cause of cardiac failure & major risk factor for atherosclerosis & cerebrovascular
disease
• Complex multifactorial disease & can be asymptomatic until late in its pathological course
• Major factor in the progression & complications of CVD, but also a risk factor for CVD
• 2 main forms
o Primary (essential) hypertension ➔ 90-95%
▪ Cause – genetic & environment
▪ Mechanism (?) – abnormal Na handling by kidney; abnormal Na/Ca
metabolism in smooth muscle; abnormalities of RAAS
o Secondary hypertension ➔ 5%
▪ Cause – renal disease, endocrine disorders, pregnancy, diabetes, obesity,
medical treatment
▪ Mechanism – disorder leading to Na retention and/or peripheral
vasoconstriction
• Affects blood vessel structure:
o Artery wall thickening & narrowing of lumen ➔ hyaline arteriosclerosis
o Increased endothelial cell proliferation
o Blood vessel necrosis
o Hypertensive effects ➔ left ventricular hypertrophy (cardiac cell growth) ➔ heart
failure
Normal & abnormal:
• Systolic blood pressure (SBP) = force of heart on artery walls each beat
o Normal = <120 mmHg
• Diastolic blood pressure (DBP) = force of heart on artery walls in between beats
o Normal = <80 mmHg
>140/90 ➔ consider GP referral
>180/110 ➔ urgent GP referral
Complications:
• Vascular pathology
o Accelerates atherosclerosis ➔ organ/limb ischaemia
o Necrotic arteriole walls
o Aneurysms of weakened arteries/arterioles ➔ haemorrhage
o Arterial dissection = pressure leeches blood between layers of vessel wall
• Chronic kidney disease
o Narrowed renal arteries ➔ poor perfusion ➔ glomerular sclerosis (hardening) or
necrosis
o Haematuria (blood in urine)
o Uraemia (urea in blood)
o Proteinemia (proteins in blood) & reduced GFR
• Cardiac failure
o Pulmonary oedema (excess fluid in lungs)
o MI
o Left ventricular hypertrophy
• Nervous pathology
o Stroke/TIA
▪ Haemorrhage and/or ischaemia/infarction
▪ Seizures
▪ Vascular dementia (due to reduced BF to brain)
Page 4 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
o Blindness
▪ Hypertensive retinopathy (retinal vascular damage)
▪ Exudates (fluid leakage from blood vessels)
▪ Arteriovenous nicking (arteriole crosses venule leading to vein compression)
▪ Retinal haemorrhage & papilledema
▪ Peripheral neuropathies
1.1.2 Atherosclerosis
• Non-atheromatous = thickening/hardening arterial wall
o Loss of elasticity & reduced BF ➔ ischaemia
o Due to ageing
o Types – hyaline (small arteries/arterioles); hyperplastic (large/medium arteries);
Mönckeberg's (calcification of extremity arteries)
• Atheromatous/atherosclerosis = formation of lipid plaques (atheroma) in medium/large
arteries
o Chronic inflammation, lipid deposition & fibrotic change
o Most common
o Traditional IHD
Key players in development of atheroma:
• Lipids ➔ saturated fats & LDL cholesterol
• Inflammatory response ➔ inflammatory cells & cytokines
• Immune system ➔ macrophages & t-lymphocytes
1.1.3 Ischaemic heart disease
• Coronary blood supply < myocardium O2 demand
• Cause ➔ atherosclerosis blocks >1 coronary arteries
• Clinical types ➔ Angina pectoris, Acute Coronary Syndrome (ACS), sudden cardiac death
• Leads to angina and/or MI
Angina:
• Typified by chest pain (gripping or crushing) ➔ may radiate to neck, jaw or left arm
• Cause is transient & reversible myocardial ischaemia
• Feature of longer term CVD ➔ hypertension, progressive atherosclerosis & cardiac failure
• May be precipitated by the ‘4 Es’:
o Exertion
o Exposure to cold
o Emotion
o Eating (heavy meal)
• 2 classes
o Stable angina (Angina pectoris)
▪ Caused by myocardial ischaemia normally due to atherosclerosis
▪ Central chest pain, discomfort & breathlessness ➔ increased by stress &
reduced by rest
▪ Reversible
▪ Predictable
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, MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
o Unstable angina (part of ACS)
▪ New-onset or rapidly worsening angina with minimal effort without
myocardial damage
▪ Pain behind sternum radiating to arm & neck
▪ Erosion of atheromatous plaque ➔ embolus/thrombus
▪ Worsened by exercise/emotion & relieved by rest/Rx
▪ No nausea & vomiting or increased sympathetic activity
▪ Unpredictable
▪ Can be reversed
▪ High risk of MI & death
Angina is followed by ACS = sudden, reduced BF to heart ➔ 3 clinical types:
• Unstable angina
• Non-ST-segment elevation myocardial infarction (NSTEMI)
o Less serious form of heart attack
• ST-segment elevation myocardial infarction (STEMI)
o Serious form of heart attack where coronary artery is completely blocked & large
part of myocardium is unstable to receive blood
NSTEMI vs STEMI differentiated in ECG
MI:
• Severe chest pain, often described as crushing
• May radiate to neck, jaw, epigastrium, shoulder, left arm
• Pain lasts several hours to days & not relieved by rest/Rx
• High levels of patient anxiety
• Pulse rapid and weak
• Dyspnoea (shortness of breath) & cyanosis (skin becomes blue due to lack of O2)
• Nausea & vomiting
• Sympathetic activity increased
• Irreversible
• Survival dependent on infarct size, age, complications & other diseases
Complications:
Page 6 of 68
Biomedical Science II (BMS2) – Summary
Table of content
1 – Cardiovascular pathology .......................................................................................................................................................................................................................................................................... 3
1.1 Cardiovascular diseases..................................................................................................................................................................................................................................................................... 3
1.1.1 Hypertension .......................................................................................................................................................................................................................................................................... 4
1.1.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 5
1.1.3 Ischaemic heart disease .......................................................................................................................................................................................................................................................... 5
1.1.4 Heart failure ........................................................................................................................................................................................................................................................................... 7
1.2 Risk factors ....................................................................................................................................................................................................................................................................................... 7
1.2.1 Hypertension .......................................................................................................................................................................................................................................................................... 8
1.2.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 8
1.2.3 Ischaemic heart disease .......................................................................................................................................................................................................................................................... 8
1.3 Pathogenesis..................................................................................................................................................................................................................................................................................... 8
1.3.1 Hypertension .......................................................................................................................................................................................................................................................................... 8
1.3.2 Atherosclerosis ....................................................................................................................................................................................................................................................................... 9
1.3.3 Ischaemic heart disease ........................................................................................................................................................................................................................................................ 11
1.3.4 Heart failure ......................................................................................................................................................................................................................................................................... 12
1.4 Treatment strategies ....................................................................................................................................................................................................................................................................... 13
1.4.1 Hypertension ........................................................................................................................................................................................................................................................................ 13
1.4.2 Atherosclerosis ..................................................................................................................................................................................................................................................................... 15
1.4.3 Ischaemic heart disease ........................................................................................................................................................................................................................................................ 16
1.4.4 Heart failure ......................................................................................................................................................................................................................................................................... 17
2 – Obesity ................................................................................................................................................................................................................................................................................................... 18
2.1 Pathogenesis of obesity .................................................................................................................................................................................................................................................................. 18
2.2 Pathological effects (complications) of obesity ................................................................................................................................................................................................................................ 19
2.3 Metabolic syndrome in obesity ....................................................................................................................................................................................................................................................... 21
2.4 Obesity treatment options .............................................................................................................................................................................................................................................................. 21
2.4.1 Conservative treatment ........................................................................................................................................................................................................................................................ 21
2.4.2 Pharmacological interventions.............................................................................................................................................................................................................................................. 21
2.4.3 Surgical interventions ........................................................................................................................................................................................................................................................... 22
3 – Diabetes ................................................................................................................................................................................................................................................................................................. 23
3.1 Pathogenesis of diabetes ................................................................................................................................................................................................................................................................ 24
3.2 Complications of diabetes ............................................................................................................................................................................................................................................................... 25
3.2.1 Diabetic Ketoacidosis (DKA) .................................................................................................................................................................................................................................................. 26
3.2.2 Hyperosmolar hyperglycaemic state (HHS) ........................................................................................................................................................................................................................... 26
3.3 Diabetes treatment options ............................................................................................................................................................................................................................................................ 26
3.3.1 Oral hypoglycaemic agents ................................................................................................................................................................................................................................................... 27
3.3.2 Insulin therapy...................................................................................................................................................................................................................................................................... 27
4 – Respiratory pathology ............................................................................................................................................................................................................................................................................. 28
4.1 Basic respiratory pathology classification ........................................................................................................................................................................................................................................ 28
4.2 Mechanism of asthma & COPD........................................................................................................................................................................................................................................................ 29
4.3 Drugs used in treatment of respiratory conditions .......................................................................................................................................................................................................................... 30
4.3.1 Asthma drug treatment ........................................................................................................................................................................................................................................................ 30
4.3.2 COPD drug treatment ........................................................................................................................................................................................................................................................... 31
4.4 Overview lung cancers & developmental diseases ........................................................................................................................................................................................................................... 32
4.5 Asthma & COPD .............................................................................................................................................................................................................................................................................. 33
4.5.1 Differentiation ...................................................................................................................................................................................................................................................................... 35
5 - GI tract pathology & pharmacology ......................................................................................................................................................................................................................................................... 36
5.1 Classifications of GIT disease ........................................................................................................................................................................................................................................................... 36
5.2 Infection & inflammatory disorders ................................................................................................................................................................................................................................................. 36
5.2.1 GORD & Barret’s oesophagus ............................................................................................................................................................................................................................................... 36
5.2.2 Peptic disease ....................................................................................................................................................................................................................................................................... 37
5.3 Inflammatory bowel diseases .......................................................................................................................................................................................................................................................... 39
5.3.1 Ulcerative Colitis & Crohn’s Disease (!) ................................................................................................................................................................................................................................. 39
5.3.2 Diverticular disease .............................................................................................................................................................................................................................................................. 41
Page 1 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
5.4 Hepatobiliary disease ...................................................................................................................................................................................................................................................................... 41
5.4.1 Jaundice (!) ........................................................................................................................................................................................................................................................................... 41
5.4.2 Hepatitis (liver inflammation) ............................................................................................................................................................................................................................................... 41
5.4.3 Pancreatitis (pancreas inflammation) ................................................................................................................................................................................................................................... 42
5.5 Treatment strategies....................................................................................................................................................................................................................................................................... 43
5.5.1 GORD ................................................................................................................................................................................................................................................................................... 43
5.5.2 Peptic disease ....................................................................................................................................................................................................................................................................... 43
5.5.3 IBD ....................................................................................................................................................................................................................................................................................... 44
6 – Renal & GU pathology ............................................................................................................................................................................................................................................................................. 45
6.1 Classification of renal disease .......................................................................................................................................................................................................................................................... 45
6.2 Mechanisms of acute & chronic renal failure ................................................................................................................................................................................................................................... 45
6.2.1 AKI pathogenesis .................................................................................................................................................................................................................................................................. 45
6.2.2 CKD pathogenesis ................................................................................................................................................................................................................................................................. 48
6.3 Complications of chronic renal failure ............................................................................................................................................................................................................................................. 49
6.4 Major forms of GU disease .............................................................................................................................................................................................................................................................. 49
6.4.1 CIN ....................................................................................................................................................................................................................................................................................... 49
6.5 Treatment strategies ....................................................................................................................................................................................................................................................................... 50
6.5.1 AKI........................................................................................................................................................................................................................................................................................ 50
6.5.2 CKD ...................................................................................................................................................................................................................................................................................... 51
7 – Bone & joint pathology ........................................................................................................................................................................................................................................................................... 52
7.1 Assessment of bone disease............................................................................................................................................................................................................................................................ 52
7.2 Classification of common bone pathology ....................................................................................................................................................................................................................................... 52
7.3 Mechanisms of major metabolic bone diseases ............................................................................................................................................................................................................................... 53
7.3.1 Osteoporosis ........................................................................................................................................................................................................................................................................ 53
7.3.2 Osteopenia ........................................................................................................................................................................................................................................................................... 54
7.3.3 Osteomalacia / Rickets disease ............................................................................................................................................................................................................................................. 54
7.3.4 Hyperparathyroidism ............................................................................................................................................................................................................................................................ 54
7.3.5 Renal osteodystrophy ........................................................................................................................................................................................................................................................... 54
7.3.6 Paget’s disease (less important) ............................................................................................................................................................................................................................................ 55
7.4 Differentiation of joint diseases ...................................................................................................................................................................................................................................................... 55
7.4.1 Osteoarthritis (OA) ............................................................................................................................................................................................................................................................... 56
7.4.2 Rheumatoid arthritis (RA) ..................................................................................................................................................................................................................................................... 57
7.4.3 OA vs RA ............................................................................................................................................................................................................................................................................... 57
7.4.4 Septic arthritis (less important) ............................................................................................................................................................................................................................................. 57
7.4.5 Gout ..................................................................................................................................................................................................................................................................................... 58
7.5 Treatment strategies ....................................................................................................................................................................................................................................................................... 58
7.5.1 Metabolic bone disease ........................................................................................................................................................................................................................................................ 58
7.5.2 Joint diseases ....................................................................................................................................................................................................................................................................... 59
8 – Endocrine pathology ............................................................................................................................................................................................................................................................................... 61
8.1 Scope of common endocrine diseases ............................................................................................................................................................................................................................................. 61
8.2 Clinical features of major endocrine disorders................................................................................................................................................................................................................................. 62
8.2.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 62
8.2.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 63
8.2.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 63
8.2.4 Reproductive management (only MCQ) ................................................................................................................................................................................................................................ 65
8.3 Laboratory investigations for (differential) diagnosis ....................................................................................................................................................................................................................... 66
8.3.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 66
8.3.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 66
8.3.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 66
8.4 Treatment strategies ....................................................................................................................................................................................................................................................................... 67
8.4.1 Hypothalamic & pituitary disorders ...................................................................................................................................................................................................................................... 67
8.4.2 Thyroid disorders.................................................................................................................................................................................................................................................................. 67
8.4.3 Adrenal disorders ................................................................................................................................................................................................................................................................. 68
Page 2 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
1 – Cardiovascular pathology
Stroke = disruption in blood supply to brain ➔ 3 types:
1) Ischaemia = blockage of an artery
o Response = infarction = necrosis
2) Haemorrhage = bleeding from a ruptured blood vessel
3) Transient ischaemic attack (TIA) = mini stroke due to temporary disruption in blood supply
to brain
Aneurysm = ballooning at weak spot in an artery wall ➔ increases stroke/haemorrhage risk
1.1 Cardiovascular diseases
Cardiovascular disease (CVD) = interlinked group of diseases that affect the structure & function of
the heart and/or blood vessels:
• Major forms:
o Hypertension = persistently high BP in the arteries
o Atherosclerosis = build-up of fats, cholesterol & other substances in/on artery walls
(plaques) which can restrict BF ➔ arterial wall thickening & loss of elasticity
o Ischaemic heart disease (IHD) = inadequate BF to myocardium ➔ ischaemia ➔
▪ Angina = chest pain or pressure due to insufficient blood flow to the heart
muscle (myocardium)
▪ Myocardial infarction (MI) / heart attack = decrease/halt in BF to a part of
the heart ➔ permanent damage to the heart muscle
o Heart/cardiac failure = inability of the heart to balance supply & demand for BF ➔
reduced cardiac output ➔ inadequate tissue perfusion
• Stroke (cerebrovascular disease)
• Miscellaneous conditions ➔ rheumatic heart disease, cardiomyopathy, heart arrhythmia,
congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery
disease & thromboembolic disease
Page 3 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
1.1.1 Hypertension
• Commonest cause of cardiac failure & major risk factor for atherosclerosis & cerebrovascular
disease
• Complex multifactorial disease & can be asymptomatic until late in its pathological course
• Major factor in the progression & complications of CVD, but also a risk factor for CVD
• 2 main forms
o Primary (essential) hypertension ➔ 90-95%
▪ Cause – genetic & environment
▪ Mechanism (?) – abnormal Na handling by kidney; abnormal Na/Ca
metabolism in smooth muscle; abnormalities of RAAS
o Secondary hypertension ➔ 5%
▪ Cause – renal disease, endocrine disorders, pregnancy, diabetes, obesity,
medical treatment
▪ Mechanism – disorder leading to Na retention and/or peripheral
vasoconstriction
• Affects blood vessel structure:
o Artery wall thickening & narrowing of lumen ➔ hyaline arteriosclerosis
o Increased endothelial cell proliferation
o Blood vessel necrosis
o Hypertensive effects ➔ left ventricular hypertrophy (cardiac cell growth) ➔ heart
failure
Normal & abnormal:
• Systolic blood pressure (SBP) = force of heart on artery walls each beat
o Normal = <120 mmHg
• Diastolic blood pressure (DBP) = force of heart on artery walls in between beats
o Normal = <80 mmHg
>140/90 ➔ consider GP referral
>180/110 ➔ urgent GP referral
Complications:
• Vascular pathology
o Accelerates atherosclerosis ➔ organ/limb ischaemia
o Necrotic arteriole walls
o Aneurysms of weakened arteries/arterioles ➔ haemorrhage
o Arterial dissection = pressure leeches blood between layers of vessel wall
• Chronic kidney disease
o Narrowed renal arteries ➔ poor perfusion ➔ glomerular sclerosis (hardening) or
necrosis
o Haematuria (blood in urine)
o Uraemia (urea in blood)
o Proteinemia (proteins in blood) & reduced GFR
• Cardiac failure
o Pulmonary oedema (excess fluid in lungs)
o MI
o Left ventricular hypertrophy
• Nervous pathology
o Stroke/TIA
▪ Haemorrhage and/or ischaemia/infarction
▪ Seizures
▪ Vascular dementia (due to reduced BF to brain)
Page 4 of 68
,MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
o Blindness
▪ Hypertensive retinopathy (retinal vascular damage)
▪ Exudates (fluid leakage from blood vessels)
▪ Arteriovenous nicking (arteriole crosses venule leading to vein compression)
▪ Retinal haemorrhage & papilledema
▪ Peripheral neuropathies
1.1.2 Atherosclerosis
• Non-atheromatous = thickening/hardening arterial wall
o Loss of elasticity & reduced BF ➔ ischaemia
o Due to ageing
o Types – hyaline (small arteries/arterioles); hyperplastic (large/medium arteries);
Mönckeberg's (calcification of extremity arteries)
• Atheromatous/atherosclerosis = formation of lipid plaques (atheroma) in medium/large
arteries
o Chronic inflammation, lipid deposition & fibrotic change
o Most common
o Traditional IHD
Key players in development of atheroma:
• Lipids ➔ saturated fats & LDL cholesterol
• Inflammatory response ➔ inflammatory cells & cytokines
• Immune system ➔ macrophages & t-lymphocytes
1.1.3 Ischaemic heart disease
• Coronary blood supply < myocardium O2 demand
• Cause ➔ atherosclerosis blocks >1 coronary arteries
• Clinical types ➔ Angina pectoris, Acute Coronary Syndrome (ACS), sudden cardiac death
• Leads to angina and/or MI
Angina:
• Typified by chest pain (gripping or crushing) ➔ may radiate to neck, jaw or left arm
• Cause is transient & reversible myocardial ischaemia
• Feature of longer term CVD ➔ hypertension, progressive atherosclerosis & cardiac failure
• May be precipitated by the ‘4 Es’:
o Exertion
o Exposure to cold
o Emotion
o Eating (heavy meal)
• 2 classes
o Stable angina (Angina pectoris)
▪ Caused by myocardial ischaemia normally due to atherosclerosis
▪ Central chest pain, discomfort & breathlessness ➔ increased by stress &
reduced by rest
▪ Reversible
▪ Predictable
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, MAN Y2 2021 BMS2 McTimoney College of Chiropractic Michael Verouden
o Unstable angina (part of ACS)
▪ New-onset or rapidly worsening angina with minimal effort without
myocardial damage
▪ Pain behind sternum radiating to arm & neck
▪ Erosion of atheromatous plaque ➔ embolus/thrombus
▪ Worsened by exercise/emotion & relieved by rest/Rx
▪ No nausea & vomiting or increased sympathetic activity
▪ Unpredictable
▪ Can be reversed
▪ High risk of MI & death
Angina is followed by ACS = sudden, reduced BF to heart ➔ 3 clinical types:
• Unstable angina
• Non-ST-segment elevation myocardial infarction (NSTEMI)
o Less serious form of heart attack
• ST-segment elevation myocardial infarction (STEMI)
o Serious form of heart attack where coronary artery is completely blocked & large
part of myocardium is unstable to receive blood
NSTEMI vs STEMI differentiated in ECG
MI:
• Severe chest pain, often described as crushing
• May radiate to neck, jaw, epigastrium, shoulder, left arm
• Pain lasts several hours to days & not relieved by rest/Rx
• High levels of patient anxiety
• Pulse rapid and weak
• Dyspnoea (shortness of breath) & cyanosis (skin becomes blue due to lack of O2)
• Nausea & vomiting
• Sympathetic activity increased
• Irreversible
• Survival dependent on infarct size, age, complications & other diseases
Complications:
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