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x Figures
11.2 The cerebral cortex from the right side showing the major lobes 221
11.3 Internal view of the brain showing areas in the brain important for
processing consciousness: the frontal and prefrontal cortex and the
cingulate cortex 222
11.4 Map of the left cerebral cortex according to cell function 222
11.5 The sensory cortex (Brodmann areas 1, 2 and 3), showing the layout of
cells according to the areas of the body from which they receive
transmissions 224
11.6 The rostral dorsolateral pontine tegmentum (RDPT) has connections
with both the left ventral anterior insula (AI) and the pregenual anterior
cingulate cortex (pACC) in relation to maintaining consciousness 225
11.7 Different types of neuron 225
11.8 The neuron 226
11.9 Neurons in clusters form grey matter (cell bodies) and white
matter (axons) 227
11.10 Action potentials and the synapse 228
11.11 The gamma-aminobutyric acid (GABA) and glutamate (glutamic acid)
cycle 229
11.12 The consciousness-coma continuum and the sleep-wake cycle 230
11.13 The Glasgow Coma Scale, partly completed to show a patient
regaining consciousness 233
11.14 Events that occur during a t 235
11.15 The blood supply to the brain from the heart 236
11.16 The arteries of the circle of Willis distributing blood to the brain 237
11.17 Contracoup trauma to the brain in head injury 238
11.18 The meninges, showing the sites within the three layers of a subdural
and an extradural haematoma 239
11.19 The sudden rise in the intracranial pressure (RICP) occurs when the
brain compensatory mechanism fails 240
12.1 Inammation 248
12.2 Pain mediators 249
12.3 Pain mediator molecules bind to nociceptors (1, 2 and 3) 249
12.4 All sensations, including pain, use a three-neuronal system from
periphery to the brain 251
12.5 The gate control theory 252
12.6 Thalamic response to pain 253
12.7 The signs of pain 254
12.8 Areas of referred pain and the organs the pain is derived from 254
12.9 Verbal descriptor scale for pain 255
12.10 Visual analogue scale for pain 256
12.11 The 1986 original 3-step analgesic ladder 263
12.12 Revised analgesic ladder 263
13.1 Section through the eye 269
13.2 View of the retina through an ophthalmoscope showing a normal
optic disc 269
13.3 Superior view of the optic pathways 270
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Figures xi
13.4 Left side of the brain showing the pathways taken to achieve visual
consciousness 271
13.5 The external (skeletal) eye muscles and their innervation from the
brainstem nuclei of the cranial nerves III, IV and VI. LR: lateral rectus
muscle; MR: medial rectus muscle 272
13.6 Pupil size innervation in normal conditions (shown on the right side of
the brain) and in head injury (shown on the left side of the brain) 273
13.7 Diagram showing detail of the pathways involved in establishing pupil
size in response to light 275
13.8 Pupil sizes 276
13.9 Pathways in the brain that respond to light intensity 279
13.10 Control of eye movements 280
13.11 Areas of the cerebral cortex involved in eye movement control 281
13.12 Disturbance of eye positions in various cranial nerve palsy 282
13.13 The range of movements in nystagmus 283
13.14 The retina with papilloedema (swelling of the optic disc) 284
14.1 The pyramidal tracts 288
14.2 The left main motor cortex (area 4) showing the layout of the cells
according to function (i.e. the muscle they control) 289
14.3 Superior view of a cross section of the spinal cord showing the motor
pathways within the white matter of the cord 290
14.4 The corticobulbar tracts to the cranial nerves 291
14.5 Some extrapyramidal tracts 292
14.6 Areas that make up the basal ganglia 293
14.7 Muscle tone 294
14.8 Basal ganglia motor loop 294
14.9 Section through the cerebellum showing the lobes and brain stem
(midbrain, pons and medulla) 295
14.10 The pathways from the cerebellum that control balance by adjusting
thebody’s skeletal muscles 296
14.11 The reex arc 297
14.12 The crossed extensor reex 298
14.13 Antagonistic muscle pairs 298
14.14 The signs of Parkinson Disease 303
14.15 Decorticate and decerebrate symptoms 305
15.1 Hepatic portal vein (HPV) from the gut to the liver 313
15.2 The half-life of a drug 314
15.3 The therapeutic window 315
15.4 The two parts of the autonomic nervous system (ANS) 318
15.5 The antimuscarinic drug side effects 319
15.6 The nigrostriatal pathway 321
15.7 The normal REM-NREM sleep pattern for a young adult 323
15.8 The vestibulo-ocular reex (VOR) 326
15.9 Pharmacodynamic drug interaction between two drugs 330
15.10 The release of histamine from mast cells by an immune response 331
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xii Figures
15.11 The complement system, a chain reaction occurring between various
plasma proteins (C proteins) leading to a membrane attack complex
(MAC) 332
15.12 Type IV skin test reactions 333
16.1 The normal maternal blood pressure through pregnancy 338
16.2 The main hormones in pregnancy and labour 340
16.3 Diagram showing two cells, endothelial cell (above) and muscle cells
(below) with endothelin and ET receptors 342
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Plates
Plate 1 Different colours of urine and sedimentation
Plate 2 Different densities of urine and specic gravity
Plate 3 Urine testing strips
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Tables
1.1 Red ag warnings of deteriorating condition 17
2.1 The differences in the systolic and diastolic phases at heart rates of 67
and 180 beats per minute (bpm) 29
2.2 Heart rate in children of different ages when awake and asleep 30
2.3 Class I: Sodium channel blocking and other anti-arrhythmic drugs 36
2.4 Class II: Beta-receptor blocking drugs 37
2.5 Class III: Potassium channel blockers 38
2.6 Class IV: Calcium channel blockers 38
2.7 Red ag warnings of deteriorating condition 40
3.1 Blood pressure measurement errors 49
3.2 Korotkoff sounds and phases 51
3.3 Child blood pressures by age 57
3.4 Blood pressure cuff size in children 57
3.5 Drug inhibitors of the ACE system 58
3.6 Beta-blocking drugs 59
3.7 Vasodilator drugs 61
3.8 Thiazide diuretic drugs 61
3.9 Centrally acting anti-hypertensive drugs 61
3.10 Calcium-channel blocking drugs 62
3.11 Anti-hypotensive drugs 62
3.12 Red ag warnings of deteriorating condition 63
4.1 Abbreviations and symbols used in the tables 66
4.2 Blood protein tests 68
4.3 Blood tests for vitamins 72
4.4 Blood fats and cholesterol tests 74
4.5 Statins 75
4.6 Blood chemistry tests 76
4.7 Blood enzyme tests 80
4.8 Blood hormone tests 82
4.9 Blood clotting factors 85
4.10 Anticoagulant drugs 87
4.11 Blood immunity tests 87
4.12 Blood gases 89
4.13 Blood toxin tests 89
4.14 Blood cell tests 91
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Tables xv
4.15 Blood groups and antigens 94
4.16 The ABO blood groups compatibility grid 94
5.1 The ABCDE assessment 114
5.2 Red ag warnings of deteriorating condition 115
5.3 Child normal respiratory rates 115
5.4 β
2
selective agonist bronchodilators to treat bronchoconstriction 117
5.5 Antimuscarinic bronchodilators 117
5.6 Corticosteroid drugs used to prevent bronchoconstriction, as in asthma 118
6.1 Four major electrolytes present in body uids, the terms used to
denote excess and insufciency and the symptoms 133
7.1 Essential and non-essential amino acids 137
7.2 Eicosapentaenoic acid (EPA) and linoleic acid, showing omega numbers 139
7.3 The major vitamins, food sources, need and deciency 142
7.4 The major minerals 144
7.5 Foods young children should avoid 146
7.6 Energy requirements at different ages 147
7.7 Gene mutations possibly involved in weight gain 150
8.1 Red ag warnings of deteriorating diabetic condition 167
8.2 Urine colour 169
8.3 Water and sodium in urine 170
8.4 Types of renal stones 175
8.5 Loop diuretic drugs 178
8.6 Aldosterone antagonists 178
9.1 Laxative medications 186
9.2 Red and amber ag warnings of deteriorating condition 187
10.1 Sensory nerve endings in the dermis and their functions 201
10.2 Skin lesions 204
10.3 The ABCDE of nevi (mole) changes that require medical attention 215
10.4 Red and amber ag warnings of deteriorating skin conditions 216
11.1 Brodmann numbers as shown in Figure 11.3 223
11.2 The various types of epilepsy 234
11.3 Stages of a grand mal seizure 235
11.4 General anaesthetics 243
11.5 Red and amber ag warnings of deteriorating consciousness 243
12.1 The NSAI analgesic drugs 258
12.2 The opioid analgesics 260
12.3 Red and amber ag warnings of deteriorating pain condition 265
13.1 Antimuscarinic drugs affecting pupil size 277
13.2 Red and amber ag warnings of deteriorating condition 278
14.1 The symptoms and causes of decortication and decerebration 305
14.2 Red ag warnings of deteriorating mobility condition 308
15.1 Red ag and warnings of deteriorating condition 333
16.1 The foetus contains 50% genes from the father 340
16.2 The systolic and diastolic pressure values for normal blood pressure,
mild, moderate and severe hypertension 343
16.3 Terms used for hypertension at different stages of pregnancy 343
16.4 Red and amber ag warnings of deteriorating condition 344
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Preface to the fourth edition
William T. Blows
Medical science has been ghting for many years against three enemies: aging, disease
and ignorance.
On the face of it, aging is inevitable, but science is making progress in creating health-
ier and disease-free elderly. There is no reason why aging must always result in ill-health.
The goal is to have a healthy and happy life, even if you live beyond 90 years of age!
Fighting disease has always been the main thrust of medical research, and there have
been successes in both treatment and prevention of disease. This will continue with
increasing pace as a result of advances in many areas, notably genetics, pharmacology,
diagnostics, vaccinations, epidemiology and, perhaps surprisingly, computing science,
articial intelligence and robotics. There are still many hurdles to overcome, especially
in cancer medicine, neurological and genetic conditions and viral pandemics to mention
just a few.
Ignorance is still a major problem. What we know about the health risks linked to
smoking, illicit drugs and obesity should be enough to prevent these conditions from ever
happening again. But there are still many smokers and illicit drug takers and the popula-
tion generally, especially in the west, is gradually increasing in weight. There are also
specic problems that arise, such as vaccine deniers and pandemic conspiracy theorists
who set up barriers to promoting health. Over the years political actions, such as banning
smoking in restaurants, have helped to make advances in health promotion. Maybe there
is a case for putting health science on the school curriculum from an early age.
Biological studies are a major part of any healthcare training programme because the
sciences are vital for working as an autonomous practitioner. The client’s problems will
be affecting a biological system, and the assessment and treatment will have a biological
basis.
Medical sciences have never seen such a remarkable ood of new knowledge as
we are seeing today, knowledge that is already changing the way we treat disease. If
healthcare professionals are going to remain at the front of this revolution, they must be
familiar with the sciences and technologies that underpin the changing face of the care
they give.
Clinical decision-making is based on accurate observations. A thorough understanding
of the underpinning sciences is essential to broaden the number of choices available and
to facilitate making the correct choice.
This book takes clinical observations and explores the biology underpinning them. It
gives the possible pathological basis for variations in the observed results. It looks at both
fundamental and advanced observations, e.g. neurological observations. This book will
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also be of use to educators and trained professionals with students under their leadership.
The fourth edition has been updated with new information on many topics, including
signs of a patient’s deteriorating condition (red-ag tables) and an expanded pharmacol-
ogy chapter, with drug tables added to several chapters.
William T. Blows
May 2023
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Acknowledgment
The author wishes to thank Dr Ian Hill-Smith and Dr Gina Johnson for allowing me to use
information from their excellent book Little Book of Red Flags which was published by the
National Minor Illness Centre, Bedfordshire, in 2021.
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1 Temperature
• Introduction
• Heat gain
• Heat movement and loss
• Heat regulation: gain versus loss
• Temperature scales and normal temperature variation
• Taking the body temperature in adults
• Temperature in children
• Abnormal high body temperatures
• Abnormal low body temperatures
• Thermal injury
• Key points
• Notes
• References
Introduction
Stabilising the internal environment of the body, e.g. temperature, is a process called
homeostasis (see page 10). At 37°C, the temperature is balanced to provide the opti-
mum conditions for tissue metabolism. Cooler temperatures would slow down the rate
of cellular chemistry and function. Many chemical reactions require enzymes to speed
up the process to a level necessary for life. When these temperature-sensitive reactions
are cooled, the slowing of metabolism becomes dangerous to health. Hotter tempera
-
tures cause metabolic systems to become inefcient and enzymes to become denatured.
Denaturing is a heat-related change in protein structure which leads to failure of cellular
activity.
This essential stabilisation of optimum temperatures happens despite changes in
the environmental temperature, i.e. the ambient temperature. External factors such
as shelter, clothes and res allow humans to survive in low or high temperatures that
DOI: 10.4324/9781003389118-1
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