diagnosis of diseases

conventional & naturopathy diagnosis methods used

1. DIAGNOSIS OF DISEASES PRESENTED BY: ANUPAM PANDEY ASHWANI KUMAR MISHRA NEHA SINGH NIKITA SHARMA ONAM VERMA SAKSHI SINGH SHIVANGI SAXENA

2. CONTENT INTRODUCTION : DIAGNOSIS DIAGNOSIS METHODS ACCORDING TO CONVENTIONAL MEDICINE LAB INVESTIGATIONS RADIOLOGICAL INVESTIGATIONS

3. ORIGIN OF TERM DIAGNOSIS The word is derived through Latin from Greek word :

4. INTRODUCTION Diagnosis is a part of internal medicine A s we all, know “ internal medicine is medical speciality dealing with the prevention, diagnosis & treatment of adult diseases”.

5. MEANING OF MEDICAL DIAGNOSIS DEFINITION - Identification of a disease on objective (measurable) & subjective (non-measurable) symptoms.

6. APPROACH TO PATIENT

7. FUNDAMENTAL OF DIAGNOSIS DIAGNOSIS : Identification of a disease by investigation of its signs and symptoms. IDENTIFICATION Inquiry Physical examination Laboratory tests/Special examination ANALYSIS Basic knowledge of medicine Overall analysis Scientific way of clinical thinking

8. CLASSIFICATION OF DIAGNOSIS IN MEDICINE

9. 1.MOLECULAR DIAGNOSIS

10. CONT. Molecular Diagnosis is a collection of techniques used to analyse biological markers in the individual genetic code[genome & proteome] & how their cells express their genes as proteins. Used to diagnose & monitor diseases, detects risk & decide which therapies will works best for the individual patient. Useful in range of med. Specialism,including -infectious diseases, oncology, pharmacogenomics –the genetic prediction of which drugs will work the best.

11. MOLECULAR DIAGNOSIS ACROSS MEDICAL DISCIPLINE 1.INFECTIOUS DISEASES Pathogen identification; eg- MTB(Mycobacterium tuberculosis) Pathogen quantification; eg- HIV Load Drug resistance status; eg- MRSA(methicillin resistant staphylococcus aureus) 2. ONCOLOGY Predictive testing; e.g.- BRSA(bilirubin rat serum albumin ) Comparison diagnostics; e.g.-EGFR(epidermal growth factor ) Disease monitoring; e.g.- BCR-ABL(fusion genes found in myelogenous leukemia) Prognostic testing; e.g.- Oncotype 3. ENDOCRINOLOGY Eg- Neonatal diabetes, Congenital adrenal hyperplasia 4. HAEMATOLOGY Blood disorders ; e.g.- thalassemia 5. IDENTITY Transplantation ; eg- HLA Typing 6. PRENATAL TESTING Eg- Trisomy 21 testing by aminocentesis, CVS or NIPD 1.INFECTIOUS DISEASES Pathogen identification; eg- MTB(Mycobacterium tuberculosis) Pathogen quantification; eg- HIV Load Drug resistance status; eg- MRSA(methicillin resistant staphylococcus aureus) 3. ENDOCRINOLOGY Eg- Neonatal diabetes, Congenital adrenal hyperplasia 4. HAEMATOLOGY Blood disorders ; e.g.- thalassemia 5. IDENTITY Transplantation ; eg- HLA Typing 6. PRENATAL TESTING Eg- Trisomy 21 testing by aminocentesis, CVS or NIPD

12. 1.MEDICAL DIAGNOSIS(   Process of determining ,which disease or condition explains a person’s symptoms & signs. Information required for diagnosis is typically collected from a history of patient & physical examination. It is often challenging because many signs & symptoms are non-specific . Eg-redness of skin (erythema) by itself is a sign of disorder & thus doesn’t tell the health care professional the exact cause .

13. HISTORY OF MEDICAL DIAGNOSIS First recorded examples are of Imhotep in ancient Egypt. Empiricism, logic & rationality in diagnosis of a disease was introduced by Esagil-kin-apli in Babylon medical textbook i.e. Diagnostic Handbook Huang di nei jing described 4 diagnostic methods which are used in TCM till now they are- Inspection, auscultation- olfaction, interrogation & palpation. Father of medicine, Hippocrates was known to make diagnosis by evaluating his patient’s urine & sweat.

14. MEDICAL USES Diagnosis is an attempt at classification of an individual’s condition into separate & distinct categories that allow medical decision about treatment & prognosis to be made. It is often described in terms of disease & other condition . Diagnostic procedure does not necessarily involve elucidation of etiology (cause) of the diseases. Diagnosis is initial task to detect a medical indications.

15. CONT. INDICATIONS INCLUDES: Detection of any deviation from normal For eg- anatomically (structure of body) Physiologically (how body works) Psychologically (thought & behaviour) Knowledge of what is normal & measuring of patients current condition against those norms.

16. DIAGNOSTIC CRITERIA The term designates the specific combination of signs ,symptoms & test results that physician uses to attempt to determine the correct diagnosis. And accordingly treatment should be given.

17. POSSIBLE ADVERSE EFFECTS OVERDIAGNOSIS Diagnosis of diseases that will never cause symptoms. It is a major problem because it turns people into patient. Lead to economic waste (overutilisation) & treatments that may cause harm.

18. II.ERRORS According to 2015 report of “ NATIONAL ACADEMIES OF SCIENCES,ENGINEERING & MEDICINE’’: M ost of the people experiences atleast 1 diagnostic errors in their life time . Causes & factors of errors: Manifestation of disease are not suffciently noticeable. Disease is omitted from consideration.

19. CONT. 3. Too much significance is given to some aspect of the diagnosis. 4.Rare diseases with symptoms suggestive of many other conditions. III . LAG TIME It is a delay time until a step towards diagnosis of disease or condition is made.

20. CONT. TYPES: 1.Onset to medical encounter lag time- The time from onset of symptoms until visiting a health care provider. 2.Encounter to diagnosis lag time -Time from first medical encounter to diagnosis.

21. TYPES OF MEDICAL DIAGNOSIS MAIN TYPES CLINICAL LABORATORY RADIOLOGY PRINCIPAL ADMITTING OTHER TYPES DIFFERENTIAL PRE-NATAL DIAGNOSIS OF EXCLUSION SELF-DIAGNOSIS REMOTE NURSING COMPUTER-AIDED

22. CLINICAL DIAGNOSIS Content of Clinical Diagnostics: Symptomatic diagnosis Physical diagnosis Lab/clinical ancillary tests Medical record Diagnostics processes & the way of clinical thinking

23. SYMPTOMATIC DIAGNOSIS History taking –Interview Symptoms – P atients complaints Symptomatic diagnosis

24. HISTORY TAKING

25. INTRODUCTION Aim: At the end of the session students should know fundamentals of history taking and take a history of a simple disease Objectives: At the end of the session students should record: Chief complaint Present illness Past medical history Systemic enquiry Family history Drug history Social history

26. CHIEF COMPLAINTS The main reason push the point to seek for visiting a physician or for help. Usually a single symptoms, occasionally more than one complaints eg: chest pain, palpitation, shortness of breath, ankle swelling etc. The patient describe the problem in their own words . It should be recorded in points own words . What brings your here? How can I help you? What seems to be the problem?

27. CHIEF COMPLAINTS SHOULD BE: Short/specific in one clear sentence communicating present/major problem/issue. Timing – fever for last two weeks or since Monday Recurrent –recurring episode of abdominal pain/cough Any major disease important with PC e.g. DM, asthma, HT, pregnancy. Note: CC should be put in patient language.

28. PRESENT ILLNESS Elaborate on the chief complaint in detail Ask relevant associated symptoms Have differential diagnosis in mind Lead the conversation and thoughts Decide and weight the importance of minor complaints

29. PAIN{OPQRST} O nset of disease P osition/site Q uality, nature, character-burning sharp, stabbing, crushing & also explain depth of pain –superficial or deep R elationship to anything or other bodily functions /position R adiation-where moved to R elieving on aggravating factors –any activities or position

30. CONT. S everity –how it affects daily work/physical activities ; unable to sleep,unable to do any work T iming-mode of onset [abrupt/gradual] , progression[cont./intermittent; if intermittent ask frequency & nature] T reatment received or outcome

31. PAST MEDICAL HISTORY Start by asking the patient if they have any medical problems Heart Attack/DM/Asthma/HT/TB/Jaundice .E.g . if diabetic- mention time of diagnosis/current medication/clinic check up Past surgical/operation history E.g . time/place/ and what type of operation. Note any blood transfusion and blood grouping. History of trauma/accidents E.g . time/place/ and what type of accident

32. DRUG HISTORY Always use generic name or put trade name in brackets with dosage, timing and how long. Example: Ranitidine 150 mg BD PO Note: do not forget to mention OCP/Vitamins/Traditional medicine/KAP

33. DRUG HISTORY bd ( Bis in die) - Twice daily (usually morning and night) tds (ter die sumendus)/tid (ter in die) = Three times a day mainly 8 hourly qds (quarter die sumendus)/qid (quarter in die) = four times daily mainly 6 hourly Mane /(om – omni mane) = morning Nocte /(on – omni nocte) = night ac (ante cibum) = before food pc (post cibum) = after food po (per orum/os) = by mouth stat – statim = immediately as initial dose Rx (recipe) = treat with

34. SOCIAL HISTORY Smoking history - amount, duration and type. A strong risk factor for heart disease Drinking history - amount, duration and type. Cause cardiomyopathy, vasodilatation Occupation, social and education background , family social support and financial situation

35. OTHER RELEVANT HISTORY Gyanae/Obstetrics history [if female] Immunization if small child Travel and sexual history if suspected STD or infectious disease Note If small child, obtain the history from the care giver. Make sure; talk to right care giver . If some one does not talk to your language, get an interpreter(neutral not family friend or member also familiar with both language)ask simple & straight question but do not go for yes or no answer

36. GENERAL SYSTEM REVIEW Weakness Fatigue Anorexia Change of weight Fever Lumps Night sweats

37. GASTROINTESTINAL/ALIMENTARY SYSTEM REVIEW Appetite (anorexia/weight change) Diet Nausea/vomiting Regurgitation/heart burn/flatulence Difficulty in swallowing Abdominal pain/distension Change of bowel habit Haematemesis , haematophagia Jaundice

38. CARDIOVASCULAR SYSTEM REVIEW Chest pain Paroxysmal Nocturnal Dyspnoea Orthopnoea Short Of Breath(SOB) Cough/sputum (pinkish/frank blood) Swelling of ankle(SOA) Palpitations Cyanosis

39. RESPIRATORY SYSTEM REVIEW Cough(productive/dry) Sputum (colour, amount, smell) Haemoptysis Chest pain SOB/Dyspnoea Tachypnoea Hoarseness Wheezing

40. URINARY SYSTEM REVIEW Dysuria Urgency Hesitancy Terminal dribbling Nocturia Back/loin pain Incontinence Character of urine color / amount (polyuria) & timing Fever Frequency

41. NERVOUS SYSTEM REVIEW Visual/Smell/Taste/Hearing/Speech problem Head ache Fits/Faints/Black outs/loss of consciousness(LOC) Muscle weakness/numbness/paralysis Abnormal sensation Tremor Change of behaviour or psyche

42. GENITAL SYSTEM REVIEW Discharge Unusual bleeding Sexual history Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception Obstetric history – Para/ gravida/abortion Pain/discomfort/itching

43. MUSCULOSKELETAL SYSTEM REVIEW Weakness/movement Pain – muscle, bone, joint Deformities Gait Swelling

44. SOAP Subjective : how patient feels/thinks about him. How does he look. Includes PC and general appearance/condition of patient Objective – relevant points of patient complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and interpretation Assessment – address each active problem after making a problem list. Make differential diagnosis . Plan – about management, treatment, further investigation, follow up and rehabilitation

45. SYMPTOMS & SIGNS A symptom(complaint) is subjective feeling from the patient point of view . • A symptom is what the patient experiences about the disease . • Symptoms can only be experienced, they are not able to be observed or measured objectively . • Pain is a symptom. I do not know you are having pain unless you tell me. Nausea is also a symptom, as are: chills, numbness, fatigue, vertigo,malaise,itching,stomach cramps, burning on urination, etc.

46. CONT. Subjective sensation that patient describes Physiological & functional Pathological & morphological Fever Cough Rash Mass

47. CONT. A sign is an objective physical manifestation of disease. • It is an objective finding, something one can observe and measure . • A rapid pulse, a high temperature, a low blood pressure, an open wound, bruising, etc. are all signs . • Signs give a more definite indication of the presence of a particular disease to the physician . So in the simplest form, signs are observations of the doctor and symptoms are the experiences of the patient.

48. LAB INVESTIGATIONS

49. LAB/CLINICAL ANCILLARY TESTS Serum test Urine test B lood test stool test Sputum test Serous membrane fluid CSF test

50. LABORATORY TEST Laboratory tests check a sample of blood, urine, or body tissues. A technician or doctor analyses the test samples to see if results fall within the normal range. The tests use a range because what is normal differs from person to person. Many factors affect test results. These include:- Sex, age and race What to eat and drink Medicines How well the pre-test instructions are followed

51. CONT. It is often useful in comparing the results to results from previous tests. Laboratory tests are often part of a routine check-up to look for changes in the health. It also help doctors diagnose medical conditions, plan or evaluate treatments and monitor diseases.

52. A1C/GLYCOHEAMOGLOBIN/Hb A1C TEST It is used to test for type 2 diabetes & prediabetes It measures –Average blood glucose or blood sugar level over past 3 months This is often used to see how well one is managing diabetes It is different from blood sugar checks that people with diabetes do everyday

53. CONT. CLINICAL VALUES OF A1C TEST NORMAL VALUE= Below 5.7% PRE-DIABETES=B/W 5.7 -6.4% TYPE 2 DIABETES= Above 6.5% Done twice in a year for diabetic patients May need to retests every year for pre-diabetic patients

54. RECENT CLINICAL TRIALS [BY U.S. National institutes of Health] Designer functional foods on parameters of metabolic & vascular in pre-diabetes condition =pre-diabetes Interventions = dietary supplements:functional ingredient group, dietary supplements:conrol ingredients group

55. 2.Effects of RBC survival on a commonly used diabetes lab test HbA1C Condition = diabetes mellitus,impaired fasting glucose, pre-diabetes Interventions = biological: re-infusion of biotin labelled cells, behavioural: diabetes education & medication adjustments.

56. 3.USING PEER MENTORS TO SUPPORT PACT TEAM EFFORTS TO IMPROVE DIABETES CONTROL Condition= type 2 diabetes mellitus Interventions= Behavioural: peer mentoring

57. BLOOD COUNT TESTS Also known as- CBC, complete blood count, hematologic tests Blood contains –RBC,WBC,& platelets This test measures no. & types of cells present in blood Tests can diagnose disease conditions such as-anaemia, infections, clotting problems, blood cancer, & immune system disorders

58. COMPOSITION OF BLOOD

59. 7 SPECIFIC TYPES INCLUDES TESTS FOR: RBC - The no., size & types of RBC in blood WBC - The no. & types of WBC in blood PLATELETS - The no. & size of platelets Hb- iron rich protein in RBC that caries oxygen HEAMATOCRIT – total space occupied by RBC in blood RETICULOCYTE COUNT –No. of young blood cells in blood MEAN CORPUSCULAR VOLUME(MCV) -Average size of RBC

60. RBC

61. DIFFERNTIAL COUNT Absolute neutrophil count A measure of the number of neutrophil granulocytes

62. CLINICAL VALUES OF ANC Normal – ANC = 1500 - 8000 cells/µL Neutropénie - ANC < 500 cells/µL Neutrophilia – ANC > 8000 cells/µL.

63. PLATELET COUNT NORMAL= 150,000-400,000/ml Thrombocytopenia –platelet count less than 150,000/ml Mild thrombopenia = 100,000-150,000/ml Severe thrombopenia=less than 50,000/ml

64. PLATELET & AGING

65. HAEMOGLOBIN

66. HAEMOCRIT [Ht OR HCT] “ Packed cell volume (PCV)” or “Erythrocyte volume fraction (EVF)” It is the volume percentage (%) of RBC in blood. It is normally 45% for men and 40% for women.

67. MEAN CORPUSCULAR VOLUME It is average volume of a RBC. The normal range is : 80-100 fL An elevated MCV is termed as Macrocytic & is associated with : Alcoholism Folic acid deficiency Vit. B12 Deficiency A low MCV is termed as Microcytic & is also associated with: Iron deficiency Thalassemia Chronic disease

68. MEAN CORPUSCULAR Hb It is the average mass of Hb per RBC A normal value is 27 - 31 pg./cell Hypochromic: MCH < 27 pg/cell Hyper chromic: MCH > 31 pg/cell

69. RETICULOCYTE COUNT Normal “Reticulocyte Count” value = 1% of the red blood cell. Reticulocyte count can sometime be misleading because it is not really a count but rather a percentage

70. RETICULOCYTE VALUE

71. TESTS FOR HEMOSTASIS Platelet count Capillary resistance/ fragility test Bleeding time Clotting time Clot retraction test

72. CONT. Prothrombin time (PT) Activated partial thromboplastin time (APTT) Thrombin time (TT) Tests for DIC

73. BONE MARROW EXAMINATION: Type of examination- Bone marrow aspiration . Trephine biopsy.

74. SITE FOR BONE MARROW ASPIRATION Sternum Posterior superior iliac spine Spinous process of vertebrae Shin of tibia ( <2 years of age ) Anterior superior iliac spine

75. CAUSES OF FAILURE OF ASPIRATION Dry tap -Failure to aspirate any material at all is referred to as Blood tap Aspiration of blood without any marrow particles is referred to as blood tap . (A) Faulty technique ( B) Pathological factors

76. PATHOLOGICAL FACTORS FOR BLOOD GROUP 1. Increased connective tissue in bone marrow Myelofibrosis. Hairy cell leukaemia Other myeloproliferative disorders. Lymphoma. Metastatic carcinoma. Tuberculosis. 2. Bone marrow hyperplasia 3. Localization of needle tip in neoplastic tissue Metastatic carcinoma. Lymphoma. Multiple myeloma . 4. Idiopathic

77. TESTS FOR URINARY SYSTEM URINE ROUTINE TEST[URT] RFT CREATENINE LEVEL BLOOD UREA NITROGEN

78. URT CONTENT OF URT General properties Chemical tests Microscopic examinations GENERAL PROPERTIES URINE VOLUME APPEARANCE/COLOUR URINE PH SPECIFIC GRAVITY OSMOTIC PRESSURE

79. URT

80. URINE VOLUME Daily urine produced -1.5 L/day Polyuria - 3L/24 hr Oliguria- <400ml/24hr Anuria - <100ml/24hr  

81. APPEARANCE /COLOUR Normal, fresh urine is pale to dark yellow of colour Abnormal appearance: Haematuria Hemoglobinuria Pyuria Bilirubinuria Crystalluria

82. CONT. 1.HEMATURIA: Macroscopic haematuria-frank blood in the urine Microscopic haematuria-RBC is seen only by the help of microscope

83. CONT. HEMOGLOBINURIA-Colour is like strong tea or wine due to presence of free Hb Pyuria-presence of WBCs, cloudy ,eg- UTI

84. CONT. BILIRUBINURIA- Presence of direct bilirubin, dark yellow colour CRSTALLURIA-Presence of salt crystals, cloudy

85. CONT. We can see urine for clarity:

86. URINE   Normal urine pH: 6 - 6.5 Aciduria- gout, meat consumption,etc. Alkauria-UTI

87. SPECIFIC GRAVITY SPECIFIC GRAVITY -Ratio of the density of a substance to density of a reference substance (H2O). -Directly proportional to solute concentration of urine NORMAL SPECIFIC GRAVITY -1.003-1.03 LOWER SG -chronic renal failure, diabetes insipidus, etc. HIGH SG -acute nephritis ,diabetes mellitus, etc.

88. OSMOTIC PRESSURE Normal value-250mosmol-300mosmol

89. URT-CHEMICAL TESTS Urine protein Urine glucose Urine ketone

90. URINE PROTEIN Normal : (-) or 20-80 mg/24 hrs Abnormal : (+ ) or > 150 mg / 24 hrs

91. URINE GLUCOSE Normal : (-) or < 15mg/Dl

92. URT –MICROSCOPIC EXAMINATION Cells Casts Crystal bodies Pathogen

93. CRYSTALS FINDINGS Calcium oxalate crystals Phosphate crystals Urate Cystine Yeast

94. RENAL FUNCTION TEST Also known as “Kidney Function Test” Kidney function test is a collective term for a variety of individual tests and procedures that can be done to evaluate how well the kidneys are functioning.

95. RFT Can be divided into two categories: Test for function of Glomerulus GFR Test for Function of Tubule Reabsorption secretion

96. TEST INVOLVES IN RFT

97. RENAL CLEARANCE Renal clearance of a substance is the volume of plasma that is cleared of the substance by the kidneys per unit time . It is the measurement of the renal excretion ability Substances used for estimating kidney condition-INULIN ,CREATININE ,PAH

98. INULIN Inulin Clearance Can Be Used to Estimate GFR (eGFR) Inulin is : Freely filtered Neither reabsorbed Nor secreted Whatever, inulin is filtered, all of it is excreted in the urine.

99. INULIN EXCRETION

100. CREATININE Also known as- serum creatinine, urine creatinine Waste product in blood comes from protein [taken as food] & from the normal breakdown of muscles protein Elimination of it is done by kidney through urine Test can diagnose –creatinine level in blood which shows how well your kidneys are working

101. CREATININE Creatinine Clearance Can Be Used to Estimate GFR . It is not practical to measure urine creatinine level to estimate GFR, so many scientist has given many ways to calculate GFR by being based upon only blood creatinine.

102. eGFR Also, used to stage the Chronic Kidney Disease (CKD)

103. SERUM CREATININE(SCr) Normal range( Highly Variable ) - 0.5 to 1.0 mg/dl If, GFR < 50% normal, SCr will increase markedly But it is not an early marker of kidney disease

104. BLOOD UREA NITROGEN (BUN) The normal range is 6 - 20 mg/dL. Increased BUN Azotaemia Uraemia Azotaemia is used when the abnormality can be measured chemically but is not yet so severe as to produce symptoms. Uraemia is the pathological manifestations of severe azotaemia.

105. MECHANISM OF BUN

106. BUN BUN increased in: Renal failure Urinary tract obstruction Nephrotoxic drugs Shock, Burn, GI bleeding, Dehydration BUN is decreased in : Hepatic failure NS(normal saline) Cachexia (low-protein and high-carbohydrate diets)

107. BUN:CREATININE RATIO Normal Value= 12-20 The principle behind this ratio is the fact that both urea (BUN) and creatinine are freely filtered by the glomerulus, however urea reabsorbed by the tubules can be regulated (increased or decreased) whereas creatinine reabsorption remains the same (minimal reabsorption).

108. BUN: Cr RATIO IN KIDNEY INJURY

109. OTHER ORGAN FUNCTION TESTS LIVER FUNCTION TEST THYROID FUNCTION TEST KIDNEY FUNCTION TEST

110. LFT Helps to determine liver condition by measuring levels of Liver enzymes ,proteins, & bilirubin in blood Often used: To screen liver (hepatitis c) To monitor effects of medications To measure degree of liver cirrhosis

111. WHICH TEST MAKES LFT COMPLETE ALT(alanine transaminases) AST(aspartate transaminases) Albumin Bilirubin ALP(alkaline phosphatases)

112. ALBUMIN Protein made by liver Has important clinical value: Prevents fluid leakage from blood vessels nourishes tissues transports hormones, vitamin, minerals& other nutrient substances throughout the body albumin level decreased= impaired liver functioning

113. BILIRUBIN Waste product obtained by breakdown of RBC Increased level of bilirubin = impaired liver functioniong Normal range =Highly variable Normal adult = Total Bilirubin < 17µmol/L (1mg/dl) Out of which, around 30% is Direct bilirubin Normal Direct Bilirubin < 5.1µmol/L (0.3mg/dl)

114. HOW AST OR ALT INCREASES ?

115. ALT It is used up by your body to metabolise protein Liver damage = ALT released in blood Female ≤ 34 IU/L Male ≤ 52 IU/L Formerly known as serum glutamate-pyruvate transaminase (SGPT).

116. AST Type of enzyme found in several body parts such as liver, heart,& muscles Increased AST= liver infections Male 8 - 40 IU/L Female 6 - 34 IU/L Formerly known as serum glutamic oxaloacetic transaminase (SGOT).

117. AST/ALT RATIO Also known as "De Ritis Ratio" Specially used for alcoholic liver disease. It is AST to ALT ratio of 2:1 or greater, particularly with increased Gamma-Glutamyl Transferase.

118. LACTATE DEHYDROGENASE(LDH) Found in many body tissues, including the liver. Elevated levels of LDH may indicate liver damage. Elevated LDH maybe due to, Cancer Meningitis Encephalitis Acute pancreatitis HIV

119. ALKALINE PHOSPHATASE Found in bones, bile ducts,& liver Increased ALP = liver damage, blockage of bile duct & bone disorders

120. ALKALINE PHOSPHATASE Normal = 20 to 140 IU/L Although higher in children and pregnant Concomitant increases of ALP with GGT should raise the suspicion of hepatobiliary diseases

121. THYROID FUNCTION TEST

122. TFT : AN OVERVIEW Thyroid is a small gland located in lower front part of neck Helps to regulate – metabolism, energy generation, & mood It mainly produces 2 hormones: triiodothyronine(T3) & thyroxine (T4) TFT are series of blood test used to measure how well your thyroid gland is working Test includes-T3, T3RU, T4, & TSH

123. SECRETIONS As we all know secretions are of 2 forms – more or less i.e. hyper or hypo resp. According to secretion of hormones thyroid is of 2 types 1. hyperthyroidism 2.hypothyroidism

124. HYPER & HYPO ?? HYPERTHYROIDISM HYPOTHYROIDISM WEIGHT LOSS WEIGHT GAIN TREMORS LACK OF ENERGY INCREASED ANXIETY DEPRESSION

125. UNDERSTANDING RESULTS High levels of T4 = hyperthyroidism symptoms = anxiety, unplanned wt. less, tremors, diarrhoea TSH indicates = normal 0.4-4.0 m IU/L of blood if value ranges - above 2.0 mIU/L of blood T4 & TSH - routine performed on new-born babies to identify a low functioning thyroid gland which can lead to developmental abnormalities T3 RESIN UPTAKE RESULTS- measures hormone called thyroxine-binding globulin(TBG)

126. CONT. If T3↑ = TBG ↓ abnormal increase in TBG = kidney problems = body is not getting sufficient amount of protein ↑TBG = ↑ estrogen = pregnancy / obesity

127. TOTAL THYROXINE Total thyroxin includes free as well as protein bound thyroxin. Normal levels: 5 to 12.5ug/dL, largely bound to transport protein esp. TBG(Thyroid binding globulin ) T4 combined with TSH gives the best measurement of thyroid function.

128. THYROXINE INCREASE Hyperthyroidism Factitious hyperthyroidism Pituitary TSH secreting pituitary tumour Raised TBG DECREASE Primary hypothyroidism Secondary/pituitary hypothyroidism Severe non thyroidal illness Decrease TBG

129. ADVANTAGES OF THYROID SCANNING Distinguishes diffuse glandular activity from patchy pattern seen in goitre Functional classification of nodules: warm, hot, cold In association with thyroid suppression regimes, TSH dependent or autonomous nature of hot nodules Information regarding size, shape, position of gland Identification & localisation of functioning thyroid tissue in ectopic or metastatic sites Helps on differentiating various causes of thyrotoxicosis

130. INDICATIONS & CONTRAINDICATIONS INDICATIONS 1.Thyroid nodule(s) 2. Diffuse or multinodular goitre 3. Clinical hyper- or hypothyroidism 4. Evaluation of sub-sternal mass 5 . Sub-acute thyroiditis, early phase 6 . Patient with previously treated with radiation Contraindications: 1.Pregnancy 2.Lactation

131. FINE NEEDLE ASPIRATION CYTOLOGY (FNAC) THYROID Indications: Diagnosis of diffuse non toxic goitre Diagnosis of solitary or dominant thyroid nodule Confirmation of clinically obvious malignancy To obtain material for special laboratory investigations aimed at defining prognostic parameters. Main limitation : Inability to distinguish between follicular adenoma & carcinoma.

132. Complications: H aematoma . Transient laryngeal nerve paresis Tracheal puncture Rarely , needling causes formation of a hot nodule

133. CEREBRAL SPINAL FLUID

134. CSF Test to analyse condition which affects brain & spine CSF is the clear fluid which cushions & delivers nutrients to CNS (brain & spine) CSF is produced in the brain & then reabsorbed into blood stream CSF has a direct contact with our brain & spine therefore, it is more effective than a blood test to understand CNS Sample is collected by the method of LUMBAR PUNCTURE

135. CSF

136. LP[LUMBAR PUNCTURE] Also known as spinal tap Useful in examination for – proteins, glucose, RBC, fluid pressure, WBCs, chemicals, bacteria etc. Procedure to collect & look at the fluid(cerebrospinal fluid) surrounding the brain & spinal cord It should be performed only after a neurologic examination but should never delay

137. LP Most accurate test is culture. Most sensitive test for acute bacterial meningitis is elevation of protein in CSF . (Not elevated protein Rules out Acute bacterial meningitis) Increase in WBC is the indicator to start treatment.

138. INDICATIONS & CONTRAINDICATIONS INDICATIONS: Suspicion of meningitis Suspicion of subarachnoid haemorrhage(SAH) Suspicion of CNS , E.g.-carcinomatous meningitis Therapeutic relief of pseudotumor cerebri CONTRAINDICATIONS: Increased intra cranial pressure Brain abscess Loss of suprachiasmatic & basilar cisterns

139. WIDELY USED IN Multiple sclerosis is a chronic condition In this body’s own immune system destroys the protective coverings of nerves i.e. myelin Abnormal results in CSF is seen when there is: infections, encephalitis , Reye’s syndrome- rare fatal disease in children & is associated with viral infections & aspirin ingestion Scarcoidosis- granulomatous condition of unknown cause affecting many organs such as lungs, joints, & skin

140. SEROUS MEMBRANE FLUID Also known as serosa, is a layer of tissues that wraps around organs & helps to lubricate them so they don’t get rubbed raw. Made up of squamous epithelium or mesothelium

141. TRANSUDATE VS, EXUDATE Transudate It is extravascular fluid with low protein content and a low specific gravity (< 1.012 ) It results from increased fluid pressures or diminished colloid oncotic forces in the plasma. Exudate It is a fluid emitted by an organism through pores or a wound, a process known as exuding. Composition of an exudate varies, but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood.

142. STOOL TEST Appearance Consistency Odour Chemical tests Microbiology tests Faecal Occult Blood Test

143. SPUTUM Mucus coughed up from the lower airways is called as sputum . Phlegm : Same sputum when it is within body. Appearance Microbiological investigations Cytological investigations

144. SPUTUM Sputum can be : Bloody(Haemoptysis ) lung cancer; Alveoli Pulmonary TB Lung abscess Bronchiectasis Rusty coloured - pneumococcal bacteria Greenish coloured – Pseudomonas Purulent - containing pus . Thick purulent : staphylococcus Thin purulent : Streptococcus pyogenes Frothy pink - pulmonary embolism

145. RADIOLOGICAL EXAMINATION

146. OBJECTIVES To provide a guide to selecting the appropriate imaging studies in common emergency settings

147. NATURAL DIAGNOSIS METHODS

148. CONTENT FACIAL DIAGNOSIS IRIS DIAGNOSIS TONGUE DIAGNOSIS NAIL DIAGNOSIS URINE DIAGNOSIS STOOL DIAGNOSIS PULSE DIAGNOSIS PALPATION & PERCUSSION AUSCULTATION & OLFACTION

149. NO CONFUSION !! Diagnosis is mentioned in various systems of medicine but the aim of each system is same

150. IN ALL SYSTEMS OF HOLISTIC MEDICINE FOLLOWING IS THE SEQUENCE: INSPECTION(LOOKING) AUSCULTATION(LISTENING) OLFACTION(SMELLING) INTERROGATION(ASKING) PALPATION(EXAMINATION OF PATIENT BY TOUCH) PERCUSSION(ACT OF TAPPING/STRIKING)

151. ACCORDING TO GREEK VISUAL FACIAL TONGUE AUSCULTATION & OLFACTION PULSE URINE PAPITATION &PERCUSSION STOOL

152. ACCORDING TO TCM

153. ACCORDING TO NATUROPATHY FACE NAIL TONGUE

154. ACCORDING TO NATUROPATHY EYE IRIS PULSE

155. FACIAL DIAGNOSIS FATHER- LOUIS KUHNE IN MEDICAL TERMINOLOGY this art is known as physiognomy In this physician examines patient’s facial expressions & signs As chief function of face is expression, which is the giving of visible outer form/ manifestations of inner state of physical & mental being

156. FACIAL DIAGNOSIS As we all know face has following things to express: S pirit & countenance F orehead Temples Eyebrows Eyes Nose Glabella region Mouth & Lips

157. FACIAL DIAGNOSIS COUNTENANCE - traditional term for overall presentation of the face SPIRIT - radiates from countenance bright /radiant = overall healthy dull muddled/confused = mental & emotional

158. FOREHEAD P rimarily responsible for expressing - spiritual radiance Transverse line /wrinkles = worries, anxieties, insomnia, stress, & stress vertical lines = on Rt. side = liver problems & vertical lines on Lt. side = spleen problems

159. TEMPLES H ollow indentations on the lateral side of the forehead unduly/sunken/hollowed out = dehydration, general state of malnutrition & emaciation(↓to excessive) prominent blood vessels = ↑ B.P. Red inflamed = migraine (sometimes hot)

160. EYEBROWS Rooftops of the eye Thick /heavy eyebrows = strong , robust constitution Missing in lateral 1∕3rd = blood sugar problems(diabetes) heavy prominent /beetle brow with cheek bone/elongated chin = acromegaly

161. NOSE protruding part of face that bears nostrils Deep horizontal furrow at nose = prone to allergies, bronchial asthma Red nose tip = overload on heart, common cold, anger

162. EYES Pair of organ of sight Commonly we diagnose bags above or below eyes above eyes= impaired function of adrenal gland Rings around eyes (semilunar Rt. below the eyes)= high cholesterol, metabolic disorder

163. EYES

164. EYES slanting lines at the core of eyes = weak liver, deficiency of vitamin A, eye problems, headache

165. SIGNS, SYMPTOMS ⇰DIAGNOSIS SIGNS & SYMPTOMS DIAGNOSIS 1.TOTALLY WHITE EYE CHRONIC MTB 2.PUPIL SINKS & BECOMES SMALL OPIUM EATER 3.SWELLING IN EYES ARTHIRITIS, SPONDYLOSIS 4.DULLNESS OF EYES ILL HEALTH 5.RAPID EYE MOVEMENT IMPROPER MENTAL STATE 6.AVOIDING EYE CONTACT LYING OVER BLINKING MENTALLY CONFUSE,TENSED, LYER,HESITANT

166. CHEEKS either sides of the face below eyes Tender area at the centre of the cheek = sinus congestion, digestive problems

167. MOUTH Opening & cavity present in face & is surrounded by lips Deep line by side of the mouth = sex problems Line at the corners of the mouth = weak respiratory system

168. LIPS Dark spots on lips - colon problems spots, whitish discoloration -parasites in colon blue/purple discoloration - poor circulation

169. LIPS Portrays condition of digestive system UPPER LIP- associated with stomach, liver, spleen, lungs, thorax LOWER LIP- intestine CONDITION /SYPMPTOMS DIAGNOSIS PALE LIPS ANEMIA BLUE/PURPLE LIPS ↓INNATE HEAT ,EXTREME COLD,CYANOSIS, FREQUENT CANKER SORES LUNG INFECTION BROWN LIPS ADRENAL FUNCTION IS IMPAIRED ANGULAR STOMATITIS INFLAMMATION & EROSION OF CORNERS OF LIPS- VIT. B12 DEFICIENCY

170. ACCORDING TO TCM

171. ACCORDING TO GREEK

172. ACCORDING TO AYURVEDA

173. TONGUE DIAGNOSIS Muscular organ present in mouth used for tasting, swallowing & in articulating speech

174. ACCORDING TO TCM

175. ACCORDING TO NATUROPATHY

176. REAL VIEWS !!

177. NAIL DIAGNOSIS Nail is a horn like envelope covering the tip of the finger Made up of tough protective protein- keratin similar to claws of animals

178. ACCORDING TO AYURVEDA

179. ACCORDING TO AYURVEDA

180. ACCORDING TO CONDITION

181. PULSE DIAGNOSIS P ulse represents tactile a rterial palpation of heartbeat I mportant basis of pulse diagnosis: movement/ gathi Rate/ vega Rhythm/ tala Force/ bala etc.

182. ACCORDING TO AYURVEDA

183. ACCORDING TO TCM

184. IRIS DIAGNOSIS FATHER - BERNARD JENSEN T hin, circular structure of the eye R esponsible for controlling diameter & size of pupil HOW IT WORKS: ACCORDING TO Dr. BERNARD JENSEN The iris is connected to every organ and tissue of the body by way of the brain and nervous system. The nerve fibers receive their impulses by way of their connections to the optic nerve, optic thalami and spinal cord They are formed embryologically from mesoderm and neuro-ectoderm tissues. Both sympathetic and parasympathic nervous systems are present in the iris

185. STUDY OF IRIS=IRIDOLOGY Nerve fibres in the iris respond to changes in body tissues by manifesting a reflex physiology that corresponds to specific tissue changes and locations IRIS CHART – chart represents the placement of organs and tissues as would a map. There are signs and features in the iris that are in-explainable and unknown at this time

186. IRIDOLOGY Iridology does not name diseases; instead, it reads tissue condition, From that information, predispositions, tendencies and directions toward or away from these conditions are noted. Levels of toxic settlement and accumulation are observable

187. 7 ZONES OF IRIS

188. DRUG DEPOSITION

189. LESIONS ,CRYPT

190. DISEASE STAGE ACCORDING TO IRIDOLOGY THE FOUR STAGES AS THEY A PPEAR IN THE IRIS 1-ACUTE 2 - SUBACUTE, 3-CHRONIC 4-DEGENERATIVE NUMBER 5 DESIGNATES THE AUTONOMIC NERVE WREATH 6 IS THE PUPILLARY MARGIN.

191. NERVE RINGS IN BROWN IRIS

192. TOXIN SKIN= SCURF RIM

193. WHITE RINGS IN PERIPHERY =LYMPHATIC CONGESTION

194. METABOLIC IMBALANCE = SODIUM RING

195. SMALL TIGHT PUPIL = EXTREME NERVOUS TENSION

196. REAL CASES (varicose vein) RIGHT SIDE LEFT SIDE

197. THANK YOU BE HAPPY & BE HEALTHY