Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type II, Hypercholesterolemia , MANAGEMENT AND TREATMENT. This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.

1. VELEZ COLLEGE
College of Nursing
F. Ramos Street, Cebu City
A Case Study of S.G. Diagnosed with Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus­Type II,
Hypercholesterolemia
Presented by: Dave Jay S. Manriquez, RN.
August 2007
INTRODUCTION
RATIONALE
The student nurse researchers picked the case of S.G. a patient diagnosed with Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type 2, and Hypercholesterolemia.
As a health care provider, the student-nurses have the responsibility for planning with the patient and the family the continuation of care with eventual outcome of an optimal state of wellness.
Planning, setting goals, and choosing appropriate interventions are essential for the delivery of quality nursing care. Properly written and used plans of care can provide direction and continuity
of care by facilitating communications among the client and health care provider. They also provide guideline for documentation and a tool for evaluating the care provided.
Creating a plan of care begins with the collection of data or assessment. It consists of subjective and objective information. A nursing diagnosis is a decision about a problem that
requires nursing intervention and management.
The problem may be anything that interferes with client’s quality of life. Desired client outcomes are identified to facilitate chosen appropriate plans and to serve as evaluators of both
nursing care and a client’s response. Interventions are the actions, steps taken to achieve the desired outcome. Interventions are designed to specify the actions of the health care provider and
the client. Evaluations are identified to assist the health care provider in formulating individual client outcomes and to support the evaluation process. With the help of the nursing care plans the
health care provider can be more knowledgeable with the case they are handling.
Investigative delving into the cases of each client also provides the student-nurse with the amount of information about the disease and the condition of the client which would feed
experiences skills to the student nurse. These in the future would bring the student –nurse into immediate action and provide the necessary interventions whenever the student-nurse would
encounter the same case or similar cases. These does not only gather the various views of the health team, it also brings their ideas into one goal and that is to bring the continuity of care and
the well-being of the patient.
STATEMENT OF THE PROBLEM

2. The purpose of this study is to provide efficient and effective nursing care based on Jean Watson’s Human Caring Theory in caring for patient S.G., who was admitted at CVGH-PPW
4th floor last Wednesday, August 22, 2007 for complaints of difficulty in breathing 8 hours PTA and an episode of vomiting amounting to 1 glass per episode noted 9 hours PTA. The
following are the sub-problems of the study:
1. What were the predisposing factors that led to the client acquiring bronchial asthma, diabetes mellitus-type 2 and hypercholesterolemia?
2. What were the signs and symptoms of bronchial asthma, diabetes type 2 and hypercholesterolemia that the client manifested?
3. What system, organs or parts of the body does the disease process affect?
4. What were the interventions done to manage the client’s condition?
a. What were the nursing and collaborative interventions done to the client’s condition?
b. How did the client respond to the interventions given to her?
THEORETICAL BACKGROUND
Jean Watson (Human Caring Theory)
This theory focuses around the caring process, assisting clients in attaining or maintaining health. This caring process requires that the nurse be knowledgeable about human behavior
and human responses to actual or potential health problems, individual needs, how to respond to others, and strengths and limitations of the client and the family, as well as those of the nurse.
In addition, the nurse comforts and offers compassion and empathy to clients and their families. Caring represents all of the factors the nurse uses to deliver health care to the client. The
practice of caring is central to nursing, describes nursing as grounded in a set of universal human values (kindness, concern, and love of self and others). Caring is described as the moral ideal
of nursing; it involves the will to care, the intent to care and caring actions. Caring actions include communication,
positive regard, support, or physical interventions by the nurse. Nursing interventions related to human care are referred
to as carative factors, a guide Watson refers to as the Core of Nursing.
Carative Factors:
• Formation of a Humanistic-altruistic system of values;
• Instillation of faith-hope;
• Cultivation of sensitivity to one's self and to others; Behavior
• Development of a helping-trusting, human caring relationship;
• Promotion and acceptance of the expression of positive and negative feelings;
• Systematic use of a creative problem-solving caring process;
• Promotion of transpersonal teaching-learning;
• Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment;
• Assistance with gratification of human needs;
• Allowance for existential-phenomenological-spiritual forces.

3. Watson’s Assumptions of Caring:
• Human caring in nursing is not just an emotion, concern, attitude, or benevolent desire. Caring connotes a personal response.
• Caring is intersubjective human process and is the moral ideal of nursing.
• Caring can be effectively demonstrated only interpersonally.
• Effective caring promotes health and individual or family growth.
• Caring promotes health more than does curing.
• Caring responses accept a person not only as they are now but also for what the person may become.
• A caring environment offers the development of potential while allowing the person to choose the best action for the self at a given point in time.
• Caring occasions involve action and choice by nurse and client. If the caring occasion is transpersonal, the limits of openness expand, as do human capacities.
• The most abstract characteristic of a caring person is that the person is somehow responsive to another person as a unique individual, perceives the other’s feelings, and sets one
person apart from another.
• Human caring involves values, a will and a commitment to care, knowledge, caring actions, and consequences.
• The ideal value of caring is a starting point, a stance, and an attitude that has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete
acts.
THEORETICAL FRAMEWORK
Jean Watson’s philosophy of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. The action of nursing is directed at understanding the
interrelationship between health, illness, and human behavior. Nursing is concerned with promoting and restoring health and preventing illness.
OVERVIEW OF THE STUDY
I. ASTHMA
Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. It is a chronic inflammatory disorder of the airways in which many cells and cellular
elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes
of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction
that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial responsiveness to a variety of stimuli.
Forms of Asthma
Cardiac Asthma
With cardiac asthma, the reduced pumping efficiency of the left side of the heart leads to a build up of fluid in the lungs (pulmonary edema). This fluid build up causes the airways to narrow
and can cause wheezing. Cardiac asthma is often indistinguishable from bronchial asthma. The main symptoms are:
• Shortness of breath with or without wheezing;
• Increase in rapid and shallow breathing;
• Increase in blood pressure and heart rate; and
• A feeling of apprehension.

4. The pattern of shortness of breath also provides a clue — people with bronchial asthma tend to experience a shortness of breath early in the morning, whereas people with heart failure and
cardiac asthma often find they wake up breathless a few hours after going to bed, and have to sit upright to catch their breath. This is because in people with heart failure, lying down for
prolonged periods will cause fluid to accumulate in the lungs leading to shortness of breath. These people also often have problems with swollen ankles that worsen during the course of the
day.
Bronchial Asthma
For most people with bronchial asthma, the pattern is periodic attacks of wheezing alternating with periods of quite normal breathing. However, some people with bronchial asthma alternate
between chronic shortness of breath and episodes of even worse shortness of breath.
Strong risks for developing bronchial asthma include being a person who is genetically susceptible to asthma and being exposed early in life to indoor allergens, such as dust mites and
cockroaches, and having a family history of asthma or allergy.
Bronchial asthma attacks can be triggered (precipitated or aggravated) by various factors, including:
• Respiratory tract infections;
• Cold weather;
• Exercise;
• Cigarette smoke and other air pollutants; and
• Stress.
Some people can develop asthma in adult life due to a intolerance that their body develops to aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) (in which case exposure to
aspirin or NSAIDs can trigger an asthma attack), or due to an allergy that they develop to certain chemicals in the workplace.
The symptoms of bronchial asthma include:
• A feeling of tightness in the chest;
• Difficulty in breathing or shortness of breath;
• Wheezing; and
• Coughing (particularly at night).
There is currently no cure for bronchial asthma, but it can be controlled.
Types of (Bronchial) Asthma
Asthma is sometimes classified in various ways. Often, these quot;types of asthmaquot; describe the triggers that may cause an asthma episode (or asthma attack) or the things that make asthma worse
in certain individuals. There are various different types of asthma, some of which are difficult to readily diagnose.

5. 1. Child-Onset Asthma
When asthma does begin in childhood, it often does so in a child who is likely, for genetic reasons, to become sensitized to common quot;allergensquot; in the environment (atopic person). When
these children are exposed to house-dust mites, animal proteins, fungi, or other potential allergens, they produce a type of antibody that is intended to engulf and destroy the foreign
materials. This has the effect of making the airway cells sensitive to particular materials.
2. Adult-Onset Asthma
Adult-onset asthma develops after age 20. It is less common than asthma in children, and it affects more women than men. Although less common than asthma in children, adult-onset
asthma can also be triggered by allergies. Between 30 percent and 50 percent of all adult cases are associated with allergies, but often allergic exposures don't seem to be the most
important, driving factors. This non-allergic adult-onset asthma is sometimes called quot;intrinsic.quot; Many adults who are not allergic do have such conditions as sinusitis or nasal polyps, or
they may be sensitive to aspirin and related drugs.
3. Exercise-Induced Asthma
Shortness of breath and/or wheezing occurring after strenuous exercise is called exercise-induced asthma. Although this phenomenon happens in up to 80% of people with recognized
asthma, it frequently takes place as an isolated event without any other symptoms of asthma at any other time. This complicates any diagnosis of asthma as an underlying cause because
frequently this form of asthma is confused with poor physical conditioning or possible heart problems. Exercise-induced asthma involves symptoms that occur about 5-20 minutes after
beginning an exercise that involves breathing through the mouth. Sports and games that require continuous activity or that are played in cold weather (for example, long-distance running,
hockey, soccer, and cross-country skiing) are the most likely to trigger an asthma attack.
4. Cough-Variant Asthma
Coughing can occur alone, without the other symptoms of asthma that are usually present and recognized by the physician or patient. Cough variant asthma causes great difficulty for the
physician to accurately diagnose the true underlying cause of the cough as being asthma because it can be easily confused with other conditions, such as chronic bronchitis and postnasal
drip due to hay fever or sinus disease. Coughing can occur day or night.
5. Occupational Asthma
Occupational asthma occurs in response to a trigger in the workplace. Triggers include contaminants in the air, such as smoke, chemicals, vapors (gases), fumes, dust, or other particles;
respiratory infections, such as colds and flu (viruses); allergens in the air, such as molds, animal dander, and pollen; extremes of temperature or humidity; and emotional excitement or
stress. In most people with occupational asthma, the symptoms appear a short time after beginning work and subside after leaving work.
6. Nocturnal Asthma

6. Nocturnal asthma occurs between midnight and 8 am. It is triggered by allergens in the home such as dust and pet dander or is caused by sinus conditions. Nocturnal or nighttime asthma
may occur without any daytime symptoms recognized by the patient. The patient may have wheezing or short breath when lying down or may not notice these symptoms until awoken by
them in the middle of the night, usually between 2 and 4am. Nocturnal asthma may occur only once in a while or frequently during the week. Nighttime symptoms may also be a common
problem in people who have daytime asthma as well, but then its true nature is more readily recognized. When there are no daytime symptoms to suggest asthma is an underlying cause of
the nighttime cough, this type of asthma will be more difficult to recognize and usually delay proper therapy. The cause (or causes) of this phenomenon is unknown, although many
possibilities are under investigation.
7. Steroid-Resistant Asthma (Severe Asthma)
While the majority of patients respond to regular inhaled glucocorticoid (steroid) therapy, some are steroid resistant. Airway inflammation and immune activation plays an important role
in chronic asthma. Current guidelines of asthma therapy have therefore focused on the use of anti-inflammatory therapy, particularly inhaled glucocorticoids (GCs). One of the major
mechanisms by which glucocorticoids act in asthma is by reducing airway inflammation and immune activation. However, patients with steroid resistant asthma have higher levels of
immune activation in their airways than do patients with steroid sensitive (SS) asthma. Furthermore, glucocorticoids do not reduce the eosinophilia or T cell activation found in steroid
resistant asthmatics.
Incidence of Asthma
• Asthma can strike at any age, but half of all cases occur in children under 10.
• It affects over 10 percent of children and 5-10 percent of adults in many countries, with an estimated 100 million people worldwide suffering from this condition. It has a hereditary
predisposition with 64-84 percent of patients reporting a family history of asthma.
• The International Study of Asthma and Allergies in Childhood (ISAAC) reported a prevalence of 12 percent in the Philippines or about 8 million Filipinos with asthma.
• One of 10 Filipinos has asthma and the Philippines have the highest incidence of asthma cases in Asia.
Causes
Airway obstruction is often caused by abnormal sensitivity of cholinergic and peptidergic receptors, which cause the muscles of the airways to contract when they should not. Certain cells in
the airways, particularly mast cells, are thought to be responsible for initiating the airway narrowing. Mast cells throughout the bronchi release substances such as histamine and leukotrienes,
which cause smooth muscle to contract, mucus secretion to increase, and certain white blood cells to migrate to the area. Eosinophils, a type of white blood cell found in the airways of people
with asthma, release additional substances, contributing to airway narrowing.
In an asthma attack, the smooth muscles of the bronchi narrow (called bronchoconstriction), and the tissues lining the airways swell from inflammation and secrete mucus into the airways. The
top layer of the lining of the airways can become damaged and shed cells. These actions further narrow the diameter of the airways; the narrowing requires the person to exert more effort to
move air in and out of the lungs. In asthma, airway obstruction is reversible, meaning that with appropriate treatment or on their own, and the muscular contractions of the airways stop, the
airway obstruction ends, and the airflow into and out of the lungs returns to normal.

7. In a person who has asthma, the airways narrow in response to stimuli that usually do not affect the airways in normal lungs. The narrowing can be triggered by factors that include any of the
following:
• Environmental allergens (House dust mites, animal allergens [especially cat and dog], cockroach allergens, and fungi are most commonly reported.)
• Viral respiratory infections
• Exercise; hyperventilation
• Gastroesophageal reflux disease (GERD)
• Chronic sinusitis or rhinitis
• Aspirin or nonsteroidal anti-inflammatory drug hypersensitivity, sulfite sensitivity
• Use of beta-adrenergic receptor blockers (including ophthalmic preparations)
• Environmental pollutants, tobacco smoke
• Occupational exposure
• Irritants such as household sprays and paint fumes
• A variety of high and low molecular weight compounds are associated with the development of occupational asthma such as insects, plants, latex, gums, anhydrides, wood dust, and
fluxes.
• Emotional factors or stress
• Perinatal factors (Prematurity and increased maternal age increase the risk for asthma; breastfeeding has not been definitely shown to be protective. Both maternal smoking and
prenatal exposure to tobacco smoke also increase the risk of developing asthma.)
Diagnosis
A doctor suspects asthma based largely on a person's report of characteristic symptoms. A diagnosis of asthma can be confirmed using spirometry tests. During an asthma attack, the test
reveals decreased air flow, but over hours or days, narrowing improves and is therefore reversible.
Complications
The most common complications of asthma include:
• Respiratory fatigue
• Pneumonia
• Pneumothorax- pneumothorax is collection of air or gas in the space surrounding the lungs.
• Pneumomediastinum- a condition in which air is present in the mediastinum (the space in the chest between the two lungs). One cause is when increased pressure within the lungs or
airways ruptures the air sacs or airways, allowing air to escape into surrounding structures. Such pressure can be caused by excessive coughing, sneezing, vomiting or repeated
Valsalva maneuvers (bearing down to increase abdominal pressure, such as during childbirth or defecation).
• Respiratory failure requiring intubation in severe exacerbations
• Side effects of asthma medications
• Death

8. Medical Management
Management strategies include management of exacerbations and regular follow-up care. Classify the severity of asthma before treatment, based on symptom prevalence and measurement of
lung function. Classification of severity and treatment options are shown below.
• Step 1 – Intermittent
o Intermittent symptoms occurring less than once a week
o Brief exacerbations
o Nocturnal symptoms occurring less than twice a month
o Asymptomatic with normal lung function between exacerbations
o No daily medication needed
o FEV1 (forced expiratory volume) or PEF (peak expiratory flow) rate greater than 80%, with less than 20% variability
• Step 2 – Mild Persistent
o Symptoms occurring more than once a week but less than once a day
o Exacerbations affect activity and sleep
o Nocturnal symptoms occurring more than twice a month
o Inhaled steroid (low dose), cromolyn (adult: 2-4 puffs tid/qid; child: 1-2 puffs tid/qid), or nedocromil (adult: 2-4 puffs bid/qid; child: 1-2 puffs bid/qid) (Children usually
begin with a trial of cromolyn or nedocromil.)
o FEV1 or PEF rate greater than 80% predicted, with variability of 20-30%
• Step 3 – Moderate Persistent
o Daily symptoms
o Exacerbations affect activity and sleep
o Nocturnal symptoms occurring more than once a week
o Anti-inflammatory, inhaled steroid (medium dose), or inhaled steroid (low-to-medium dose) and long-acting bronchodilator, especially for nighttime symptoms (either long-
acting inhaled beta2-agonist [adult: 2 puffs q12h, child: 1-2 puffs q12h], sustained-release theophylline, or long-acting beta2-agonist tablets) (If needed, give inhaled steroids
in a medium-to-high dose.)
o FEV1 or PEF rate 60-80% of predicted, with variability greater than 30%
• Step 4 – Severe Persistent
o Continuous symptoms
o Frequent exacerbations
o Frequent nocturnal asthma symptoms
o Physical activities limited by asthma symptoms
o Anti-inflammatory or inhaled steroid (high dose) and long-acting bronchodilator (either long-acting inhaled beta2-agonist [adult: 2 puffs q12h, child: 1-2 puffs q12h] and
sustained-release theophylline or long-acting beta2-agonist tablets and steroid tablets or syrup long term) (Make repeated attempts to reduce systemic steroid and maintain
control with high-dose inhaled steroid.)

9. FEV1 or PEF rate less than 60%, with variability greater than 30%
o
II. DIABETES MELLITUS
Diabetes is a disease in which blood glucose levels are above normal. Most of the food we eat is turned into glucose, or sugar, for our bodies to use for energy. The pancreas, an organ that lies
near the stomach, makes a hormone called insulin to help glucose get into the cells of our bodies. When you have diabetes, your body either doesn't make enough insulin or can't use its own
insulin as well as it should. This causes sugar to build up in your blood.
Diabetes can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations. Diabetes is the sixth leading cause of death in the United
States.
Types of Diabetes
• Type 1 Diabetes, which was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, may account for 5% to 10% of all diagnosed cases of diabetes
• Type 2 Diabetes, which was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes, may account for about 90% to 95% of all diagnosed cases of
diabetes
• Gestational diabetes is a type of diabetes that only pregnant women get. If not treated, it can cause problems for mothers and babies. Gestational diabetes develops in 2% to 5% of all
pregnancies but usually disappears when a pregnancy is over
• Other specific types of diabetes resulting from specific genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses may account for 1% to 2% of all diagnosed
cases of diabetes
Type 2 Diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way your body metabolizes sugar (glucose), your body's main source of
fuel. Type 2 diabetes is often preventable, but the condition is on the rise — fueled largely by the current obesity epidemic. When you have type 2 diabetes, your body is resistant to the effects
of insulin — a hormone that regulates the absorption of sugar into your cells — or your body produces some, but not enough, insulin to maintain a normal glucose level. Left uncontrolled, the
consequences of type 2 diabetes can be life-threatening.
Signs and Symptoms
Type 2 diabetes symptoms may seem harmless at first. In fact, you can have type 2 diabetes for years and not even know it. Look for:
• Increased thirst and frequent urination
• Extreme hunger
• Weight loss
• Fatigue
• Blurred vision
• Slow-healing sores or frequent infections
• Patches of dark, velvety skin in the folds and creases of their bodies (acanthosis nigricans)

10. Risk Factors
• Weight
• Inactivity
• Family history
• Race. (Blacks, Hispanics, American Indians and Asian Americans)
• Age. (Especially after age 45)
• Prediabetes
• Gestational diabetes
Screening and Diagnosis
Various blood tests can be used to screen for diabetes, including:
• Urine sugar test
• Urine ketones test
• Oral Glucose Tolerance Test (OGTT) - also called quot;glucose challengequot; test.
• Blood glucose tests
• Fasting plasma glucose (FPG)
• Random plasma glucose
• C-peptide blood test
• Insulin level blood test
Complications
Short term
• High blood sugar (hyperglycemia)
• Increased ketones in your urine (diabetic ketoacidosis)
• Low blood sugar (hypoglycemia)
Long-term
• Skin and mouth conditions
• Osteoporosis
• Alzheimer's disease
Treatment
• blood sugar monitoring

11. • blood sugar level changes in response to:
o Food
o Physical activity
o Medication
o Illness
o Alcohol
o Stress
o For women, fluctuations in hormone levels
• Healthy eating
o plenty of fruits, vegetables and whole grains
o foods that are high in nutrition and low in fat and calories
o fewer animal products and sweets
• Physical activity
o regular aerobic
o walking, swimming or biking
• Diabetes medications and insulin therapy
o insulin is injected using a fine needle and syringe or an insulin pen injector
o insulin pump
III. HYPERCHOLESTEROLEMIA
Cholesterol is found in every cell in your body. This fat-like substance is an important component of cell membranes and a building block in the formation of some hormones. But your body
makes all the cholesterol it needs. Any cholesterol in your diet is extra – and it's up to no good. When there's too much cholesterol in your blood, you may develop fatty deposits in your blood
vessels. Eventually, these deposits make it difficult for enough blood to flow through your arteries. Your heart may not get as much oxygen-rich blood as it needs, which increases the risk of a
heart attack. Decreased blood flow to your brain can cause a stroke. High blood cholesterol (hypercholesterolemia) is largely preventable. A healthy diet, regular exercise and other lifestyle
changes can go a long way toward reducing high cholesterol. Sometimes medication is needed, too.
Signs and Symptoms
High cholesterol has no symptoms. A blood test is the only way to detect high cholesterol.
Causes
Cholesterol is carried through your blood attached to proteins. The cholesterol-protein package is called a lipoprotein. The main types of lipoproteins are:
• Low-density lipoprotein (LDL). LDL, or quot;bad,quot; cholesterol
• High-density lipoprotein (HDL). HDL, or quot;good,quot; cholesterol

12. Risk Factors
You're more likely to have high cholesterol if you're inactive, obese or eat unhealthy foods. Although high cholesterol can lead to heart disease on its own, other factors compound the risk:
• Smoking
• High blood pressure
• Diabetes
• Family history of heart disease
• Age older than 45 if you're a man, or older than 55 if you're a woman
Screening and Diagnosis
A blood test to check cholesterol levels – called a lipid panel or lipid profile – typically reports:
• Total cholesterol, LDL cholesterol and HDL cholesterol
Complications
Atherosclerosis - a dangerous accumulation of fatty deposits on the walls of your arteries. These deposits — called plaques — can reduce blood flow through your arteries. If the arteries that
supply your heart with blood (coronary arteries) are affected, you may have chest pain and other symptoms of coronary artery disease. If plaques tear or rupture, a blood clot may form —
blocking the flow of blood or breaking free and plugging an artery downstream. If blood flow to part of your heart stops, you'll have a heart attack. If blood flow to part of your brain stops, a
stroke occurs.
Treatment – Lifestyle changes such as eating a healthy diet, getting regular physical activity and avoiding smoking.
REVIEW OF RELATED LITERATURE
Effect of Raw Garlic vs. Commercial Garlic Supplements on Plasma Lipid Concentrations in Adults with Moderate Hypercholesterolemia: A Randomized Clinical Trial
Summary: Garlic, in supplements or its raw form, had no measurable effect on cholesterol levels in people with moderately high levels of cholesterol in their blood.
Why it’s important: Many people take garlic or better-tasting garlic supplements in the hope that it will reduce their cholesterol levels. Knowing if it really works could help people decide
whether to continue this practice.

13. What’s already known: Crushing garlic creates a chemical called allicin, which has been shown to stop the formation of cholesterol in experimental studies in the laboratory. However, when
the effects of garlic are studied in people, the results are inconsistent — it works in some studies and not in others. Some people believe that the chemicals important to the cholesterol-reducing
effect work differently in the raw garlic and the supplements.
How this study was done: The 192 people in the study were age 30 to 65. All had a low-density cholesterol (bad cholesterol) level between 130 and 190 mg/dL. Their triglyceride (the form in
which the body stores fat) levels were below 250 mg/dL and their body-mass indices were between 19 and 30 — from normal to overweight. Three forms of garlic were used over the six-
month study period: raw garlic and two pill forms. The pills were Garlicin, which releases allicin in amounts similar to those found in raw garlic, and Kyolic, a popular brand of garlic
supplement. Participants were divided into four groups. One group took four grams or an average-sized clove of garlic crushed in a blender each day for six days a week. A second took four
Garlicin tablets daily for six days a week. A third group took six Kyolic tablets six days a week. The fourth group took four to six inactive pills called placebo.
All groups received sandwiches so that they would consume the same amount of calories and fat. The sandwiches made the raw garlic more palatable for the people in that group, who used it
as a condiment. Participants kept diaries that detailed the numbers of sandwiches they ate and whether they missed any servings. A total of 169 people completed the six-month studies.
What was found: No statistically significant differences in cholesterol levels were found for any of the treatment groups. The authors, led by Christopher D. Gardner, Ph.D. of Stanford
University Medical School in California, concluded: “Based on our results and those of other recent trials, physicians can advise patients with moderately elevated LDL-C (low-density
lipoprotein or “bad” cholesterol) concentrations that garlic supplements or dietary garlic in reasonable doses are unlikely to produce lipid benefits.”
The bottom line: This study, which sought to test equivalent doses of garlic (raw and two pill-based supplements), found that this ancient remedy has no effect on the levels of cholesterol in
people who had moderately high levels. If you are thinking about using garlic to reduce your cholesterol levels, consult your Physician to discuss other options.
FDA Approves Continuous 7-Day Glucose Monitoring System
The U.S. Food and Drug Administration today approved a device that measures glucose levels continuously for up to seven days in people with diabetes.
While a standard fingerstick test records a person’s glucose level as a snapshot in time, the STS-7 Continuous Glucose Monitoring System (STS-7 System) measures glucose levels every five
minutes throughout a seven-day period. This additional information can be used to detect trends and track patterns in glucose levels throughout the week that wouldn’t be captured by
fingerstick measurements alone. However, diabetics must still rely on the fingerstick test to decide whether additional insulin is needed.
“The STS-7 System supplements standard fingerstick meters and test strips, providing diabetics ages 18 and older with a way to see trends and track patterns,” said Daniel Schultz, M.D.,
director of FDA’s Center for Devices and Radiological Health. “It can help detect when glucose levels drop during the overnight hours, show when glucose levels rise between meals and
suggest how exercise and diet might affect glucose levels.”
The STS-7 System, manufactured by DexCom Inc. of San Diego, Calif., uses a disposable sensor placed just below the skin in the abdomen to measure the level of glucose in the fluid found in
the body’s tissues (interstitial fluid). Sensor placement causes minimal discomfort and can easily be done by patients themselves. The sensor must be replaced weekly. An alarm can be
programmed to sound if a patient’s glucose level reaches pre-set lows or pre-set highs.
Diabetes is caused by the body’s inability to produce or use insulin, a hormone that unlocks the cells of the body, allowing glucose (sugar) to enter and fuel them.

14. An estimated 20.8 million people in the United States—7 percent of the population—have diabetes. Most have type 2 diabetes, a condition in which the body does not properly use insulin. An
estimated 5 percent to 10 percent of people with this chronic disease have type 1 diabetes, which results from the body's failure to produce insulin. People with type 1 diabetes must take insulin
every day.
Diabetes can lead to wide fluctuations in blood sugar levels. Over time, abnormally high levels of glucose can damage the small and large blood vessels, leading to diabetic blindness, kidney
disease, amputations of limbs, stroke, and heart disease.
While there is no known cure, studies have shown that patients who regularly monitor and regulate their blood glucose levels have lower incidences of complications associated with the
disease.
FDA’s approval of the STS-7 System was based on results of a study conducted by DexCom of 72 patients with diabetes at five clinical sites in the United States. The study demonstrated that
the STS-7 System was safe and effective for detecting trends and tracking patterns in glucose levels in adults.
A three-day version of the device, the STS Continuous Glucose Monitoring System, was approved in March 2006.
Allergies Not Linked to Asthma in Urban Adults
NEW YORK (Reuters Health) - Asthmatic adults living in inner-city areas are often allergic to many triggers, such as dust mites or pets, but this sensitization does not appear to increase the
severity of their asthma.
quot;We were expecting that sensitization would be related to worse asthma outcomes, as in children,quot; lead investigator Dr. Juan P. Wisnivesky told Reuters Health.
quot;Inner-city adults are heavily exposed to these allergens and are commonly sensitized -- as shown in our study, as well as by others,quot; he noted. quot;Thus, we were expecting to find an association
between sensitization and asthma control.quot;
Wisnivesky, from the Mount Sinai School of Medicine, New York, and his associates evaluated 245 inner-city adults with persistent asthma. The patients were mostly women, insured by
Medicaid. Sixty percent were Hispanic, 30% African American, and 5% were white. The average income for most patients was less than $15,000 per year.
After being tested for sensitization to cockroaches, dust mites, cat, mold and mouse, 152 (62 percent) of the patients were found to be positive for at least one of these indoor allergens.
However, scores on a standardized questionnaire assessing asthma control were not significantly worse among patients sensitized to indoor allergens compared with those who were not, the
team reports in the Journal of Allergy and Clinical Immunology.
quot;This is not to say that there is not an important allergic component to asthma,quot; Wisnivesky commented. quot;The point is that these factors may be more relevant in children than in adults.quot;
Given these results, Wisnivesky says doctors with adult asthma patients should quot;focus less on assessing sensitization or educating the patients on environmental factors, and pay attention to
other issues, such as how patients use their inhaled corticosteroids or if they understand that asthma is a chronic disease.quot;

15. Biocapsule Can Provide Steady Insulin Supply; Potential Breakthrough for Diabetes Patients
Science Daily — Pushing the frontiers of drug delivery technology, a biomedical engineer at the University of Illinois at Chicago has developed an implantable capsule that releases a steady
supply of insulin to the bloodstream of people with diabetes. The biocapsule, developed by Tejal Desai with support from the National Science Foundation (NSF), features two innovations
designed to overcome previous obstacles. A biological process allows the capsule to continuously produce insulin, rather than using up a limited supply. The capsule is made of a material
designed to overcome the problem of implant rejection.
quot;The capsule essentially acts as a bioreactor; it contains insulin-secreting cells that borrow nutrients from the body to keep producing insulin indefinitely,quot; Desai said. quot;As long as the body
produces glucose, the cells will respond with insulin.quot;
Desai has also broken new ground by developing a successfully implantable micro-scale device. Tiny devices made with microchip technology have been researched extensively for
implantable medical applications, but biocompatibility has been a continuing problem.
To prevent the capsule from being attacked and destroyed by the immune system, Desai developed a silicon membrane covered with tiny uniform pores, each seven nanometers across. The
membrane acts as a quot;microfilter,quot; allowing the secretion of insulin from the capsule but blocking the entrance of antibodies.
The membrane is fabricated with photolithographic techniques commonly used for silicon microchips.
Desai reported the results of short-term testing of the capsule, and the prospects for other micro-devices for drug delivery, today at a meeting of the American Vacuum Society in San
Francisco, California. The results will be published in the November issue of IEEE Transactions in Biomedical Engineering.
The next steps are testing the capsule for long-term usage and evaluating the ideal dosage level.
If Air Gets Scarce: New Gene Causes Asthma in Children
Science Daily — Usually harmless external stimuli like animal hair, pollen and house dust causes a life-endangering narrowing of the bronchi in asthma patients. An international team of
scientists headed by researchers from the Ludwig-Maximilians University (LMU), Munich, and Oxford University, UK, have now been able to identify a gene that clearly increases the risk for
asthma in childhood.
Dr. Thomas Illig, head of the working group Molecular Epidemiology at the GSF National Research Centre for Environment and Health in Neuherberg, near Munich, has also been involved in
this large-scale study. The team examined over 300,000 genetic marker in thousands of asthmatic children and compared their data with those of healthy controls. The newly found gene,
ORMDL3, is a promising object of research: it could help to improve the prevention and diagnosis of asthma, and possibly to develop a new therapy.

16. In Germany, one child in ten suffers from asthma – without any hope of being cured. At best, until now, only symptoms can be treated. However, the research team has now been able to
identify one of the main players in the complex interaction of genetic and environmental factors that lead to asthma. The scientists used the fact that the genetic material of different individuals
shows differences. One type of DNA variants is called SNPs, short for “Single Nucleotide Polymorphisms”. They can be compared and statistically analyzed.
To a hitherto unprecedented extent, in the present case, more than 300,000 SNPs were analyzed in about 2,300 study participants, and briefly half had suffered from asthma since childhood.
The comparison of their genetic data with those of their healthier contemporaries showed that several genetic variations clearly raise the risk of asthma in infancy.
Above all, the gene expression of the gene ORMDL3 was influenced by them. However, significant associations must be examined in so-called replication studies of further case-control
groups. “Thus, in the GAC, the Genome Analysis Centre of GSF, we have analyzed an asthma population that was recruited in the LMU by Dr. Michael Kabesch, and, in this way, we could
confirm the previous results”, reports Illig.
The asthma study is promoted in Germany by the National Genome Research Network (NGFN) and was carried out within the scope of the EU-financed GABRIEL project to decipher the
causes of asthma. Illig is involved as a partner in both projects. Now he and his colleagues have planned follow-up investigations. “This really was an excellent joint effort that we shall
continue”, the molecular biologist commented. “GSF is involved in such high-grade projects, not least because the Genome Analysis Centre is one of the few institutions that can carry out
genome-wide studies on this scale. In the field of genotyping, we belong to the leading groups in Germany.”
Gene Treats Diabetes but Hurts Liver
HOUSTON, Aug. 11 (UPI) -- U.S. researchers say they've found a gene that can either cure fatty liver disease and increase diabetes or treat diabetes and aggravate fatty liver disease.
The study by Texas A&M Health Science Center Institute of Biosciences and Technology at Houston, published online in the journal Diabetes, said a general drug that inhibits the FGFR4 gene
will cure fatty liver disease in the obese while at the same time aggravating cholesterol, cardiovascular disease and diabetes.
quot;A drug enhancing this gene's activity will prevent waistline fat, heart disease and diabetes but aggravate liver disease if you overeat and are obese,quot; lead author Wallace McKeehan, director in
the Center for Cancer and Stem Cell Biology, said Friday in a release.
Fatty liver is a little-known consequence of obesity that is most common in alcoholics. Non-alcoholic fatty liver disease in obese individuals is similar to the alcoholic version, resulting in
hepatitis, cirrhosis, liver failure and liver cancer.
Obesity from overeating high-fat foods constantly stimulates liver FGFR4, overloading the organ's ability to keep fat for only transient storage, the report said.
Soda Warning? High-fructose Corn Syrup Linked To Diabetes, New Study Suggests
Science Daily — Researchers have found new evidence that soft drinks sweetened with high-fructose corn syrup (HFCS) may contribute to the development of diabetes, particularly in
children. In a laboratory study of commonly consumed carbonated beverages, the scientists found that drinks containing the syrup had high levels of reactive compounds that have been shown
by others to have the potential to trigger cell and tissue damage that could cause the disease, which is at epidemic levels.

17. HFCS is a sweetener found in many foods and beverages, including non-diet soda pop, baked goods, and condiments. It is has become the sweetener of choice for many food manufacturers
because it is considered more economical, sweeter and more easy to blend into beverages than table sugar. Some researchers have suggested that high-fructose corn syrup may contribute to an
increased risk of diabetes as well as obesity, a claim which the food industry disputes. Until now, little laboratory evidence has been available on the topic.
In the current study, Chi-Tang Ho, Ph.D., conducted chemical tests among 11 different carbonated soft drinks containing HFCS. He found 'astonishingly high' levels of reactive carbonyls in
those beverages. These undesirable and highly-reactive compounds associated with quot;unboundquot; fructose and glucose molecules are believed to cause tissue damage, says Ho, a professor of food
science at Rutgers University in New Brunswick, N.J. By contrast, reactive carbonyls are not present in table sugar, whose fructose and glucose components are quot;boundquot; and chemically stable,
the researcher notes.
Reactive carbonyls also are elevated in the blood of individuals with diabetes and linked to the complications of that disease. Based on the study data, Ho estimates that a single can of soda
contains about five times the concentration of reactive carbonyls than the concentration found in the blood of an adult person with diabetes.
Ho and his associates also found that adding tea components to drinks containing HFCS may help lower the levels of reactive carbonyls. The scientists found that adding epigallocatechin
gallate (EGCG), a compound in tea, significantly reduced the levels of reactive carbonyl species in a dose-dependent manner when added to the carbonated soft drinks studied. In some cases,
the levels of reactive carbonyls were reduced by half, the researchers say.
quot;People consume too much high-fructose corn syrup in this country,quot; says Ho. quot;It's in way too many food and drink products and there's growing evidence that it's bad for you.quot; The tea-derived
supplement provides a promising way to counter its potentially toxic effects, especially in children who consume a lot of carbonated beverages, he says.
But eliminating or reducing consumption of HFCS is preferable, the researchers note. They are currently exploring the chemical mechanisms by which tea appears to neutralize the reactivity of
the syrup. Ho's group is also probing the mechanisms by which carbonation increases the amount of reactive carbonyls formed in sodas containing HFCS. They note that non-carbonated fruit
juices containing HFCS have one-third the amount of reactive carbonyl species found in carbonated sodas with HFCS, while non-carbonated tea beverages containing high-fructose corn syrup,
which already contain EGCG, have only about one-sixth the levels of carbonyls found in regular soda.
In the future, food and drink manufacturers could reduce concerns about HFCS by adding more EGCG, using less HFCS, or replacing the syrup with alternatives such as regular table sugar, Ho
and his associates say. Funding for this study was provided by the Center for Advanced Food Technology of Rutgers University. Other researchers involved in the study include Chih-Yu Lo,
Ph.D.; Shiming Li, Ph.D.; Di Tan, Ph.D.; and Yu Wang, a doctoral student.
This research was reported August 23 at the 234th national meeting of the American Chemical Society, during the symposium, quot;Food Bioactives and Nutraceuticals: Production, Chemistry,
Analysis and Health Effects: Health Effects.quot;
Being Fat Needn't Be All Bad News
Science Daily — Many individuals become type 2 diabetics because the cells of their body no longer respond to insulin.

18. It is thought that one reason over eating causes insulin resistance is that fat is deposited in organs of the body, such as the liver, rather than in the fat tissue. This idea is now supported by the
work of Phillip Scherer and colleagues at Albert Einstein College of Medicine, New York, who have shown that insulin resistance in mice is not determined by how fat they are but rather
where the fat is stored.
Mice that are obese because they lack leptin (ob/ob mice) become insulin resistant. In the new study, researchers show that if ob/ob mice are engineered to express adiponectin they do not
become insulin resistant.
However, these mice were morbidly obese and the mass of their fat tissues was much increased compared with
normal ob/ob mice. The authors therefore suggest that an inability to maintain high levels of adiponectin might
be what causes insulin resistance in individuals who over eat because it would mean that the excess food they
consume is stored in regions of the body other than the fat tissues.
ANATOMY AND PHYSIOLOGY
PANCREAS
The pancreas, located close to the stomach in the abdominal cavity adjacent to the duodenum, is a
mixed gland. Probably the best hidden endocrine gland in the body are the Pancreatic Islets, formerly called the
Islets of Langerhans. These little masses of hormone –producing tissue are scattered among the enzyme-
producing acinar tissue of the pancreas.
Although there are a million islets, separated by exocrine, each of these tiny clumps of cells busily
manufactures its hormones and works like an organ within an organ. Two important hormones produced by the
islet cells are Insulin and Glucagon.
High levels of glucose in the blood stimulate the release of insulin from the beta cells of the islets.
Insulin acts on just about all body cells and increases their ability to transport glucose across their plasma
membranes. Once inside the cells, glucose is oxidized for energy or converted to glycogen or fat for storage.
These activities are also speeded up by insulin. Since insulin sweeps glucose out of the blood, its effect is said
to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release ends-another classic case of
negative feedback control. Many hormones have hyperglycemic effects, but insulin is the only hormone that
decreases blood glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells. Without
it, essentially no glucose can get into the cells to be used.
Glucagon acts as an antagonist of Insulin; that is, it helps to regulate blood glucose levels but in a way opposite to that of Insulin. Its release by the alpha cells of the islets is stimulated
by low blood levels of glucose. Its action is basically hyperglycemic. Its primary target organ is the liver, which it stimulates to break down stored glycogen to glucose and to release the
glucose into the blood.

19. RESPIRATORY SYTEM
The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi and their
smaller branches, and the lungs, which contain the alveoli or terminal air sacs. Since gas exchanges
with the blood happen only in the alveoli, the other respiratory system structures are really just
conducting passageways that allow air to reach the lungs. However these passageways have another
very important job. They purify, humidify and warm incoming air. Thus, the air finally reaching the
lungs has fewer irritants than when it entered the system and it is warm and damp.
After the primary bronchi enter the lungs, they subdivide into smaller and smaller branches,
finally ending in the smallest of the conducting passageways, the bronchioles. Because of this
branching and rebranching of the respiratory passageways within the lungs, the network formed is
often referred to as the bronchial or respiratory tree. All but the smallest branches have reinforcing
cartilage in their walls.
The terminal bronchioles lead into respiratory zone structures, even smaller conduits that eventually
terminate in alveoli or air sacs. The respiratory zone which includes the respiratory bronchioles,
alveolar ducts, alveolar sacs and alveoli, is the only site of gas exchange. All other respiratory passages
are conducting zone structures that serve as conduits to and from the respiratory zone.
There are millions of the clustered alveoli, which resembles bunches of grapes, and they
make up the bulk of the lungs. Consequently, the lungs are mostly air spaces. The balance of the lung
tissue, its stroma, is elastic connective tissue. Thus, inspite of their relatively large size, the lung
weighs only about 2 ½ lbs., and they are soft and spongy.
The walls of the alveoli are composed largely of a single, thin layer of squamous epithelial cells. Alveolar pores connect neighboring air sacs and provide alternate routes for air to
reach alveoli whose feeder bronchioles have been clogged by mucus or otherwise blocked. The external surfaces of the alveoli are covered with a “cobweb” of pulmonary capillaries. Together
the alveolar and capillary walls, their fused basement membranes, and occasional elastic fibers contract the respiratory membrane (air-blood barrier), which has gas (air) flowing past on one
side and blood flowing past on the other.
The gas exchanges occur by simple diffusion through the respiratory membrane-oxygen passing from the alveolar air into the capillary blood and carbon dioxide leaving the blood, to
enter gas filled alveoli. It has been estimated that the total gas exchange surface provided by the alveolar walls of a healthy man is 50-70 square meters, or approximately 40 times greater than
the surface area of his skin.
The final line of defense for the respiratory system is in the alveoli. Macrophages, sometimes called “dust cells,” wander in and out of the alveoli picking up bacteria, carbon particles,
and other debris. Also scattered amid the epithelial cells that form most of the alveolar walls are chunky cuboidal cells, which look very different. The cuboidal cells produce a lipid molecule
called surfactant, which coats the gas exposed alveolar surfaces and is very important in lung function. It lowers the surface tension of the film of water lining each alveolar sac so that the
alveoli do not collapse between each breath.
Respiratory Physiology

20. The major function of the respiratory system is to supply the body with oxygen and to dispose of carbon dioxide. To do this, at least four distinct events , collectively called
respiration, must occur:
1. Pulmonary Ventilation – air must move into and out of the lungs so that the gases in the alveoli of the lungs are continuously changed and refreshed. This process of pulmonary ventilation
is commonly called breathing.
2. External Respiration - gas exchange between the pulmonary blood and alveoli must take place. Gas exchanges are being made between the blood and the body exterior.
3. Respiratory Gas Transport – oxygen and carbon dioxide must be transported to and from the lungs and tissue cells of the body via the bloodstream.
4. Internal Respiration – at systemic capillaries, gas exchanges must be made between blood and tissue cells. Gas exchanges are occuring between the blood and the cells inside the body.
Mechanics of Breathing
Inspiration – when the inspiratory muscles, the diaphragm and the external intercostals, contract, the size of the thoracic
cavity increases. Since the lungs adhere tightly to the thorax walls, they are stretched to the new, larger size of the thorax. As
intrapulmonary volume increases, the gases within the lungs spread out to fill the larger space.
The resulting decrease in the gas pressure in the lungs produces a partial vacuum, which sucks air into the lungs. Air
continues to move into the lungs until the intrapulmonary pressure equals atmospheric pressure.
Expiration – a passive process that depends more on the natural elasticity of the lungs than on muscle contraction. As the
inspiratory muscles relax, both the thoracic and intrapulmonary volume decreases, and the intrapulmonary pressure rises to a point
higher than the atmospheric pressure. This causes the gases to flow out to equalize the pressure.
Respiratory Volumes and Capacities
1. Tidal Volume- normal quiet breathing moves approximately 500 ml of air into and out of the lungs with each breath.
2. Inspiratory Reserve Volume – amount of air that can be forcibly inhaled over the tidal volume. Normally, between 2100 to 3200
ml.
3. Expiratory Reserve Volume – amount of air that can be forcibly exhaled after a tidal expiration. ERV is approximately 1200 ml.
4. Residual Volume – amount of air in the lungs that cannot be voluntarily expelled. About 1200 ml.
5. Vital Capacity – total amount of exchangeable air. VC is the sum of the TV+IRV+ERV, 4800 ml.
6. Dead Space Volume – amount of air that remains in the conducting zone passageways and never reaches the alveoli, 150 ml.
7. Functional Volume – amount of air that actually reaches the respiratory zone and contributes to gas exchange, is about 350 ml.
BLOOD
The blood is a sticky opaque fluid with a characteristic metallic taste. The color of the blood depends on the amount of oxygen it is carrying, it varies from scarlet red to a dull red. It is
heavier than water and five times more viscous. It is slightly alkaline, with a pH between 7.35 – 7.45. its temperature (38 degrees celsius or 100.4 degrees fahrenheit) is always higher than
body temperature. It accounts for approx. 8% of body weight and is 5 to 6 liters in volume. Normal blood contains 12 to 18 grams of hemoglobin.
Blood Components

21. 1. Plasma
It is the liquid part of blood and makes up 55% of blood. Plasma is made up of 90% water, which is used to absorb heat and as a solvent for carrying other substances. Electrolytes,
namely; sodium, potassium, calcium, magnesium, chloride and bicarbonate which contributes to osmotic balance, pH buffering, and regulation of membrane permeability. Plasma
Proteins, suchas albumin for osmotic balance and pH buffering, fibrinogen for the clotting of blood, and globulins for defense and lipid transport. Substances transported by blood, like
nutrients (glucose, fatty acids, amino acids, vitamins), waste products of metabolism (urea, uric acid), respiratory gases (O2 and CO2) and hormones.
2. Formed elements – are solid portion of blood. Is composed of the following:
• Erythrocytes/Red Blood Cell – most abundant formed element. Anucleate. Conatains very few organelles. Are literally sacs of hemoglobin molecules, a single rbc contains about 250
million hemoglobin molecules. Are small cells shaped like biconcave discs. Heavily contributes to blood viscosity. 4 to 6 million per cubic millimeter of blood. It transports oxygen
bound to hemoglobin molecules; also transport small amount of carbon dioxide. ( hemoglobin – iron bearing protein, trnasports the bulk of oxygen that is carried in blood.)
• Leukocytes/White Blood Cell – 4000 to 11000 per cubic millimeter of blood, accounts for less than 1%of total blood volume. Has a nucleus and has the usual organelles. Is subdivided
into:
Granulocytes
o
1. Neutrophils – 3000 – 7000 (40 – 70% of WBC). Cytoplasm stains pale pink to and cojntains fine granules, which are difficult to see; deep purple nucleus consists of
three to seven lobes connected by thin strands of neoplasm. Are active phagocytes. Its number increases rapidly during short term or acute infections.
2. Eosinophils – 100 -400 (1 -4% of WBC). Red coarse cytoplasmic granules; figure 8 or bilobed nucleus stains blue-red. It kills parasitic worms; increases during
allergy attacks; might phagocytize antigen-antibody complexes and inactivate some inflammatory chemicals.
3. Basophils – 20 – 50 (0 – 1% of WBC). Cytoplasm has a few large blue-purple granules; U- or S-shaped nucleus with constrictions, stains dark blue. Its granules
contain histamine (vasodilator chemical), which is discharged at the site of inflammation.
Agranulocytes
o
1. Lymphocytes – 1500 – 3000 (20 – 45% of WBC). Cytoplasm pale blue and appears as thin rim around nucleus; spherical (or slightly indented) dark purple-blue
nucleus. It is part of the immune system; one group (B lymphocytes) produces antibodies; other group (T lymphocytes) involved in graft rejection, fighting tumors
and viruses, and activating B lymphocytes.
2. Monocytes – 100 – 700 (4 – 8% of WBC). Abundant gray-blue cytoplasm; dark blue purple nucleus often kidney-shaped. Active phagocytes that become
macrophages in the tissues; long term “clean up team”; increase in number during chronic infections.
• Thrombocytes/Platelets – 250000 – 500000. essentially irregularly shaped cell fragments; stain deep purple. Is needed for normal blood clotting; initiate clotting cascade by clinging to
broken area; help to control blood loss from broken blood vessels.
BLOOD VESSELS
Blood circulates inside the blood vessels, which form a closed transport system, the so-called vascular system. As the heart beats, blood is propelled into the large arteries leaving the
heart. It then moves into successively smaller and smaller arteries and then into the arterioles, which feed the capillary beds in the tissues. Capillary beds are drained by venules, which in turn
empty into veins that finally empty into the great veins (vena cavae) entering the heart.

22. Thus arteries, which carry blood away from the heart, and veins, which drain the tissues and return blood to the heart, are simply conducting vessels. Only the tiny hair-like capillaries,
which extend and branch through the tissues and connect the smallest arteries (arterioles) to the smallest veins (venules), directly serve the needs of the body cells. It is only through their walls
that exchanges between the tissue cells and the blood can occur.
Tunics
Except for the microscopic capillaries, the walls of blood vessels have three
coats, or tunics.
1. Tunica Intima – lines the lumen or interior of the vessels, is a thin
layer of endothelium resting on a basement membrane.
• Its cells fit closely together and form a slick surface
that decreases friction as blood flows through the
vessel lumen.
2. Tunica Media – the bulky middle coat. It is only smooth muscle
and elastic tissue. Some of the larger arteries have elastic laminae,
complete sheets of elastic tissue in addition to the scattered elastic
fibers.
• The smooth muscle, which is controlled by the
sympathetic nervous system, is active in changing the
diameter of the vessels. As the vessels constrict or
dilate, blood pressure increases or decreases,
respectively.
3. Tunica Externa – the outer most tunic; composed largely of fibrous
connective tissue. Its function is basically to support and protect the
vessels.
Structural Differences between Arteries, Veins and Capillaries

23. The walls of the arteries are usually much thicker than the walls of veins. Their tunica
media, in particular, tends to be much heavier. This structural difference is related to a difference in
function of these two types of vessels. Arteries, which are closer to the pumping action of the heart,
must be able to expand as blood is forced into them and then recoil passively as the blood flows off
into the circulation. Their walls must be strong and stretchy enough to take these continuous changes
in pressure.
On the other hand, veins are far from the heart in the circulatory pathway, and the pressure
in them tends to be low all the time. Thus veins have thinner walls. However, since the blood
pressure in veins are usually too low to force the blood back to the heart and blood returning to the
heart often flows against gravity, veins are modified to ensure that the amount of blood returning to
the heart equals the amount being pumped out of the heart at anytime.
The lumen of veins tend to be much larger than those of corresponding arteries, and the
larger veins have valves that prevent backflow of blood. Skeletal muscle activity also enhances
venous return. As the muscles surrounding the veins contract and relax, the blood is forced or
squeezed through the veins toward the heart.
The transparent walls of the capillaries are only one cell layer thick-just the tunica intima.
Because of this exceptional thinness, exchanges are easily made between the blood and the tissue
cells. The tiny capillaries tend to form interweaving networks called capillary beds.
The flow of blood from an arteriole to a venule –that is, through a capillary bed-is called
microcirculation. In most body regions, a capillary bed consists of two types of vessels: a vascular
shunt, a vessel that directly connects the arteriole and venule at opposite ends of the bed, and true
capillaries, the actual exchange vessels.
The true capillaries number 10 to 100 per capillary bed, depending on the organ or tissues
served. They usually branch off the proximal end of the shunt and return to the distal end, but
occasionally they spring from the terminal arteriole and empty directly into the precapillary venule.
A cuff of smooth muscle fibers, called a precapillary sphincter, surrounds the root of each true capillary and acts as a valve to regulate the flow of blood into the capillary. Blood
flowing through a terminal arteriole may take one of two routes: through the true capillaries or through the shunt. When the precapillary sphincters are relaxed, blood flows through the true
capillaries and takes part in exchanges with tissue cells. When the sphincters are contracted, blood flows through the shunts and bypasses the tissue cells.

24. PATHOPHYSIOLOGY OF BRONCHIAL ASTHMA IN ACUTE EXACERBATION, DIABETES MELLITUS TYPE 2, AND HYPERCHOLESTEROLEMIA
HOST AGENT ENVIRONMENT
51 year old, female stressful environment
barbecue vendor for more than 10 years exposure to allergens such as animal
dander, HFD of asthma on paternal side pollens and dust
EXERCISE, COLD, EXPOSURE TO AN ALLERGEN, INGESTION OF ASPIRIN, PULMONARY INFECTION, INHALED IRRITANTS, STRESS
IgE PRODUCTION
RE-EXPOSURE TO ANTIGEN
RELEASE PRE-FORMED MEDIATORS THAT OPEN TIGHT JUNCTIONS BETWEEN
ANTIGEN ENTER THE MUCOSA
ACTIVATION OF MUCOSAL MAST CELLS AND
MEDIATORS: HISTAMINE, SRS-A, PROSTAGLANDIN, BRADYKININES, LEUKOTINES
AIRWAY HYPERRESPONSIVENESS
↓ VASCULAR PERMEABILITY BRONCHOSPASM FURTHER RELEASE ↓ NO. OF MUCUS BY BASEMENT
OF LEUKOCYTES GOBLET CELLS IN MEMBRANE
(NEUROPHILS, MUCOSA AND UNDERLYING
EDEMA
EOSINOPHIL, HYPERTROPHY OF THE MUCOSAL
BASOPHIL, SUBMANDIBULAR EPITHELIUM IS
LYMPHOCYTES) GLANDS THICKENED AND
THERE IS
HYPERTROPHY
CHEST WHEEZES
INTENSE PRODUCTIVE
PEAK FLOW SHORTNESS OF INFLAMMATION COUGH
VARIABILITY BREATH OF BRONCHIAL
WALLS

25. ↓ no. of receptor sites of insulin receptor Defect in existing insulin
β cells became less efficient in responding to future glucose
cells receptor
Decrease in insulin
Abnormal coupling between insulin receptor complexes and glucose
transport system
CONTINUED III CONTINUED II
HYPERGLYCEMIA
↑ BLOOD OSMOTIC EFFECT KIDNEY RESPONSE TO
↑ HEPATIC GLUCOSE
CELL HUNGER
RESTORE BALANCE BY
PRODUCTION
EXCRETING EXCESS
↑ BLOOD
GLUCOSE
HEMODILUTION
SIGNAL THE
CELL UTILIZES
TACHYCARDIA ↓ BLOOD FLOW
HYPOTHALAMUS
PROTEIN FOR
TO INCrease
METAOBLISM ANEMIA GLUCOSE ATTRACTS WATER
APPETITE POOR WOUND HEALING
BODY WASTING
↓Hgb and ↓Hct GLYCOSURIA/OSMOTIC DIURESIS
POLYPHAGIA RISK FOR INFECTION
POOR WOUND
HYPOKALEMIA
PALE SKIN, LIPS,
ORAL MUCOSA
AZOTEMIA
POLYDIPSIA
AND CONJUNCTIVA
NEPHROPATHY DEHYDRATION
HEPATIC ENCEPPHALOPATHY SHOCK
DAMAGE OF VITAL ORGANS
COMA
DEATH

26. GLYCOPROTEIN CELL WALL DEPOSITS
ADDED LAYERS AND INCrease THICKNESS IN BASAL LAMINA
MICROVASCULAR COMPLICATION NEOROPATHIC COMPLICATIONS MACROVASCULAR COMPLICATION
AFFECTS THE NERVES VASCULAR OCCLUSION
AFFECTS THE AFFECTS THE
EYES KIDNEYS
INTERFERES W/ METABOLIC ACTIVITY, DEGENERATION
HYPERTENSION
CLOUDY HYPERTROPHY OF AND DEMYELINATION OF SCHWANN CELLS
APPEARANCE NEURONS
OF THE EYES CORONARY ARTERY DiseaSE
↓ GFR AXONAL LOSS
CEREBROVASCULAR DiseaSE
BLURRING OF
VISION
LOSS OF NEPFRON
DIMINISHED SENSATION PERIPHERAL INSUFFICIENCY
Function
BLINDNESS;
RETINOPATHY RISK FOR GANGRENE
PROTEINURIA & LOSS OF SENSES ESPECIALLY THE
HEMATURIA; LOWER EXTREMITIES
NEPHROPATHY
INFECTION

27. III
Excess glucose is converted into fats
Increased level of cholesterol
Accumulation of fats in the blood vessel wall
Fats are hardened by circulating Ca++;
Loss of arterial elasticity; arteriosclerosis
atherosclerosisCONTINUED III

28. OUTCOME PRESENT STATE TEST MODEL
CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
S.G., 51 years old, female, was admitted for ER MANAGEMENT
the 9th time at Cebu Velez General Hospital on
August 22, 2007 at 9:47pm accompanied by August 22, 2007 – Wednesday
her husband and daughter via ambulance for Time In: 9:47 pm Time Out: 11: 10 pm
complaints of difficulty in breathing noted 8 BP=130/80 mmHg PR=103 bpm
hours prior to admission and vomiting RR=25 cpm T= 36.8ºC/axilla
amounting to 1 glass of previously eaten food
noted 9 hours prior to admission. Doctor’s Orders:
1. Salbutamol Neb 1 nebule now 10:00pm
HISTORY OF PRESENT ILLNESS 2. Oxygen Inhalation at 2 lpm via nasal
cannula 9:47pm
Two days prior to admission, patient had 3. Salbutamol + ipratropium bromide neb 1
productive cough with mucopurulent nebule now 10:30pm
sputum. No medications were taken. 4. CBG 1 & 5 mg/dL
5. Start venoclysis with D50.3NaCl 1L at
One day prior to admission, patient sought 30gtts now 11:00pm
consult at Dr. Florentino Berdin’s clinic. She
was advised nebulization with Salbutamol + PHYSICAL EXAMINATION
Ipatropium 120 mg/20 mg which she took at
home. She was relieved. GENERAL APPEARANCE
Nine hours prior to admission, patient had the August 23, 2007 – Thursday
onset of vomiting amounting to 1 glass of Approached sitting on bed, awake, conscious,
previously eaten food. Minutes after the first responsive, coherent, tachypneic, afebrile,
episode of vomiting, patient had another with O2 inhalation at 2L/min flowing well,
episode which consists of saliva. She didn’t with IVF 1 D5.3NaCl @ 40gtts/min infusing
take medication for relief of symptoms. well at left arm, with the following vital signs:
Patient only rested on a sitting position.
BP=110/80 mmHg PR=80bpm
8 hours prior to admission, patient had the RR=25cpm T=37˚C/axilla
onset of difficulty in breathing. It was
precipitated since she wasn’t able to sleep Height=5 feet and 2 inches
well because she was awoken up by her ABW=55 kg
mother. No consult was done. Difficulty of IBW=51.73 kg – Overweight
breathing is associated with nasal flaring. Nutritional Status=106.32% Normal
Patient took Salbutamol + ipratropium

29. nebulization with slight relief of symptoms. SCALE FOR NUTRITIONAL STATUS
She also positioned herself on a sitting position 110-90%=Normal
to aid her in breathing. 89-76% =First Degree Malnourished
75-61% =Second Degree Malnourished
Hours prior to admission, patient had 60% ↓ =Third Degree Malnourished
difficulty in breathing that cannot be
tolerated. She took Salbutamol + Skin and Appendages: no lesions, brown
ipratropium nebulization but no relief was complexion, (-) jaundice, (-) cyanosis, (-)
noted. Her husband decided to bring her to the edema, hair evenly distributed, good skin
hospital. Patient was brought to Cebu Velez turgor, warm to touch, pinkish nailbed, no nail
General Hospital and was advised to be clubbing, short and dirty fingernails and
admitted at PPW 4th floor under the service of toenails
Dr. Florentino Berdin Dept. of Family
Medicine Head: normocephalic, skull and face are
symmetrical, black hair, evenly distributed
PAST MEDICAL HISTORY: hair, no dandruff, no deformities, no masses,
no lesions, no swelling
Patient is a known diabetic for 1 year with
the highest CBG of 333mg/dL and lowest Eyes: white sclerae, pink palpebral
CBG of 108mg/dL. She was diagnosed with conjunctiva, no abnormal discharges, evenly
DM Type II last 2006 by Dr. Manuel distributed eyebrows
Emerson Donaldo at Cebu Velez General
Hospital. Patient is also a known asthmatic Ears: Pinna in line with inner canthus, no
for 13 years.She was diagnosed with asthma discharges noted, symmetrical in shape, no
by Dr. Danggoy at Compostela Clinic. masses, no lesions, (+) cerumen, no
Medications were unrecalled. She is non- tenderness, no swelling
smoker, non-alcoholic, and non-hypertensive.
Heredofamilial Disease includes asthma on Nose and Sinuses: Nasal septum is straight
her paternal side and diabetes on her and perforated, no nasal flaring, no nasal
maternal side. Patient is allergic to chicken discharges, pinkish mucous membrane, (+)
and seafoods which include shrimp, crab, transillumination on frontal sinuses, (-)
and squid. She is also allergic to Fluticasone transillumination on maxillary sinuses
+ Salmeterol (Seretide).
Mouth: pinkish lips, no masses and
Year 1994 – Patient sought consult at ulcerations, uvula at midline, pinkish gums,
Compostela Clinic for complaints of (+) halitosis, (-) hoarseness of voice, has 9
difficulty in breathing. It was triggered by teeth ( 5 upper and 4 lower), presence of
exposure to dust and smoke and by dental caries, decayed teeth
emotional stress. She was given an unrecalled
medication via IM prescribed by Dr. Danggoy. Neck: supple neck, no lesions, no masses,

30. trachea at midline, lymph nodes not palpable
Year 1999 – Patient was admitted at Visayas
Community Medical Center for complaints of Chest and Lungs: equal chest expansion,
difficulty in breathing. She was diagnosed wheezes heard on both lung fields, no
with asthma. She stayed in the hospital for 1 palpable masses, no lesions
week and was discharged improved.
Medications were unrecalled but claimed that Heart: distinct heart sounds S1 and S2 with
she was not prescribed with nebulization. regular rhythm
Year 2000 – Patient was admitted at Cebu Breast and Axillae: no discharges, no
Velez General Hospital for complaints of tenderness, symmetrical, no masses, everted
difficulty in breathing under the service of nipple
Dr. Giselita Maambong. She was diagnosed
with bronchial asthma. She stayed in the Abdomen: normoactive bowel sounds,
hospital for 4 days. She was prescribed with 7clicks/minute, no organomegaly, flabby,
Salbutamol (Ventolin) 2.5 mg [ Classification: smooth and even surface, no lesions,
Bronchodilator Beta Receptor Agonist Action: umbilicus at midline, no masses
Dilate the airways of the respiratory tree,
making air exchange and respiration easier for Genitalia: grossly female, no itchiness and
the client , and relax the smooth muscles of the irritations, no abnormal discharges
bronchi] which she took thrice a day with good
compliance. Other medications were Rectum: Perforated anus, no hemorrhoids, no
unrecalled but taken with good compliance. abnormal discharges, no irritations and
itchiness
May 2005 – Patient was admitted for asthma
attack at Cebu Velez General Hospital under Extremities: no swelling, no lesions, no
the service of Dr. Manuel Emerson Donaldo of edema, CRT on both upper and lower
the Dept. of Internal Medicine and Dr. Vinci extremities are < than 2 seconds, pinkish
Urgel of the Dept. of Pulmonary. She stayed at nailbeds, strong and palpable pulses
the hospital for 6 days and was discharged with
improved condition. Medication taken was NEUROLOGIC ASSESSMENT
Salbutamol (Ventolin) [ Classification:
Bronchodilator Beta Receptor Agonist Action: Cognitive: oriented to time, person, and place,
Dilate the airways of the respiratory tree, able to recall recent events, long term
making air exchange and respiration easier for memory= can recall date of his wedding, short
the client , and relax the smooth muscles of the term memory= can recall persons who visited
bronchi] and other medications were him yesterday and what he ate in the morning
unrecalled.
Cerebellar: able to perform finger to nose
July 2005 – Patient was admitted for test, (-) Romberg exam, able to touch fingers

31. difficulty in breathing secondary to with thumb
bronchial asthma at Cebu Velez General
Hospital under the service of Dr. Manuel Sensory: able to feel sensation, (+)
Emerson Donaldo. She was given with graphesthesia, (+) sterognosis, (+) kinesthesia
Salbutamol (Ventolin) via nebulization. Other
medications were unrecalled. She stayed at the CRANIAL NERVES
hospital for 3 days and discharged improved.
I. Olfactory: able to distinguish smell
September 2005 – Patient was admitted for alcohol from perfume
difficulty in breathing and productive cough II. Optic: able to read student’s
at Cebu Velez General Hospital under the nameplate at 2 feet distance
service of Dr. Manuel Emerson Donaldo. She
III. Oculomotor: (+) cardinal gaze, (+)
was diagnosed with Bronchial asthma, CAP
PERRLA
( Community Acquired Pneumonia) and
IV. Trochlear: (+) cardinal gaze, (+)
Urinary Tract Infection. Medications given
PERRLA
include Cefuroxime (Zegen) [ Classification:
V. Trigeminal: can blink eyes with a
Anti-infective Cephalosporin Second
wisp of a cotton, able to masticate
Generation Action: Binds to bacterial cell wall
food well, able to clench teeth
membrane, causing cell death] 500 mg twice a
VI.
day, Prednisone (10) 2 tabs twice a day, Abducens: (+) cardinal gaze, (+)
Fluticasone + Salmeterol (Seretide) 250 mg, PERRLA
Salbutamol (Ventolin) via nebulization. She VII. Facial: able to smile, frown, raise
stayed in the hospital for 3 days and was eyebrows, puff out cheeks, able to
discharged improved. distinguish taste on the anterior 2/3
of tongue
November 2005 – Patient was admitted again
VIII. Vestibulocochlear: able to hear
at Cebu Velez General Hospital for complaints
whipered voice from 2 ft distance
of difficulty in breathing secondary to
IX. Glossopharyngeal: able to swallow,
bronchial asthma under the service of Dr.
(+)gag reflex, able to distinguish
Vinci Urgel. She stayed in the hospital for 3
taste at the posterior 1/3 of tongue,
days and was discharged improved.
uvula and soft palate rise upon saying
“ahh”
January 2006 – Patient was admitted at Cebu
X. Vagus: (+) gag reflex, can swallow
Velez General Hospital under the service of
and chew food
Dr. Manuel Emerson Donaldo of Dept. of
XI.
Internal Medicine. She was diagnosed with Spinal Accessory: can shrug
Bronchial asthma and Contact Dermatitis. shoulders against resistance
Medications include, Salbutamol (Ventolin) XII. Hypoglossal: tongue at midline upon
via nebulization, Ambroxol [Classification: protrusion, able to move tongue from
Mucolytic Action: Lowers the viscosity of the side to side and up and down

32. mucus] 75 mg taken once a day, and
Betamethasone (Betnuvate) cream She stayed MUSCLE STRENGTH
in the hospital for 5 days and was discharged
improved. 5/5 5/5
5/5 5/5
August 2006 – Patient was again admitted at
Cebu Velez General Hospital under the service SCALE FOR GRADING MUSCLE
of Dr. Manuel Emerson Donaldo of Dept. of STRENGHT
Internal Medicine for complaints of difficulty 5 – Full ROM against gravity, full resistance
in breathing secondary to bronchial asthma. 4 – Full ROM against gravity, some resistance
She was also diagnosed with Diabetes 3 – Full ROM with gravity
Mellitus Type 2. Medications taken include: 2 – Full ROM with gravity eliminated
Salbutamol (Ventolin) 2.5 ml nebulization, (passive motion)
Ambroxol (Mucosolvan) 75 mg/tab taken once 1 – Slight Reaction
a day, Ciprofloxacin (Pharex) 500 mg one tab 0 – No Reaction
taken once a day [ Classification:Anti-infective
Fluoroquinolones Action: Inibits bacterial DEEP TENDON REFLEXES
DNA synthesis by inhibiting DNA gyrase] (+2) biceps reflex, (+2) triceps reflex, (+2)
Prednisone (Pred 30) 300 mg one tab taken brachioradialis reflex, (+2) patellar reflex
once a day [ Classification: Intemediate-acting
Glucocorticoids Action: Suppression of SCALE FOR GRADING REFLEX
inflammation and modification of the normal RESPONSES:
immune response], and Metformin 0 – No Reflex Response
[ Classification: Oral Hypoglycemic agent +1 – Minimal Activity
Biguanides Action: Decrease hepatic +2 – Normal Response
production of glucose] 500 mg one tab taken +3 – More Active than Normal
thrice a day. She stayed in the hospital for 5 +4 – Maximal Activity (Hyperactive)
days and was discharged improved.
August 24, 2007 – Friday
August 10, 2007 – Patient was admitted again Examined lying on bed, awake, conscious,
for complaints of difficulty in breathing responsive, coherent, afebrile, with ease in
secondary to Bronchial asthma under the respiration, with IVF 4 D5.3NaCl 1 lL @ 30
service of Dr. Florentino Berdin of Dept. of gtts/min, with the following vital signs:
Family Medicine. She stayed in the hospital for
5 days and was discharged improved. BP=100/60mmHg PR=92bpm
Medications given include: Salbutamol RR=20 cpm T=36.5˚C/axilla
(Ventolin) 2.5 ml via nebulization, Metformin
500 mg one tab thrice a day. Significant Findings:
 dirty fingernails and toenails
GORDON’S FUNCTIONAL HEALTH  (-) transillumination on maxillary