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than 5 to 10 percent per week. This cannot apply in the initial stages of a training schedule, where less than 10 miles a week are run, but above these levels, this guide will help to prevent overuse injuries. Pain is probably the best warning sign of injury, but it may appear in a variety of forms. Although the suffering that occurs during a tough training session is probably ultimately beneficial in the improvement of performance, the experienced runner will soon learn to recognize pain in other parts of the anatomy that does not disappear when the exercise has ended. External factors that may induce injury include the surface run on and the clothing and shoes worn by the runner. The force of landing with something like three to four times your body weight onto concrete affects the joints much more than a more forgiving and softer surface like sand or even snow. Too many runners use only one side of a road and forget that the camber will pitch them toward the sidewalk and cause a tilt to the pelvis, which may translate into a twisted lower back or strain to the ligaments of the ankle joint. Running demands thought just as much as other sports that require different skills. It is too easy to be dazzled by a new pair of running shoes, which cause blistering on the first occasion on which they are used, simply because you forgot to break them in. All shoes and clothing should be worn in but not worn out! Because the diagnosis of injury is likely to be complex, any unexplained pain or symptom should be rapidly assessed by a professionally qualified doctor. However, a considerable number of commonsense first aid measures can and should be taken in the early stages of injury. It would seem sensible to follow the guidelines that any doctor would use. First, take a history. Ask yourself these questions: Was the injury sudden, or did it build up over a series of runs? Does it cover a small area, or is it more diffuse? Does it hurt to touch? Does it disappear with rest? There are countless more questions, but the object is to make you think about the injury. Next, a doctor will look at the injury. Observation can distinguish asymmetry, swelling, discoloration, and so on. You can do the same in a mirror. Only this stage of examination by gentle palpation, followed by active and passive movement, will elucidate the cause. By this stage there may be a differential diagnosis, a choice of likely and then less common causes. If the diagnosis is pretty much certain, first aid treatment can begin; if not, further tests can be arranged after a visit to the doctor. To a certain extent these can run concurrently, as treatment can be started while test results are awaited. If the results suggest a different diagnosis, then treatment can be amended. The diagnosis and treatment phases of an injury should be interrelated and reciprocal so that if the one is questionable or ineffective, then the other can be reviewed and reassessed. The areas of the body that are likely to suffer most from running are the lower back, the groin, the muscles of the leg, the knee and ankle areas, and the feet. The tissues that suffer most are joints, bones, ligaments, muscles, and tendons. Some choice! A typical muscle tear is most likely to occur if the runner overstretches between two joints, especially if a halfhearted warm-up procedure has been used. The pathology behind this is that a blood vessel inside the muscle will be pulled beyond its limits, burst, relatively flood the area with blood, and stop bleeding only when the counterpressure exerted by the surrounding soft tissues or strapping is equal to that of the blood seeping out. The pressure of this bleeding causes pain in the soft tissues and is always a good indicator of injury. Cooling is another major factor that speeds up healing, so the rapid application of an ice pack to any acute injury, muscle or otherwise, is unlikely to do much harm; if it limits the swelling, it may well reduce the time spent in recovery. Statistically, the back and the knee are the most commonly injured sites for runners. A runner’s back pain will usually be localized to the lower lumbar and sacral areas (figure 10.1), and all too often it is a result of repetitive training with a lack or loss of low back flexibility, accompanied by attempts to run through the pain. It may be related to poor posture, a real or artificial difference in leg length (such as what occurs with the camber running referred to earlier), or a sudden move to hill work. If there is any suggestion that the pain is referred down either leg or is associated with numbness or weakness of the limb, then this could signify a more serious condition such as a prolapsed intervertebral disc, for which a more urgent medical opinion should be sought. Much the same is true of the knee (figure 10.2). An injury followed by swelling or locking within the joint, especially if this happens rapidly over a few hours, is not a simple runner’s knee and needs prompt diagnosis. Runners are more prone to patellofemoral pain as a result of the failure of the patella to glide through the center of the groove at the base of the femur rather than severe internal disruption as might occur with a skiing or football injury. When we stand, our knees and ankles are usually together, but the hip joints can be separated by 12 inches or more. The effect is that when the quadriceps muscles contract, the forces of nature pull the patella laterally and twist it within the femoral groove. The vastus medialis muscle counteracts the pull of the outer quads, but can do so only if it has been strengthened and developed suffi-ciently, which requires it to be exercised with the knee locked and extended. If pain can be localized, it is easier to diagnose the cause. Pain on the outside of the lower thigh is in all probability a result of iliotibial band (ITB) syndrome, in which this piece of generally inelastic connective tissue rubs against the lateral condyle of the femur. If appropriate exercises to stretch it fail, podiatric adjustment of shoes and insoles may bring about a cure. Figure 10.1 (a) Lumbar region of the back; (b) vertebrae. Figure 10.2 Knee. This treatment may also help with the foot pain of metatarsalgia. With a dropped longitudinal arch (known as pes planus, or flat feet), constant landing on a particular bone in the foot and a pull on the surrounding ligaments can be extremely painful, but proper support to the arch with exercises for the intrinsic muscles of the feet may dissipate the pain rapidly. Pain associated with bones is deeper and more resistant to analgesia than that from the soft tissues. One particularly important cause of bone pain is the so-called stress fracture, which can be equated with metal fatigue or the crack that can occur in a china cup. (Figure 10.3 shows the most common sites of stress fractures in runners, in the tibia and fibula.) The fracture is undoubtedly present, but the opposing surfaces remain together because of surface tension and the binding from soft tissues. It is characterized by “crescendo” pain, which worsens with increasing distance run; it most commonly but not exclusively affects the lower leg or foot, and it stops only when the run finishes. On the next run it will begin earlier and worsen sooner. If this symptom is ignored, it may proceed to a complete fracture, with all the potential for disability of any broken bone, and will take at least double the time of a stress fracture to heal. Any runner with these symptoms who suspects a stress fracture is strongly advised to stop running immediately and seek a definitive diagnosis. Figure 10.3 Common sites of stress fractures in the tibia and fibula. Plantar fasciitis is often such a painful condition that it commonly prevents any running at all. The weakest part of this sheet of fibrous tissue that runs between the heel and the metatarsal heads (figure 10.4) is at the heel, where it becomes injured through chronic overuse, ill-fitting shoes, or sudden stretching from an irregularity in the running surface. The typical sufferer will wince when the underside of the heel is even lightly touched. If the exercises in this chapter are ineffective, then a physician’s steroid injection can produce a cure. Figure 10.4 Foot: (a) underside showing plantar fascia; (b) medial side. If an Achilles (figure 10.5) or any other tendon is injured, healing is delayed by the poor blood supply to these tissues. Although the diagnosis may not be too difficult—the tendon becomes locally tender and stiff, especially if stretched—there has been much dispute concerning the best method of treatment. Current opinion tends toward a regimen of extensive stretching, which needs to be repeated endlessly even after a cure has been effected in an attempt to prevent recurrence. To be of value, a stretch should be uncomfortable rather than painful, held for between 15 to 30 seconds, and never used in a jerky or unstable position, such as the performance of a quadriceps stretch by standing on one leg. Figure 10.5 Tendons, bones, and muscles of the lower leg and foot. Note, however, that self-diagnosis of any sporting injury is fraught with danger. Every injury is different in some way from every other and each requires individual assessment and management. It would be irresponsible of us to attempt to manage injury in a book that is aimed at improvement, so the preceding paragraphs should encourage you, the runner, to be aware that your body is not just a mean, well-oiled speed machine but, like all machinery, may need a little fine-tuning! Specific Training Guidelines Warm up by doing some light running before performing the stretch. If the stretch is part of a rehabilitation of a tight iliotibial band and running is not an option, walk or perform a warm-up exercise for the legs for 10 minutes to promote blood flow. There are many supposedly therapeutic treatments for running injuries, and many methods of performing those treatments. For example, the role of stretching in running training is widely debated. How often, what body parts to stretch, and how long to hold the stretch are some of the questions most runners ask running experts. Because the emphasis of this book is anatomy and strength training, an in-depth examination of these topics and the unraveling of the mysteries of stretching are left to you. We offer some best practices, but we also believe in the authorship of your own running training system. Attempt the strength-training and rehabilitation exercises prescribed in this book, and supplement these with others that your experience has proven successful. ITB Stretch Execution for Standing ITB Stretch 1. Stand next to a wall. Cross the outside leg in front of the inside leg (closest to the wall). Press a hand against the wall for support. 2. Lean the inside hip toward the wall, touching the wall if possible. Both feet should remain flat on the ground. 3. Hold the static stretch for 15 to 30 seconds. Repeat multiple times. Switch sides. Execution for Sitting ITB Stretch 1. Sit on the floor with one leg extended and the other leg crossed at the knee, knee in the air, and foot firmly on the ground. The opposite hand is supporting the knee joint. 2. Gently press the outside of the knee that is crossed toward the opposite armpit. 3. Hold the static stretch for 15 to 30 seconds. Repeat multiple times. Switch sides. Muscles Involved Primary: gluteus maximus, tensor fasciae latae Soft Tissue Involved Primary: iliotibial band Running Focus As mentioned in chapter 9, tight iliotibial bands are normally a result of supination, not overpronation. The inversion of the foot can cause tight calves, lateral knee pain, and tight iliotibial bands. Even pronators who are overcorrected by their stability shoes or orthotics, essentially creating underpronation, can suffer from this injury. Performing the standing and sitting iliotibial band stretch will help stretch this thick band

of soft tissue, preventing the painful rubbing over its attachment at the lateral femoral epicondyle. These stretches can be performed several times a day. Proprioceptive Standing Balance Execution 1. Stand between two walls, one on each side. Extend the arms sideways at shoulder height for balance. Do not use the walls to balance unless needed to prevent falling. 2. Lift one knee until it is at a 90-degree angle with the hip and the tibia is at a 90-degree angle to the femur. Close your eyes. 3. Hold the position for 15 to 30 seconds. Lower the leg and repeat with the other leg. Perform multiple reps. Muscles Involved Primary: peroneus longus, peroneus brevis Soft Tissue Involved Primary: plantar tendon Running Focus This exercise has a neuromuscular and physiological component. It may take a while to establish proper balance, but the foot and lower leg are working to find equilibrium, so the exercise is productive even if you don’t find balance immediately. Standing Calf Stretch Execution 1. Stand, facing a wall with one leg extended backward, foot planted on the ground. The other leg, flexed at the knee, has the foot planted on the ground straight down from the hip. Arms are extended forward at upper-chest height, shoulder-width apart. Hands are placed on the wall. 2. Press gently into the wall and gradually press the heel of the extended leg into the floor. A stretch should be felt through the length of the gastrocnemius. 3. Stretch statically for 15 to 30 seconds and repeat multiple times, or switch legs after every rep. Muscles Involved Primary: gastrocnemius, soleus, hamstrings Running Focus Runners with neutral or underpronated biomechanics often suffer with tight calves. This stretch helps alleviate the pain of a chronically injured calf and also helps prevent calf injuries by keeping the muscle supple. Standing Heel Raise With Eccentric Component Start position. Finish position. Execution 1. Stand with both feet on a step with the heels off the step. Hands are pressed against the wall in front. 2. Raise up onto the metatarsal heads of both feet to full extension (plantarflexed). 3. Lower gradually to full extension (dorsiflexed). Muscles Involved Primary: gastrocnemius, soleus Soft Tissue Involved Primary: Achilles tendon TECHNIQUE TIP ▶ Do not forcefully dorsiflex; it will place too much stress on the Achilles tendon. Running Focus This exercise both concentrically contracts (shortens) the calf muscle during plantarflexion and eccentrically contracts (lengthens) the muscle during dorsiflexion. As mentioned in chapter 9, including an eccentric, or negative, component adds value to this specific calf and Achilles tendon exercise. Studies have found that performing exercises with an eccentric component actually shortens the time it takes to heal an injury. Hamstring Stretch Execution 1. Sit upright lengthwise on a bench in a stable position. The leg with the hamstrings to be stretched is on the bench, and the other leg is placed on the floor with the foot flat to help stabilize the position. Place a towel or soft roll under the knee to be stretched with the knee bent no more than 5 degrees, and rest the heel lightly on the bench. 2. Move the torso forward toward the bench and flex at the hip joints to stretch the hamstrings. Maintain the position for 10 seconds or so, then slowly unwind. (There is no need to stretch out with the arms or to grasp the shin. This may lead to poor posture and an ineffective stretch!) Repeat three times. Alternate both legs in turn. Muscles Involved Primary: hamstrings Secondary: piriformis TECHNIQUE TIP ▶ There is no need to perform a hamstring stretch with the knee straight for specifically increasing hamstring muscle flexibility. When the leg is straightened, the tendency is for the stretch to be taken up more by the tendons and less by the hamstrings. Running Focus There are some runners whose particular style is to “pitter-patter” along with a short stride. Even if they are successful, this sort of running does them no favors if the race speeds up or a final sprint is involved. This exercise helps to increase the stride length without putting more strain on the lower back and sacroiliac regions. It should enable the stride length to be maintained longer as the runner tires, and eventually lead to improved performance. Seated Knee Press Execution 1. Sit upright in a comfortable position with room to extend the legs and knees. The back should be against a solid, supportive object. Both knees are slightly bent, heels on the floor. 2. Slowly straighten one knee in an attempt to push the back of that knee into the ground. Hold this position for six seconds. 3. Relax and allow the knee to flex slightly back to its resting position. Repeat the exercise but with the opposite leg. Do 10 repetitions with both knees. Muscles Involved Primary: vastus medialis Secondary: rectus femoris, vastus lateralis, vastus intermedius, hamstrings, gastrocnemius Soft Tissue Involved Primary: posterior cruciate ligament, hip joint ligaments TECHNIQUE TIP ▶ If you perform this correctly, you should have a pulling sensation at the back of the knee, and a visible bulge will appear above and medial to the knee as the vastus medialis is contracted and its bulk develops. Running Focus Knee pain is the greatest source of difficulty for most runners; runner’s knee is the biggest culprit. This exercise strengthens the vastus medialis muscle and counteracts the slightly lateral (outward) pull of the other quadriceps muscles, which tends to cause patellofemoral pain as the bone shifts in the femoral groove. There is no nonoperative cure other than the development of the vastus medialis muscle, so this should be an essential exercise in every runner’s training program. Knee-to-Chest Stretch Execution 1. Lie on your back on a firm but comfortable surface. 2. Use the quadriceps to lift and bend the knee to 90 degrees, then grasp behind the knee with both hands and pull it toward the chest so that you feel a pulling sensation in the lowest part of the back and upper buttocks. At the same time, resist the urge to flex the other hip, but push it down onto the surface. 3. Hold the position for 15 to 30 seconds and repeat no more than five times, two or three times per day. Alternate with the other leg. Muscles Involved Primary: hamstrings Secondary: piriformis, erector spinae Running Focus The lower back is usually ignored as a vital element of running until pain develops. By then it may be too late to correct. This exercise and those that follow give the lower back flexibility and strength. This is particularly important when climbing or descending hills. If the back can accommodate the changes of gradient, the stride length will also be increased by this flexibility in the hips and lower back. As with all stretching exercises, the aim should be to achieve discomfort without pain. Wall Press Execution 1. Stand approximately 18 inches from a wall with feet shoulder-width apart, toes pointed inward. 2. Press your pelvis to the wall, adjusting the distance from the wall and the angle of the toes to gain the best stretch of the soleus. Keep your heels on the floor. 3. Hold stretch for 15 to 30 seconds and repeat. Muscles Involved Primary: soleus, gastrocnemius, tibialis anterior Running Focus Shin splints, or diffuse anterior lower leg pain, can be either soft-tissue related or bone (tibia) related. Both problems usually stem from overpronation; however, the soft-tissue variety is normally associated with midfoot horizontal plane abduction. This exercise can help prevent muscle pain in the anterior compartment of the gastrocnemius. This exercise can be performed multiple times daily and is effective when done regularly. Ankle Plantarflexion Execution 1. Sit upright on a comfortable, hard-backed chair. The foot is initially flat on the floor, with the knee bent about 45 degrees or so, depending on the height of the chair. Raise the heel off the ground, then invert the foot as though pointing the toes like a ballet dancer. Hold the position for 15 seconds and repeat up to 10 times, two or three times per day, with both feet. With tubing. 2. Place the chair in a position where a piece of flexible elastic such as Theraband can be attached to an immovable object on a wall in a loop. Sit in the same stretched position as previously and put the elastic around the midfoot farthest away from the wall. Use this as resistance to ease the foot farther into inversion and pull against it, strengthening the tibialis anterior muscle. Hold the position for 15 seconds and repeat up to 10 times, two or three times per day, with both feet. Muscles Involved Primary: tibialis anterior Running Focus The importance of the tibialis anterior muscle is in the flexibility it gives to the ankles and feet. It is very involved in increasing stability when running on uneven terrain because it helps to adjust the position of the foot and therefore the leg. As such, any prolonged hill or undulating rough ground will bring it increasingly into use. If untrained, it will tire rapidly and slow the runner down, as well as increase the risk of a sprained ankle. When strengthened, it will also help to limit the pronation and supination of the foot, the cause of further problems for the runner. Partial Sit-Up Execution 1. Lie on a firm, supportive surface on your back with both knees bent and feet flat on floor. Have the hands resting loosely on or hovering slightly above the thighs. 2. Lift the arms a couple of inches and slowly raise the head and shoulders off the floor. Reach with both hands toward the knees and attempt to hold the position for 10 seconds. Repeat five times. Concentrate on performing the exercise smoothly without jerking; just as important, also ensure a slow return to the resting position between stretches. Muscles Involved Primary: rectus abdominis Secondary: transversus abdominis, external oblique, internal oblique Running Focus It is impossible to overemphasize the importance of a stable core for a runner. Weak abdominal muscles cannot help support the back. If the torso crumples under the weight of the upper body, running becomes difficult and painful. This exercise also helps to preserve the link between the abdomen and the lower limbs, and it adds some strength to the knee lift, which in turn will enable the stride length to be maintained. Seated Straight-Leg Extension Foot out. Foot straight up. Foot in. Execution 1. Sit on the floor with your arms behind you for support and one leg outstretched. In the early stages the ankles should not have weights attached, but as you become more adept, you may wish to attach up to 10 pounds of weight incrementally to improve strength. 2. Turn the foot outward and slowly lift the leg, locked straight but not hyperextended at the knee, until it is no more than six inches off the floor. Hold for 10 seconds, then, equally slowly, lower the ankle to the ground and rest. Repeat the exercise 10 times for 10 seconds and alternate with the opposite leg. The foot position can be changed to work all the muscles of the quadriceps evenly. Muscles Involved Primary: vastus medialis Secondary: rectus femoris, vastus intermedius, vastus lateralis Soft Tissue Involved Primary: medial collateral ligament, patellar tendon TECHNIQUE TIP ▶ At first this may seem difficult, which is why you should not attach weights. The upper leg may well develop a tremor when first exercised in this fashion, but as strength is acquired, this will reduce and the whole exercise becomes easier. Running Focus If sports medicine clinics banned runners with knee pain, they would become very lonely places! Unfortunately, too many coaches place far too much emphasis on general quadriceps development and fail to comprehend the role of the vastus medialis in stabilizing the knee and the prevention of patellofemoral pain. This is the most effective way of producing the increase in strength and power in this muscle to ward off the demon of anterior knee pain. CHAPTER 11 ANATOMY OF RUNNING FOOTWEAR Runners who assiduously perform the strength-training regimen outlined in chapters 5 through 9 of this book, arrange their training to conform to the basic tenets of an intelligent training program as explained

in chapter 2, and take the time to perform the injury-prevention exercises described in chapter 10 can still be stymied in their efforts to improve running performance. Simply by wearing the wrong training shoes or the wrong orthotic device for his or her foot type, a runner may short-circuit his or her well-intentioned efforts to improve. This chapter endeavors to present some sound wisdom about footwear and orthotic selection by presenting an overview of how and why running shoes are constructed for particular biomechanics and how runners can choose the right footwear and orthotics for their specific needs. Why Wear Running Shoes? Running shoes work for running because they are designed and manufactured to meet the demands of bearing three to four times the body’s weight on impact, are designed for the biomechanics of running that are outlined in chapter 3, and are biomechanically (and, to a lesser extent, terrain) specific. Running shoes are designed on lasts, or forms that are models of the human foot. These lasts have shapes ranging from curved to straight with variations on the degrees of the curve, which make the shoes appropriate for the various foot shapes of runners. The term last also applies to the methodology of construction. A combination-lasted shoe stitches the upper fabric underneath a cardboard heel to provide stability. A slip-lasted shoe stitches the upper directly to the midsole, ensuring flexibility. A full-board-last (cardboard from heel to toe) shoe is the most stable lasting technique but currently is almost nonexistent in shoe manufacturing. Theoretically, curved slip-lasted shoes are designed for higher-arched, rigid feet, whereas straight combination-lasted shoes are designed for flatter, more flexible feet. Because flat feet tend to pronate (the inward rolling of the rear foot, controlled by the subtalar joint) more than high-arched feet, straight- lasted shoes, with the aid of stability devices embedded in the midsole, help limit the rate and amount of pronation. Conversely, runners who underpronate should wear curved to slightly curved slip-lasted shoes, which allow the foot to generate as much pronation as possible to help aid in shock absorption. Many runners err in choosing shoes because they do not know what foot type they have. If an underpronator trains in stability shoes, predictable injuries like calf pain, Achilles tendinitis, and iliotibial band syndrome will occur. If an overpronator trains in a cushioning-only shoe, stress injuries (including fractures) to the foot, tibia, and the medial knee likely will occur. For most runners, a qualified employee at a running specialty store can evaluate foot biomechanics, possibly by using a treadmill and a video camera, and successfully recommend multiple shoe models that, in theory, will prevent injury and provide a pleasurable ride. Occasionally, evaluating the foot becomes tricky due to motion not seen clearly by the naked eye, and a slow-motion camera may be needed to ascertain true foot movement. This is rare and usually not found in recreational runners due to lower training volume and velocity. Understand that biomechanics can change; what was once corrected may no longer be a problem, and new problems can arise. History of 20th-Century Running Shoes The history of the running shoe in the 20th century begins with Spalding’s introduction of the long-distance running shoe. The company outfitted the 1908 U.S. Olympic marathon team in its models, and based on observations of the marathon and the shoes’ performances, it created a line of marathon shoes in 1909. Both high-top and low-top shoes with a pure gum sole and leather uppers were “full finished inside so as not to hurt the feet in a long race.” Within five years, the gum rubber sole had been replaced by the leather sole, and the research and marketing of running shoes had begun in earnest, albeit in fits and starts. Although Spalding continued tinkering with its running shoe models, the intrigue in running shoes sparked by the 1908 Olympic marathon in London gave way to a fascination with track spikes, particularly those manufactured by the Dassler brothers of Germany. Worn by Jesse Owens in the Munich Olympics, the spiked shoes were little more than a soft leather upper sewn to hard leather soles with permanent “nails” built into the soles to provide traction on the dirt tracks. An interest in production of running shoes was rekindled in the United States in the mid-1960s through the mid-1970s, which ushered in the era of the running specialty business. Facing competition from the Japanese-imported Tiger running shoes, Hyde, New Balance, and Nike all began production of serious running shoes. The features of the new shoes were a higher heel, midsole cushioning material (EVA), and nylon uppers. In some cases, the shoes were well made; in most cases, they were not. By the late 1970s, Runner’s World began lab-testing the running shoes, and the manufacturers were forced to improve the quality of their shoes or lose market share. This change in the mind-set of the companies began a period of intense competition (that still lasts today) to provide the best fit with the most cushioning, stability, and durability in a shoe that looks good. Components of Running Shoes This section describes the components of the running shoe and their significance for the runner. The emphasis is on finding the right shoe, from a biomechanical and a fit standpoint. One part of the equation without the other could lead to injury. When purchasing shoes, remember that the cost of the shoe does not ensure its success. For one runner, an expensive shoe may only deplete his bank account without aiding performance; for another, the shoe may be expensive and perfect. Your foot type, shape, and biomechanics determine what is best when it comes to shoes. Upper The upper of a running shoe (figure 11.1) is the material that covers the top and the sides of the foot. It can be made of multiple pieces of fabric sewn or glue-welded together, or it can be made of a one-piece, seamless material. All current running shoes are of human-made materials (nylons) for breathability, comfort, and weight reduction. Leather is no longer used because of its lack of breathability, nonconforming shape after repeated use, weight, and cost. The front of the upper is referred to as the toe box of the shoe (figure 11.2). It takes its shape from the last of the shoe (the form the shoe is built on), but its style is determined by the shoe designer to meet the needs of the shoe wearer. The toe boxes of many of the shoes built recently are wider and deeper to accommodate the higher-volume feet that seem to have become more prevalent as the second running boom has corralled more recreational runners with larger frames into the sport. The midfoot of the shoe’s upper can be designed in conjunction with or independently of the lacing system (e.g., ghillie lacing) to allow for various upper fits. Occasionally, companies will attempt a nonsymmetrical lacing pattern ostensibly designed to improve the fit of the upper and remove “hot spots” (pre-blister-forming areas) from developing on the foot during running. Figure 11.1 Lateral view of shoe: upper, midsole, and outsole. Figure 11.2 Upper. The design of the upper of the shoe determines the fit of the shoe—not the length of the shoe, but how the shoe envelops the foot. This is important because if the shoe fit is improper, the biomechanical needs of the runner may not be met. Only when the fit of the shoe is spot-on can the function (be it stability, motion control, or cushioning) work as designed. For example, if the fit of the upper is too baggy in the midfoot, excessive pronation can occur despite the presence of a medial support. The lack of a proper fit renders the stability device ineffective in combating the pronation it was designed to limit. Injuries can occur—in this case, tibial pain—even if a runner wears a shoe that is the correct category for his or her foot type. This scenario often leads to disenchantment when purchasing shoes because of the confusion resulting from following the suggestions and guidelines and still not getting relief from pain. Here is a general point when purchasing shoes: If the shoe doesn’t fit your foot well, it isn’t the best shoe for you, regardless of whether its biomechanics are matched to your foot type. For example, it could be argued that for a mild overpronator, a cushioned shoe that fits perfectly is more stable than a mild stability shoe that is too roomy. In conjunction with proper fit, a heel counter embedded in the upper material ensures a secure, mildly stable ride when running. Heel counters (figure 11.3) are hard plastic devices that stabilize the rear foot, helping the foot through the normal cycle of heel strike, midfoot stance (avoiding excess pronation), forefoot supination (the outward rolling of the forefoot), and toe-off from the smaller toes of the foot. Heel counters can be removed in shoes manufactured for underpronators, but the possibility of Achilles tendinitis is increased because of the increased movement of the calcaneus and the subsequent pulling on the Achilles tendon. Figure 11.3 Heel counters and heel clefts. Midsole The midsole of a running shoe (figure 11.4) is made of EVA (ethylene vinyl acetate) or rubberized EVA used to cushion or stabilize the ride of the shoe during foot strike. Developed in the early 1970s as a cushioning material to rival polyurethane (which is denser and heavier), EVA has been combined with other proprietary cushioning materials such as air and gel as well as engineering designs like wave plates, footbridges, cantilevers, and truss systems to minimize impact shock generated during the foot strike and to guide the foot through its normal path. The holy grail of midsole technology has been to find a material that provides a moderately soft ride and has the durability to withstand compression, which limits the life span of the shoe. A reasonable expectation for a running shoe’s life is 350 to 500 miles. The development of a midsole that could provide 750 miles of consistently comfortable running would be a boon both to runners and to the manufacturing company that patented the material. Figure 11.4 Midsole. The current crop of rubberized midsoles provide dramatically better cushioning than their “sheet” EVA predecessors from the 1970s, but there is an environmental cost associated with producing the material. Traditional EVA midsoles take approximately 1,000 years to entirely biodegrade. Some running shoe manufacturers are marketing eco-friendly “green” midsoles that are touted as environmentally sound because they degrade 50 times faster in a traditional landfill environment. Most runners look at the outsoles of their shoes to determine whether the shoes need to be replaced. Unfortunately, when the outsole of a running shoe has worn away enough to show significant wear, the midsole has been long compromised in providing cushioning. Because midsoles provide cushioning, they also absorb and dampen the shock of impact. During a 30-minute run, each shoe lands on the ground approximately 2,700 times. That is multiplied by an impact force of three to four times a runner’s body weight, so it’s amazing that no more than a two-inch-thick wedge of EVA can withstand approximately 150 of these training runs before being replaced. The midsole is also the part of the shoe that contains the various stability devices designed to prevent pronation. These devices are always placed on the medial side of the shoe, usually between the arch and the heel. The devices are located in this area to counter the effects of pronation, which is mainly controlled by the subtalar joint that is located in the area of the foot closest to this part of the shoe. Occasionally a shoe will be produced with forefoot posting (to prevent late-stage pronation of the forefoot), but this is a nontraditional method of design. Posting of the lateral side of the shoe is never done because increasing the rate and degree of pronation is problematic for pronators (leading to increased tibia discomfort) and needless for underpronators (a cushioned shoe allows for the foot to pronate as it needs to). Outsole The outsole of a running shoe (figure 11.5) has evolved dramatically from a materials standpoint from the gum rubber of the 1908 Spalding marathon trainers. The outsole (the part of the shoe that actually touches

the road) is made of carbon and blown rubber composites used jointly to make for a durable yet appropriately flexible ride. Most runners strike the lateral heel of the foot upon impact. Hence, manufacturers place the most durable carbon rubber in this area of the shoe to ensure longevity of the outsole. Despite the added durability of the carbon rubber, excessive wear will still appear in that area of the shoe for most runners. This is to be expected and does not indicate a proclivity toward overpronation or underpronation. It simply means the runner is a heel striker. If the outsole is completely worn through in the forefoot of the shoe, the midsole cushioning was compromised long before, and the shoe is worthless as a shock-absorbing entity. Because the outsole of the shoe lasts much longer than the midsole cushioning, using outsole wear as a guide for when to replace your running shoes is erroneous. The best method of measuring the life of a shoe requires little work. Pay attention to the mileage on your shoes by keeping a log or quick estimation of miles per week multiplied by weeks of training, and after approximately 350 miles, replace your shoes when you begin to have aches or pains in your legs that you did not have for the first 350 miles of the shoe’s life. Normally, if a shoe model is not correct for a runner’s biomechanics, weight, flexibility, or foot shape (all factors that determine the best shoe), discomfort or injury will occur within the first 100 miles of running. Thus, the wrong shoe should rarely be confused with an old shoe. Figure 11.5 Outsole. Shoe manufacturers are constantly altering the strike path of a shoe’s outsole and the surface pattern of the rubber to improve comfort and durability. Although these aims of the manufacturers seem to be worthwhile, the role of aesthetics in shoe design cannot be ignored. At every phase of design and development, the aesthetics of the shoe, its attractiveness to the consumer, must be weighed against the practicality of building the shoe and the effectiveness of the shoe for running purposes. Often the aesthetics of the shoe take precedence, and a much-hyped shoe proves to be a performance dud—albeit a dud with an expensive advertising campaign. Insoles and Orthotics Runners want to wear comfortable running shoes that help prevent injuries; however, because running shoes are not custom-made, there will always be a bit of a compromise when it comes to fit. Because each runner’s foot is unique and not even symmetrical with the other foot, it becomes apparent that accommodations may be needed in order to enhance a running shoe’s fit and its function. To customize the fit and function of their shoes, runners turn to insoles and orthotics. Each pair of running shoes comes with an insole. It is made of EVA or a material combined with EVA to add comfort (shock absorption) and to aid the fit of the shoe. It costs less than 50 cents to manufacture, and it is mostly useless. It is removable, and for a good reason. Most runners remove the inexpensive insole and replace it with a more cushioned or more stable insole that actually has some resemblance to the shape of the human foot. In the past decade, over-the-counter replacement insoles have become a serious revenue generator for running specialty stores. The proliferation of these stores has led to more retail outlets for the sales of insoles, and the insole manufacturers have responded by producing good-quality products for less than $30. It seems a bit redundant to spend $90 on a pair of shoes and $30 on a pair of insoles when you could just buy a $120 pair of running shoes. The true value of the insole is that it customizes the shoe to the runner’s foot. Thus, the $90 shoe feels closer to a perfect fit than the $120 shoe because it more closely resembles a shoe made from a mold of the runner’s own foot. Not only does the insole aid fit, but current insoles also help correct for poor biomechanics. They can be posted to compensate for pronation factors or high-arched to help prevent plantar fasciitis. They do work well, but they are not for every runner. Many runners can do without insoles because they do not have major biomechanical problems that their training will exacerbate. For those runners who have run a lot of miles in their lives, are training at a high volume, or have chronic injuries, insoles are a viable option. For those runners who do not find relief with an over-the-counter insole, the next step is to visit an expert (certified pedorthist or podiatrist) to obtain custom-made orthotics. An orthotic device is meant to correct an anatomical or biomechanical abnormality. In theory, an orthotic device realigns the foot strike, which, in turn, alleviates any imbalances or weaknesses through the kinetic chain of events initiated by running. Do orthotics work? Sometimes. Upon visiting a podiatrist or certified pedorthist, a runner should expect the following procedure to occur before an orthotic device is produced. The specialist should take a thorough history of running injuries, shoes worn, and remedies attempted. Measurements of leg length and an evaluation of joint mobility should be completed. X-rays can be taken, but they are often not necessary. After evaluating the feet, the specialist will proceed to make plaster molds of them. The doctor will place each foot in a “neutral” position and wrap plaster-soaked strips of gauze around each one. The most important step is placing the foot in the neutral position. This position is the key element in producing an orthotic that works well. Because the goal of an orthotic is to correct, the foot must be in the neutral position so a cast can be fabricated that shows any corrections to be made. The difference between the runner’s foot and the appropriate position of the runner’s foot when in neutral is the correction that needs to be made. When the cast is sent to an orthotics lab to produce the orthotic, a technician will evaluate the cast and take more measurements. From the “negative” cast, a “positive” model is created from plaster and is ground to the specifications provided by the doctor. A hard orthotic is fabricated from thermoplastic and filled with cushioning material. It is posted medially no more than 4 degrees to help position the foot in neutral at midstance. It is covered by a thin layer of synthetic material. A soft orthotic, also referred to as an accommodative orthotic, is more of a custom-made arch support than a posted orthotic. Its goal is less medial stabilization for pronation and more arch support for a runner with high, rigid arches. Normally, a running orthotic will be full length, replacing the insole of the shoe. It is not uncommon for a laboratory to offer a three-quarter-length orthotic. Because most rear-foot motion issues can be alleviated with a three-quarter-length orthotic, logic would dictate that the weight-saving inherent to a three- quarter-length orthotic would be welcome. Unfortunately, the lack of a continuous surface under the complete length of the foot leads runners to fabricate their own system of completing the orthotic. Purchase an orthotic with a full-length cover. The litmus test of a well-constructed orthotic is twofold. Does it fit comfortably into a running shoe (although it may be a different, larger shoe than you were wearing), and does the orthotic device eliminate the running injuries it was created to combat without causing other injuries? The answer should be a resounding yes! If not, contact your doctor for a follow-up appointment to reevaluate the orthotic. The pairing of an orthotic device and a running shoe is a combination of art and science. If a hard, corrective orthotic is worn, a neutral cushioned shoe that encompasses the orthotic well and provides a good fit may suffice in eliminating any overpronation injuries. If a stability shoe is still needed with a hard, corrective orthotic, take caution to avoid the possibility of overposting the foot. This marriage of a stability shoe and corrective orthotic is a possible recipe for iliotibial band syndrome, an injury usually associated with underpronators who stay on the lateral aspect of their foot through the foot strike, creating tightness in all the muscles and soft tissue laterally from the foot to the hip. At the first sign of pain on the lateral side of the knee or tightness in the hip area, reconsider the use of a stability shoe and corrective orthotic. Underpronators who wear accommodative orthotics should continue to wear cushioned shoes. The only caveat, and this is true for overpronators with orthotics as well, is that an extra half size may be needed in order to fit the orthotic into a running shoe. The orthotic replaces the insole that comes with the shoe, but it is higher in volume and thus needs to be fit properly so that the biomechanics it is meant to promote during running can proceed seamlessly. Barefoot Running Barefoot running could have been included in chapter 9’s list of exercises to strengthen the foot because that is essentially what barefoot running does best (along with developing some proprioceptive awareness). But daily barefoot training is not really a substitute for running in shoes. Given that most runners log the majority of their miles on asphalt, concrete, treadmills, and gravel-strewn trails, running barefoot daily seems a bit painful at the least; however, running without shoes does have many practical applications when used as a supplement to running training, much like the strength-training exercises outlined in chapters 5 and 6 of this book. It should not replace traditional (with shoes) training. The argument has been made that many African runners have trained barefoot and have had success (native South African Zola Budd is a famous example), but the counterargument is that all the world records are held by shoe-wearing runners. Proponents of barefoot running tout the muscular strength gained through barefoot running, which is an accurate assessment in the proper context. Advocates of barefoot running also tout the psychological release derived from running on sand and lush grass, which may also be because sand and lush grass are normally found in places more likely to be idyllic, although it is a tenuous connection to aiding running performance. The best reason to do some barefoot running on lush grass or hard-packed sand (not more than twice a week and no more than 100 meters straight for a total of 400 meters per session to begin) is to train the muscles of your feet to work differently than they do when running shoes are worn. Barefoot running forces the feet to work, preventing atrophy in the muscles of the foot that function the same way during every run in running shoes with or without orthotics. The antiorthotic movement in running espouses mixing in barefoot running and running in neutral shoes for overpronators to force the foot to strengthen itself to prevent future injuries. Just as the exercises in this book have detailed how to strengthen your body to improve running performance, barefoot running can help strengthen your feet to withstand the countless training miles required of them. As with all strength training, if you feel pain while barefoot running, stop. Summary The ultimate goal of a well-designed and constructed running shoe and orthotic device is to promote injury-free and comfortable running. Extra cushioning to limit the impact forces of the foot strike, stability devices adding medial posting to limit pronation generated by the subtalar joint, and transitional EVA densities to ease the transition from heel strike to midstance are all designed to meet this goal. Appropriate footwear and orthotic devices (matched to a runner’s biomechanical needs), when combined with the strength-training program for the lower leg and foot presented in chapter 9, should eliminate all leg and foot injuries. One caveat is that the running shoe and orthotic must be appropriate to the foot that wears it, and the shoe and orthotic device must be replaced when its cushioning, stability, and accommodative properties are compromised. Normally, a running shoe can be expected to last at least 350 miles, an aftermarket insole should last through every other shoe purchase, and a custom

orthotic should last at least two years (although the cover may need to be replaced). Trained employees at running specialty stores can help runners match current running shoes with the appropriate foot types and match feet with nonprescription insoles that provide similar protection as orthotic devices, but are not custom-made by a podiatrist. The effectiveness of any running shoe and orthotic device hinges not just on biomechanics but also on fit. A well-constructed shoe that is the right biomechanical choice for a runner may not function correctly if the shoe is ill-fitted to the foot. When purchasing a shoe, make sure the shoe is neither too long or too short, nor too wide or too narrow. Also, try the new shoes with the orthotic device to be worn in order to replicate the fit of the shoe-and-insert combination. Remember, if it doesn’t work in the store, it is not going to work on the road, trail, or track! CHAPTER 12 FULL-BODY CONDITIONING Chapters 5 through 9 of this book deal with strength training and the specific anatomy affected by properly performed resistance exercises. This chapter deals with alternative forms of exercise that complement the strength-training exercises detailed in the previous chapters. Specifically, this chapter examines water running and plyometrics as performance-enhancing training tools for runners. Full-body conditioning is an important training element because it can diminish the injury potential that a repetitive, high-impact exercise such as running can have on the musculoskeletal system. By substituting a deep-water running session for a land running session, you can avoid countless tons of force on the body’s anatomy without a concurrent loss in cardiovascular stimulation. Also, incorporating plyometrics into a training plan strengthens muscles, aiding the ability to withstand the impact of accumulated running training miles. It also helps in recovery from injury (when performed at the appropriate time), and it can improve running economy. Water Running Most runners have been introduced to water running as a rehabilitative tool for maintaining cardiorespiratory fitness after incurring an injury that precludes dryland running. However, runners should not assume that aquatic training’s only benefit is injury rehabilitation. Running in water, specifically deep-water running (DWR), is a great tool for preventing overuse injuries associated with a heavy volume of aerobic running training. Also, because of the drag associated with running in water, an element of resistance training is associated with water running that does not exist in traditional running-based training. Although shallow-water running is a viable alternative to DWR, its benefits tend to be related to form and power. Although the improvement of form and power is important, it comes at a cost. Because shallow-water running requires impact with the bottom of a pool, it has an impact component (although the force is mitigated by the density of the water). For a runner rehabbing a lower leg injury, shallow-water running could pose a risk of injury. More important, balance and form are easier to attain in shallow-water running because of a true foot plant. Fewer core muscles are engaged to center the body, as in DWR, and there is a resting period during contact that does not exist in DWR. For our purposes, all water-related training exercises focus on DWR. In performing a DWR workout, proper body positioning is important (figure 12.1). The depth of the water should be sufficient to cover the entire body: Only the tops of the shoulders, the neck, and the head should be above the surface of the water. The feet should not touch the bottom of the pool. Runners tend to have more lean body mass than swimmers, making them less buoyant; therefore, a flotation device will be necessary. If a flotation device is not worn, body position can become compromised and an undue emphasis is placed on the muscles of the upper body and arms to keep the body afloat. Once buoyed in the water, assume a body position similar to dryland running. Specifically, the head is centered, there is a slight lean forward at the waist, and the chest is “proud,” or expanded, with the shoulders pulled back, not rotated forward. Elbows are bent at 90 degrees, and movement of the arms is driven by the shoulders. The wrists are held in a neutral position, and the hands, although not clenched, are more closed than on dry land in order to push through the resistance of the water. (See figure 12.2 for an example of poor body position during DWR.) The strength gained from performing wrist curls and reverse wrist curls (see chapter 6) are beneficial for this. Figure 12.1 Proper body position for deep-water running. Leg action is more akin to faster-paced running than general aerobic running because of the propulsive force needed for overcoming the resistance caused by the density of the water. The knee should be driven upward to an approximate 75-degree angle at the hip. The leg is then driven down to almost full extension (avoiding hyperextension) before being pulled upward directly under the buttocks before the process is repeated with the other leg. During the gait cycle, the feet change position from no flexion (imagine standing on a flat surface) when the knee is driving upward to approximately 65 degrees of plantarflexion (toes down) at full extension. This foot movement against resistance both facilitates the mechanics of running form and promotes joint stability and muscle strength as a result of overcoming the resistance caused by drag. Due to the unnatural training environment (water) and the resistance created when driving the arms and legs, improper form is common when beginning a DWR training program. Specifically, it is common to make a punting-like motion with the forward leg instead of snapping it down as shown in the B motion on page 24. This error is due to fatigue of the hamstrings from the water resistance, resulting in poor mechanics. To correct this error, rest at the onset of the fatigue, and don’t perform another repetition until the time goal is met. Do not try to push through it. You won’t gain fitness, and you will gain poor form. Figure 12.2 Incorrect body position for deep-water running. Figure 12.3 shows a DWR technique that most closely resembles dryland running form. It is the best technique for facilitating proper running form while training in deep water. A high-knee alternative does exist (figure 12.4), but it is less effective in mimicking the nuances of proper running form. Instead, it more closely resembles the form used on a stair-stepping exercise machine. There is little running action other than the lift phase and therefore very little muscle involvement. DWR is effective because it elevates the heart rate, similar to dryland running. And because of the physics of drag, it requires more muscular involvement, thus strengthening more muscles than dryland running does without the corresponding overuse injuries associated with such training. Specifically, it eliminates the thousands of impact-producing foot strikes incurred during non-DWR running. DWR is easily integrated into a running training program either as a substitute for an aerobic run, lactate, or V O2max effort or as a supplemental workout, such as a second running workout of the day. Because pace is easily controlled by speeding up or slowing down leg turnover, adjusting efforts based on heart rate or perceived effort is simple. Studies have found that heart rates during water running are about 10 percent lower than during land running, so a heart rate of 150 beats per minute (bpm) during water running equates to a heart rate of 165 bpm on land. Also, perceived effort is greater in water because of the combination of greater muscle involvement and the warmer temperatures of most pools. Because running for an hour in the pool is boring to most runners, we recommend 50 minutes in a pool as a good substitute for an on-land easy run; fartlek and interval-type efforts should be the emphasis of DWR training. Also, multiple intense efforts akin to speed work on land can be performed weekly because of the lack of ground impact. The following are two sample DWR workouts. Figure 12.3 Deep-water running, traditional form. Figure 12.4 Deep-water running, high-knee form. Sample Lactate Workout The goal of this workout is to elevate the blood-lactate accumulation. At the end of each subsequent repetition, muscle fatigue should be increasingly present because the one-minute rest does not allow full recovery. This is not an easy workout, but it would not be a true speed session. Warm-up: 15 min easy running + 4 × :30 @ 5K race pace (perceived effort) 2 × 10 min @ 10K race pace (perceived effort) with 1 min recovery jog 1 × 15 min @ 10K race pace (perceived effort) with 1 min recovery jog Cool-down: 10 min easy running SampleV O2max Workout The goal of this workout is to simulate 5K race effort. Because pace can’t be replicated in a pool, the emphasis of the workout is on perceived effort. Heart rate can be used; if you know your training zones from an LT test and you own a waterproof heart rate monitor, the exact effort can be substituted. Rest is given to allow for proper form on each repetition. Note that, as in running on dry land, body position is an important component of running efficiency. Good body position (as described and illustrated earlier in the chapter) leads to a more productive workout. This would be a moderately hard effort for a trained runner and a difficult effort for a beginner. Warm-up: 15 min easy running + 4 × :30 @ 5K race pace (perceived effort) 5 × 2 min @ 5K race pace (perceived effort) with 2 min recovery jog 3 × 3 min @ 5K race pace (perceived effort) with 3 min recovery jog 3 × 2 min @ 5K race pace (perceived effort) with 2 min recovery jog Cool-down: 10 min easy running Plyometrics The term plyometrics is mysterious to many distance runners, although it is a common training tool for many elite distance runners, middle-distance runners, and sprinters, most professional athletes, and many athletes rehabilitating from injuries. For the noninitiated, it sounds like, and at times is represented as, a hyperspeed method of improving performance. Just perform plyometrics, drink amino acid-laced recovery drinks, and voilà, instant performance improvements. By definition, plyometrics means measurable increases, in this case through body-weight exercises. Because it is the use of strength, not raw strength, that contributes to speed development, plyometric exercises have one main goal: the conversion of strength to speed by generating a large amount of force quickly. Plyometric exercises train the neurological and muscular systems to increase the speed at which the body’s strength can be used. By performing plyometric exercises, runners can measurably improve running performance, but not in the way they may think. A by-product of the development of muscular power is an improvement in running economy. Running economy is the cost, or amount of oxygen, required to maintain a defined pace. The less oxygen used to maintain a certain pace relative to other runners or your previous measurement, the better the running economy. It does not quantify the efficiency of running form (the terms are often confused), although running form may affect running economy. Plyometric exercises trigger improved running economy through recruitment of muscle fibers in a way that distance training does not. A plyometrically trained athlete’s muscle contractions are shorter in duration; because less strength is required to perform the contraction (a result of both increased strength and neurological development), running economy improves. This chain of events leads to faster performances caused by the delay of muscle fatigue. But, unlike DWR, plyometrics cannot be substituted for running training to improve performance for distance runners. Although DWR has an impact on LT and V O2max, plyometric exercises train the neuromuscular systems with almost no impact on the cardiothoracic systems described in chapter 2. Without running training, plyometric training could not sustain improvements in running performance. There is debate about the phase of training in which plyometrics should be incorporated. There are no definitive answers, but we suggest one plyometric session per week during lactate training and two sessions per week during V O2 max training. The workout should be done before the LT or V O2 max workout takes place, in a separate training session

Endobronchial Ultrasonography Companion DVD This book has a companion DVD with: • A searchable database of 36 video clips showing procedures described in the text • All clips are referenced in the text where you see this icon: Endobronchial Ultrasonography Noriaki Kurimoto MD, PhD Professor of Chest Surgery Department of Surgery St Marianna University Kawasaki City Kanagawa Prefecture Japan David I. K. Fielding MB, BS, FRACP, MD Director of Bronchology Department of Thoracic Medicine Royal Brisbane and Women’s Hospital Brisbane, QLD, Australia Ali I. Musani MD, FCCP, FACP Associate Professor of Medicine and Pediatrics; Director Interventional Pulmonology National Jewish Health Associate Professor of Medicine University of Colorado School of Medicine Denver, CO, USA A John Wiley & Sons, Ltd., Publication Disclaimer: This eBook does not include ancillary media that was packaged with the printed version of the book. This edition first published 2011 © 2011 by Noriaki Kurimoto, David I. K Fielding and Ali I. Musani Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientifi c, Technical and Medical business to form Wiley-Blackwell. Registered offi ce: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. 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No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Kurimoto, Noriaki. Endobronchial ultrasonography / Noriaki Kurimoto, David I. K. Fielding, Ali I. Musani. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-8272-0 1. Bronchi–Cancer–Ultrasonic imaging. 2. Endoscopic ultrasonography. 3. Bronchi–Ultrasonic imaging. I. Fielding, David I. K. II. Musani, Ali I. III. Title. [DNLM: 1. Bronchi–ultrasonography. 2. Bronchoscopy–methods. WF 500 K96e 2011] RC280.B9K87 2011 616.99'423–dc22 2010019095 A catalogue record for this book is available from the British Library. This book is published in the following electronic formats: ePDF 9781444314373; Wiley Online Library 9781444314366 Set in 8.75 on 12 pt Meridien by Toppan Best-set Premedia Limited 01 2011 Contents Dedication, vi 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy, 73 Foreword, vii 9 Diagnosis of Peripheral Pulmonary Lesions Using Preface, viii Endobronchial Ultrasonography with a 1 An Overview of Endobronchial Guide Sheath, 89 Ultrasonography, 1 10 Endobronchial Ultrasonographic Analysis 2 Anatomy of Mediastinal and Hilar Area, 16 of Airway Wall Integrity and Tumor Involvement, 96 3 How to Perform Endobronchial Ultrasonography, 26 11 EBUS in Interventional Bronchoscopy, 111 4 Endobronchial Ultrasound-Guided Transbronchial 12 Future Directions for Endobronchial Needle Aspiration (EBUS-TBNA), 36 Ultrasonography, 118 5 Tips and Diffi culties in EBUS-TBNA, 52 13 Case Reports, 120 6 Endoscopic Ultrasound-Guided Mediastinal Appendix: Videos, 160 Lymph Node Aspiration for Lung Cancer Index, 162 Diagnosis and Staging, 59 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography, 62 Companion DVD This book has a companion DVD with: • A searchable database of 36 video clips showing procedures described in the text • All clips are referenced in the text where you see this icon: v Noriaki Kurimoto MD To my wife and children: Mayumi, Satoshi, Wataru, Misturu, and Manabu David Fielding MD To my wife and children: Siobhan, Josie, Alison, Eveline, and Michael Ali I. Musani MD To my wife and children: Lubna, Sara, and Sef vi Foreword How nice it is for us to be able to learn from this text- by a tireless and enthusiastic surgeon, Dr. Kurimoto, book the up- to - date knowledge and techniques of whom I thank for his friendship and encouragement, echobronchoscopy. which I will always appreciate. The main part has been written by Professor N. The two coauthors, Drs. D. Fielding and A. Musani, Kurimoto. The few years during which I worked with are both leading bronchoscopists, and good friends of Dr. Kurimoto in the Department of Chest Surgery St. mine. Many times we shared knowledge and desire in Marianna Univerisity School of Medicine was very the bronchoscopy, especially in echobronchoscopy, fruitful, especially because we could feel that we were with each other at St. Marianna University. I am in contributing to our specialty by developing the theory the position to congratulate an epoch making publica- and technique of echobronchoscopy. As soon as Dr. tion in this attracting fi eld. Kurimoto joined us, it became routine for a lobe just removed in the theater to reach the pathology section Hiroaki Osada, M.D. by being carried in Dr. Kurimoto’ s own hands for a Professor Emeritus redo echobronchoscopy. St. Marianna University School of Medicine This book shows what those lobes have taught us Kawasaki Japan regarding how exact the preoperative diagnosis had Chair of the World Association for Bronchology been, or why the original lesion had been undiagnosed. and Interventional Pulmonalogy The essence of this book is the product brought about August, 2010 vii Preface Gastrointestinal and genitourinary ultrasound tech- Endobronchial ultrasound has truly revolutionized nologies have gone through dramatic improvements the diagnosis and staging of lung cancer and many and growth over the last three decades. However, the other diseases of the mediastinum and lungs. We feel pulmonary applications of ultrasound, endobronchial honored to have been a part of its development and ultrasound (EBUS), started much later, in the early dissemination. 1990 ’ s. We sincerely hope that our book will help physi- In the fi rst half of this book we present a compre- cians learn the technique of endobronchial ultrasound hensive review of the principals of ultrasound and and its applications to its fullest. its application in thoracic medicine. We summarize We would like to thank Mr K. Hirooka and Mr K. mediastinal anatomy, the basic technique of needle Nishina of the Ultrasound Development Group at aspiration of lymph nodes, and how to perform suc- Olympus Optical Co. Ltd, and Ms. Cathryn Gates of cessful endobronchial ultrasound guided transbron- Wiley - Blackwell for her editing assistance. We would chial aspiration. We also discuss the use of peripheral also like to express our gratitude to Dr F. Tanaka of ultrasound for the localization of pulmonary nodules, the Hyougo Medical University Department of Thoracic and the role of endobronchial ultrasound in interven- Surgery and Dr R Amemiya of the Ibaraki Prefectural tional pulmonology. This book is an evidence- based Central Hospital for the illustrations used in this book. refl ection of our collective experience of hundreds of Without their invaluable assistance, this book would thousands of cases. not have been possible. The second half of this book focuses on the correla- tion of EBUS images with the histology and pathology August 2010 of mediastinal lymph nodes and pulmonary nodules. Noriaki Kurimoto In our experience, careful and methodical analysis of David I. K. Fielding ultrasound images of these structures could predict the Ali I. Musani benign vs. malignant nature of these structures with signifi cant sensitivity and specifi city. viii 1 An Overview of Endobronchial Ultrasonography 2 Iizuka 1992: Evaluation of airway smooth muscle Introduction (A History of Endobronchial contractions in vitro by high - frequency ultrasonic Ultrasonography) imaging [3] . 3 Ono 1992: Bronchoscopic ultrasonography in the Endobronchial ultrasonography (EBUS) is a diagnostic diagnosis of lung cancer [4] . modality whereby a miniature ultrasonic probe is 4 Goldberg 1994: US - assisted bronchoscopy with use introduced into the bronchial (tracheal) lumen, pro- of miniature transducer - containing catheters (deline- viding tomographic images of the peribronchial (peri- ation of central and peripheral pulmonary lesions) [5] . tracheal) tissue. Endoscopic ultrasonography (EUS) 5 Becker 1995: Endobronchial ultrasonography – a is already an indispensable technique for examining new perspective in bronchology? (tracheobronchial the gastrointestinal tract, particularly the stomach and wall 7 - layer structure) [ 6] . large intestine. Applications of EUS include assessment 6 Kurimoto 1999: Assessment of usefulness of endo- of the depth of tumor invasion, detection of lymph bronchial ultrasonography in determination of depth node metastases, tumor staging, and fi ne needle of tracheobronchial tumor invasion (tracheobronchial aspiration (FNA) under EUS guidance. wall 5 - layer structure) [ 7] The fi rst reported clinical use of a narrow gauge ultra- Based on these studies, the present applications of sonic probe was for intravascular ultrasonography by EBUS are: Pandian et al. [1] in 1988. The history of EBUS began a Determination of the depth of tumor invasion of the with the report by H ü rter et al. [2] of endobronchial tracheal/bronchial wall (allocation of patients to local- ultrasonography of the lung and mediastinum in 1990. ized endobronchial treatments such as photodynamic Since then, development and research has been carried therapy (PDT). out mainly by Becker (Germany) and ourselves (Japan). b Identifi cation of the location of a peripheral lung EBUS probes are typically of the 20 MHz radial type. lesion during bronchoscopic examination (more accu- Tissue penetration of the ultrasound waves is there- rate than fl uoroscopy in determining contact between fore of the order of 2– 3 cm, in other words, EBUS lesion and bronchus, thereby reducing abrasions, provides a tissue cross - section image with a radius of the time to determine biopsy sites and duration of 2 – 3 cm centered on the trachea or bronchus. fl uoroscopy). Some important EBUS reports include the c Qualitative diagnosis of peripheral lung lesions and following: differentiation between benign and malignant lesions. 1 H ü rter 1990. Endobronchial sonography in the d Determination of position and shape of peribron- diagnosis of pulmonary and mediastinal tumors [in chial structures, particularly lymph nodes (at the time German] [2] . of transbronchial

needle aspiration). e Determination of spatial relationship between bron- chus and lesion in the short axial image of the Endobronchial Ultrasonography, 1st edition. bronchus (if the bronchus is situated near the center By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. of the lesion, the lesion may have arisen from the Published 2011 by Blackwell Publishing Ltd. bronchus). 1 Endobronchial Ultrasonography Problems arising from the application of EBUS Wavelength Wavelength until now, and the results of studies, include the following: 1 Standardization of how the layers in the tracheo- bronchial wall structure are interpreted (how many layers do you see?). High frequency Low frequency 2 Changes in the layer structure of the tracheobron- chial wall with the use of higher frequencies, e.g. Figure 1.1 Relationship between frequency and wavelength. 30 MHz. 3 Evaluation of the accuracy of qualitative diagnosis, and differentiation between benign and malignant lesions, from EBUS images of peripheral lung lesions. Speed of Sound 4 Evaluation of peribronchial lymph node metastases. Sound travels through a variety of materials such as 5 Comparison of the diagnostic accuracy of EBUS- air and water (hereafter media), and the speed at guided FNA and unguided FNA cytology and which it travels through each medium is the speed of histology. sound for that medium. The speed of sound through 6 A worldwide standard nomenclature for this the human body is generally considered to be 1530 m/s, technique. although the actual speed of passage varies for differ- EBUS allows us to examine the state of the bronchial ent organs and tissues. wall and extramural tissue that we are unable to visu- alize with bronchoscopy alone. This book will present Production of Ultrasound Images an overview of EBUS with reference to actual clinical Transmitting and Receiving Ultrasound cases. Waves (Figure 1.2 ) Ultrasonic probes used in medical ultrasonography use a sensor that transforms electrical signals into Principles of Ultrasonography ultrasound, and ultrasound into electrical signals. When an electric signal is applied to the electrode of What is A Sound Wave? the ultrasonic transducer (also oscillator/transformer), Defi nition of Ultrasound ultrasound waves are transmitted from the surface In general, ultrasound refers to sound wavelengths of the device, and when ultrasound waves are greater than 20 MHz that cannot be heard by the received by the device surface, an electrical signal is human ear. There are considerable variations in the generated. range of frequencies audible to humans, however, so we often defi ne sounds in terms of their purpose. In Propagation and Attenuation of this case, ultrasound is “ sound not intended for Ultrasound Waves humans to hear ” . The ultrasound waves produced by the ultrasonic transducer travel through a medium; this is called Frequency and Wavelength propagation. As the soundwave is propagated, the The frequency of a sound tells us whether it is high energy of its oscillations is absorbed and scattered, and or low in pitch. The unit of frequency is hertz (Hz), becomes steadily weaker. This phenomenon is called defi ned as the number of oscillations per second. For attenuation. In general, the higher the frequency, the example, a sound with a frequency of 20 MHz has greater is the attenuation rate. Medical ultrasonogra- 20 × 106 oscillations per second. Medical ultrasound phy equipment uses high frequencies that do not equipment produces sounds with a frequency between propagate well through the air due to the high attenu- 2 MHz and 50 MHz. The wavelength is the length of a ation ratio. A medium such as water is therefore soundwave, and varies inversely with the frequency, needed between the ultrasonic transducer and the so the higher the frequency the shorter the wave- object of study to allow effi cient propagation of ultra- length (Figure 1.1 ). sound waves. 2 CHAPTER 1 An Overview of Endobronchial Ultrasonography Ultrasound transducer Ultrasound transducer Transmit ultrasound Receive ultrasound Figure 1.2 Transmitting and receiving ultrasound waves. Add electrical signals Generate electrical signals Medium A B C D Ultrasound transducer 1 Transmit pulse wave 1 2 2 2 3 2 Penetrate 3 Attenuate 4 4 Reflect 4 4 5 Receive 5 Figure 1.3 How an Ultrasound image ultrasound image is made. Refl ection and Penetration and receive ultrasound pulses (electronic scanning). As with light, a proportion of ultrasound waves are This method of ultrasound imaging is called B- mode refl ected at the boundary between different media, (B is for brightness). and a proportion penetrate the boundary. The ultra- sonic processor uses these refl ections to construct Resolution images. Axial Resolution The ultrasonic transducer emits pulses of ultra- An ultrasound pulse wave has a defi nite length, so a sound, and receives the ultrasound pulses refl ected boundary between media has a defi nite width on from the boundaries between media (Figure 1.3 ). The an ultrasound image. If we reduce the distance ultrasonic processor calculates the positions (distance between the two boundaries of a medium, the pulse from the probe) of boundaries between media based waves from the two boundaries will overlap, making on the time between transmitting and receiving ultra- it diffi cult to distinguish the two boundaries on the sound pulses, and converts the strength of the return- ultrasound image. The ability to distinguish between ing pulses into the brightness of the image. objects on an ultrasound image is called the resolu- Following the above steps alone gives information tion, and the resolution in the direction traveled by about a body along a single line, so we obtain a two - the ultrasound pulse is the axial resolution. In general, dimensional image by moving the ultrasonic trans- the higher the frequency the shorter the ultrasound ducer (mechanical scanning) or using a linear array of pulse, so distance resolution improves with higher multiple ultrasonic transducers that sequentially emit frequencies (Figure 1.4 ). 3 Endobronchial Ultrasonography Medium A Medium B Medium C Ultrasound transducer High frequency Ultrasound image Low frequency Ultrasound image Figure 1.4 Difference in axial resolution between different frequencies. High frequency Large size Small size Low frequency Figure 1.5 Pulse wave Difference of transducer size Difference of frequency spreading. Lateral Resolution Resolution in the direction perpendicular to the direc- High frequency tion traveled by the ultrasound pulse, in other words in the direction the probe moves or in the direction of the array of transducers, is called the lateral resolu- tion. The ultrasound pulse wave emitted by the trans- ducer gradually spreads out as it propagates through a medium. The degree of spread depends on the trans- Low frequency ducer size (aperture area) and the frequency. As the transducer size and/or frequency increases, the degree of spreading decreases (Figure 1 .5 ). Lateral resolution improves with decreased spread (Figure 1.6 ). Figure 1.6 Lateral resolution. 4 CHAPTER 1 An Overview of Endobronchial Ultrasonography Depth Penetration appropriate image quality adjustment is performed. Ultrasound waves are attenuated as they propagate The fundamentals of image quality adjustment are through a medium, so they can only reach a certain gain, contrast and sensitivity time control (STC). distance. Ultrasound images can therefore only be attained for a certain distance from the ultrasonic Gain probe. This distance is called the depth penetration (or Gain, also called brightness, is the mechanism for penetration). The depth penetration also depends on adjusting the overall brightness of the ultrasound the frequency and the transducer size (aperture area). image. Adjustment of the gain increases or decreases The attenuation rate of an ultrasound wave increases the entire ultrasound signal (the signal from the ultra- as its frequency increases, so depth penetration sonic transducer converted for display on the monitor) improves as the frequency decreases (Figure 1.7 ). As evenly. Changes in the gain make the entire image the aperture area of the ultrasonic transducer increases, brighter or darker, but do not alter the differences it can emit a stronger pulse, and it can also convert in brightness between light and dark sections of the weaker received pulses into electrical signals. Depth image (Figure 1.8 ). penetration therefore increases as the transducer size increases. Contrast Contrast is the mechanism for adjusting the difference Image Quality Adjustment in brightness between light and dark sections of the Even when using an ultrasonic probe appropriate to image. Adjustment of the contrast makes the greatest the task, its abilities cannot be fully harnessed unless changes in the sections of the image with the strongest Medium A B C D E Ultrasonic transducer Attenuation: heavy High frequency Ultrasound image Attenuation: slight Low frequency Figure 1.7 Differences in depth Ultrasound image penetration at different frequencies. Increase Increase Decrease Decrease Figure 1.8 Adjustment of gain (brightness). Strength of ultrasound signal Position on the monitor 5 Brightness on the monitor Brightness on the monitor Endobronchial Ultrasonography ultrasound signal, in other words changing the con- sor amplifi es the ultrasound signal according to the trast mainly alters the brightness of the lighter sections current distance from the probe (the time for the ultra- of the image, and the darker sections are changed but sound pulse to return to the transducer) (Figure 1.10 ). little. Increasing the contrast of an ultrasound image By altering the degree of amplifi cation, adjustment of yields an image with enhanced differences between STC can make the ultrasound image lighter or darker light and dark areas, whereas decreasing the contrast according to the distance from the probe (Figure 1.11 ). yields an image with minimal differences between light and dark areas (Figure 1.9 ). Procedure for Image Quality Adjustment Image quality adjustment should be conducted in Sensitivity Time Control accordance with the properties of the ultrasonic proc- Sensitivity time control (STC) also known as time gain essor, monitor and printer. Adjustment of gain (bright- compensation (TGC), is the mechanism for adjusting ness) and contrast are performed in the following the gain according to the distance (depth) from the manner: ultrasonic probe. As shown in Figure 1.7 , attenuation 1 Switch on the system, and bring up an image on the of the ultrasound wave increases with the distance monitor (Figure 1.12 ). from the probe, so ultrasound signals from distant 2 Adjust the brightness and contrast controls of the (deep) regions are weaker than those from near monitor so that the gray scale bar in the ultrasound (shallow) regions. In order to correct this and make the image is displayed with smoothly varying gradations overall image as even as possible, the ultrasonic proces- (Figure 1.13 ). Increase Increase Decrease Decrease Figure 1.9 Adjustment of Strength of ultrasound signal Position on the monitor contrast. In case that STC is; 1~2cm: –1 3~4cm: +1 4~5cm: +2 0 1 2 3 4 5 cm 0 1 2 3 4 5 cm Distance from transducer Distance from transducer Figure 1.10 STC default settings. Figure 1.11 Adjustment of STC. 6 Brightness on the monitor Amplitude ratio of ultrasound signal Brightness on the monitor Amplitude ratio of ultrasound signal CHAPTER 1 An Overview of Endobronchial Ultrasonography 3 Adjust the brightness and contrast controls of the printer so that the gray scale bar in the printed image Gain Gray scale bar corresponds closely to the monitor image. 4 Adjust the gain, contrast and STC of the ultrasonic Contrast processor according to the study subject and purpose of the study. When the EU - M30 system is used with a 20 MHz ultrasonic probe, images with appropriate gradations can be obtained by setting the gain to between 10 and 13, the contrast to between 2 and 5, and the STC to all zero (center position). Figure 1.12 Monitor image (EU- M2000 endoscopic ultrasound system). Equipment Endoscopic Ultrasonic Probe In this section, we will introduce the equipment used by the author, manufactured by Olympus Corporation. The frequencies and outer diameters of the endo- scopic ultrasonic probes we use are shown in Table 1.1 . Since the resolution and depth penetration of an ultrasonic probe are dependent on the frequency and size of the transducer (as the outer diameter of the probe increases, the size of the ultrasonic transducer also increases), the probe needs to be selected to suit the aim of the procedure. Ultrasound examinations can be performed using either the balloon (the probe contacts the object Figure 1.13 Adjustment of gray scale bar. of study through a balloon fi lled with medium) Table 1.1 Ultrasonic probes Model name Maximum

outer diameter F requency Compatible biopsy channel UM - 2R 2.5 mm 12 MHz 2.8 mm or more UM - 3R 2.5 mm 20 MHz 2.8 mm or more UM - 4R 2.4 mm (2.0 mm at proximal side) 20 MHz 2.6 mm or more UM - S20 - 20R 1.7 mm (2.0 mm at proximal side) 20 MHz 2.2 mm or more 2.55 mm (incl. guide sheath SG - 201C) 2 .6 mm or more UM - S30 - 20R 1 .7 mm (2.0 mm at proximal side) 30 MHz 2.2 mm or more 2.55 mm (incl. guide sheath SG - 201C) 2 .6 mm or more UM - S30 - 25R 2.5 mm 30 MHz 2.8 mm or more UM - BS20 - 26R 2.6 mm (incl. balloon sheath MAJ- 643R) 20 MHz 2.8 mm or more UM - S20 - 17S 1.4 mm (1.7 mm at proximal side) 20 MHz 2.0 mm or more 1.95 mm (incl. guide sheath SG - 200C) 2 .0 mm or more 7 Endobronchial Ultrasonography or direct contact method (the probe makes direct or a rigid bronchoscope with an instrument channel contact with the object of study). The method is of 11.5 Fr or more. usually selected according to whether the object of The direct contact method does not require a study is centrally or peripherally situated, and probe balloon, so the probe is passed directly down the bron- selection is also made according to the region being choscope instrument channel. examined. When the balloon method is used, the UM - BS20 - Bronchoscope 26R ultrasonic probe (which can be inserted in a bron- Having selected the ultrasonic probe in accordance choscope instrument channel with a diameter of at with the aim of the investigation and the region being least 2.8 mm) is generally used (Figures 1.14, 1 .15 ). examined, it is then necessary to select a broncho- Other probes can also be used in the balloon method scope suitable for use with that probe. In particular in combination with the balloon sheath MH - 246R when the balloon method is selected, care must be (Figure 1 .16 , outer diameter 3.6 mm). This will require taken to prepare a bronchoscope with an instrument a special bronchoscope such as the BF- ST49, with an channel diameter of at least 2.8 mm. Table 1 .2 shows instrument channel with a diameter of at least 3.7 mm, the endoscopes compatible with the various probes. Ultrasonic transducer O-ring Balloon Balloon sheath MAJ-643R Ditch Ultrasonic probe UM-BS20-26R Balloon sheath MAJ-643R Balloon sheath connector MAJ-667 Balloon applicator MAJ-564 Ultrasonic probe UM-BS20-26R Adapter Figure 1.14 Structure of Balloon sheath connector mounting section UM - BS20 - 26R. Figure 1.15 Distal end of UM - BS20 - 26R with balloon sheath. Figure 1.16 UM - BS20 -2 6R with balloon sheath (MH - 246R). 8 CHAPTER 1 An Overview of Endobronchial Ultrasonography Table 1.2 Compatibility between bronchoscopes and ultrasound probes Bronchoscopes Guide sheath method Direct contact method Balloon method UM - S20 - UM - S20 - UM - UM - S20 - UM - UM - UM - UM - 2R/3R 17S 20R/ S20 - 17S 20R/ 4R 2R/3R BS20 - UM4R + MH - 246R UM - S30 - UM - S30 - UM - 26R UM - S20 - 20R 20R 20R S30 - 25R UM - S30 - 25R BF - 200/240 * 1 Yes No Yes Yes No No No No BF - P200/P240 * 1 BF - 6C240 * 1 BF - 160/MP160F * 2 BF - P150/P160/P180 * 2 BF - Q180 * 2 BF - Q180 - AC * 2 BF - 260/6C260 BF - MP60 BF - P260F (2.0 mm CH) BF - 30 * 1 Yes No Yes Yes No No No No BF - 40 BF - P30/P40 * 1 BF - P60 BF - 20D/P20D * 2 BF - PE/PE2 * 2 (2.2 mm CH) BF - 1T200/1T240 * 1 Yes Yes Yes Yes Yes No No No (2.6 mm CH) BF - 1T30/1T40 * 1 Yes Yes Yes Yes Yes Yes Yes No BF - 1T240R * 1 BF - 1T150/1T160 * 2 BF - 1T260 BF - LT30 BF - 1T20D * 2 BF - TE/TE2 * 2 (2.8 mm CH) BF - 1T60/1T180 * 2 Yes Yes Yes Yes Yes Yes Yes No (3.0 mm CH) BF - XT20/XT30 * 1 Yes Yes Yes Yes Yes Yes Yes N o BF - XT40 BF - XT160 * 2 (3.2 mm CH) BF - ST40 * 1 Yes Yes Yes Yes Yes Yes Yes Yes (3.7 mm CH) * 1: Discontinued model. * 2: Not available in Japan. 9 Endobronchial Ultrasonography (a) (b) Figure 1.18 Ultrasound image obtained with the EU- M2000. Figure 1.17 Endoscopic Ultrasound Center (EU- M2000), Probe Driving Unit (MH - 240). Select a bronchoscope which can be used with an ultrasonic probe. When the balloon method is selected, it is necessary to use an endoscope that has an instru- ment channel diameter of 2.8 mm or more. Ultrasonic Processor and Probe Driving Unit Figure 1.19 Ultrasound Center (EU- M30S). Ultrasound images are obtained by attaching the endo- scopic ultrasound probe to the Endoscopic Ultrasound Center EU - M2000 (Figure 1 .17a) via the Probe Driving Unit MH - 240 (Figure 1.17b ). Preparations The EU - M30 videoconverter system is fully compat- ible with both videoscopes and fi berscopes, and its Required Equipment subscreen function allows simultaneous display of Ultrasonic probe (sterilized). both ultrasound and endoscopic images on the one Balloon sheath. monitor, or switch between images (Figure 1 .18) . The Balloon sheath connector (for attachment of the EU - M30 ultrasonic processor is compatible with fre- balloon sheath to the probe). quencies from 7.5 to 30 MHz, can be used for distance 3 - way stopcock with extension tube. and area calculations, and is compatible with gastroin- Sterile water or physiological saline, 20 mL. testinal endoscopic ultrasound (EUS) and a variety of 20 mL syringe. endoscopic ultrasonic probes. It is highly compact, and fi ts on the standard endoscopic equipment trolley. Assembling the Balloon Probe The EU - M30S (Figure 1.19) ultrasonic processor is Using the Endoscopic Ultrasound designed for use with miniature probes. It is equipped Probe UM - BS 20 - 26 R with a probe drive unit as standard, and the main unit The advantages of this probe are that it can be used is compact and highly portable. This probe - dedicated with fl exible bronchoscopes with a standard instru- system makes it easy to obtain high quality ultrasound ment channel with a diameter of at least 2.8 mm images, and includes full image quality adjustment (BF - IT20, IT30, IT40, IT240R), and balloon defl ation functionality. has become simpler. 10 CHAPTER 1 An Overview of Endobronchial Ultrasonography Figure 1.21 Push the O- ring into the groove. Figure 1.20 Probe main unit (above), probe inside balloon sheath (below). Assemble the balloon probe in accordance with the instructions in the manual provided. a Pass the balloon sheath connector from the probe tip down, and fi x it to the balloon sheath connector attachment on the probe. b Insert the balloon sheath from the probe tip, and Figure 1.22 Balloon infl ated with water. press the balloon sheath clasp into the balloon sheath connector. c The optimum position for the ultrasonic transducer is not in the center of the balloon, but rather the g After all air in the balloon has been eliminated, fi x transducer should just protrude from the base of the the probe by hand through the balloon, and push the balloon (Figure 1 .20) . This allows the transducer to O - ring on the balloon tip into the groove in the probe rotate within the maximally expanded portion of the tip, by hand or using a balloon applicator (Figure balloon when it has been infl ated. 1.21 ). Once the balloon has been fi lled with water, d Draw up 15 mL of sterile water (or physiological and checked for leaks and air bubbles, preparation is saline) into the syringe, fi ll the 3- way stopcock exten- complete (Figure 1.22 ). sion tube with water, and attach the extension tube to the balloon sheath connector inlet. Connection of the Probe to the Driving Unit e Pull back on the syringe to create negative pressure, Insert the connection pin of the ultrasonic probe into drawing out as much air as possible from between the the connector on the driving unit, pointing the pin at balloon sheath and probe. After performing this step the 12 o’ clock position. three times, slowly release the negative pressure and then slowly fi ll inject sterile water into the balloon. Connecting the Power and Data Entry f Continue to push the syringe plunger with the Only turn on the power to the Ultrasound Center after balloon tip pointing upwards, fi lling the balloon with the probe has been connected. The ultrasonic probe water. Although a small bubble of air will enter the will be damaged if it is connected when the power is balloon, the tip of the balloon is separate, with a hole on. After the power has been connected, switch the in it. Pulling the balloon in the direction of the tip, monitor to the ultrasound input, and enter the express the air and water in the tip. patient ’ s identity number, age and name. 11 Endobronchial Ultrasonography Checking the Image process, hold the probe at a point 2 or 3 cm away from Unfreeze and rotate the ultrasonic probe. If it is the instrument port with each hand in turn. It is working properly, multiple echoes with fi ve to seven important to be aware that there are two places with layers will be seen centered on the probe. If multiple greater resistance within the instrument channel, echoes are not seen, the probe may be disconnected between the instrument port and the distal end of or there may be air bubbles in the medium in contact the bronchoscope. The fi rst site is 4 – 5 cm from the with the probe. instrument port, where the suction and instrument channels join, and the second is 2– 3 cm from the bron- Inverting the Image choscope tip, where the instrument bends. When Next press the “ Image Direction ” switch to change the resistance is high at either site and the probe is diffi cult monitor image from normal to inverse. This inverts to pass, then the probe should be removed and jelly the ultrasound image so that left and right are the reapplied, and if that fails, remove the bronchoscope same as the endoscopic image, to an image seen from from the patient and reinsert the probe. the rostral direction. In gastrointestinal EUS, the normal ultrasound image is seen from the caudal Operating the Probe direction, for easy comparison with computer tomog- Advance the probe to a point slightly distal to the site raphy (CT) scans, but in EBUS it is desirable for the of interest. Inject 1 – 3 mL of sterile water (physiological directions in the ultrasound image to coincide with the saline may also be used with the UM- BS20 - 26R), image from the bronchoscope, for the purposes of FNA infl ating the balloon while scanning so that it contacts from the tracheobronchial lumen. The normal mode the bronchial wall circumferentially. The optimum is only used in special situations, such as for compari- volume of water is that which just achieves circum- son with CT images. ferential contact with the bronchial wall. Over- infl ation can cause compression of bronchial wall structures or bursting of the balloon. Operation Then, while scanning and capturing images (always make a videorecording), retract the probe from deep Anesthesia (distal) to superfi cial (proximal). The important point In principle, anesthesia for EBUS is the same as for to remember about scanning is to retract the probe regular bronchoscopic examinations. It should be kept very slowly. If necessary, ask the patient to hold their in mind, however, that until the operator has become breath while scanning. Advancing the probe from more experienced, procedures will tend to be some- superfi cial (proximal) to deep

(distal) can cause what longer in duration. When EBUS is performed in damage to the probe, and should be avoided. conjunction with another procedure, such as laser- induced fl uorescence endoscopy (LIFE), then intrave- nous anesthesia may be used, allowing spontaneous Tips for Achieving Optimum respiration. An important consideration for the anes- Ultrasound Images thetist is to confi rm, under direct observation using To obtain clear, easily understandable images: the laryngoscope, that local anesthetic spray is applied a Rotate the ultrasound image so that it corresponds directly to the pharynx and larynx, in particular to the to the endoscopic images. vocal chords. After bronchoscopic examination of the b To assess the depth of tumor invasion, the ultra- trachea and bronchi, local anesthetic is further applied sound pulse must penetrate the tracheal/bronchial to the bronchus (bronchi) into which the balloon wall perpendicularly. probe will be introduced. Rotate the Ultrasound Image So that It Inserting the Probe Corresponds to the Endoscopic Images Apply xylocaine jelly liberally to the distal end of the i A t a bifurcation (e.g. the opening of the right upper balloon probe, and slowly insert it into the instrument lobe bronchus), we can line up the direction so that channel of the bronchoscope. During the insertion the balloon is not in contact with the bronchial lumen 12 CHAPTER 1 An Overview of Endobronchial Ultrasonography on the endoscopic image, with no echo on the EBUS pulmonary artery runs anteriorly to the right main image. bronchus and right middle lobe bronchus, from 10 ii F or example (Figure 1.23) , in the left ultrasound o ’ clock to 2 o’ clock (Figure 1 .24 right). Identify the image below, the direction has no echo, because the position of these structures, and rotate the EBUS balloon is not in contact with the bronchial lumen, image accordingly. and direction is from 4 to 6 o ’ clock. In the right endo- scopic image, the balloon is not in contact with the bronchial lumen and direction is from 2 to 4 o ’ clock. To Assess the Depth of Tumor Invasion, To match up the images, we need to rotate the EBUS Obtain Images with the Ultrasound image anticlockwise 45 ° . Pulse Penetrating the Tracheal/ iii R otate the EBUS image according to the relative Bronchial Wall Perpendicularly positions of the bronchial tree and the esophagus and If the fi rst layer (marginal echo, refl ected at the great vessel. boundary between tissues) is highly echoic, the image When scanning from the lower part of the trachea can be said to be derived from an ultrasound pulse to the left main bronchus, the esophagus is located penetrating the tracheal/bronchial wall nearly per- at the 6 o’ clock direction (Figure 1.24 left). The right pendicularly (Figure 1.25 ). Right pulmonary artery Opening of right upper bronchus Opening of right upper bronchus Figure 1.23 Tips for achieving optimum ultrasound images. Rotation of the ultrasound image so that it corresponds to the endoscopic images. Right pulmonary artery Esophagus Figure 1.24 Tips for achieving optimum ultrasound images. Rotation of the EBUS image according to the relative positions of the bronchial tree and the esophagus and great vessels. 13 Endobronchial Ultrasonography Figure 1.27 Aspiration Needle (NA- 201SX -4 022, Olympus). Figure 1.25 Tips for achieving optimum ultrasound images. To assess the depth of tumor invasion, obtain images with the ultrasound pulse penetrating the tracheal/bronchial wall perpendicularly. The arrows in the fi gures indicate a highly echoic fi rst layer, with a clearly lineated layer structure in that region. Figure 1.28 Ultrasonic bronchoscope with needle. bronchoscope has a working channel with a diameter of 2.0 mm; we can insert the disposable biopsy instru- ment with a 22 G needle (Figure 1 .27 , NA- 201SX - 4022, Olympus) through the working channel (Figure 1.28 ). After the convex probe is covered by the balloon, saline is injected into the balloon, fi lling its inner space. Figure 1.26 Ultrasonic bronchoscope (BF- UC160F, Olympus). This bronchoscope is connected to the ultrasound unit (EU- C60) and the power switch turned on (Figure 1.29 ). Equipment of E BUS Guided The scope shows us the target lesion for TBNA Transbronchial Needle Aspiration beyond the bronchial wall. The transducer provides ( EBUS - TBNA ) longitudinal planes of peribronchial areas, and the ultrasonographic image shows us real - time movement The curved array transducer is combined at the tip of of the TBNA needle. the bronchoscope for EBUS - TBNA (Figure 1 .26 , BF - As this convex bronchoscope has an oblique forward UC160F, Olympus). This convex bronchoscope con- viewer, there is a little diffi culty when inserting this sists of an oblique forward viewer with a convex scope through the vocal cord. Observing the 12 o’ clock transducer mounted in front of the lens. The convex direction of the vocal cord, the tip of the scope is transducer is 7.5 MHz and covered by a balloon . The straight and it is easy to enter the trachea. 14 CHAPTER 1 An Overview of Endobronchial Ultrasonography 6 Becker H . Endobronchialer Ultraschall - Eine neue Perspektive in der Bronchologie. Ultraschall in Med 1996 ; 17 : 106 – 112 . 7 Kurimoto N , Murayama M , Yoshioka S , et al. Assessment of usefulness of endobronchial ultrasonography In deter- mination of depth of tracheobronchial tumor Invasion. CHEST 1999 ; 115 : 1500 – 1506 . Frequently Asked Questions Figure 1.29 Ultrasound processor (EU - C2000). 1 Which generation of the bronchial tree needs the balloon to visualize the bronchial wall using EBUS? References A: From trachea to sub- sub or sub- sub - subsegmental bronchus, the balloon is necessary to obtain excellent 1 Pandian N G , K reis A , B rockway B , et al. U ltrasound images using EBUS. angioscopy: real - time, two dimensional, intraluminal 2 Could the miniature probe reach the subpleural area? ultrasound imaging of blood vessels . Am J Cardiol A: Yes, the miniature probe of 1.4 – 2.5 mm in diameter 198 ; 62 : 493 – 494 . expands to the subpleural area 2 H ü rter T h , H anarath P . E ndobronchiale Sonographie zur Diagnostik Pulmonaler und Mediastinaler Tumoren. 3 Which probe could penetrate the tissue deeper, a 20 MHz Dtsch Med Wschr 1990 ; 115 ; 50 : 1899 – 905 . probe or 30 MHz probe? 3 Iizuka K , Dobashi K , Houjou S , et al. E valuation of airway A: 20 MHz probe could. As the frequency decreases, the smooth muscle contractions in vitro by high - frequency depth penetration of the ultrasound pulse is increased. ultrasonic imaging . Chest 1992 ; 102 : 1251 – 1257 . 4 What are tips for achieving satisfactory visualization of 4 Ono R , Suemasu K , Matsunaka T . Bronchoscopic EBUS using the radial probe? Ultrasonography in the diagnosis of lung cancer. J pn J A: The probe should be located at the center of the lumen Clin Oncol 1993 ; 23 : 34 – 40 . of the bronchial tree. As the ultrasonic waves penetrate 5 Goldberg B , S teiner R , L iu J , et al. U S - assisted bronchos- the bronchial wall perpendicularly, excellent images are copy with use of miniature transducer- containing cath- visualized. eters . Radiology 1994 ; 190 ; 1 : 233 – 237 . 15 2 Anatomy of Mediastinal and Hilar Area relationship between the peribronchial organs and the Overview of Ultrasound Imaging of the bronchial tree, as seen when we pull the probe from Right and Left Bronchi While the Radial the right and left lower lobe bronchi up to the left and Probe is Being Pulled out right main bronchi, respectively. To fully understand EBUS, it is essential to understand the positional rela- EBUS images are cross- sectional images of planes per- tionship between the peribronchial organs during pendicular to the long axis of the tracheobronchial visualization while the probe is being pulled out. tree. These images are used to assist endoscopic treat- ments, so ultrasound images are generally displayed looking from the rostral direction, so that left and right Right Bronchi (Figure 2.1 ) match with endoscopic images. The positional relationship between the peribron- Right Lower Lobe Bronchi chial organs in EBUS images taken from the trachea When the balloon is infl ated in the right basal bron- corresponds to those in a reversed CT image (CT scans chus, the inferior pulmonary vein (V6) passes on the are cross- sectional images looking from the caudal dorsal side of the bronchus (1), whereas anterior to direction). EBUS images taken distal to the bifurcation the bronchus the pulmonary artery divides into A8, of the left and right main bronchi, however, are cross- A9 and A10, positioned between 9 o ’ clock and 2 sectional images of planes perpendicular to the long o ’ clock. axis of the bronchus, and therefore have a different As the probe is pulled back, A8, A9 and A10 meet at positional relationship between the peribronchial the 12 o’ clock direction and the direction of the pulmo- organs from the CT images. nary artery changes gradually to 3 o ’ clock (2, 3). When In clinical practice, when EBUS is performed for the probe is pulled further back, it approaches the bifur- centrally located lesions, the balloon is infl ated distal cation of B6. An area that does not contact the balloon to the lesion, and images are obtained while pulling appears on the bronchial wall, from where the ultra- the probe proximally (superfi cially). The reasons for sound is refl ected. As a result, the image of the layer this are that it is diffi cult to push the probe distally containing the bifurcation of B6 at 5 o ’ clock is lost. (deeper) with the balloon infl ated, and by pulling the Pulling the probe back further, the opening of the probe proximally, cross - sectional images of planes middle lobe bronchus, indicated by refl ection of the perpendicular to the long axis of the bronchus can be ultrasound pulse (because the balloon loses contact obtained without bending the probe. with the bronchial wall at the bifurcation), appears at In this part of the chapter, using schematic diagrams 12 o’ clock. The pulmonary artery has gradually moved and ultrasound images, we will describe the positional round to the 2 o ’ clock position (4). From the Right Intermediate Bronchus to Endobronchial Ultrasonography, 1st edition. the Right Main Bronchus By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. As the probe is pulled from the distal intermediate Published 2011 by Blackwell Publishing Ltd. bronchus to a point immediately below the origin of 16 CHAPTER 2 Anatomy of Mediastinal and Hilar Area   PA     V6   V6  Upper part of V6  Right lower bronchus PV PA PA  Opening of right middle lobe  Center of intermediate trunk PA PA Figure 2.1 Right bronchi. PA: pulmonary artery; PV: pulmonary vein;  Right main bronchus V6: pulmonary vein for segment 6. Upper part of intermediate trunk (opening of upper bronchus) 17 Endobronchial Ultrasonography the upper lobe bronchus, the pulmonary artery crosses As the probe is pulled back, it approaches the bifur- the bronchus from the right to the left (5, 6, 7). In the cation of B6. An area that does not contact the balloon central section of the intermediate bronchus, the appears on the bronchial wall, from where the ultra- superior pulmonary vein can sometimes be seen ante- sound is refl ected. As a result, the image of the layer rior to the pulmonary artery (5). containing the bifurcation of B6 at 7 o’ clock is lost. When the probe is pulled further back, the origin of Pulling the probe back further, the opening of the the upper lobe bronchus is indicated by refl ection upper lobe bronchus, indicated by refl ection of the of the ultrasound pulse (because the balloon loses ultrasound pulse (because the balloon loses contact contact with the bronchial wall at the bifurcation) at with the bronchial wall at the bifurcation), appears at 3 o ’ clock (7). 11 o’ clock (3). The pulmonary

artery is located below Pulling the probe back further, A1+ 3, originating the origin of the upper lobe bronchus. from the pulmonary trunk, can be seen crossing hori- zontally anterior to the right main bronchus. Retracting Left Main Bronchus the probe further, the origin of the left main bronchus The distal section of the left main bronchus is charac- at the carina is indicated by refl ection of the ultra- terized by the left pulmonary artery at 10 o’ clock, the sound pulse at 9 o ’ clock. descending aorta at 7 o ’ clock, and the left atrium from The key to reading EBUS images is to recognize the 1 o’ clock to 3 o’ clock (4, 5). As we enter the central anatomy of the peribronchial organs as the probe is section of the left main bronchus, the left atrium dis- retracted from the right lower lobe bronchus to the appears, and the esophagus appears at 6 o’ clock. The right main bronchus. subcarinal (#7) lymph node is often visible medial to the esophagus (6). Right Side When the probe is pulled further back, the origin of Right basal bronchus: inferior pulmonary vein, V6 the left main bronchus at the carina is indicated by (6 o ’ clock); PA7- 10 (2 o’ clock). refl ection of the ultrasound pulse (because the balloon Right lower bronchus: PA6- 10 (2 – 3 o ’ clock). loses contact with the bronchial wall at the bifurca- Right intermediate bronchus: right pulmonary artery tion) at 3 o ’ clock. (12 o ’ clock). The key to reading EBUS images is to recognize the Right main bronchus: right upper lobe pulmonary anatomy of the peribronchial organs as the probe is artery (12 o ’ clock). retracted from the left lower lobe bronchus to the left PA: pulmonary artery. main bronchus. 1 V6. 2 Upper part of V6. Left Side 3 Right lower bronchus. Left basal bronchus: inferior pulmonary vein, V6 (6 4 Origin of right middle lobe bronchus. o ’ clock); PA8- 10 (9 o’ clock). 5 Middle part of intermediate bronchus. Left lower bronchus: PA6 - 10 (10 o ’ clock); superior 6 Upper part of intermediate bronchus. pulmonary vein (1 – 4 o ’ clock) 7 Right main bronchus (origin of right upper lobe Left main bronchus (distal): left pulmonary artery (10 bronchus). o ’ clock); aorta (7 o’ clock); left atrium (1– 3 o ’ clock). Left main bronchus (proximal): left pulmonary artery (10 o’ clock); aorta (7 o’ clock); left atrium (1– 3 Left Bronchi (Figure 2.2 ) o ’ clock); esophagus (6 o ’ clock). PA: pulmonary artery. Left Lower Lobe Bronchi 1 Left V6. When the balloon is infl ated in the left basal bronchus, 2 Left lower bronchus. the inferior pulmonary vein (V6) passes on the dorsal 3 Origin of left lower bronchus. side of the bronchus, whereas the A8, A9 and A10 4 Lower part of left main bronchus. branches of the pulmonary artery meet at 9 o’ clock 5 Left main bronchus (LA, PA, Ao). (1, 2). 6 Left main bronchus (esophagus, #7LN). 18 CHAPTER 2 Anatomy of Mediastinal and Hilar Area       PA PA V 6  Left V6  Left lower bronchus PA PV PA LA Ao  Opening of left upper bronchus  Lower part of left main bronchus PA LA Ao Eso #7LN Figure 2.2 Left bronchi. Ao: aorta; Eso: esophagus; LA: left atrium; LN: lymph nodes; PA: pulmonary artery; PV: pulmonary vein; V6: inferior  Left main bronchus (LA, PA. Ao)  Left main bronchus, pulmonary vein. (esophagus, #7LN) 19 Endobronchial Ultrasonography Ultrasound Imaging of Mediastinal and #7 LN : Subcarinal Lymph Node (Figure 2.3 ) Hilar Lymph Nodes for EBUS- TBNA by the For approaching #7 LN, the convex bronchoscope is Convex Bronchoscope inserted into the right main bronchus. While scanning at the 9 o’ clock direction, we can confi rm the largest To carry out EBUS- TBNA procedures successfully, the area of the #7 LN. While rotating right handed and bronchoscopist should have a good understanding of scanning at the 11 o ’ clock direction, we can observe ultrasonographic images of the peribronchial vessels the right main pulmonary artery. and lymph nodes. Ascending aorta Superior vena PA #6 cava Left lower bronchus #5 #10 Left upper Right upper #5 PA bronchus A3 PA #4 #4 A1+2a+b Right upper A6 A1+2c #10 #2 bronchus #10 Azygousvein Descending aorta Esophagus #7LN PA Figure 2.3 Subcarinal lymph node. PA: pulmonary artery. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 45 with permission.) 20 CHAPTER 2 Anatomy of Mediastinal and Hilar Area 11 R LN : Right Intralobar Lymph Node ning at the 12 o’ clock direction, we can confi rm the (Between Right Lower Lobe Bronchus and largest area of the #11R LN. While rotating right Right Middle Lobe Bronchus) (Figure 2.4 ) handed and scanning at the 3 o’ clock direction, we For approaching #11R LN, the convex bronchoscope can observe the right pulmonary artery. is inserted into the right basal bronchus. While scan- [Anterior] rt. middle PA V5 PA rt. middle PV V4b rt. superior PV #12 V4a rt. upper PV #11 A8 V8 [Medial] A2b [Lateral] #12 rt. middle bronchus B7 B8+9+10 V9+10 rt. inferior PV A9+10 B6 V6 #9 A6 #10 [Posterior] Figure 2.4 Right intralobar lymph node. PA: pulmonary artery; PV: pulmonary vein. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 48 with permission.) 21 Endobronchial Ultrasonography 11 R LN : Right Intralobar Lymph Node located at the 12 o ’ clock direction from the intermedi- (between the Right Intermediate Trunk ate trunk. While scanning at the 12 o’ clock direction, and Right Upper Lobe Bronchus) (Figure 2.5 ) we can confi rm the largest area of the #11R LN. While For approaching #11R LN, the convex bronchoscope rotating left handed and scanning at the 9 o’ clock is inserted into the right intermediate trunk. On the direction, we can observe the right main pulmonary bronchoscopic fi ndings, the right upper bronchus is artery. [Anterior] rt. upper PV rt. main PA PA V1 2 V3 V #11s B3 3 #10 A [Medial] #10 [Lateral] B1 #7 A1 B2 #12 rt. intermediate trunk #10 rt. upper bronchus [Posterior] PA Figure 2.5 Right intralobar lymph node. PA: pulmonary artery; PV: pulmonary vein. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 47 with permission.) 22 CHAPTER 2 Anatomy of Mediastinal and Hilar Area 11 L LN : Left Intralobar Lymph lobe bronchus. While scanning at the 12 o’ clock direc- Node (Figure 2.6 ) tion, we can confi rm the largest area of the #11L LN. For approaching #11R LN, the convex bronchoscope While rotating left handed and scanning at the 10 is inserted into left basal bronchus. On the broncho- o ’ clock direction, we can observe the right pulmonary scopic fi ndings, the left upper lobe bronchus is artery. located at the 12 o ’ clock direction from left lower B3 B1+2 3 V1+2 V [Anterior] A1+2C B4 #12 #12 B5 V4+5 #12 #12 A6 B6 V6 It. superior PV #13 B8 B9+B10 [Posterior] It. superior PV PA Figure 2.6 Left intralobar lymph node. PA: pulmonary artery; PV: pulmonary vein. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 46 with permission.) 23 Endobronchial Ultrasonography 4 L LN : Lymph Node (Figure 2.7 ) o ’ clock direction, we can confi rm the largest area of the For approaching #4L LN, the convex bronchoscope is #4L LN. While pushing the scope to the distal site about inserted to the distal site of the trachea. On the bron- 1 – 2 cm, we can observe the left main pulmonary artery. choscopic fi ndings, the left side of the trachea is located While pushing the scope to the proximal site about at the 12 o ’ clock direction. While scanning at the 12 1 – 2 cm, we can observe aortic arch. ascending aorta PA #6 Left lower bronchus #5 #10 Left upper #3 bronchus A3 Left PA #4 #4 A1+2a+b A6 A1+2C #10 #7 #2 Descending aorta Esophagus PA Aorta Aorta Figure 2.7 Left lower paratracheal nodes. PA: pulmonary artery. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 45 with permission.) 24 CHAPTER 2 Anatomy of Mediastinal and Hilar Area 4 R LN : Lymph node (Figure 2.8 ) scanning at the 2 o ’ clock direction, we can confi rm For approaching #4R LN, the convex bronchoscope is the largest area of the #4R LN. While scanning 4R LN, inserted to the distal site of the trachea. On the bron- we can observe the superior vena cava (SVC) just choscopic fi ndings, the membranous portion of the below. While pushing the scope to proximal site about trachea is located at the 6 o’ clock direction. While 1 – 2 cm, we can observe the aortic arch #4R LN. Ascending aorta Superior vena cava PA #6 Left lower bronchus #5 SVC #10 Left upper #3 Right upper PA bronchus A3 #4 # A1+2a+b Right upper A6 A1+2C #10 #7 bronchus #2 #10 SVC SVC Azygous vein Descending aorta Esophagus Figure 2.8 Right lower paratracheal nodes. PA: pulmonary artery; SVC: superior vena cava. (From Bronchoscopy, 1st ed. Tokyo, IGAKU-SHOIN, 1998, p. 45 with permission.) Frequently Asked Questions 1 On the right bronchus, what is most useful for recognizing A: By rotating the convex probe right - handed or left- handed, the direction of the peribronchial organs? the margin of a lymph node may not be continued. By A: At the intermediate bronchus and the right main bronchus, rotating the convex probe right- handed or left- handed, the the right pulmonary artery is located at the 12 o’ clock margin of a vessel may be continued. Power Doppler mode is direction. also useful to differentiate a lymph node from vessels. 2 On the left bronchus, what is most useful for recognizing 4 How do you avoid bleeding during EBUS - TBNA? the direction of the peribronchial organs? A: We should avoid puncturing the great vessels (PA, PV, A: At the left main bronchus, the esophagus is located at the or aorta) and the bronchial artery, particularly when the 6 o ’ clock direction. bronchial artery is located between the bronchial wall and 3 How can one differentiate a lymph node from vessels the target lymph node. I recommend checking the route of during EBUS - TBNA? the needle before puncturing. 25 3 How to Perform Endobronchial Ultrasonography however, and must be used with a bronchoscope with Introduction a big channel (BF - ST40, working channel diameter: 3.7 mm). In recent years, I usually use a thinner I commenced endobronchial ultrasonography (EBUS) 20 MHz mechanical radial ultrasonic probe (UM- BS - in August 1994. Initially, I performed EBUS using a 20 - 26R, Olympus) with a balloon - tip sheath (MH- radial probe without a guide sheath for the diagnosis 676R, Olympus) through the 2.8 mm diameter of peripheral pulmonary lesions. Guide sheaths working channel of a fl exible bronchoscope (BF - became available in 1996 to aid in the accurate iden- 1T260, Olympus). These probes are able to connect tifi cation of the location of peripheral pulmonary with the Endoscopic Ultrasound System (EU- M 30 lesions. Another early application of EBUS was the and EU - M 2000, Olympus). radial probe with a balloon to visualize the layer struc- tures of the tracheobronchial wall. In recent years, the Preparation of the Balloon Probe use of convex probes combined with the broncho- (Video clip 3.1) scope for EBUS guided transbronchial needle aspira- The ultrasonic probe is inserted into the balloon sheath. tion (EBUS - TBNA) has rapidly expanded in many The probe and sheath are fi xed in place by the connect- countries. Here I will describe the equipment used for ing unit. A 25 mL syringe containing about 15 mL of EBUS using a radial probe and EBUS - TBNA, and some saline is connected to the injection port in the connect- tips for various procedures. ing unit. Most of the air between the inner surface of the sheath and the outer surface of the probe is removed in two or three aspirations using the 25 mL syringe. Balloon Probes for Central Lesions Saline

is injected from the syringe into the sheath and the balloon at its tip, infl ating the balloon to a diameter Air always inhibits the visualization of ultrasound of about 15 mm with saline fi lling the balloon. When images. Beyond the subsegmental bronchi, the outer the tip of the balloon is slightly compressed, a small surface of the probe fi ts snugly to the bronchial amount of air is collected in the uppermost part of the surface. A balloon probe is needed to obtain ultra- balloon and withdrawn into the sheath. This completes sound images of central lesions located between the the preparation of the balloon probe. trachea and subsegmental bronchi using EBUS. Performing E BUS Using A Balloon Probe Equipment (Figure 3.1 ) We use fl exible bronchoscopes (1T - 40, 1T- 240R, For some time, I used a 20 MHz mechanical radial Olympus) with a working channel 2.8 mm in diameter ultrasonic probe (UM - 3R, Olympus Optical Co., Ltd, for all EBUS procedures using a balloon probe. Tokyo, Japan) with a balloon - tip sheath (MH- 246R, Suffi cient local anesthetic is applied to the bronchi that Olympus). The diameter of this sheath is 3.6 mm, the balloon probe will make contact with, to avoid the patient coughing during the procedure. The balloon probe is inserted into the working channel of the bron- Endobronchial Ultrasonography, 1st edition. choscope, advanced beyond the lesion, and then By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. infl ated with the minimum amount of saline required Published 2011 by Blackwell Publishing Ltd. to obtain an EBUS image of the entire circumference 26 CHAPTER 3 How to Perform Endobronchial Ultrasonography Probe Central Peripheral (balloon method) (direct contact method) UM-3R+MH246R 3.7 mm(BF-XT30,40) 2.5 mm; UM-3R 1.7 mm; UM-S20-20R Esophagus UM-BS20-26R+MAJ 643R 1.4 mm; UM-S20-17S 2.8 mm(BF-1T30,40) Figure 3.1 Radial probes for EBUS. Balloon method for central lesions: we use a thick ultrasonic probe (UM- 3R, 20 MHz, Figure 3.3 Orientation of the radial probe. Orientation of the 2.5 mm diameter) covered by a balloon sheath (MH - 246R), or a 12 o ’ clock position does not correspond to the bronchoscopic thin ultrasonic probe (UM - BS20 - 26R, 20 MHz, 2.0 mm diameter) 12 o ’ clock orientation. The peribronchial anatomy gives us the covered by a balloon sheath (MAJ- 643R). Direct contact method correct angle to rotate the EBUS image. On this image at the for peripheral pulmonary lesions: we use a thick ultrasonic left main bronchus, the location of esophagus is located probe (UM - 3R, 20 MHz, 2.5 mm diameter), a thin ultrasonic posterior to the left main bronchus, providing the correct probe (UM - S20 - 20R, 20 MHz, 1.7 mm diameter), or thinner orientation for the radial probe. ultrasonic probe (UM- S20 - 17S, 20 MHz, 1.4 mm diameter). Orientation of the 12 o ’ clock position does not cor- 5 respond to the bronchoscopic 12 o ’ clock orientation. 3 Comparison of bronchoscopic images and the EBUS image makes it expedient to rotate the EBUS image 1 (Video clip 3.2). The peribronchial anatomy gives us the correct angle to rotate the EBUS image (Figure 3.3 ). We therefore routinely rotate the EBUS image to give the same orientation as the bronchoscopic image. The balloon probe is withdrawn gradually to enable acquisition of EBUS images in the short axis of lesions and the tracheobronchial wall. Figure 3.2 EBUS image obtained using a balloon probe. The Tips for Successful EBUS Using balloon probe is inserted into the bronchoscope working A Balloon Probe channel, and infl ated with the minimum volume of saline 1 Keep the probe in the center of the balloon. needed to obtain an EBUS image of the entire circumference of 2 Assess the depth of the tumor center at a site where the bronchial wall. The cartilaginous portion of the extra - the fi rst layer is a thick hyperechoic layer. pulmonary bronchus is visualized as fi ve layers (arrows indicate Keeping the probe in the center of the balloon allows the fi rst, third and fi fth layers). the ultrasound wave to enter the bronchial wall per- pendicularly. The layers of the bronchial wall can be visualized clearly where the fi rst layer is a thick hyper- of the bronchial wall (Figure 3.2 ). Scanning is per- echoic layer, with the ultrasound pulse penetrating formed while retracting the probe slowly from deep the bronchial wall perpendicularly [1] . (distal) to superfi cial (proximal). Advancing the probe Because the balloon covers the lesion, it is sometimes from superfi cial (proximal) to deep (distal) can cause diffi cult to ascertain whether an often thin bronchial damage to the probe, and should be avoided. lesion, visible bronchosopically, has been actually been 27 Endobronchial Ultrasonography covered by the balloon to allow successful ultrasound scanning. There are two ways of solving this problem. Improved procedure Original procedure The fi rst is to place the defl ated balloon directly against the lesion to confi rm its presence, then re - infl ate the 4 mm balloon and scan the entire 360 ° circumference to accurately identify the position of the lesion. The other Thin GS Thick GS outer diameter: 2 mm outer diameter: 2.5 mm method is to infl ate the balloon and make a 360 ° cir- cumferential scan, then pull back the balloon slightly UM-BS20-20R into instrument channel, moving the bronchoscope tip UM-BS20-17R 1.7mm 1.4mm so that it indents the balloon, directly observing through the saline - fi lled balloon the positions of the probe transducer and lesion, and then identifying the lesion in the ultrasonic images (Video clip 3.3). Figure 3.4 Equipment used in EBUS using a guide sheath (EBUS - GS). In the original procedure, we used a thick guide Performing E BUS Using a Guide sheath 2.5 mm in diameter and an ultrasonic probe 1.7 mm in diameter. In the improved procedure, we use a thin guide Sheath (E BUS - GS) for Peripheral sheath 2.0 mm in diameter, an ultrasonic probe 1.4 mm in Pulmonary Lesions diameter, and a thin bronchoscope 4 mm in diameter. Fluoroscopy is not able to confi rm whether forceps have reached the site for endobronchial brushing and Equipment (Figure 3.4 ) transbronchial biopsy (TBB). EBUS cannot create We use two miniature ultrasonic probes (UM - S20 - 20R, images of normal air - fi lled lungs, but it can delineate UM - S20 - 17R; 20 MHz, mechanical radial, Olympus) peripheral pulmonary lesions because only small with outer diameters of 1.7 mm and 1.4 mm, respec- amounts of air come into contact with the probe. The tively. Probes are connected to an Endoscopic exploration of some bronchi with the miniature probe Ultrasound System (EU - M30, EU - M2000, Olympus). allows us to determine, more defi nitively than with The Guide Sheath Kit ( K - 201 - 202, K - 203 - 204,Olympus fl uoroscopy, which bronchus should be selected for Optical Co., Ltd.) contains a guide sheath (1.95 mm, endobronchial brushing and TBB. EBUS is also useful 2.55 mm outer diameter, respectively), a disposable for examining lesions that are diffi cult to visualize by brush (BC - 204D - 2010, BC - 202D - 2010: 1.4 mm, fl uoroscopy (e.g. lesions behind the mediastinum or 1.8 mm outer diameter, respectively), and disposable diaphragm, ill- defi ned opacities, small lesions, and biopsy forceps (FB - 233D, BC- 231D - 2010: 1.5 mm, lesions behind other TBB). EBUS clearly identifi es 1.9 mm outer diameter, respectively). which bronchus is most closely related to the lesion and should be subjected to biopsy. Using fl uoroscopy, Preparation for E BUS - GS (Video clip 3.4) the probe appears at a slight distance even when it is 1 A bronchial brush (BC - 202D - 2010, BC - 204D - 2010, adjacent to the lesion, as demonstrated by the defi ni- Olympus), or biopsy forceps (FB - 231D, FB - 233D, tive diagnosis of adenocarcinoma by endobronchial Olympus) for transbronchial biopsy (TBB), is intro- brushing at the site using EBUS. This suggests that the duced into the specially made guide sheath, so that area at the margins of the lesions contains more air, the tip of the forceps reaches the far end of the sheath so the margins may appear normal on fl uoroscopy, to facilitate manipulation. The forceps are marked at leading to underestimation of the size of the lesion. the near end of the sheath using the stopper during Since 1996, we have deployed the ultrasonic probe bronchoscopy. in a guide sheath with the active part of the probe 2 A miniature probe is introduced into the guide sheath protruding from the tip, identifi ed the location of the (SG - 201C, SG- 200C, Olympus) until the tip of the lesion ultrasonically, and then passed instruments probe including the 2 mm long transducer just pro- such as brushes and biopsy forceps down the guide trudes from the far end of the sheath. Then, the probe sheath to collect cytology or tissue specimens [ 2] . and the sheath are bound together at the proximal 28 CHAPTER 3 How to Perform Endobronchial Ultrasonography end of the sheath with the stopper so that the tip of the reaches the proximal end of the sheath (Figure 3 .5 – 3). probe remains positioned at the far end of the sheath. A few vigorous back - and - forth movements of the brush are made under fl uoroscopic guidance to collect How to Perform EBUS - GS a sample on the brush. We use a fl exible fi beroptic bronchoscope (BF 1T- 30, After the brush is withdrawn, the biopsy forceps are 40, 240R, 260, P260F) for all procedures. once again introduced into the sheath until the stopper After the bronchoscope is advanced beyond the on the surface of the forceps reaches the end of the vocal cords, all segments of the bronchial tree are sheath. The forceps cusps are opened, the forceps are visualized. Based on the radiographic fi ndings, the advanced 2 or 3 mm into the lesion and the cusps miniature probe with the guide sheath is negotiated closed under imaging guidance. After an adequate into the bronchus of interest. That is, by careful study biopsy specimen is obtained, it is placed in formalin. of the CT and the segment where the lesion lies, the The guide sheath is left in place for about 2 minutes subtending bronchus is chosen. With small lesions, to put pressure on the biopsy site to control bleeding. choosing the correct bronchus can be diffi cult and a The procedure is concluded after confi rmation that list of possible 5th or 6th order candidate bronchi can haemostasis has been achieved. be made by the bronchoscopist before the procedure. The probe is advanced until it reaches a point where the operator feels resistance, and is then pulled back Evaluation of the Diagnostic Yield for scanning (Figure 3.5 – 1). Once an EBUS image of Using E BUS - GS for Peripheral the lesion has been obtained and the location of the Pulmonary Lesions [ 2] lesion has been identifi ed precisely using EBUS, the probe is withdrawn, leaving the guide sheath in place We found that the diagnostic yield for EBUS- GS (Figure 3.5 – 2). (thick guide sheath, outer diameter: 2.5 mm) was 77% Biopsy forceps or a bronchial brush is introduced (116/150 patients) overall, 81% (82/101) for malig- into the sheath until the point marked by the stopper nant lesions, and 73% (35/45) for benign lesions. Procedure of EBUS-GS Guide sheath Guide sheath Biopsy forceps Transducer 1 2 3 Tumor Tumor Tumor Figure 3.5 Procedure for EBUS- GS. (1) The probe is advanced image. (2) Once the location of the lesion has been identifi ed until it reaches a point where the operator feels resistance, and precisely using EBUS, the probe is withdrawn, leaving the guide is then pulled back for scanning. Once an EBUS image of the sheath in place. (3) Biopsy forceps or a bronchial brush is lesion has been obtained, the probe is withdrawn and a guide introduced into the sheath until the point marked by the device is inserted into the guide sheath. After searching for

the adhesive tape reaches the proximal end of the sheath. lesion using the guide device under fl uoroscopy, the guide A few vigorous back - and -f orth movements of the brush are device is withdrawn and once again the probe is inserted into made under fl uoroscopic guidance to collect a sample on the guide sheath and another attempt made to obtain an EBUS the brush. 29 Endobronchial Ultrasonography Leison Leison Probe Probe Figure 3.6 Location of the probe in EBUS - GS for peripheral pulmonary lesions. The diagnostic yield when the probe was within the lesion on the ultrasound image Within Adjacent to was 87% (105/121), better than that of 42% (8/19) when the probe was adjacent to the lesion. The diagnostic yield was 60% (90/150) for brushing ultrasonic probe 1 mm at a time until the probe cytology, and 70% (89/128) for transbronchial biopsy. transducer enters the sheath. When the transducer The diagnostic yield when the probe was within the completely enters the guide sheath, the ultrasonic lesion on the ultrasound image was 87% (105/121), pulse will be blocked by the guide sheath, and the better than that of 42% (8/19) when the probe was ultrasound image will suddenly become darker. If the at the periphery of the lesion (Figure 3.6 ). site of this phenomenon is within the lesion, the guide No difference was seen in diagnostic yield according sheath will be placed precisely within the peripheral to lesion size, with 76% (16/21) for lesions ≤ 10 mm, pulmonary lesion. 76% (19/25) for lesions > 10 and ≤ 15 mm (p = 0.99, χ 2 ), 2 Moving the guide sheath from adjacent to the lesion 69% (24/35) for lesions > 15 and ≤ 20 mm (p = 0.41, χ 2 ), to within the lesion (Figure 3 .8 ). Diagnostic yield has and 77% (33/43) for lesions > 20 and ≤ 30 mm (p = 0.96, been reported to be superior when the probe is within χ2 ). In other words, EBUS - GS can diagnose large and the lesion than when it is adjacent to the lesion [2] . small lesions with equal accuracy. A high diagnostic With 4 mm diameter bronchoscopes as commonly yield of 74% (40/54) was also achieved with lesions used presently, when we introduce the probe into the ≤ 20 mm, that cannot be detected using fl uoroscopy. selected sub - subsegmental bronchus to delineate a We are now achieving favorable diagnostic results lesion using EBUS, the probe is sometimes placed adja- with the introduction of ultrasonic probes in smaller cent to the lesion. In that case, the probe should be gauge guide sheaths via smaller diameter broncho- introduced into another sub- subsegmental bronchus scopes, following the route to the lesion determined in an attempt to place the probe within the lesion. by virtual bronchoscopy using a CT - based navigation When a lesion cannot be delineated using EBUS, the system. ultrasonic probe should be removed without moving the guide sheath, guiding device introduced into the Tips for Successful EBUS - GS guide sheath until their tips protrude (Figure 3.9 ). The These comprise tips for using a guide sheath, and tips tip of the guiding device (a hinged curette) is bent in for introducing the probe into the lesion. the direction of the lesion, and the guiding device is 1 Use of signal attenuation caused by the guide sheath then withdrawn slowly, looking for a point at which (Figure 3.7 ). This is a method of accurately placing the they move slightly towards the lesion under fl uoro- guide sheath within a peripheral pulmonary lesion. scopic guidance. The aim is to enter a bronchus leading Once a peripheral lesion has been delineated using to the lesion branching off from the initial bronchus EBUS, at the point the lesion appears at its largest and point, and if the tip of the guiding device is advanced clearest, the assistant should keep the guide sheath in this direction the guide sheath will follow, reaching stationary and after undoing the connection of the the lesion. Sometimes such a branch point can be felt ultrasound probe to the guide sheath withdraw the as a slight “ crank ” as the curette drops into a bronchial 30 CHAPTER 3 How to Perform Endobronchial Ultrasonography Guide Transducer sheath Figure 3.7 Confi rmation of the location of the guide sheath until the probe transducer enters the guide sheath. When the within the lesion. This is a method of accurately placing the transducer completely enters the guide sheath, the ultrasonic guide sheath within a peripheral pulmonary lesion. Once a pulse will be refl ected by the guide sheath, and the ultrasound peripheral lesion has been delineated using EBUS, at the point image will suddenly become darker. If the site of this the lesion appears at its largest and clearest, the assistant phenomenon is within the lesion, the guide sheath will be should withdraw the ultrasonic probe about 2– 3 mm at a time placed precisely within the peripheral pulmonary lesion. Adjacent to Within Figure 3.8 Moving the probe from adjacent to the lesion to within the lesion – method 1. When we introduce the probe into the selected sub- subsegmental bronchus to delineate a lesion using EBUS, the probe is sometimes placed adjacent to the lesion. In that case, the probe should be introduced into another sub - subsegmental bronchus in an attempt to place the probe within the lesion. 31 Endobronchial Ultrasonography Figure 3.9 Moving the probe from adjacent to the lesion to which they move slightly towards the lesion. A bronchus leading within the lesion – method 2. Top: the lesion was located in to the lesion branches off from this point, and if the tip of the right upper lobe. Left: When a lesion cannot be delineated guiding device is advanced in this direction the guide sheath will using EBUS, the ultrasonic probe should be removed without follow, reaching the lesion. This allows accurate placement of moving the guide sheath, guiding device introduced into the the guide sheath within the peripheral pulmonary lesion. Right: guide sheath until their tips protrude. Middle: The tip of the The guiding device is then removed, the ultrasonic probe is guiding device is bent in the direction of the lesion, and the reintroduced, and the lesion can be delineated. guiding device is then withdrawn slowly, looking for a point at opening. This allows accurate placement of the guide sheath within the peripheral pulmonary lesion. The guiding device is then removed, the ultrasonic probe is reintroduced, and the lesion can be delineated. The main benefi ts of EBUS - GS are as follows: 2.0 mm working channel 6.9 mm 1 The position of lesions can be accurately determined. 2 Forceps can be introduced any number of times to the same bronchial segment. 3 The internal structure of lesions can be analysed. 4 There is very little post - transbronchial biopsy bleeding. EBUS Guided Transbronchial Needle 7.5 MHz Optical system Aspiration (E BUS - TBNA ) convex forward oblique Equipment (Figure 3.10 ) We use a convex bronchoscope (BF - UC260F, 7.5 MHz, Figure 3.10 Bronchoscope used in EBUS - TBNA (BF - UC260F, Olympus) with an outer diameter of 6.9 mm. The 7.5 MHz, Olympus Optical Co., Ltd., Tokyo, Japan). 32 CHAPTER 3 How to Perform Endobronchial Ultrasonography probe is connected to an Endoscopic Ultrasound The target lesion is clearly outlined by EBUS. By System (EU- C2000, Olympus). rotating the bronchoscope on its axis slightly in both directions, the transducer at its tip will scan and How to Perform EBUS - TBNA delineate the entire target lesion. In this way, the We usually carry out EBUS- TBNA with topical pha- bronchoscopist measures the size of the target lesion ryngeal anesthesia, and sedation (e.g. midazolam). (Figure 3.11 ). First, B mode scanning determines The assistant elevates the patient ’ s jaw to maximize whether the internal echoes of the lesion to be punc- the pharyngeal space. The convex bronchoscope is tured are homogenous or heterogenous. Scanning in inserted into the pharynx. We should observe the 12 power Doppler mode should be performed for the o ’ clock position of the vocal cord in order to pass the target lesion as well as the path that the needle is larynx smoothly, as this scope has an oblique forward expected to traverse. This additional information view. should help avoid unintended puncture of interposed Another way of introducing the bronchoscope into small vessels and bronchial arteries located between the trachea is to insert an endotracheal tube, leaving the bronchial wall and the target lesion. Sometimes this in place for the duration of the procedure. An the target lesion is a lymph node with some necrotic 8.0 – 8.5 Fr endotracheal tube is placed over the com- areas, in which case optional power Doppler mode monly used bronchoscope, and the tip of the broncho- scanning will show the necrotic areas with reduced scope introduced into the trachea. With the tip of the blood fl ow to be avoided, and allow identifi cation of patient ’ s jaw elevated, the endotracheal tube is then the region with tortuous blood fl ow (1 mm vessels) introduced into the trachea using the bronchoscope as within the target lesion that is to be punctured. a guide. Intubation in this way has the advantage that The transducer must constantly be held in fi rm emergency treatment for hemorrhages can be given contact with the tracheobronchial wall during punc- even if the visual fi eld is obscured by blood on the ture. The needle is prepared immediately before punc- bronchoscope lens. ture is to be performed, and is inserted into the During assessment of the location of the lesion on working channel of the bronchoscope. We take care chest CT, the infl ated balloon containing the probe is that the edge of the outer sheath just protrudes from in contact with the bronchial wall adjacent to the the bronchoscope. The stylet is withdrawn a few cen- lesion. timeters to expose the sharp needle. A problem with Right- Left- handed handed LN PA Figure 3.11 Rotating the bronchoscope for the target lesion. The target lesion is LN clearly outlined by EBUS. By rotating the bronchoscope on its axis slightly in both directions, the transducer at its tip will scan and delineate the entire target lesion. 33 Endobronchial Ultrasonography placed against the tracheobronchial wall and the target lesion. The needle, containing the partially withdrawn stylet, is then advanced into the lesion under real time ultrasound guidance. The stylet is repositioned before it is withdrawn to remove the primary tissue plug containing superfi cial layers and bronchial cartilage from the needle (Video clip 3.6). Suction is then applied through the needle using a 10 Outer sheath of or 20 mL syringe. The needle is further advanced into the needle the lesion and moved back and forth under ultrasound control, with 5 to 10 strokes within the lesion usually Cartilage suffi cient. Suction is then equilibrated while the tip of the needle is still in the lesion. The needle is now withdrawn, and the needle and the outer sheath Figure 3.12 The tip of the puncture between cartilages. The tip of the outer sheath is then pushed toward the bronchial removed. wall, aiming for the membranous part between cartilages. In order to retrieve the tissue sample from the needle, the stylet is inserted into the needle from the currently available aspiration needles is that when the tip of the needle, and the sample will emerge from the needle is advanced, its outer sheath often protrudes needle tip. This is piled up on a piece of fi lter paper to too far with it. There is a way to overcome this problem facilitate histopathological examination. Any cellular (Video clip 3.5). The needle is pushed anteriorly material remaining inside the needle is then fl ushed within the bronchus, so that when the needle comes out using air from the syringe, and sent off for cyto- near the tip of the outer sheath the sheath approaches logical examination (Video clip 3.7). the transducer, and through the bronchoscope we can see the tip of the outer sheath suddenly drop a millimeter or so down. The needle is stopped

at this References point, and the outer sheath is withdrawn once again 1 Kurimoto N , Murayama M , Yoshioka S , et al. Assessment until it can just be seen through the bronchoscope. If of the usefulness of endobronchial ultrasonography in we advance the needle now, puncture can be per- tracheobronchial depth diagnosis. Chest 1999 ; 115 : formed with almost no movement of the outer sheath. 1500 – 1506 . The tip of the outer sheath is then pushed toward the 2 Kurimoto N , Miyazawa T , Okimasa S , et al. Endobronchial bronchial wall, aiming for the membranous part ultrasonography using a guide sheath increases the between cartilages (Figure 3 .12) . This step is very ability to diagnose peripheral pulmonary lesions endo- important for a successful puncture. The needle is scopically . Chest 2004 ; 126 : 959 – 965 . 34 CHAPTER 3 How to Perform Endobronchial Ultrasonography Frequently Asked Questions 1 Is it always necessary to use the balloon? 5 What happens if the needle goes into a pulmonary artery A: The balloon is necessary to scan the cartilaginous portion branch? (horse -s hoe shape) of extrapulmonary bronchus for avoiding A: If the needle goes into a pulmonary artery branch, bleeding air between cartilages. The balloon is unnecessary for scanning is not usually severe. I have experienced no case of puncturing the membranous portion of extrapulmonary bronchus, and great vessels, but on animal experiments there was a little intrapulmonary bronchus. bleeding after puncturing great vessels. We should check 2 If N1 and N2 nodes are to be sampled how is this managed bleeding around the great vessel in the mediastinum by – should different needles be used for each site? EBUS. A: Ideally different needles should be used for each site. 6 How do you avoid the esophagus? However, the needle is very expensive and the fi rst puncture A: From trachea to left main bronchus, the esophagus is should be performed at the more proximal site (ex: N2). The located beside the bronchus. We can detect the esophagus lumen of the needle should be cleaned by fl ushing with containing air in the lumen. saline. 7 Which nodes are easiest to biopsy? 3 Is a standard bronchoscopy necessary before doing a convex A: The EBUS- TBNA for 11L or 11R is easiest to biopsy, probe EBUS procedure? because the bronchial cartilage around 11L or 11R is small. A: For checking a bronchial lesion before TBNA, a standard 8 Should on - site cytology be used? bronchoscopy is necessary. For EBUS- TBNA, a standard A: On - site cytology is very useful when deciding to end the bronchoscopy is unnecessary. EBUS - TBNA for a malignant lesion . 4 How much bleeding usually occurs after a TBNA? A: In most of cases, bleeding is very little (about 0– 3 mL). If bleeding is severe, the balloon is useful to press the bleeding point on the bronchus. 35 4 Endobronchial Ultrasound- Guided Transbronchial Needle Aspiration ( EBUS - TBNA ) should be referred to as the hilar nodes. Station 8 Anatomy should be called para- esophageal nodes, and should be distinguished from the subcarinal nodes, or station 7. Mediastinal lymph nodes are generally described In addition to the lymph node stations, the locations according to their anatomic location in the United of major vascular structures in relation to airways and States. In Europe, Asia, and other parts of the world, lymph nodes should be committed to memory. As they are referred to using international nomenclature. shown in Figures 4 .2 , 4 .3 , 4 .4 , 4 .5 , and 4.6 the ascend- The following diagram (Figure 4 .1 ) depicts their names ing part of the aorta lies anteriorly, along the left side and locations. It is important to learn the international of the trachea. It then descends, making a curve nomenclature of mediastinal lymph node stations around the left hilum, heading posteriorly. The main (i.e., their numbers) in order to be able to communi- pulmonary artery lies in front and just to the left of cate with surgical and international colleagues. the distal trachea and carina. It bifurcates into left and The lymph node stations easily accessible using right pulmonary arteries that travel anterior to the left endobronchial ultrasound- guided transbronchial and right mainstem bronchi, respectively. At the level needle aspiration (EBUS - TBNA) include the following of each hilum, the pulmonary arteries further divide, mediastinal stations: highest mediastinal (station 1), following the branching of the airways. At each poten- upper paratracheal (stations 2R and 2L), lower parat- tial transbronchial needle aspiration (TBNA) site, the racheal (stations 4R and 4L), and subcarinal (station location of the vessels may vary, as shown in. It is 7). The accessible hilar stations are hilar (station 10), helpful to post a chart of these fi gures in the bron- interlobar (station 11), and lobar (station 12). choscopy room and review it prior to the procedure. Some commonly encountered discrepancies between the US and international nomenclature are as follows. Lymph node station 4L is often referred to as the Transbronchial Needle Aspiration AP (aorto - pulmonary) window node in the US, instead of the lower left paratracheal nodes. In reality, the Transbronchial needle aspiration (Figure 4.7 ) has been station 5, subaortic node is the “ aorto - pulmonary used for decades, but with very inconsistent yield. Low node ” and it is not accessible by TBNA (Figure 4.1 ). yield may be related to multiple factors, including the Similarly, station 11, rather than station 10, lymph expertise of the bronchoscopist and the variation in nodes are often referred to as hilar nodes in the US. size and location of the target lymph nodes. Fear of According to the international nomenclature, station vascular punctures, often due to inadequate training 11 should be called the interlobar nodes, since it is in the technique, is probably the most common reason located below the upper lobe take - off, and station 10 for the low yield of TBNA. In order to use EBUS - TBNA to its maximum poten- tial, the bronchoscopist must fi rst hone his or her Endobronchial Ultrasonography, 1st edition. standard TBNA skills. Endobronchial ultrasound By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. merely provides real- time images to prevent non - nodal Published 2011 by Blackwell Publishing Ltd. needle insertion. Good samples ultimately depend on 36 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) (c) (b) Ligamentum (a) arteriosum 3 Brachiocephalic 6 artery 1 Ao 5 Phrenic nerve PA 2 Azygos vein 4 Ao Superior mediastinal nodes 1 Highest mediastinal PA 2 Upper paratracheal 3 Prevascular and retrotracheal 4 Lower paratracheal (including azygos nodes) 10R 7 Aortic nodes 5 Subaortic (A-P window) 10L 6 Paraaortic (ascending aorta or 11R phrenic) 11L Inferior mediastinal nodes 8 7 Subcarinal 8 Pareasophageal (below carina) 9 Pulmonary ligament 12R N1 nodes 10 Hilar 12 9R 9L L 11 Interlobar 12 Lobar 13 Segmental 14 Subsegmental Inferior pulmonary ligaments N2 any ipsilateral single digit node N3 any contralateral or any supraclavicular node Figure 4.1 (a) Anterior view of mediastinal lymph node stations in relation to major airways and vascular structure. (b) Lat view of station 5 and 6 in relation to aorta and main pulmonary artery. (c) Station 3 node along trachea with close proximity to phrenic nerve. good TBNA technique, and the feeling of EBUS- TBNA Some are little stiffer than the others, depending upon is very similar to standard TBNA with the added benefi t the manufacturer (Figure 4.8 ). of visualization. Being comfortable with standard Generally, the fi rst pass should be performed with TBNA removes much of the “ mystery ” about EBUS- a small needle, such as a 22 G, to minimize the risk of TBNA, and makes clear the intuitive aspects of the inadvertent vascular puncture. Once the safety of the design of the EBUS- TBNA needle. In the following puncture site is established with the 22 G needle, one section, the knowledge and instruments necessary for may use a larger bore (19 G) or histology needle. successful TBNA are briefl y reviewed. Larger bore needles are generally required to ade- quately sample lymph nodes in diseases such as lym- Needles phoma or sarcoidosis, because tissue architecture plays TBNA needles range in size from 19 to 22 gauge (G). a pivotal role in their diagnosis. Alternatively, there is Their length usually varies between 13 to 15 mm. a double needle that has a 21 G inner needle with a 37 Endobronchial Ultrasonography Left common carotid artery Trachea Left subclavian artery Brachiocephalic artery Arch of aorta Right main bronchus Left main bronchus Descending thoracic aorta Esophagus Figure 4.2 Anatomy of trachea and major airways in relation to the arch of aorta and its main branches “ anterior view” . Trachea Ascending aorta Arch of aorta Right main bronchus Left pulmonary Right pulmonary artery artery Left main Right superior bronchus lobar bronchus Pulmonary trunk Right superior Left superior pulmonary vein pulmonary vein Right inferior Left inferior pulmonary vein pulmonary vein Figure 4.3 Anatomy of major airways in relation to aorta, pulmonary artery, pulmonary vein and their branches. 38 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) Trachea Right pulmonary artery Left pulmonary artery Left main bronchus Right main bronchus Right superior pulmonary vein Left superior pulmonary vein Right inferior pulmonary vein Left inferior Figure 4.4 Anatomy of trachea and pulmonary vein bilateral main stem bronchi with major vessels. Main crina Subcarinal lymph node Right main stem bronchus Pulmonary trunk Ascending aorta Left main stem Subcarinal bronchus lymph node Figure 4.6 Endotracheal and endobronchial area is highlighted to show the proper site for needle insertion for subcarinal node TBNA. Trachea 19 G histology needle that slides over it, from the same catheter. 12 11 1 Planning the Approach 10 2 The chest CT with contrast should be thoroughly 9 3 reviewed, regardless of whether or not EBUS will also be used. Often, it is helpful to reverse the CT fi lm in 8 4 order to better visualize the relationship between 7 5 6 lymph nodes, airways, and vascular structures, as they Figure 4.5 Locations of sub- carinal (station 7) lymph nodes in will be encountered during the bronchoscopy. All relation to trachea, main stem bronchi, aorta and pulmonary lymph node stations should be thoroughly evaluated artery. The anatomical clock at the bottom shows unsafe areas on the CT scan, and a strategic plan to approach differ- for needle insertion by red arrows pointing in that direction. ent stations in the order of preference should be made. 39 Endobronchial Ultrasonography In the event of potential or known malignancy, one station lymph nodes cannot be successfully sampled, should always attempt to sample the node that would one should then move to the second highest station. stage the disease at its highest level. For example, in The issue of changing the needles between different a patient with a 1 cm left upper lobe nodule (T1) and stations is still under investigation. adenopathy at left paratracheal, subcarinal, and right paratracheal stations, the fi rst target should be the Insertion Technique right paratracheal lymph nodes (N3), which, if posi- The four most common techniques for standard TBNA tive, would make the disease stage III B. Sampling needle insertion described in the literature are the so- only the subcarinal (N2) or left paratracheal (N2) called hub, jab, piggy - back, and cough techniques. The nodes would result in staging at a lower level, namely technique used is purely a matter of personal prefer- stage III A (Figure 4.9 ). This approach allows one to ence. I prefer the hub technique, mainly because it is diagnose and stage the patient appropriately in a safer and easier to teach. The “ hub ” technique (Figure single, minimally invasive, out- patient procedure and 4.10 ) involves placing the hub of the needle/catheter precludes unnecessary surgical staging. If the highest at desired site of insertion and, after watching for needle movement during a few respiratory cycles, pushing the needle out while holding the scope and the hub in place. The “ jab ” technique (Figure 4.11 ) involves fi rst advancing the needle out of the catheter and then entering the

target area by pushing the cath- eter down while holding the scope in place. The “ piggy - back ” technique (Figure 4 .12 ) entails having the needle out of the catheter, with the catheter out of the working channel, at a fi xed distance in the airway lumen. The scope is then advanced into the target as one unit. The “ cough ” technique (Figure 4.13 ) requires a relatively awake and cooperative patient. In this tech- nique the patient is asked to cough while the needle coming out from the catheter is held in a steady posi- tion on the airway wall. The cough brings the airway wall onto the needle allowing it to penetrate the tissue. Figure 4.7 Transbronchial needle aspiration: the needle is passed through the airways wall in between the cartilage with In whichever technique is chosen, once the needle an angle as perpendicular as possible. The lymph node or mass is inside the target area, suction is applied fi rst to lying outside of the airways is traversed blindly or under confi rm the avascular nature of the insertion site. ultrasound guidance. Generally when within a lymph node suction on the Figure 4.8 A typical transbronchial needle and attached catheter. 40 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) N2 Jab method N3 N2 T1 Figure 4.11 Jab technique – having the needle out of the catheter and then entering the target area buy pushing the Figure 4.9 A CT slice depicting a left upper lobe nodule (T1) catheter down while holding the scope in place. and a mediastinal adenopathy at stations 4L (N2), 4R (N3) and prevascular area (N2). Piggy-back method Hub method Figure 4.12 Piggy back technique – having the needle out of the catheter while holding the catheter out of the working Figure 4.10 Hub technique – by placing the hub of needle at channel at a fi xed distance in the lumen of the airway. The desired site of insertion, the needle is pushed out while holding scope is then driven down into the target by the operator as the scope and the catheter in place. one unit. needle should meet with fi rm resistance. In case bleeding stops, another attempt can be made in differ- of bloody return, suction should be turned off imme- ent location. diately and the needle should be retracted and Once the needle ’ s location outside of a vascular removed from the working channel. Any blood from structure is verifi ed, a rapid and shallow in - and - out the puncture site should be suctioned. In general, motion is used to obtain the sample, while keeping the bleeding in these situations is minor and stops spon- bronchoscope fi xed at the patient ’ s nose or mouth. An taneously. Signifi cant bleeding is very rare. Once the assistant may help to limit the scope motion. The 41 Endobronchial Ultrasonography motion should be deliberate and swift. Attention the scope can be lacerated. The bronchoscopist should should be paid to keep the scope straight between the deliberately pause at this time to clear any secretions patient and the operator ’ s hand. If there is slack in the from the tip of the bronchoscope to allow as clear a scope, much of jabbing motion is lost before reaching view of the tip of the TBNA needle as possible to ensure to needle. I usually jab between fi ve and ten times. The that the sharp needle has been completely retracted. suction should be slowly released before pulling the needle back in the catheter, to prevent aspirating bron- Sample Handling chial cells on the way out. Once the needle is fully Rapid on- site cytology (Rapid On Site cytologic inside the catheter, the catheter should be removed Evaluation – ROSE) allows for differing additional from the working channel. Care must be taken to make biopsy with outloss in diagnostic yield, likely lower sure that the needle is fully inside the catheter when procedural risk and is cost effective [1] . If on - site cytol- going in and out of the working channel, otherwise ogy is available, the sample from the needle should be transferred directly to the slides. We usually make at least two slides from each pass, one for Diff - Quick and Cough method the other for hematoxylin and eosin (H & E). The usual air drying method is employed for the preparation of these slides. The remaining sample is pushed into a container fi lled with the saline for a cell block. The needle/catheter is purged with air and saline to prevent clotting. The entire process can be repeated in the event of a negative yield on the fi rst pass. Endobronchial Ultrasound Endobronchial ultrasound was created by modifying and miniaturizing the endoscopic ultrasound used by Figure 4.13 Cough technique – in this technique the patient gastroenterologists. Please refer to Chapter 1 of this is asked to cough while the needle is held in a steady position book for a review of the physical principals of ultra- on the airway wall. The cough brings the airway wall onto the sound. The initial version was a radial ultrasound needle allowing it to penetrate the tissue. probe (radial probe) (Figure 4 .14 ). This probe passed (a) (b) US probe Guide sheath Figure 4.14 (a) Endobronchial ultrasound balloon probe (UM- BS20 -2 6R) extending out of the working channel of a fl exible bronchoscope. The balloon over the probe is infl ated with normal saline. (b) Endobronchial ultrasound probe is extended in the lumen of the airway through the working channel of a fl exible bronchoscope. Once the balloon is infl ated, the probe can pick up the sonographic features of a mass around the airways. 42 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) Channel Fiber optics Transducer Scanning direction/range EBUS-TBNA scope Miniature probe (one example) Figure 4.15 Comparative structures of EBUS scope and radial the view is 90 ° and the direction of the view is 30 ° forward probe. The EBUS scope (XBF - UC260F - OL8, Olympus, Tokyo, oblique. The radial probe can pass through the working channel Japan) has a convex/linear transducer (7.5 MHz) extending ahead of the bronchoscope into the lumen of the airway. It rotates of the light source and camera. The outer diameter of the scope 360 ° and gives a circular image of objects all around it. itself is 6.7 mm whereas that of a tip is 6.9 mm. The angel of (a) (b) Figure 4.16 (a) The EBUS scope (XBF- UC260F - OL8, Olympus, Tokyo, Japan). (b) The balloon is over the transducer is infl ated with saline. through the working channel of the bronchoscope (linear scope or convex scope) and the radial probe is into the airway lumen and could rotate 360° . A its capacity to provide real - time images during TBNA. balloon sheath over the probe was infl ated with saline The EBUS scope (BF- UC260F - OL8, Olympus, Tokyo, to fi ll up the airway lumen. The saline - fi lled balloon Japan) (Figure 4.15 ) has a convex/linear transducer provided a good medium for sonic coupling between (7.5 MHz) extending ahead of the light source and the probe and the target tissue. Once the images were camera. The outer diameter of the scope is 6.7 mm, captured and recorded, the probe was pulled out of whereas the tip is 6.9 mm (Figure 4.16 ). The angle of the scope ’ s working channel to allow for insertion of the view is 90 ° , and the direction of the view is 30 ° the TBNA needle/catheter. As a result, the operator forward oblique. The convex surface should be in needed to make a mental picture of the potential direct contact of the airway wall, or the space between needle insertion site in reference to the airway and them should be fi lled with a good sound - conducting vascular structures. Hence, this was a “ blind ” tech- medium, such as saline. The ultrasound image is proc- nique, (not real- time) which limited its utility and essed in the ultrasound scanner (EU - C2000, Olympus, popularity. It did however allow for more confi dence Tokyo, Japan). A small balloon (Figure 4.17 ) mounted in less commonly needled sites such as hilar or left over the linear /convex probe is fi lled with saline once paratracheal. the probe is in the airway lumen. An extra opening In early 2000, a real - time EBUS device was intro- under the working channel, below the handle of the duced. The major difference between the EBUS scope scope (Figure 4.18 ), allows for saline to be instilled 43 Endobronchial Ultrasonography (a) (b) (c) (d) (e) Figure 4.17 (a) Balloon to go over the convex probe. (b) The pad of index fi nger over the tiny knob at the distal most aspect balloon is held between the two arms of the application forceps of the convex probe. All the bubbles should be released from at half length and reversed over it. (c) The balloon is applied the tip of the balloon after fi rst infl ation with saline before over convex probe with the wider opening of the balloon pushing the tip of the balloon onto the tip of the convex probe. sitting in the crease on the distal aspect of the convex probe. (e) Infl ated balloon on the convex probe without any air (d) Smaller opening of the balloon is pushed down with the bubbles. into and removed from the balloon. Because the assembly (Figure 4.20 ) is a stylet. Just under the camera faces 30 ° forwards and upwards, maneuvering handle bar is a white needle lock that controls the the scope in the airway can be somewhat challenging. length of the needle. The length of the needle is also I think of it as lying on one’ s back in a tunnel looking controlled by a stop bar slightly distal to handle bar. up and ahead while dragging forward. When placed at number three, the stop bar limits the The needle set- up of the EBUS scope appears rather functional length of the needle to 20 mm. Under the complex at fi rst, and requires a good understanding of stop bar is a white sheath lock. This lock allows the its operation. The needle comes out at a 45 ° angle from sheath covering the needle to be moved forward or the working channel of the EBUS scope, passing above backwards (Figures 4.21 and 4 .22 ). Usually, I advance and away from the balloon on the probe (Figure 4.19 ). the sheath to the tip of the working channel so that it The needle provided with the EBUS system is 22 G. appears on the upper right portion of the monitor However, the inner diameter of this needle is equal to screen prior to the actual insertion. This prevents the a 21- gauge needle, which allows larger, histological scope from being pushed away from the tissue when core samples. The most proximal portion of the needle trying to introduce the needle in the tissue. 44 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) The EBUS scope set up also includes connecting the scope via a scope cable to the control panel as shown in Figure 4.23 . Once connected and secured properly, monitor settings should be chosen for optimal picture quality. Our usual setting are depth 4 cm, penetration mode, and GI2 (contrast 2). The gain is certain at every start up of this ultrasound machine (Figure 4.24 ). Step - by - Step Endobronchial Ultrasound- Guided Transbronchial Needle Aspiration A thorough examination of the airway is performed with a conventional (non - EBUS) bronchoscope prior to EBUS - TBNA. Endobronchial lesions should be excluded which may obviate the need for EBUS- TBNA. An EBUS scope is then inserted through the oral cavity. Some experts go directly to the TBNA site, while others perform a thorough ultrasound examina- tion of the mediastinum prior to proceeding to the pre - selected site. I favor the latter approach, because the ultrasound survey often provides more practical Figure 4.18 An extra opening under the working channel port information

about the location and accessibility of of the scope allows for infl ation of balloon over the transducer with saline. This opening is connected with the 20 cc syringe nodes, compared with the CT scan. However, one fi lled with saline via IV tubing and a stop cock. should still abide by the predetermined plan to sample lymph nodes that would, if positive, stage the disease to the highest level in the smallest number of attempts. After the ultrasound - guided mediastinal survey, and before the fi nal approach to the insertion site, the tip of the scope is placed in a large airway, where the catheter and needle are positioned at its tip (Figure 4.25 ). The catheter is pushed out to the tip of the scope by loosening the catheter lock. The catheter tip should be barely visible on the upper right portion of the monitor screen showing bronchoscopic fi ndings. This can be done either before passing the scope or when inside the bronchial lumen. The needle lock is then Figure 4.19 This fi gure depicts the relationship between the loosened and the needle is advanced out to the tip of convex probe, balloon covering the convex probe, needle the catheter. This can be demonstrated by observing a extending from the working channel and penetrating the lymph “ drop ” in the needle apparatus as the needle is node behind the airway wall. advanced with the sheath locked. From this point the sheath is pulled back to its original position just exiting from the channel tip. Once the catheter tip and needle Under the sheath lock, there is a safety adaptor to are in place, the locks are tightened and the stylet is lock the needle handle to the biopsy port. The purpose pulled back about 2 cm to allow the bevel of the needle of this lock is to prevent movement of the needle to lead. Optionally it is possible to lave the stylet assembly from the scope. fully in, as some operators report less contamination 45 Endobronchial Ultrasonography (a) Stylet Stylet knob Wire Aspiration port Needle slider Lot number Handle section Model reference label Needle adjuster Single use adapter biopsy valve (MAJ-1414) Needle adjuster knob Pull-tab Scale Stopper Connector section Sheath adjuster knob Needle attachment section Connecting-slider Insertion port Stylet distal end Boot Echo enhanced region Protective plate Needle tube Needle distal end Insertion portion/ working length Sheath Distal portion (b) Connector section Stopper Needle adjuster Aspiration port Needle slider Scale Stylet knob Connecting slider Sheath adjuster knob Needle adjuster knob Figure 4.20 (a) A complete needle assembly system for EBUS- TBNA. (b) Proximal portion of the needle assembly focusing on the needle and sheath adjuster knobs and the needle stopper to determine the functional length of the needle. with epithelial cells with this method. The target is inserting the needle. Once the tissue is penetrated, the identifi ed, and the balloon is infl ated, allowing ultra- picture returns to the screen. This image “ blackout ” sound confi rmation of the location. As shown in happens because the needle pushes the scope away Figure 4 .26 the target is kept in the center of the screen, from airway wall, leading to loss of contact between with the green dot marking the entry point on the the balloon and the tissue. This is either because the right upper edge of the screen. A brief Doppler ultra- sheath is pushing the bronchial wall away having sound examination is performed at this point, to iden- extended beyond the tip of the needle, or because tify any vascular structures in or around the target. the needle has come up against bronchial cartilage After observing respiratory movement in relation to preventing penetration. With the latter scenario the EBUS picture for a couple of respiratory cycles, the coming away and re approaching the wall at a slightly needle lock is loosened and the needle is advanced altered angle is preferred, particularly aiming at a into the tissue. An assistant should hold the scope at point “ on top of” a cartilage ring to facilitate passage the patient ’ s mouth while the needle is advanced. between the rings. Once the scope is pushed down and Often, an assistant is asked to push the scope down the needle has penetrated the tissue, the balloon forcefully, yet smoothly, to facilitate penetration. It is comes back in contact with tissue and the image not unusual to lose the image of the target while reappears. 46 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) Needle adjuster knob (a) (b) Sheath adjuster knob Handle section Connecting-slider (c) (d) Stylet knob 50 mm Sheath adjuster knob Handle section Figure 4.21 Different parts of a needle assembly system used with EBUS- TBNA scope. (a) The needle assembly’ s handle section showing how the connecting slider fi ts on the adaptor attached to the working channel port of the scope. (b) The connector slider is pushed backwards. Needle adjustor knob is located above the sheath adjuster knob. (c) Sheath adjuster knob is loosened by rotating counter clockwise. (d) The stylet is pulled back by holding the stylet knob. Once the needle is in the lymph node, the stylet is the pre- loaded suction syringe is connected, and pushed forward a couple of times to force out bron- suction is applied. If no blood is seen in the catheter, chial cells captured along the way. One can see the gentle jabbing is begun, as previously described, tissue and blood being pushed out of the needle on a making sure that the needle does not come out of the real - time ultrasound image. The stylet is then removed, lymph node. Five to ten long, smooth passes are made, 47 Endobronchial Ultrasonography (a) (b) (c) (d) (e) (f) Figure 4.22 Proper technique for loading the needle assembly assembly). (d) Before lowering the needle, the position of the on the scope, step - by - step. (a) The needle is passed through the needle length slide lock should be confi rmed at 3, allowing only working channel and the entire needle assembly is loaded in the about 20 mm of needle to come out of the scope. (e) The stylet special working channel cap provided with the needle kit. The is pulled back a couple of centimeters to allow the bevel of the tightening knobs should face forward. The sheath and the needle to lead. The needle is then unlocked by loosening the needle should be completely retraced by pulling their sliders all needle lock knob just prior to penetration in the tissue. Once the way up. (b) Once the needle assembly is tightly fi tted in the the target is penetrated, the stylet is pushed forward a couple working channel; the lock should be applied by sliding it of times to push out the unwanted epithelial cells captured on backwards. (c) In preparation for needle insertion, the sheath is the way. (f) Suction is applied after removing the stylet with a pushed out by loosening the sheath lock (lower knob on the locking syringe. 48 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) (a) (b) (c) Figure 4.23 (a) Endobronchial ultrasound processor EU - C2000. (b) Endobronchial ultrasound bronchoscope (BF- UC260F - OL8) attached to the processor. (c) Same as (b) seen in close up. Figure 4.24 Endobronchial ultrasound monitor. The basic settings and format is shown here. Detailed set up is discussed in Chapter 1 . 49 Endobronchial Ultrasonography (a) (b) (c) Figure 4.25 (a) Endobronchial ultrasound convex probe with balloon is defl ated. The angulation of the needle allows for near needle sheath pushed out of the working channel. The balloon perpendicular angle between the target and the needle. (c) is defl ated to show the safety margin between the catheter and Needle pushed out of the catheter pointing at an angle of 45° . needle that comes out of it and the probe. (b) Needle pushed The needle stays clear of the infl ated balloon. out of the catheter pointing at an angle of 45° . Again the (a) (b) Needle Lymph in the node lymph node Figure 4.26 (a) A small mediastinal lymph node is seen on EBUS monitor. (b) A needle is penetrated diagonally across the lymph node. The entry point of the needle is at the green dot on the right upper corner of the ultrasound fi eld. 50 CHAPTER 4 Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) much like picking ice. Before removing the needle genetic studies, the procedure can be concluded. from the lymph node, the suction is turned off to However, if the sample contains lymphoid material avoid collecting unwanted cells in the needle on the but no malignant cells or granulomata, one may way out. The needle is then retracted into the cathe- proceed to another TBNA of the same site or another ter. The needle assembly is unlocked at the biopsy port site. The number of aspirates performed is a matter and removed from the working channel. of personal preference. There are no randomized, The needle containing the specimen should be controlled trials to suggest that multiple punctures of taken immediately to the slides, which have been pre- same lymph node improve the yield. I generally viously laid out, labeled, and numbered. Some bron- perform at least two TBNAs at the same site before choscopists push the specimen out with the stylet onto going to the next lymph node station. If lymphoma or a fi lter paper or gauze to absorb blood and separate sarcoidosis is a strong possibility, I usually insert a 19 G the core tissue biopsy. The core tissue is then put into needle at the same puncture site, without EBUS, formalin for histopathologic examination. Some of the before proceeding to the next station. Overall, experi- specimen in the needle is pushed out onto the slides ence with this strategy for EBUS - TBNA has been very for cytologic examination by blowing air through the good. In general, post - procedure chest radiographs are needle. Sample remaining in the needle is placed into not needed following an uncomplicated TBNA. a tube containing normal saline. After the specimen has been pushed from the needle with the stylet, the stylet is cleaned with an alcohol swab to clean blood Acknowledgements clots from its surface. Another technique is to push the specimen on the slide with the stylet, then push I would like to acknowledge and thank Dr. Esther air and saline to deliver any remaining specimen into Langmack for editorial assistance, Barry Silverstein for saline for later staining and cell blocks. End paper photographic expertise and Boyd Jacobson for excel- method is used for cell block/histology after the mate- lent art work. rial for slides has been obtained. If on- site cytology is not available, the specimen retrieved in the needle should be pushed into a tube References containing normal saline. However, if on - site cytology is available, the cytologist may help determine whether 1 Baram D , Garcia RB , Richman PS . I mpact of rapid a second aspirate is needed. If malignant cells, granu- on - site cytologic evaluation during transbronchial needle lomata, or other features reveal a diagnosis, and no aspiration . Chest 2005 ; 128 ( 2 ): 869 – 875 . more tissue is needed for further confi rmation or 51 5 Tips and Diffi culties in E BUS - TBNA in this technique. The most commonly aspirated sites Tips would be the right paratracheal and subcarinal posi- tions and the anatomical relations of these two sites Wang ’ s Descriptions of TBNA Positions can be quickly gleaned from the Wang descriptions. The technique of transbronchial needle aspiration has been in the literature for over 25 years [ 1] , and there Radiological Anatomy is much useful material to be obtained from Wang ’ s The proceduralist needs to become familiar with inter- original description to facilitate transbronchial needle preting the CT scan for the presence of mediastinal aspiration. The addition of EBUS aids the practitioner and hilar lymphadenopathy. An excellent reference in confi rming the localization of the lymph node [2] , for this is Ko, 2000 [6] . In fact, with EBUS, only the as shown in early

studies with an EBUS balloon probe. following are accessible: the highest mediastinal However, an understanding of the common locations (station 1), the upper paratracheal (station 2R and of the lymph nodes adjacent to the trachea and main 2L), the lower paratracheal station (4R and 4L), the bronchi as well as their main relationships can be subcarinal (station 7), hilar (station 10), the interlobar obtained from careful scrutiny of these early papers (station 11) and the lobar nodes (station 12). Stations [1,3] . In his papers, Wang described 11 nodal positions 5 and 6 are the subaortic and para- aortic lymph nodes starting at the anterior carina and progressing down respectively and neither of these are directly applied the main bronchi, to the subcarina and, ultimately, the to the trachea. Similarly, the number 8 and 9 lymph hilar positions. At each of these 11 sites, a description nodes are too far posterior and inferior to be accessed of the best point to insert the needle was given in by the TBNA scope. Both of these can be accessed by terms of a clock - face with respect to the bronchial endoscopic ultrasound. The number 13 and 14 seg- lumen. These 11 positions provide an invaluable start- mental and subsegmental lymph nodes are usually not ing point for the student of transbronchial needle aspi- able to be biopsied simply because the TBNA scope is ration whether using a standard TBNA needle or using too large to proceed further out the bronchial tree the convex probe and a bronchial ultrasound scope. It towards these nodes. On occasion, a number 13 might should be remembered that these numbered positions be accessible. are different from the traditional lymph node stations Some of the important vascular- relations are as described by Naruke and the American Thoracic described in Ko ’ s paper. The level 1 nodes are only Society in their classifi cations [4,5] . Even familiarity very uncommonly biopsied by EBUS- TBNA. The with two or three of these positions is adequate for important vascular relation is that this node is cranial the learning practitioner to quickly develop expertise to the brachiocephalic vein where it crosses the trachea. The station 2 para - tracheal lymph nodes are positioned below the top of the left brachiocephaic vein but above the top of the aortic arch. Station 4 Endobronchial Ultrasonography, 1st edition. lymph nodes can be divided radiographically into a By Noriaki Kurimoto, David Fielding and Ali Musani. superior and inferior subset. Superior nodes are infe- Published 2011 by Blackwell Publishing Ltd. rior to the top of the aortic arch and above the azygous 52 CHAPTER 5 Tips and Diffi culties in EBUS-TBNA vein; inferior station 4 lymph nodes are below the on right and left, the pulmonary artery can be horizontal line drawn at the superior aspect of the readily seen in the lateral position (3 o ’ clock on the azygous vein. Of course, lymph nodes in this station right, and 9 o ’ clock on the left). By rotating the scope 4 para - tracheal position can be contiguous between directly anteriorly, each of these vascular points can the superior and inferior positions. In the lower para- be avoided and the node easily visualized in this loca- tracheal position, these nodes can be classifi ed as tion just at the origin of the right or left lower lobe either 4R or 4L depending on whether they are on the bronchus. right or left of the lower trachea. The nomenclature is The fi nal tip is with hard copy fi lm or even on an important with respect to 4L as these are separated electronic copy to fl ip the fi lm horizontally so that a from the number 5 or aortopulmonary window lymph bronchoscopic type view (standing at the head looking nodes by the ligamentum arteriosum, with 4L lymph at the feet) is obtained to further visualize the likely nodes being medial to this structure. Station 10 hilar direction of needle puncture. lymph nodes are anterior and posterior to the right upper lobe bronchus. The demarcation point between Which Nodes will be Most Commonly station 4 mediastinal and station 10 hilar nodes is the Sampled? top of the right upper lobe bronchus; mediastinal Lymph nodes most commonly sampled will be the number 4 nodes are superior to this and station 10 right paratracheal and subcarinal lymph nodes and it hilar nodes are inferior to this point. Familiarity with is suggested to do just 10 or 20 cases at these two sites these positions and enlargement of lymph nodes at alone to develop familiarity with the process and this point obviously brings familiarity with the vascu- needle puncture. The number 4L position can be dif- lar relations. fi cult to access because of the sharper angle of the left In general terms, the anatomy of these major struc- main bronchus coming off the lower trachea com- tures is not nearly as variable as is seen in assessing pared to the right. As such, it is diffi cult to maintain the peripheral airways and small vascular branching good application of the EBUS balloon to the tracheo- at subsegmental levels and therefore it allows the bronchial angle and the help of an assistant to hold trainee to rapidly develop a concept of pattern recog- the bronchoscope in position can be required. To a nition [7]. The nodal positions 1, 2R, 4R, 4L, 11L, and lesser extent, this can be true at the right tracheobron- 11R and 7 all have fairly constant vascular relations chial angle in low number 4 or number 10 nodes. and, as such, a “ snap - shot ” or pattern recognition image can be used by the trainee [ 7] . For example, in Setting Up the Scope the commonest position, the number 7 subcarinal The TBNA convex probe dedicated needle made by location, it is a simple matter of demonstrating the Olympus (NA- 201SX - 4022) has a number of moving right main pulmonary artery immediately anteriorly parts with which the operator can become rapidly at the origin of the right main bronchus and turning familiar. away anticlockwise to the subcarinal position at the 9 The needle apparatus is released by unwinding the o ’ clock location. In the number 2 right paratracheal screw on the gray sleeve. By holding the apparatus position, the best known vascular relation deep to the above this sleeve between fi nger and thumb it can be lymph node would be the superior vena cava which easily pulled down in a controlled fashion to protrude can be seen as an elongated vascular structure usually the needle from the tip. Stabilize the hand on the at the 3 o ’ clock position. (This may be poorly seen if apparatus by winding the fi fth fi nger of the same hand the node is not suffi ciently enlarged.) Turning back around it below the needle apparatus. Before com- anticlockwise slightly to the 1 – 2 o’ clock position mencing the procedure, check that the needle moves brings the node into view. In the number 4 lower right freely in and out in the same way as one would paratracheal position, the superior vena cava can be prepare a simple cannula for venous cannulation. seen in its lower end, whereas at the lower end, more Immediately on completing this simple task and at all anteriorly, both the azygous vein and right pulmonary times when using the needle, the needle shaft should artery can be relatively easily seen in a commonly be pulled back until a click is felt and heard and the observed pattern. In both the number 11 positions screw on the gray sleeve retightened. This ensures that 53 Endobronchial Ultrasonography the sharp needle is fully retracted within the plastic front of the optic which is not visualized. Therefore to sheath and, as such, the needle tip is unable to damage facilitate ease of passage of the scope through the vocal the biopsy channel of the bronchoscope. Next, the cords it can be helpful for an assistant to provide ante- needle apparatus as a whole needs to be calibrated for rior jaw lift to open up full viewing of the vocal cords. length against the biopsy channel. The needle appara- If the anterior commissure is viewed it means the tus is passed into the channel and the white knob scope itself is pointed at the mid point of the cords and unscrewed to allow inward or outward movement of the scope will easily pass through. This part of the the plastic sheath. This sheath should be aligned at the procedure requires practice particularly the need to end of the biopsy channel; when this plastic sheath have the scope tip go anteriorly over the arytenoids just comes into view on the monitor it implies that the and not be caught and pushed posteriorly. In patients sheath has come out the end of the biopsy channel with crowded upper airways this can be diffi cult even and, therefore, should be fi xed in this position so that with anterior jaw lift. Similarly, when in the bronchial when the needle is protruded from the sheath it will tree to pass the main carina one would overcorrect do so from outside the biopsy channel thereby not much earlier than with a standard bronchoscope damaging it.. The sheath should not be fi xed too far where the viewing optic is at the very end of the out as this will hamper needle penetration attempts scope. For example, 2 or 3 cm before the main carina, by pushing the ultrasound transducer away from the the scope would be rotated to the right and very close wall and hampering imaging just prior to biopsy. Once to the lateral tracheal wall to facilitate passage into the this position has been found, the white knob should right main bronchus. generally not be adjusted until during the procedure. Depending on local preference anesthetic support is Now the balloon can be set up on the transducer available in some centers with the ability to intubate tip. Draw up 30 mL of saline into a Leuer lock syringe the patient either with standard ETT or laryngeal mask with fl exible giving set and 3- way tap attached. It is airway (LMA). Sarkiss et al. reported their anesthetic best to remove all air bubbles; this is best achieved by technique for EBUS - TBNA [8] . They use a number 4 drawing up the saline slowly and then expelling the LMA because it has a large internal diameter and is bubbles by holding the syringe in a vertical position the most suitable device to secure the airway and with the three way tap uppermost, gently tapping the provide adequate ventilation around the broncho- syringe as required. Having done this, one can prime scope. The outer diameter of the XBFUC 160F EBUS- the balloon channel on the scope with 2 or 3 mL of TBNA scope is 6.7 mm and 6.9 mm at the tip. These saline. The three way tap is then closed. The balloon authors used a total intravenous anesthesia (TIVA). itself then needs to be fi tted to the convex probe end TIVA was preferred over volatile anesthetics because of the scope over the ultrasound transducer. There is frequent suctioning of airway by the bronchoscopist a dedicated applicator for this. Having applied this to resulted in contamination of the procedure room the convex probe, the probe tip is held upwards and atmosphere by the anesthetic gases and also causes the fl uid syringe held downwards and 5– 10 mL of inconsistent delivery of the anesthetic gas to the saline is used to slowly fl ush through the balloon patient. channel until bubbles are removed from the balloon. They used propofol infusion at a rate of 75 µ g/kg/ Once it appears that this has been complete, the very min once intravenous catheter and standard monitor- tip of the balloon can be folded back over the dedi- ing for general anesthesia were in place. Small doses cated balloon holder at the tip of the scope. This of fentanyl or remifentanil were given for induction. should only be done once all bubbles have been An alternative to the LMA is

an endotracheal tube removed as bubbles can no longer be removed once (8.5). The indications for ETT placement were diffi cult this has been folded into place. laryngeal mask airway placement, obesity, and severe untreated gastro- esophageal refl ux. The EBUS can Passing the Bronchoscope and Anesthesia only fi t in a size 8.5 or 9.0 mm internal diameter As described in the previous chapter the practitioner endotracheal tube. These authors used an 8.5 ETT for needs to adjust for the anterior view of the white light female patients and a size 9.0 for male patients. optic and the fact that there is about 1 cm of scope in To some extent, the endotracheal tube does make it 54 CHAPTER 5 Tips and Diffi culties in EBUS-TBNA diffi cult to oppose the convex probe against the bron- of the lower cartilage, the ultrasound balloon can chial wall because the tube brings the scope into the then be fl exed back up against the bronchial wall to center of the lumen. The ETT can be manually “ leaned ” image the fi rst pass of the needle into the node. towards the side of biopsy to some extent. Prior to performing puncture, it may be possible to In general an LMA is preferable because an ETT can push the plastic sheath in and out allowing visualiza- at times hinder in access to paratracheal lymph nodes; tion of this to occur as it indents the space between ETTs may have to be pulled back if this occurs, some- the cartilage rings, and makes it easy to pass the needle times repeatedly, to allow free access to the side of the through. tracheal wall. The second method is to simply hold the broncho- scope with the infl ated balloon against the node at its The Reach of the Bronchoscope most upper or cranial point and to gently advance Usually, it is diffi cult to access the segmental bronchi the needle into the node without any movement of with this 6.4 mm diameter bronchoscope. It is possible the scope away from the bronchial wall. The disad- to easily access the origins of the right and left main vantage of this method is that it is common for bronchi, both lower lobe bronchi. On the right, occa- the needle to come up against cartilage rings. To over- sionally it is possible to enter the right upper lobe come this problem it requires re - manipulation or rota- bronchus origin to puncture the top end of a number tion of the scope 5 or 10 ° in either direction. Again 11S lymph node. Occasionally it is also possible to this can be made easier by slightly advancing the enter the origin of the right middle lobe bronchus to plastic outer sheath and visualizing this indenting access anterior lymph nodes at this point. On the left, the top right of the ultrasound image. This method it is usually possible to access the most proximal parts might be easier to use in the more peripheral puncture of the upper division bronchus although the indica- sites such as the number 11 in the origin of each tions to do this are very infrequent and this region is lower lobe. The obvious reason being the diffi culty very vascular. Accessing the left upper lobe bronchus of fl exing the bronchoscope away from the wall and lingula are usually not possible. at these points given the small bronchial lumen diam- eter. Also the cartilage rings here tend to be less Passing the Needle through the Wall obstructive. After infl ation of the convex probe balloon a biopsy Before doing either of these methods, it is possible site is chosen, usually by selecting the most proximal to improve puncture by having the sharp needle end of the lymph node. Careful Doppler examination come to the tip of the plastic sheath before formally at this point should reveal no small bronchial artery; advancing it into the lymph node. Somewhat unex- if this is present, simply rotating the scope in an axial pectedly when the needle is protruded inside the plane should be able to remove the vessel from the plastic sheath, the sheath is elongated by this action. anticipated needle puncture track. Puncture of the That is, the sheath will move out in front of the needle tracheal wall can be done using two different methods. even though it has not been specifi cally released The fi rst and preferred method is to visually determine itself. This pushes up against the wall of the bronchus, a mark or minor vascular structure on the tracheal or and can effectively “ push ” the balloon away from the bronchial wall where the needle will be passed. This wall before the needle can be advanced. A quick is determined by fi rst using ultrasound examination method to prevent this problem has been recently showing the position of the most cranial (near) end of described by Kurimoto and others: with the scope the lymph node. The bronchoscopic white light views in the middle of the bronchus lumen away from are then carefully scrutinized to show a mark at this the wall the needle is protruded and observed exact point, obviously just above a cartilage ring. The closely. The needle will have just reached the tip of next step is to fl ex the bronchoscope a little backwards the sheath when there is a slight downward move- and away from the bronchial wall so that the needle ment of the tip of the sheath. The needle shaft is can be passed more directly straight into the wall at then left in this position and the plastic sheath with- the desired point as described. Having passed the drawn to its original position just outside the biopsy needle into this cartilaginous space, usually on the top channel. 55 Endobronchial Ultrasonography Obtaining Samples was confi rmed in 41 stations in 30 patients. Two areas It is often helpful to ask an assistant to hold the bron- of malignancy as documented by surgery were missed choscope still at the exit from the mouth as this will in two patients. Sample adequacy was 90.1% for one prevent slight movements of the scope which can aspiration and it reached 100% for three aspirations. hinder adequate visualization during insertion of the The sensitivity for differentiating the malignant from needle. Sometimes as the needle is being inserted, the benign lymph node stations was 69.8%, 83.7%, scope is pushed backwards in a cranial direction and 95.3%, and 95.3% for 1, 2, 3 and 4 aspirations respec- re - advancing the scope the 1 or 2 mm helps to regain tively. Maximum diagnostic values were achieved in the image. Because of the effect of slight movements three aspirations. The negative predictive value of it helps to have two monitors (one for EBUS and one 86.5% for one aspirate and 97.6 for four aspirates for bronchoscopic fi ndings) on continuous display respectively. These authors concluded that optimal rather than alternating the view on one monitor. results could be obtained in three aspirations per It is important to keep the full length of the needle lymph node station for mediastinal staging of the in view on the monitor during the TBNA procedure potentially operable non - small cell carcinoma. They specifi cally with reference to the distal tip of the felt that if a tissue core specimen could be obtained in needle. the fi rst or second aspiration, then two aspirations per Occasionally, once the needle has been inserted in lymph node station would be acceptable. the node, it is diffi cult to push the stylet fully in to remove cartilaginous material from the tip of the needle. This is particularly true when the broncho- Side Effects and Risks scope is more acutely angled and it is sometimes nec- essary to gently release any angulation on the Transbronchial needle aspiration biopsy as an alone bronchoscope to allow a more straight passage in of procedure has been in clinical use for at least 25 years the stylet. Care should be taken to prevent inadvertent [1] . Tolerance of this technique was summarized in bending of the stylet during reinsertions. Occasionally, 2000 [10] . The main reported risk at that time was not when two or three insertions are made, it is necessary so much to the patient as damage to the broncho- to ensure any small amounts of blood are wiped off scope. This occurred when standard TBNA needles the stylet before it is readvanced as coagulation of were inadvertently deployed whilst still within the blood on it can make it stick in the thin channel. biopsy channel, hence causing damage to the channel. Sometimes blood comes into the suction syringe in [11] . In addition to this, standard TBNA needles can aspirations of vascular lymph nodes. This can reduce be damaged by the sharp point of the needle going the diagnostic yield and therefore it is best to remove through the plastic sheath [12] . In the review of the needle without any further passes at that point. TBNA, there were two cases of pneumothorax and Some authors recommend trials of no suction on the one case of pneumomediastinum and hemomediasti- needle in this situation just relying on the “ cutting ” num [11] . There was one patient with a reported aspect of the needle to obtain the sample. In subse- purulent pericarditis after TBNA of a subcarinal mass. quent passes it may help to just do four or fi ve move- One rare complication of standard TBNA has been in ments of the needle in and out in the node as opposed advertent liver biopsy in a patient with a right raised to the usual 20. hemi - diaphragm [13] . A 2002 report noted a medias- tinal hematoma after inadvertent puncture of the How Many Aspirations Per Target Lymph aorta; his resolved spontaneously on CT [14]. Node Station? The convex probe TBNA scope was fi rst reported in This was reported by Seok Lee et al. and is clearly 2003 and, to date, very few side effects have been relevant for those situations where rapid onsite reported [ 7] . Signifi cant bleeding has not been reported cytopathological examination is not available [9] . In in any patient since the advent of EBUS - TBNA and, this study, 163 nodal stations in 102 patients with indeed, with conventional TBNA, reports have been non - small cell lung cancer were punctured. Malignancy rare. One case of perihailar hematoma has been 56 CHAPTER 5 Tips and Diffi culties in EBUS-TBNA reported from sampling a small node in vicinity of hilar tion, the patient had coughed very forcibly and vessels - care with ultrasound examination is needed because the bronchoscope was being pushed distally [15] . There is usually a small amount of blood after with the piggy - back method, it is assumed that with removal of the TBNA needle which settles spontane- the needle coming against the cartilage and the ously within half a minute or so and is usually bleeding patient ’ s coughing effort, that there was a shearing from the small bronchial vessels. Occasionally, bleed- force at the point of the needle exit from the plastic ing can occur from within the node itself, particularly sheath. It was apparent that the needle could not be in metastatic lymph nodes from tumours such as renal seen advancing on the ultrasound image and needle cell carcinoma or melanoma due to their vascularity. breakage was immediately suspected. The needle was The theoretical increased risk of bleeding in patients retracted and a standard bronchoscope was immedi- with superior vena caval obstruction has previously ately inserted. The broken end of the needle could be been raised [16] . As is often seen at EBUS- TBNA, the seen in the subcarinal position and was removed with superior vena cava is displaced out of the way by nodal standard endobronchial biopsy forceps. The recom- tissue. The convex probe TBNA needle can be with- mendations from this problem were that the piggy- drawn should there be any excess of blood come into back method should be avoided using this needle, and the needle indicating vascular puncture, however if to use the

methods described above. There were no the node is well imaged, this is exceedingly unlikely to adverse effects with respect to the patient and there happen. The only caveat may be penetration of a small was no residual needle seen on chest X - ray immedi- bronchial artery immediately beneath the tracheal or ately following the procedure. bronchial wall and this can be quickly ruled out by Doppler imaging at the TBNA site in each case. Two recent reports concern post EBUS TBNA infec- On Site Pathology tions [17,18]. A pericardial infection followed full extension of the needle to 36 mm. Such extension The benefi ts of rapid on site cytology examination should only be used very infrequently. Another case (ROSE) in standard transbronchial needle aspiration of pneumonia following sampling of a pulmonary are well known [ 20,21] . Because fewer samples were lesion next to a bronchus occurred. In the other report required the procedure was cost effective and there- a cystic lesion was sampled in the high mediastinum fore paid for the extra expense of the cytologist ’ s as part of staging of thyroid disease [18] . An infection availability. ensued with purulent skin discharge; this settled with ROSE also offers benefi ts in EBUS - TBNA [ 22] . It is antibiotics. In both the last 2 cases antibiotics would a useful way to not only confi rm malignant cells but now be recommended post procedure. Alternatively also where nodes are likely to be benign that abundant cystic lesions should be avoided. The author has had lymphocytes can be seen at ROSE. In lung cancer one adverse event with respect to the convex probe staging with EBUS - TBNA it is usual to start by sam- TBNA needle [19] . This was a case performed by the pling N3 followed by N2 followed by N1 nodes depend- author in a patient with underlying sarcoidosis. There ing on size and accessibility [ 22] . In this respect it is were large abnormal nodes at the right paratracheal very important to not allow positive cytology speci- and subcarinal positions, both of which had been aspi- mens from one pass to contaminate a subsequent pass. rated. There had been a strongly positive PET scan Most authorities consider that simply rinsing a needle prior to the procedure and on site pathology was nega- is not adequate to prevent such contamination occur- tive for the presence of any malignancy, hence the ring. ROSE clearly can assist with this process. If an patient had four passes before the breakage of the N3 sample is positive it would be reasonable to stop TBNA needle on the fi fth pass. In retrospect, this the process there. If negative the next step would be was because the technique of needle penetration was to sample N2 nodes. It may be reasonable in these the piggy - back method as described by Wang rather circumstances to use the same needle again for the N2 than the two- step or three- step method described node, providing the initial ROSE with that needle was above. During the performance of this needle penetra- negative for malignant cells. 57 Endobronchial Ultrasonography 11 Sherling BE. Complication with a transbronchial histol- References ogy needle . Chest 1990 ; 98 : 783 – 784 . 12 Stelck MJ , Kulas MJ , Mehta AC . M aintenance of the 1 Wang K PO , T erry P B . Transbronchial needle aspiration bronchoscope and the bronchoscopy equipment. In in the diagnosis and staging of bronchogenic carcinoma . Prakash UBS , ed. B ronchoscopy . N ew York: Raven Am Rev Respir Dis 1983 ; 127 : 344 – 347 . Press , 1993 : 386 . 2 Herth F , Becker H D , Ernst A . C onventional vs endobron- 13 Mehta AC, Kathawalla SA, Fischler D , et al. Bronchoscopic chial ultrasound- guided transbronchial needle aspira- liver biopsy. J Bronchol 1994 ; 1 : 173 – 174 . tion: a randomized trial . Chest 2004 ; 125 : 322 – 325 . 14 Agli LL , Trisolini R , Burzi M , P atelli M . Mediaytinal 3 Wang KP , Brower R , Haponik EF , et al. F lexible trans- hematoma following transbronchial needle aspiration . bronchial needle aspiration for staging of bronchogenic Chest 2002 ; 122 : 1106 – 1107 . carcinoma . Chest 84 : 571 – 576 . 15 Kurimoto N . E BUS TBNA case report of hilar hematoma. 4 Narouki T . T horacic surgery. In Pearce G, Deslauriers J , Japanese Society of Respiratory Endoscopy, Yokohama Ginsberg RJ et al., eds. T horacic Surgery. N ew York : June 2010 . Oral presentation. Churchill Livingstone, 1 995 : 909 – 917 . 16 Kelly P T , Chin R , A dare N , et al. B ronchoscopic needle 5 Murray JG , Breatnach E . T he American Thoracic Society aspiration in patients with superior vena caval disease . lymph node map: a CT demonstration. E ur J Radiol J Bronchol 1997 ; 4 : 290 – 293 . 1993 ; 17 : 61 – 68 . 17 Haas AR. Infectious complications from full extension 6 Ko , J P , D rucker E A , S hepard J A , et al. CT depictions of endobronchial ultrasound transbronchial needle aspira- regional nodal stations for lung cancer staging . Am J tion . E ur Resp J 2009 ; 33 : 935 – 938 . Radiol 2000 ; 174 : 755 – 782 . 18 Steinfort DP , Johnson DF , Irving LB . Infective compli- 7 Yasufuku K , F ujisawa T . Staging and diagnosis of non- cations from endobronchial ultrasound transbronchial small cell lung cancer: invasive modalities . R espirology needle aspiration. E ur Resp J 2009 ; 34 : 524 – 525 . 2007 ; 12 : 173 – 183 . 19 Fielding D . S ifde effects of EBUS TBNA. Japnese Society 8 Sarkiss M , K ennedy M , R iedel B , et al. A nesthesia tech- of Respiratory Endoscopy, Yokohama June 2010. Oral nique for endobronchial ultrasound- guided fi ne needle presentation. aspiration of mediastinal lymph node. J Cardiothorac 20 Diacon AH , Schuurmans MM , Theron J , et al. Utility of Vasc Anesth 2007 ; 21 : 892 – 896 . rapid on site evaluation of transbronchial needle aspi- 9 Seok Lee H , Kook Lee G , Lee HS , et al. Real - time endo- rates . Respiration 2005 ; 72 : 182 – 188 . bronchial ultrasound- guided transbronchial needle 21 Baram D , Garcia RB , Richman PS . I mpact of rapid on aspiration in mediastinal staging of non- small cell lung site cytologic evaluation during transbronchial needle cancer: how many aspirations per target lymph node aspiration . Chest 2005 ; 128 : 869 – 875 . station? Chest 2008 ; 134 : 368 – 374. 22 Vincent B D , E l Bayoumi E , H offman B , et al. Real time 10 Minai , O A , D asgupta , A . M ehta A C . T ransbronchial endobronchial ultrasound - guided transbronchial lymph needle aspiration of central and peripheral lesions . In node aspiration . A nn Thorac Surg 2008 ; 85 : 224 – 230 . B olliger C T , M athur P N , eds. Interventional Bronchoscopy . Basel : Karger , 2000 : 66 – 79 . 58 6 Endoscopic Ultrasound - Guided Mediastinal Lymph Node Aspiration for Lung Cancer Diagnosis and Staging As evident from its name, endoscopic ultrasound (EUS) considered complementary to each other. When used is performed through a trans - esophageal approach together, EUS- FNA and EBUS - TBNA allow access to (Figure 6.1 ). The EUS scope, like the endobronchial almost all of the mediastinal nodes during one session ultrasound (EBUS) scope, allows for real - time ultra- of conscious sedation. However, when lymph nodes sound needle aspiration (Figures 6.2 and 6.3 ). The are potentially accessible by both modalities, the EBUS purpose of this brief chapter is to acknowledge the role approach is preferred because it also allows examina- of EUS in sampling mediastinal lymph nodes and to tion of the airways for endobronchial disease, which compare EBUS and EUS for this particular indication. may be easily missed on chest CT scans. Both EUS- An in - depth discussion of endoscopic ultrasound for FNA and EBUS - TBNA carry a very low risk of sampling mediastinal lymph nodes is beyond the scope complications. of this book. To learn more about mediastinal sampling Like EBUS - TBNA, EUS - FNA may be performed as with EUS, one should review the gastroenterology an out - patient procedure. It is usually carried out with literature. the patient under conscious sedation. The needle used Endoscopic ultrasound - guided fi ne- needle aspira- for EUS- FNA is typically 19 or 22 G. The 19 G needle tion (EUS- FNA) of mediastinal lymph nodes to stage provides the benefi t of allowing a core biopsy, which lung cancer has been performed since the 1990s. improves diagnostic accuracy in diseases such as sar- Posterior and inferior mediastinal nodes are easily coidosis and lymphoma. In a meta- analysis, the sen- accessible by EUS - FNA (Tables 6 .1 and 6 .2 ). Mediastinal sitivity of EUS - FNA was 81 – 97% and specifi city was lymph node stations accessible by EUS- FNA include 83 – 100% for the diagnosis of posterior mediastinal stations 4L (Left lower paratracheal), 7 (subcarinal), 8 lymphadenopathy in non- small cell carcinoma lung (para - esophageal), and station 9 (inferior pulmonary [1] . The major limitation of EUS- FNA was its high ligament). Superior mediastinal (stations 1, 2, 3, and false negative rate. Recent studies comparing PET scan 4R), N1 (stations 10, 11, 12, 13 and 14), subaortic with EUS- FNA for posterior mediastinal adenopathy (station 5) and the para- aortic node (station 6) are not have shown that the EUS- FNA is better than PET scan accessible by EUS - FNA. in staging lung cancer [ 2] . These studies suggest that In comparison, the lymph node stations accessible there is a high false positive rate for PET scanning; by EBUS - TBNA include stations 1, 2, 3, 4, 7, 10, 11, therefore, EUS- FNA can confi rm the benign or malig- and 12. Endobronchial ultrasound- guided fi ne- needle nant status of these lymph nodes. aspiration (EBUS- TBNA) for lung cancer staging has Endobronchial ultrasound - guided fi ne- needle aspi- been performed since the early 2000s. ration appears to have greater sensitivity and specifi city Because they can access different mediastinal lymph than EUS - TBNA. In a case report of 70 patients with node stations, EUS- FNA and EBUS- TBNA should be mediastinal (58 patients) and hilar (12 patients) aden- opathy, EBUS - TBNA for differentiating benign from malignant nodes had a sensitivity of 95.7%, specifi city Endobronchial Ultrasonography, 1st edition. of 100%, and accuracy of 97.1%, respectively [3] . By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. A recent multicenter trial of more than 500 patients Published 2011 by Blackwell Publishing Ltd. showed EBUS- TBNA to be a very sensitive and specifi c 59 Endobronchial Ultrasonography Distal end of the endoscope Trachea Distal end of the sheath Superior mediastinal nodes Echo enhanced region Bronchoscope Needle distal end Figure 6.3 Cartoon depicting endoscopic ultrasound via the esophagus. The real- time images of a mass or node outside the Inferior mediastinal walls of the esophagus allow fi ne - needle aspiration. nodes Esophagus Table 6.1 Lymph node stations Location S tation Superior mediastinal nodes Figure 6.1 Endoscopic ultrasound scope in the esophagus Highest mediastinal 1 behind the trachea. The subcarinal and para- esophageal lymph Upper paratracheal 2 nodes are easily accessible by endoscopic approach with Pre - vascular and retrotrachael 3 ultrasound - guided fi ne - needle aspiration. Lower paratracheal 4 Colored dots represent lymph nodes. Aortic nodes Subaortic (A- P window) 5 Para - aortic (ascending aorta or phrenic) 6 Inferior mediastinal nodes Subcarinal 7 Para - esophageal 8 Pulmonary ligament 9 N1 nodes Hilar 10

Interlobar 1 1 Lobar 1 2 Segmental 1 3 Subsegmental 1 4 Adapted from: Naruke T, Suemasu K and Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg Figure 6.2 Endoscopic ultrasound scope (GIF - UC 240P 1978;76:832 –3 9, with permission. Olympus Corporation). diagnostic modality for sampling mediastinal aden- CT, PET and EBUS- TBNA for diagnosing lung cancer opathy (sensitivity 94% and specifi city 100%) [4] . in mediastinal and hilar lymph nodes was 76.9%, Other studies comparing the sensitivity of PET, CT and 80%, and 92.3%, respectively. The specifi cities EBUS - TBNA for staging of lung cancer showed a were 55.3%, 70.1% and 100%, respectively. The diag- higher yield with EBUS - TBNA [5] . The sensitivity of nostic accuracies were 60.8%, 72.5% and 98% [6] , 60 CHAPTER 6 Endoscopic Ultrasound-Guided Mediastinal Lymph Node Aspiration respectively, for the three modalities. Therefore, Table 6.2 Accessibility of lymph node stations by different modalities EBUS - TBNA has better sensitivity and specifi city than either CT or PET scanning in staging mediastinal Modality Accessible lymph node stations disease in lung cancer. Standard Superior mediastinal, subcarinal mediastinoscopy Stations 1, 2, 3, 4 and 7 References Extended Aortic nodes 1 Kramer H , G roen H JM . Current concepts in the medias- mediastinoscopy Stations 5 and 6 tinal lymph node staging of non - small cell lung cancer. Anterior Aortic nodes Ann. Surg 2003 ; 238 : 180 – 188 . mediastinoscopy * Stations 5 and 6 2 Eloubeidi M A , C erfolio R I , C hen V K , et al. E ndoscopic ultrasound - guided fi ne needle aspiration of mediastinal VATS Superior mediastinal (right), lymph node in patients with suspected lung cancer after subcarinal, and aortic nodes positron emission tomography and computed tomogra- Stations 1, 2R, 3, 4R, 7, 5 and 6 phy scans. A nn Thorac Surg 2005 ; 79 : 263 – 268 . TBNA Superior mediastinal, subcarinal, N1 3 Yasufuku K , Chiyo M , Sekine Y , Chhajed PN , nodes Shibuya K , et al. Real - time endobronchial ultrasound - Stations 1, 2, 3, 4, 7, 10, 11 and 12 guided trans- bronchial needle aspiration of mediastinal and hilar lesions. Chest 2004 ; 126 : 122– 128 . TTNA Superior mediastinal (anterior) 4 Herth FJ , Eberhardt R , Vilmann P , Krasnik M , Ernst A . Stations 1, 2, 3 and 4 Real - time endobronchial ultrasound- guided transbron- EUS - FNA Left lower paratracheal, subaortic, chial needle aspiration for sampling mediastinal lymph inferior mediastinal nodes . Thorax 2006 ; 61 : 795 – 798 . Stations 4L, 7, 8 and 9 5 Yasufuku K Nakajima T , Motoori K , Sekine Y , Shibuya K , et al. Comparison of endobronchial ultrasound, posi- EBUS - TBNA Superior mediastinal, subcarinal and tron emission tomography, and CT for lymph node N1 nodes staging of lung cancer. Chest 2006 ; 130 : 710 – 718 . Stations 1, 2, 3, 4, 7, 10, 11 and 12 6 Mountain C F , D resler C M . Regional lymph node classi- fi cation for lung cancer staging . Chest 1 997 ; 111: * Chamberlain procedure. 1718 – 1723 . 61 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography logical fi ndings in cases of cystic tumor, calcifi cation, Introduction and pancreatic stones [ 12,13] . Currently there are few published comparative Numerous studies have shown that high frequency, analyses of the internal structure of peripheral pulmo- two - dimensional ultrasonography is a useful tech- nary lesions as visualized by EBUS and the histopatho- nique for evaluating the depth of invasion of gastroin- logical fi ndings, so this section will rely largely on our testinal tumors, detecting lymph node metastasis, and own results. identifying coronary arterial stenosis and thrombosis [1 – 5] . Since 1994, we have engaged in the develop- ment of endobronchial ultrasonography (EBUS) [ 6 – 7] , Correlation between Preoperative including the localization of peripheral pulmonary EBUS Scans and Histopathological lesions during endobronchial brushing and transbron- Examination of Peripheral chial biopsy (TBB). In addition to EBUS localizing a Pulmonary Lesions lesion the analysis of the images can be useful in terms of suggesting the underlying pathology. Concepts of We reviewed the records of patients who underwent the qualitative analysis of the internal structure of diagnostic preoperative EBUS for a peripheral pulmo- peripheral pulmonary lesions as visualized by EBUS nary lesion where a surgical specimen was available have been developed by comparing these fi ndings to be sectioned. The histopathological fi ndings were with the histopathological fi ndings (Figure 7 .1 ). The correlated with the internal structure of the lesions as aim of this study is to improve the criteria for distin- visualized by EBUS. guishing between benign and malignant peripheral Most cases of well- differentiated adenocarcinoma pulmonary tumors. showed preservation of blood vessels within the lesion EBUS uses high- frequency ultrasound (20 MHz) to using EBUS (Video clip 7.1). These lesions had homog- create detailed images of the internal structure of enous internal echoes overall, but some hyperechoic lesions [ 8 – 11] , although it cannot delineate tissues dots (less than 1 mm in size) were also seen, represent- external to the lesion. Endoscopic ultrasonography ing residual air in invaded alveoli. The distribution of has been used to examine the internal structure of the the hyperechoic dots was irregular, as were the pancreas, the results correlating well with histopatho- margins of the lesions. Blood vessels could be seen coursing through the lesions (Figure 7.2 ). In some cases of well- differentiated adenocarci- noma, no blood vessels were visualized. These lesions Endobronchial Ultrasonography, 1st edition. also presented an irregular distribution of hyperechoic By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. dots or arcs around the probe and had poorly defi ned Published 2011 by Blackwell Publishing Ltd. borders. 62 CHAPTER 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography EBUS Histopathological findings Figure 7.1 Qualitative analysis of the internal structure of peripheral pulmonary lesions as visualized by EBUS, comparing these fi ndings with the histopathology fi ndings. Figure 7.2 A representative case of well - differentiated adenocarcinoma. Most cases of well - differentiated adenocarcinoma show preservation of blood vessels within the lesion using EBUS. Blood vessels could be seen coursing through this lesion. In most cases of moderately differentiated adenocar- In one case of moderately differentiated adenocarci- cinoma and squamous cell carcinoma, EBUS images noma, numerous very small hyperechoic echoes showed obstruction of blood vessels within the lesions, were observed within the lesion, their distribution obstruction of bronchi, heterogenous internal echoes, identical to that of the multiple calcifi cations observed and irregular margins (Figure 7.3 , Video clip 7.2). histopathologically (Figure 7 .4 ). In some cases of 63 Endobronchial Ultrasonography Figure 7.3 A representative case of moderately- differentiated adenocarcinoma. In most cases of moderately differentiated adenocarcinoma and squamous cell carcinoma, the EBUS images show obstruction of blood vessels within the lesion, obstruction of bronchi, heterogenous internal echoes, and irregular margins. Figure 7.4 In this case of moderately differentiated adenocarcinoma, numerous very small hyperechoic echoes are observed within the lesion, their distribution identical to the multiple calcifi cations observed histopathologically. 64 CHAPTER 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography squamous cell carcinoma, numerous anechoic areas of bronchus, resulting in stenosis of the pulmonary artery various sizes were noted, their distribution corre- within the lesion (Figure 7 .7 , Video clip 7.5). In some sponding to areas of necrosis (Figure 7 .5 , Video clip cases of carcinoid, the tumor arises in the bronchial 7.3). Squamous cell carcinoma sometimes showed a wall and grows across the bronchial lumen, resulting circumferential hyperechoic line around the probe in a characteristic snowman - like form, with the neck corresponding to the bronchial wall, caused by tumor located at the cartilaginous part of the bronchus. growth and outward compression of the bronchial Bleeding within the carcinoid appears as mottled adventitia (Figure 7.6 , Video clip 7.4). Most cases of hyperechoic areas on the EBUS image (Figure 7.8 ). poorly differentiated adenocarcinoma on EBUS Homogenous internal echoes are seen in cases of showed heterogenous internal echoes, irregular primary malignant lymphoma of the lung, with an margins, and few patent blood vessels or bronchi. appearance similar to that of pneumonia. Large blood This small nodular small cell carcinoma has directly vessels remain patent within the lesions, indicating invaded the pulmonary artery adjacent to the affected that the lesions are soft. Figure 7.5 In this case of squamous cell carcinoma, numerous anechoic areas of various sizes are seen, their distribution corresponding to areas of necrosis. Figure 7.6 Outward compression of the bronchial adventitia on EBUS image. Squamous cell carcinoma sometimes shows a circumferential hyperechoic line around the probe corresponding to the bronchial wall, caused by tumor growth and outward compression of the Bronchial cartilage bronchial adventitia. 65 Endobronchial Ultrasonography Figure 7.7 This small nodular small cell carcinoma has directly invaded the pulmonary artery adjacent to the affected bronchus, resulting in stenosis of the pulmonary artery within the lesion. Figure 7.8 This carcinoid tumor arises in the bronchial wall and grows across the bronchial lumen, resulting in a characteristic snowman- like form, with the neck located at the cartilaginous part of the bronchus. Bleeding within the carcinoid can be seen as mottled hyperechoic areas in the EBUS images. Anechoic areas with star - shaped margins are visible within the lesion in this case of infl ammatory pseudo- Internal Structure of Lesions Visualized tumor, corresponding to the lumen of the dilated by E BUS by Histological Subtype bronchus (Figure 7.9 ). In contrast to histopathology, EBUS enables visualiza- We found that EBUS can clearly visualize internal tion of the internal structures of peripheral pulmonary structures of peripheral pulmonary lesions, including lesions, such as vessels, bronchioles, bleeding, calcifi ca- vessels, bronchioles, compressed alveolar air within tions, bronchial dilatation, and necrosis (Figure 7.10 ). lesions, calcifi cations, necrosis, and the homogeneity/ 66 CHAPTER 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography Figure 7.9 A representative case of infl ammatory pseudotumor. Echolucent areas with star- shaped margins are visible within the lesion in this case of infl ammatory pseudotumor, corresponding to the lumen of the dilated bronchus. internal structure of these lesions was analysed, and Calcification Bleeding lesions were typed based on these fi ndings. Bronchiole Lesions were typed based on internal echo pattern (homogenous or heterogenous), vascular patency, Dilatation of Vessel and the morphology of hyperechoic areas (refl ecting bronchus the presence of air and the state of the bronchi) Multiple cysts W/D (Figure 7.11 ). Adenoca Type I : Homogenous Pattern Type I a : Homogenous Pattern with Patent Vessels and Patent Bronchioles (Figure 7.12 , Video clip 7.6) Figure 7.10 Visualization of the internal structure of peripheral The majority of these cases were pneumonia, charac- pulmonary lesions. In contrast to histopathology, using EBUS we terized by exudate - fi lled alveoli. EBUS images of this are able to visualize the internal structure of peripheral type revealed normal blood vessels and bronchi, free pulmonary lesions, including blood vessels, bronchioles, of compression or stenosis, within the lesion. The haemorrhage, calcifi cations, bronchial dilatation, and necrosis. internal echoes were homogenous. There was there- fore little ultrasonic attenuation, and even tissue 15 to heterogeneity of the ultrasonic pattern. Tumor typing 20 mm from the probe could be seen clearly. Because based on the internal structure as visualized by EBUS lesions extend from one lobule to another, the margins can assist in distinguishing between benign and malig- were linear in some areas. nant tumors, and assessment of the degree of differ- entiation. We conducted tumor typing based on the Type I b : Homogenous Pattern with No tumor internal structure as visualized by high resolu- Patent Vessels or Bronchioles (Figure 7.13 ) tion EBUS. No blood vessels were seen within these lesions using We were able to visualize the lesion in 143 out of EBUS. Mottled or linear hyperechoic areas were 168 patients (85.1%) with a peripheral pulmonary scarce. The internal echoes were homogenous. As lesion who underwent EBUS. Of these a defi nitive with Type

Ia, there was little ultrasonic attenuation, tissue diagnosis was obtained in 124 (73.8%). The and even tissue 15 to 20 mm from the probe could be 67 Endobronchial Ultrasonography Type II; hyperechoic dots Type I; homogenous Type III; heterogenous and linear arcs Patent vessels and Without vessels With hyperechoic Without hyperechoic Without vessels With patent vessels patent bronchioles and bronchioles dots and short lines dots and short lines I a II a III a I b II b III b Figure 7.11 Type classifi cation of peripheral pulmonary lesions. II: hyperechoic dots and linear arcs pattern; Type IIa: hyperechoic Lesions are typed based on internal echo pattern (homogenous dots and linear arcs with no patent vessels; Type IIb: hyperechoic or heterogenous), vascular patency, and the morphology of dots and linear arcs with patent vessels. Type III: heterogenous hyperechoic areas (refl ecting the presence of air and the state of pattern; Type IIIa: heterogenous pattern with hyperechoic dots, the bronchi). Type I: homogeneous pattern; Type Ia: homogenous and short lines; Type IIIb: heterogenous pattern without pattern with patent vessels and patent bronchioles; Type Ib: hyperechoic dots or short lines. homogenous pattern with no patent vessels or bronchioles. Type Type I a; homogenous pattern with patent vessels and patent bronchioles Figure 7.12 EBUS of Type Ia lesion. This EBUS image shows normal blood vessels and bronchi, free of compression or stenosis, within the lesion. The internal echoes are homogenous. 68 CHAPTER 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography Type I b; homogenous pattern without vessels and bronchioles Figure 7.13 EBUS of Type Ib lesion. In this EBUS image, no patent blood vessels are seen within the lesion. Few mottled or linear hyperechoic areas are visible. The internal echoes are hypoechoic and homogenous. Type II a; hyperechoic dots and linear arcs without vessels Figure 7.14 EBUS of Type IIa lesion. In this EBUS image, no blood vessels could be visualized within the lesions. Hyperechoic dots (less than 1 mm in diameter) or hyperechoic linear arcs (primarily around the probe) were distributed irregularly within the lesions. seen clearly. The Type Ib group mainly included cases larly within the lesions. The presence of residual air of organising pneumonia and tuberculomas. in alveoli is characteristic of well - differentiated adeno- carcinoma, which grows to replace the alveolar epi- Type II : Hyperechoic Dots and Linear thelium. The air remaining in the alveoli hampered Arcs Pattern visualization of blood vessels within the lesions and Type II a : Hyperechoic Dots and Linear obscured the margins of the lesions. Arcs with No Patent Vessels (Figure 7.14 , Video clip 7.7) Type II b : Hyperechoic Dots and Linear Arcs Most cases were well- differentiated adenocarcinoma with Patent Vessels (Figure 7.15 , Video clip 7.8) which had replaced the alveolar epithelium. No blood The majority of cases were well- differentiated adeno- vessels could be visualized within the lesions using carcinoma which had proliferated and replaced the EBUS. Hyperechoic dots or hyperechoic linear arcs alveolar epithelium while preserving the blood vessels (primarily around the probe) were distributed irregu- within the lesion. In the EBUS images, the blood 69 Endobronchial Ultrasonography Type II b; hyperechoic dots and linear arcs with patent vessels Figure 7.15 EBUS of Type IIb lesion. In this EBUS image, blood vessels, almost free of compression or stenosis, are visible within the lesion, and the internal echoes are relatively homogenous. Hyperechoic dots (less than 1 mm in diameter) are distributed irregularly within the lesions, corresponding to the presence of residual air in the alveoli. Type III a; heterogenous pattern with hyperechoic dots, and short lines Figure 7.16 EBUS of Type IIIa lesion. The majority of cases are moderately differentiated adenocarcinomas that grow with a relatively high cell density and form a mass. No blood vessels are seen within the lesion using EBUS. Areas of mottling and linear hyperechoic areas are irregularly distributed within the lesion, corresponding to compressed or stenotic bronchi or alveolar air. vessels showed little or no compression or stenosis Type III : Heterogenous Pattern within the lesion, and the internal echoes were rela- Type I II a : Heterogenous Pattern with tively homogenous. Hyperechoic dots, distributed Hyperechoic Dots, and Short Lines (Figure 7 .16 ) irregularly within the lesions, corresponded to resid- The majority of cases were moderately differentiated ual air in the alveoli, a characteristic of well- adenocarcinoma which had grown with a relatively differentiated adenocarcinoma. The density of cancer high cell density and had formed a mass. No blood cells was higher and the volume of air remaining in vessels were seen within these lesions using EBUS. alveoli was smaller in Type IIb than in Type IIa, well - Areas of mottling and linear hyperechoic areas were differentiated adenocarcinoma. The margins were irregularly distributed within the lesion, correspond- irregular because the lesions grew, without any rela- ing to compressed or stenotic bronchi or alveolar tionship to existing structures. air. The internal echoes were heterogenous, with 70 CHAPTER 7 Qualitative Analysis of Peripheral Pulmonary Lesions Using Endobronchial Ultrasonography markedly attenuated sound wave transmission, so that bronchi and blood vessels can be seen as they only areas about 6 to 8 mm from the probe could be cross peripheral pulmonary lesions. The advantage of visualized clearly. Because the lesions spread in a MRI is that it is less invasive than EBUS, but the random manner, without extension along lung struc- images are of poorer quality because the beating heart tures, the margins of the lesions often were rounded. and breathing introduce motion artefacts. Moderately differentiated squamous cell carcinoma There have been a number of reports of the use of presented numerous anechoic areas corresponding to miniature ultrasound probes for diagnosing peripheral areas of necrosis within the tumor, which is charac- pulmonary lesions. H ü rter et al. [10] reported success- teristic of squamous cell carcinoma. ful visualization of peripheral lung lesions in 19 out of 26 cases, and Goldberg and colleagues [ 11] reported Type III b: Heterogenous Pattern without that EBUS provided unique information that comple- Hyperechoic Dots or Short Lines (Figure 7.17 , mented other diagnostic modalities in 18 out of 25 Video clip 7.9) cases (including six peripheral lesions and 19 hilar The majority of cases were poorly differentiated tumors). adenocarcinoma, which had a high cell density and Hosokawa et al. [ 17] reported that a typical EBUS had formed a mass. The lesions were avascular and pattern of neoplastic disease was: (1) continuous mar- showed scant mottled or linear hyperechoic areas. The ginal echo; (2) rough internal echoes; and (3) no internal echoes were heterogenous. Since the lesions hyperechoic spots representing bronchi, or no longi- extend outward, their margins tend to be roundish. tudinal continuity if present. Kuo et al. [18] assessed We reported 92.0% of Type I lesions were benign, the feasibility of EBUS in differentiating between and 99.0% of Type II and III lesions were malignant. benign and malignant lesions using the following Well -d ifferentiated adenocarcinoma accounted for three characteristic ultrasonic features indicating 88% of Type II lesions, whereas all Type IIIb cases malignancy: continuous margin, absence of a linear- were malignant, including 81.8% poorly differenti- discrete air bronchogram, and heterogenous echo- ated adenocarcinoma. genicity. The negative predictive value for malignancy Some investigators have reported that dynamic of a lesion with none of these three echoic features is magnetic resonance imaging (dynamic MRI) provides 93.7%. The positive predictive value for malignancy information on enhancement patterns of peripheral of a lesion with any two of these three echoic features pulmonary lesions [14,15]. Awaya et al. [ 16] reported is 89.2%. Type III b; heterogenous pattern without hyperechoic dots and short lines Figure 7.17 EBUS of Type IIIb lesion. In this EBUS image, the lesion is avascular, and few mottled or linear hyperechoic areas can be seen. The internal echoes are heterogenous. 71 Endobronchial Ultrasonography We developed our classifi cation system with the aim 4 Rosch T. Endoscopic ultrasonography. Endoscopy of distinguishing between benign and malignant 1992 ; 24 : 144 – 153 lesions, identifying the type of lung carcinoma, and 5 Murata Y , Muroi M , Yoshida M , et al. E ndoscopic ultra- determining the degree of differentiation. sonography in diagnosis of esophageal carcinoma. S urg Although CT and MRI scans have been used for Endsc 1987 ; 1 : 11 – 16 . 6 Kurimoto N , M urayama M , Y oshioka S , et al. A ssessment qualitative diagnosis of peripheral pulmonary lesions, of usefulness of endobronchial ultrasonography in ultrasonograms have the following advantages. The determination of depth of tracheobronchial tumor inva- guide sheath can be used to determine the following: sion . Chest 1999 ; 115 : 1500 – 1506 . 1 Patency of microvasculature within the lesion. 7 Miyazu Y , Miyazawa T , Iwamoto Y , et al. T he role of 2 The distribution of micropneumatosis (small white endoscopic techniques, laser- induced fl uorescence dots) within the lesion. endoscopy, and endobronchial ultrasonography in 3 The existence of anechoic areas corresponding to choice of appropriate therapy for bronchial cancer. necrosis within the lesion. J Bronchol 2000 ; 8 : 10 – 16 . 4 The echo strength within the lesion. 8 H ü rtur Th , Hanrath P . E ndobronchial sonography: fea- In particular, the echo strength within lesions visual- sibility and preliminary results . Thorax 1992 ; 47 : ized by 20 MHz high frequency ultrasonography varies 565 – 567 . 9 Becker H . E ndobronchialer Ultraschall - eine Neue according to factors such as the distribution and Perspektive in der Bronchologie . Ultraschall in Med density of tumor cells, presence of mucous, and inter- 1996 ; 17 : 106 – 112 [in German]. stitial hyperplasia within the lesion. The echo strength 10 H ü rter T h , H anarath P . Endobronchiale Sonographie depends on the extent that ultrasound waves are zur Diagnostik Pulmonaler und Mediastinaler Tumoren . refl ected at interfaces between tissue types. Tumors Dtsch Med Wschr 1990 ; 1899 – 1905 [in German]. with increased cell density, e.g. poorly differentiated 11 Goldberg B , Steiner R , Liu J , et al. U S - assisted bronchos- adenocarcinoma, produce a comparatively weak echo. copy with use of miniature transducer - containing cath- Bronchioloalveolar carcinoma (mucinous type), diffi - eters . Radiology 1994 ; 190 : 233 – 237 . cult to distinguish from pneumonia using CT scan- 12 Yasuda K , Mukai H , Nakajima M , et al. S taging of pan- ning, produces a stronger echo than pneumonia using creatic carcinoma by endoscopic ultrasonography . high frequency ultrasonography at 20 MHz. The Endoscopy 1993 ; 25 : 151 – 155 . 13 Rosch T , Braig C , Gain T , et al. S taging of pancreatic reason for this is unclear, but is suspected to be due and ampullary carcinoma by endoscopic ultrasonogra- to viscous mucous, or to increased refl ection from phy . Gastroenterology 1992 ; 102 : 188 – 199 . neoplastic tissue in the alveolar septa. 14 Kusumoto M , Kono M , Yamasaki K , et al. Pulmonary EBUS provides a new way to visualize the internal nodules: quantitative assessment with contrast - structure of peripheral pulmonary lesions. Classifi cation enhanced MR imaging. Radiology 1995 ; 197 : 232 . of the EBUS images suggests the pathology and 15 Guckel C , Schnabel K , Deimling M , et al. S olitary pul- histology. monary nodules: MR evaluation of enhancement pat- terns with contrast - enhanced dynamic snapshot gradient - echo imaging. Radiology 1996 ; 200 : 681 – 686 . References 16 Awaya H , Matsumoto T , Miura G , et al. E valuation of internal characteristic in small adenocarcinoma by MR 1 Grimm H , Binmolleller KF , Hamper K , et al. imaging . J pn J Radiol 2000; 45 : 47 – 57 . Endosonography for preoperative locolesional staging 17 Hosokawa S , Matsuo K , Watanabe Y , et al. Two cases of esophageal and gastric cancer. E ndoscopy 1993 ; 25 : of nodular lesions in the peripheral lung fi eld, success- 224 – 230 . fully diagnosed by endobronchial ultrasonography 2 Abe S , L ifhtdale C J , B rennan M F

. The Japanese experi- (EBUS) . Kokyuu 2004 ; 23 : 57 – 60 . ence with endoscopic ultrasonography in staging 1 8 Kuo C , Lin S , Chen H , et al. Diagnosis of peripheral lung of gastric cancer. G astrointest Endosc 1993 ; 39 : 536 – 541. cancer with three echoic features via endobronchial 3 Murata Y , M uroi M , A kimoto S , et al. Evaluation of ultrasound . Chest 2007 ; 132 : 922 – 929 . ultrasonography for the diagnosis of submucosal tumors of esophagus. S urg Endosc 1988 ; 2 : 51 – 58 . 72 8 EBUS - Guided Peripheral Pulmonary Nodule Biopsy bronchoscope [5] . This allowed ease of biopsy once Introduction the probe had been removed by simply passing forceps and brushes into the location found by the ultrasound The adaptation of ultrasound miniprobes to broncho- miniprobe prior to its removal. Further refi nements scopic diagnosis was an important step forward in have included the use of virtual bronchoscopy to aid bronchoscopy. It grew out of a need for an improved in tracking the bronchial openings which give the best way to biopsy peripheral lung nodules which tradi- access to the lesion [6] . Also, whilst the traditional tionally had been performed just with X- ray guidance means of performing this type of biopsy has been with [1,2] . Ultrasound miniprobes had previously been X - ray fl uoroscopy, with greater experience some used in the large airways; however a fl uid- fi lled authors advocate that fl uoroscopy may not be neces- balloon sheath was required to allow for a probe – sary in performing this technique [7] . Finally, the tissue interface [ 3] . An important understanding in aspect of ultrasound diagnosis by interpretation of the allowing the development of the peripheral lung mini- ultrasound images can be useful to give a qualitative probe was that no balloon sheath was required in the impression of malignancy versus benign disease and, periphery of the lung [4] . This was somewhat counter- in selected situations, may add to the histological intuitive given the air - rated structure of the lung; samples obtained [8,9] . however, there was an excellent ultrasound image obtained when the ultrasound miniprobe was placed bronchoscopically within peripheral lung lesions. Conventional Transbronchial Lung Biopsy Because of the small caliber of the bronchial airways in the periphery, the ultrasound probe was applied There has always been the need to biopsy lesions directly to the lesions and no balloon- sheath fi lled beyond the reach of a bronchoscope and the standard with water was required. It was also noted that when method has been to use X- ray fl uoroscopy with a the probe was in a bronchus surrounded by normal brush or biopsy forceps passed under X- ray guidance air - fi lled lung, there was just artifact image on the into the lesion as seen on X - ray fl uoroscopy. For best ultrasound monitor and therefore it was easy to dis- results, the X - ray fl uoroscopy is usually performed in criminate between normal and abnormal tissue. The two planes and this may be achieved by rotating the next step was the use of a guide sheath – into which fl uoroscopy C arm or altering the patient’ s position the thin caliber miniprobe could be deployed. Both the during the procedure with the bronchoscope in situ. miniprobe and the guide sheath could therefore be For lesions of 3 cm or less, there can be considerable inserted as one into the biopsy channel of the standard misjudgment of the placement of the forceps in respect of the actual lesion. Furthermore, it is not uncommon for small lesions to be totally invisible on X- ray fl uor- oscopy, particularly those close to the diaphragm and Endobronchial Ultrasonography, 1st edition. adjacent to the cardiac borders. High apical lesions By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. may also be diffi cult to visualize. Perhaps for these Published 2011 by Blackwell Publishing Ltd. reasons, there is a wide variation in overall sensitivity 73 Endobronchial Ultrasonography Table 8.1 Standard TBLB x studies. Reference Year n Lesion size < 2 cm % Sensitivity Pneumothorax % Bleeding % Popovich 1982 20 75% Fletcher 1982 101 6/21(28%) 36% 5(5%) 4(4%) Stringfi eld 1977 29 1/3(33%) 48% Radke 1976 97 0% 56% Wallace 1982 143 3/65(5%) 19% Hanson 1976 164 57% 7(4%) 15(9%) Shiner 1988 71 0 70% 1(1%) 3 hemoptysis(4%) Torrington 1993 30 9% Chechani 1996 49 6/11(55%) 72% 3(6%) severe, 6/49 moderate (12%) of this method with yield between 18 and 75% made in six of 11, 12 of 21, and 24 of 30 lesions [10 – 12] . Because of the requirement to move the C respectively [2] . Overall, from 49 bronchoscopies, arm of the patient, it can be cumbersome and time lesions which had a positive diagnosis had a mean consuming, and some radiation is always delivered to lesion diameter of 4.55 cm compared to lesions which the patient, and to a much lesser extent into the bron- were negative on biopsy which had a lesion diameter choscopy room. of 3.14 cm. In peripherally placed carcinomas, Shiner A number of studies have looked at the effi cacy of et al. showed that lesions 2– 4 cm in size, 4– 6 cm, and standard transbronchial lung biopsy for peripheral 6 – 8 cm had positive diagnoses made in nine of 13, 10 solitary pulmonary nodules (Table 8 .1 ). These pre - of 15, and two out of three lesions [14] . This series date EBUS guide sheath biopsy, from as early as 1976. excluded data from lesions less than 2 cm in size. One small retrospective study only evaluated a diag- Fletcher ’ s series lesions 2– 4 cm in size had a 40% nostic effi cacy for malignancy which was 9% [ 13] . yield, and those greater than 4 cm had a 63% yield [ 15] . The range of diagnostic effi cacies no doubt was due to Chechani et al. commented that certain pulmonary different combinations of malignant and benign segments of the bronchial tree were diffi cult to visual- disease, variable size and location of the lesions, the ize on fl uoroscopy. This is the common experience of extent to which the lesions were biopsied, incorporat- most bronchoscopists, including when dealing with ing some or all of the techniques of bronchoalveolar the basal segments of the lower lobes and the apical lavage, bronchial brushings, biopsies, and transbron- segments of the upper lobes [ 2] . An interesting chial needle aspiration. comment from Chechani et al. was that “ lesions which Typical sensitivities for lesions of less than or equal had sharp borders on X - ray had a poorer diagnostic to 2 cm in size ranged from 5% up to 55% and most rate (54%) compared to lesions which had fuzzy studies commented that there was a signifi cant reduc- borders (83%) or cavitating (100%) ” . They postulated tion in diagnostic effi cacy below 2 cm in size. Obviously, that the reason for this was that the more sharply small size would mean diffi culty in visualizing the demarcated lesions were not likely to be intra - luminal. lesion on X - ray fl uoroscopy in two planes. In one This included both benign lesions and metastatic study by Chechani, lesions less than 2 cm, less than deposits and with these there was a recommendation 3 cm, and greater than 3 cm had positive diagnoses that the transbronchial needle aspiration approach 74 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy should be used in an attempt to cross the bronchial account of the ultrasound characteristics of malignant wall into the lesion. This is mentioned by other authors and benign lesions [5] . This included cases analysed performing endobronchial ultrasound techniques as preoperatively with an ultrasound miniprobe passed discussed below. into the lesion bronchoscopically prior to surgical With respect to pneumothorax rate, where reported, resection. There was close correlation between the the incidence was between 1% and 5% [ 15] . Bleeding ultrasound image and anatomical structures such as complications were not uncommon. In one series by bronchi and small blood vessels within the lesion. As Chechani, three out of 48 patients (6%) had severe discussed below, a detailed scheme of analysis of the bronchial bleeding [2] . In addition to this, moderate internal structures was described and the potential for bleeding was seen in six out 40 cases that had trans- interpretation of ultrasound images in tissue diagnosis bronchial lung biopsies and three of 48 cases that had was raised. Both of these series used the 20 MHz mini- transbronchial brushes. In another series by Blascow probes from Olympus. These were radial probes, either in 169 patients with solitary pulmonary nodules, three UM - 3R or UM- 20 - 26R. patients had bleeding of more than 100 mL after the In 2004, Kurimoto published a series describing the biopsy [16] . Fletcher et al. also reported a 4% inci- addition of the guide sheath, the plastic sheath into dence of severe bleeds. There were no mortalities which the ultrasound miniprobe was passed prior to reported; however the extent of the bleeding is quite insertion down the biopsy channel of the broncho- different from that observed in endobronchial ultra- scope [9] . This was coupled with the introduction of sound as discussed below [ 15] . the thinner 20 MHz radial probe (UM- S20 - 20R). This probe itself had an outer diameter of 1.7 mm and, Method and Equipment combined with the guide sheath, meant that it could History be inserted into a 2 mm working channel of a fi ber- The possible role of ultrasound miniprobes in evaluat- scope. This smaller probe demonstrated its fl exibility ing and biopsying peripheral lung lesions was demon- in terms of accessing the subsegments of the smaller strated by Hurther [17] and Goldberg [ 18] . Both upper lobes which had more acute angles; in the pre- recognized the potential for ultrasound miniprobes in vious studies it had been diffi cult to access these with the lung which had previously been used in other the slightly larger caliber UM - 3R miniprobe. This specialties of gastroenterology and urology. Goldberg study also demonstrated the practical benefi ts of the demonstrated that 15 out of 25 peripheral lung lesions, guide sheath when coupled with the miniprobe with most less than 3 cm in diameter, could be localized virtually nil evidence of bleeding and facilitation of with an ultrasound probe. The characteristics of the multiple biopsies at the same site. solid tumor, blood vessels within the tumor, and air The next step was the addition of pre - procedure artifact within normal lung, were demonstrated. In evaluation of the patient using virtual bronchoscopy that series, there was no guide sheath used and the CT images [6] . By tracking the path that the broncho- biopsy point was simply determined by the position of scope and probe would take out towards the lesion the ultrasound miniprobe within the lesion and with virtual bronchoscopy, it was demonstrated that recorded by fl uoroscopy. Quite correctly, both authors choice of the correct bronchial segment could be foresaw the potential for this method in its simplicity improved. and inherent safety. In 2002, there were two publica- tions which further elucidated the benefi ts of this Equipment technique. Herth, Ernst and Becker demonstrated, in The most commonly used miniprobe for EBUS directed a prospective series of 50 patients, the ability of endo- peripheral nodule biopsy is the 20 - 20R Olympus bronchial ultrasound miniprobe biopsies to yield a Miniprobe, usually the 1.7 mm diameter probe with similar success rate to fl uoroscopic guidance (80% accompanying guide sheath. Prior to inserting this into versus 76%) [2] . This demonstrated fi rst the accurate the guide sheath, it is necessary to calibrate the biopsy localization of the lesions by EBUS, but also the forceps and brush forceps to the length of the plastic advantage that far less radiation exposure would be guide sheath. This allows the forceps to be inserted up required. Also in 2002, Kurimoto published a detailed

to a pre- marked point when the guide sheath is in situ 75 Endobronchial Ultrasonography in the lesion in the lung. This pre - marked point is sheath in the desired direction. Having obtained an simply made by placing adhesive tape on the proximal improved position in this way, the ultrasound mini- end of the forceps or brush at the point where the probe is re - inserted and moved to the best position distal end is either just protruding from the end of the based on the ultrasound image. plastic sheath in the case of the forceps, or just at the Usually the point at which the ultrasound images tip of the sheath in the case of the brush. Lastly, prior are best can be saved with a fl uoroscopy picture and to commencing the procedure, the ultrasound mini- the C arm kept stationary. If fl uoroscopy is used in this probe is placed inside the sheath and taped with way, it is possible to simply leave the guide sheath in double - ended adhesive tape. This stops the miniprobe place and advance fi rst the brush and then the biopsy slipping back into the sheath as it is passed out from into position. Fluoroscopy can be shown to demon- the end of the bronchoscope into the selected bron- strate the brush and biopsy actually taking the samples, chus. The double - ended tape means that the tape can so that it is clear that each of these have exited from be removed simply once the lesion has been located. the end of the plastic sheath. It is also a further check Now the guide sheath is available with dedicated that the parietal pleura is not being breached by these rubber markers to simplify this preparation. biopsy methods. Some centers do not advocate doing A 2.8 mm biopsy channel bronchoscope is required this to minimize fl uoroscopy exposure, given the for this procedure. It is very important to select the excellent results of the procedure done completely segmental or subsegmental bronchus which is consid- without any form of fl uoroscopy [7,19] . ered to lead most directly to the lesion in question. Having taken the necessary samples, the brush and This is determined by careful scrutiny of the CT scan biopsy forceps are removed in turn and the guide prior to the procedure. The ultrasound miniprobe in sheath is usually left in place for 1 – 2 minutes. This is the guide sheath is passed gently out into this bron- an extremely effective way to tamponade any bleed- chus towards the periphery of the lung until a slight ing from the segmental bronchus simply because the resistance is felt suggesting proximity to the visceral caliber of the sheath is usually equivalent to the caliber pleura, similar to the procedure of a standard trans- of the biopsied bronchus. Then, under bronchoscopic bronchial lung biopsy. It is possible to perform this vision, the guide sheath is carefully and slowly part of the procedure with fl uoroscopy guidance to removed, watching for bleeding in the usual way as prevent the miniprobe being passed out too far. Once one would after completion of a transbronchial lung this slight resistance is felt, the ultrasound probe is biopsy. Following the procedure, X - ray fl uoroscopy turned on by the foot pedal and slowly pulled back as can be used if available to confi rm the absence of an ultrasound pictures are obtained. Once a clear image immediate pneumothorax, and it is usually desirable is obtained, it is usual to pull the ultrasound probe to perform a departmental chest X- ray to exclude back to the proximal extent of the lesion. This is so pneumothorax after an interval of 1 – 2 hours. that biopsy forceps, when passed back down the guide More recent refi nements have included the adop- sheath, are not passed too far beyond the lesion, tion of even smaller miniprobes (1.5 mm diameter rather opening into the middle of the lesion. On occa- with a 1.7 mm bronchoscopic sheath) to go down sions, the lesion in question is only imaged peripher- the biopsy channel (2 mm diameter) of a pediatric ally, as opposed to having the lesion fully surrounding video bronchoscope (4– 4.9 mm) [20] . This has been the miniprobe. In this situation, it is best to pull the shown to further improve access into the smaller sub- miniprobe back and re - advance into an adjacent sub- segments at greater angles. These smaller miniprobes segmental bronchus, preferably done under broncho- use dedicated smaller caliber biopsy forceps and scopic vision. Sometimes only slight adjustment in this brushes. way can greatly improve the ultrasound image. Some centers use a curette passed into the guide sheath to facilitate that purpose. To do this, the ultrasound mini- Clinical Trials probe must be removed from the guide sheath and the curette passed out with angulation of the curette used The advent of endobronchial ultrasound transbron- under fl uoroscopy guidance, in order to turn the guide chial lung biopsy has been an important milestone in 76 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy the expansion of bronchoscopic techniques, in some within the lesion. This is, once again, indicative of the of the larger studies performed in various methods ability of ultrasound to locate these very small lesions. of bronchoscopy. These studies are summarized in If fl uoroscopy was not able to localize the lesion, the Table 8.2 . yield was still 74% in terms of positive histology; those The fi rst prospective study was published in 2002 small lesions where fl uoroscopy could detect the by Herth, Ernst and Becker [ 4] . The aim of this study lesion had a 67% positive histology rate. The guide was to determine the added benefi t of using ultra- sheath was left in place for two minutes after the sound compared to standard transbronchial lung biopsies in an attempt to prevent any bleeding after biopsy. Guide sheath was not used in this early study. the biopsies. Careful quantitation of bleeding was The study design was to perform both ultrasound and undertaken in this last study and, in only two patients standard fl uoroscopy- guided transbronchial lung (1%), was there moderate bleeding estimated as biopsy in each patient. The results were excellent with between 30 and 50 mL of blood, which was self - EBUS biopsies providing a tissue diagnosis in 40 limiting and did not affect the patient ’ s oxygenation patients (80%) and showed a signifi cant improvement status. The overall procedure time was not signifi - compared to standard fl uoroscopy biopsies in lesions cantly prolonged by the EBUS guide sheath proce- less than 3 cm in size where the overall diagnostic rate dure. The total procedure time was 9 minutes with the was still 80% compared to 57% for fl uoroscopically mean time of use of ultrasound being only 1 minute, guided biopsies. An important aspect was that the time and the mean time for use of fl uoroscopy also being for the EBUS- guided transbronchial biopsy was close 1 minute. to the time for the procedure performed with fl uoros- Also in 2004 Shirakawa reported 50 cases who had copy, both being approximately 6 minutes each. The EBUS - guided biopsy of a peripheral lung lesion [21] . limitation of this investigation was that whereas the These were compared with 42 controls assessed with methods were applied sequentially in random order, fl uoroscopy only. An important aspect of this study it could not exclude bias in that the location of the was that 78% of patients had their lesion accessed by lesion may have been established by the respective endobronchial ultrasound. This meant that changing fi rst method. That is, if the lesion was localized fi rst position of the patient was not required to assist in with fl uoroscopy, it could have been an aid to the fl uoroscopy. Usually fl uoroscopy should be performed subsequent EBUS - guided biopsy. However, the in two planes to facilitate lesion location and clearly authors did not feel that prior fl uoroscopy enhanced this was obviated in a large percentage of these the ability to locate lesions by EBUS, as three out of patients. Overall, this study showed trends to improve four lesions not found with EBUS were previously diagnosis with the EBUS guide sheath; however they detected by fl uoroscopy. Overall, there was a very did not reach statistical signifi cance. Nonetheless the high localization of lesions by EBUS. overall yields were high with fl uoroscopy alone The next important study was by Kurimoto and refl ecting a better than usual profi ciency with this reported the introduction of the guide sheath associ- standard technique. ated with the miniprobe [ 9] . The overall diagnostic In the same year, a study using a smaller miniprobe yield in this study once again was very high with 77% (20R - 17R, 1.4 mm outer diameter), was used [ 6] . This of procedures obtaining a tissue diagnosis in lesions could also be included in a guide sheath and, impor- which, once again, in general, were quite small. The tantly, could be used with a small caliber 4 mm bron- ultrasound was able to enter the lesion in 87% of choscope. This was because access to the upper lobe cases. The important fi nding in this study was the subsegmental bronchi is often important with these uniform high histology rate across lesion sizes, with types of biopsies. Often lesions are high in the upper lesions less than or equal to 10 mm, having a 76% lobes and acute angulation of the bronchoscope is success rate; lesions 15 – 20 mm in size having a 66% required to access these points. This study demon- success rate; and lesions 20 – 30 mm in size having a strated the ability to localize even very small lesions, 77% success rate. There were 81 lesions less than with lesions < 3 cm in size entered by the EBUS probe. 20 mm in size in this study and standard fl uoroscopy In this study, the diagnostic rate for malignancy was was not able to confi rm whether the forceps were 67%. These authors had prior long experience using 77 Endobronchial Ultrasonography Table 8.2 Prospective clinical studies: E BUS Guide sheath. Author Year R eference Miniprobe Scope Biopsy n ebus comparator comparator n channel calibre Herth 2002 4 20 - 20 1T30/1T40/ 25 standard 25 XT20 TBLBx Kurimoto 2004 9 20 - 20 iT30/1T40/ 150 240R Shirakawa 2004 21 UM3R/ 1T240 R 50 standard 42 UM4R/20 - 20 TBLBx Kikuchi 2004 6 20 - 17 260F/p240/ 2 mm 24 p200 Yang 2004 24 96 standard 122 TBLBx Asahina 2005 20 20 - 17 p 260f/p240 2 mm 29 Paone 2005 22 20 - 20 bf b3/t20 87 standard 119 TBLBx Herth 2006 7 20 - 20 bf t 160 54 Chao 2006 27 20 - 20 p 260f 131 Yamada 2007 23 20 - 17 and p 260 2 mm/ 155 20 - 20 f/1T30/1T260 2.8 mm Fielding 2007 29 20 - 20 1T40 2.8 mm 140 CT FNA 121 Chung 2007 28 20 - 20 p260f 113 Dooms 2007 25 50 Yoshikawa 2007 19 20 - 17 260/p240 2 mm 121 Asano 2009 26 20 - 17 2 mm 32 X - ray fl uoroscopy at their hospital in diagnosing small was removed. They assumed, as did Kurimoto, that peripheral lesions. In the prior 12 months, simply by the wedged guide sheath in the bronchus was tam- using fl uoroscopy alone, for lesions less than 20 mm ponading any bleeding. As with Kurimoto ’ s study, in diameter, fl uoroscopy did not allow the biopsy these authors were adept at using a doubled- hinged forceps to reach the lesion in 35%, and only 13% curette. This was used to facilitate placement of the were able to obtain a tissue diagnosis. The authors catheter in adjacent bronchi if the original pass with commented that the gap between localizing the lesion the ultrasound probe in the sheath was unsuccessful. and obtaining a tissue diagnosis could have been Clearly, using this method does require fl uoroscopy affected by the small size of biopsy

forceps and brushes and does require some skill and practice. used with this smaller caliber guide sheath. The In 2005, Paone reported a large series of 221 patients authors made qualitative comments that bleeding of who were randomly assigned to either EBUS biopsy any kind was hardly ever seen when the guide sheath or transbronchial biopsy for small peripheral lung 78 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy mean Procedure time Lesion Yield Yield Yield Yield < 3 cm Yield < 2 cm Side effects lesion entered malignat benign size mm 33.1 6 minutes EBUS 92% 8 0% 80% minor bleeding time × 2( no guide sheath), px × 1 1 min EBUS 87% 77% 81% 69% moderate > 30 ml 9 mins procedure bleeding× 2 (33/50 78% 71% < 2 cm) 18 mm 79% 5 3% 67% 33% 53% × 1 px 55 – 66% 55% 19 mm 25 mins whole 80% 6 3% exam, time to fi rst ebus imaging 12 mins 9.8 mins including 76% 79% 69% 75% 71% nil instrument set up 22 mm 12.3 mins 89% 7 0% 1 px, 3 self limited including bleeding biopsies 44 mm 63% 21 mm 67% 76% 40%((15 – 30) 29 mm 25 mins for all 66% 63% 70% 2 px bronchoscopy 25 mm 72% 6 8% - see 73% 24% × 1 px, × 5 mild comments bleeding 37 mm 74% 6 2% 31 mm 62% 76%(> 20 mm) 30% 1 px 31 mm 22 mins total 94% 80% lesions [22] . Eighty - seven patients underwent EBUS chial lung biopsy which was highly statistically signifi - and 119 had transbronchial lung biopsy. Overall, there cant. This is even allowing for the fact that many was a 76% diagnostic rate for EBUS compared to 52% centers would probably have diffi culty achieving 31% for standard transbronchial lung biopsy without EBUS. success rate with transbronchial lung biopsy alone. For As with the other studies, a variety of benign and lesions less than 2 cm in size, a similar improvement malignant conditions could be diagnosed. There was was found with 71% sensitivity for EBUS and 23% no difference in the overall success rate for lesions sensitivity for transbronchial lung biopsy. greater than 3 cm in diameter; however the evaluation In 2005, Asahina reported EBUS- guided sheath of patients with lesions less than 3 cm showed a sub- biopsy of peripheral lung lesions assisted by CT virtual stantial benefi t for EBUS- guided biopsy compared to bronchoscopy [ 20] . Prior to the bronchoscopy, a fl y- standard transbronchial lung biopsy. There was a 75% through image of the bronchial tree was created using sensitivity for EBUS compared to 31% for transbron- images reconstructed from helical CT data transferred 79 Endobronchial Ultrasonography to a worksite. Images were clear as far as the fi fth copy in 123 procedures [ 19] . Once the EBUS confi rmed general bronchi; however for more peripheral zones, the lesion, the probe was withdrawn and the guide virtual bronchoscopy images were generated using sheath left in place. Brushings and transbronchial pulmonary arterial branches. As in the study of biopsies were performed by the guide sheath; when Kukuchi, once again a thin caliber 1.4 mm EBUS mini- an EBUS image could not be obtained at that stage, probe was used. The bronchoscope was inserted as the bronchoscopic examination became a standard deeply as possible into the target bronchus under fl uoroscopically guided transbronchial lung biopsy. direct vision as suggested by the correct path from the 62% of lesions were diagnosed by the EBUS method CT virtual bronchoscopy. The miniprobe in the guide without fl uoroscopy. Amongst these lesions, those sheath was then inserted. Standard radiographic fl uor- greater than 20 mm in diameter had a 76% diagnostic oscopy and EBUS imaging were used. Using this rate and this was signifi cantly higher than those with method, EBUS was able to detect 24 of the 30 periph- lesion diameters of less than 20 mm where the histol- eral pulmonary lesions (80%) with an average diam- ogy rate was 30%. Two other interesting aspects for eter of 19 mm. The average time to the fi rst EBUS the proceduralist were fi rst that when the CT could imaging of the lesion including anesthesia of the bron- clearly identify a bronchus leading to the lesion, the chial tree and insertion of the bronchoscope and echo overall yield was 79%. In addition, there was a higher probe into the lesion, was 10 minutes. The average diagnostic yield for solid lesions (67%) compared with time for the fi rst biopsy including the time to the fi rst non - solid lesions (35%). Non - solid lesions such as EBUS imaging and adjustment of the forceps position ground glass opacities often simply surround the small was 12 minutes. Overall, the complete examination peripheral bronchus without either compressing or took 25 minutes. This elegant study demonstrated the invading it. Hence, a transbronchial lung biopsy may capacity of virtual bronchoscopy to assist the proce- have diffi culty actually catching the abnormal tissue duralist in identifying relevant small subsegmental in these cases. The goal of this study was to demon- bronchus into which the guide sheath miniprobe strate the ability of EBUS to perform the biopsy should be passed. The upper lobes can be particularly without the excessive radiation exposure for patients subject to signifi cant anatomical variations and guid- and medical workers that can occur with the use of ance in probe site selection is clearly of benefi t to the fl uoroscopy. This study extended the fi ndings of Herth proceduralist. Even lesions less than 20 mm in diam- et al. who had shown in their earlier study similar eter had a 54% success rate in tissue diagnosis. overall success rates for EBUS and fl uoroscopically In a study reported in 2006, Herth et al. presented guided transbronchial lung biopsies. The authors com- results in 54 patients with solitary pulmonary nodules mented that the previous studies by Kikuchi and that could not be visualized with standard fl uoroscopy Paone had higher diagnostic rates for lesions less than done at the time of bronchoscopy [ 7] . These were very 2 cm in diameter (53% and 71% respectively) because small lesions with an average diameter of 2.2 cm. A there could be fl uoroscopically guided confi rmation of very high percentage of these patients could be local- the peripheral pulmonary lesions in those studies. ized with EBUS (89%) and, overall, there was a tissue Second, fl uoroscopy allows the use of the hinged diagnosis in 70% of these patients. Lesions were dis- curette to facilitate repositioning of the probe. Third, tributed quite evenly throughout the lung and there fl uoroscopic guidance may assist with preventing the was a slightly better tissue diagnosis rate for malig- probe from moving during respiratory movement. nancy compared with benign lesions. The results indi- Overall, therefore, the authors concluded that fl uoro- cate the added benefi t of ultrasound in that if standard scopic guidance was not necessary for lesions more transbronchial lung biopsy is performed and the lesion than 20 mm in diameter, but probably would be cannot either be seen or located, the biopsy site required for lesions smaller than this. With respect to becomes the best estimate of the proceduralist. The lesion location, the authors made some interesting advantage of EBUS clearly is the defi nitive localization qualitative comments. First, the diagnostic yields of of the lesion. peripheral pulmonary lesions in the right middle lobe In 2007, Yoshikawa reported EBUS to guide a trans- and lingular were signifi cantly higher. The access to bronchial lung biopsy without radiographic fl uoros- these lobes is clearly easier than some of the apical 80 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy segments of the upper lobes. Others had previously shown lower success rates for biopsies in the right Analysis of Internal Structure of upper lobes [9] . Negotiating the sharp bends of the Peripheral Pulmonary Lesions Using E BUS bronchus in these airways opening with the tip of the EBUS catheter can be quite diffi cult. They also felt that In Kurimoto’ s study of 2002, a detailed analysis of the the guide sheath seemed to move and slip off more ultrasound appearance of peripheral pulmonary easily from the lesion with deep inspiration in lesions lesions when accessed by an EBUS probe was pre- in the lower lobes. With respect to peripheral pulmo- sented [ 5] . This work began in January 1996. The nary lesions which are aerated and non- solid, the overall question, of course, is whether there is a cor- authors recommended that transbronchial needle relation between ultrasound characteristics and fi nal aspiration could be used. histological confi rmation. Initially, 69 patients with In 2007, Yamada reported factors which increased preoperative EBUS images were correlated with his- the yield of small peripheral pulmonary lesions [ 23] . topathological fi ndings of surgical specimens upon As noted from these other studies, there is often a gap surgical resection. This allowed exact correlation with between the access to the lesion as confi rmed by ultra- small intra - lesional bronchi and vessels. Subsequent sound and actually confi rming a tissue diagnosis. The to that, another 124 lesions underwent bronchoscopic fi rst important parameter was the location of the probe biopsy, and EBUS pictures were analysed for their with respect to the lesion. There was clearly an internal structures depending on the fi nal tissue diag- improved diagnostic yield (83%) when the probe was nosis. The ultrasound images appeared to have cor- positioned within the lesion compared to those where relation to the lesion in question primarily on the basis it was positioned adjacent to it (61%) were outside the of how much the underlying pathology destroyed the peripheral pulmonary lesion. These were statistically usual structures in the lung, namely the bronchi, signifi cant results and indicate the need for the practi- alveoli, and blood vessels. The more destructive the tioner, possibly with the use of a curette, to facilitate lesion, such as an aggressive carcinoma, the less were placement of the probe well within the lesion. In this these structures identifi able; conversely, the more study, once again, very small peripheral lesions (85%) benign and less destructive the process, the more iden- were actually entered with the EBUS probe. Lesions of tifi able such structures as bronchi were. The former, between 15 and 20 mm, greater than 20 and less than overall, tend to therefore have a somewhat heterog- 25 mm and greater than 25 and less than 30 mm had enous appearance because of the different echodensi- diagnostic yields of 40%, 74%, 72%, and 81% respec- ties of compressed or distorted structures. The latter tively. Other useful data from this paper were that more benign lesions tend to have a homogenous there was an increasing diagnostic yield approaching appearance because of the maintenance of normal 97% where the fi nal diagnosis was made after fi ve lung tissue architecture to some extent within the biopsies. It would therefore seem that at least fi ve lesion. Residual air within a lesion was refl ected as a biopsies ought to be taken. The importance of the hyperechoic dot as air tends to give such an appear- placement of the probe within the lesion was demon- ance on ultrasound. Blood vessels could often be seen strated in that multivariant analysis showed this to be coursing through lesions, sometimes with diameters the most signifi cant factor in overall diagnostic yield, as small as 0.68 mm when measured histopathologi- even overcoming small lesion size, as small as less than cally. These structures tended to be seen more in 15 mm in diameter. The study also demonstrated the benign less destructive pathological processes. At a lack of any statistical difference between operators in frequency of 20 MHz, the spatial resolution of ultra- the procedure, all of whom had had more than four sound images is approximately 0.38 mm. years experience in bronchoscopy. Other factors in Broad groups of three EBUS images were described. biopsying lesions most effectively would be to place the Type 3 lesions had a heterogenous appearance and the guide sheath at the near end of the lesion as gauged

majority of these were malignant (Table 8.3 ). No by ultrasound. In this way, as the forceps comes out, blood vessels were seen within the lesion by EBUS and it will not over - reach the lesion as it may do if the guide there were irregular mottled and linear areas distrib- sheath is left in the middle of the lesion. uted in the lesion corresponding to the destructive 81 Endobronchial Ultrasonography Table 8.3 Differentiation of peripheral lesions on E BUS images Kurimoto Key features Type 1 Type 2 Type 3 hetrogeneous/homogeneuos H omogeneous Heterogeneous vessels seen Type 1a Type 2b Type 3a bronchi seen Type 1a Type 2b Type 3a hyperechoic points Marked Malignant 99 99 Benign 92 Kurimoto N, Murayama M, Shinchikiro S, Nishisaka T. Analysis of the internal structure of peripheral pulmonary lesions using endobronchial ultrasonography. Chest 2002;122:1887– 1894. Chao Homogenous/heterogenous Hyperechoic dots Concentric circles Continuous margin Malignant 4% 97% 5 4% 2% 22% Benign 41% 59% 7 4% 53% 9% p < 0.001 < .001 0.09 Adapted from Chao TY, Lie CH, Chung YH, et al. Differentiating peripheral pulmonary lesions based on images of endobronchial ultrasonography. Chest 2006;130:1191 – 1197. effects of the tumor compressing bronchi and alveolar some of these lesions did not have blood vessels visu- air. The echoes were therefore heterogenous and rela- alized because of the predominance of the alveolar air tively dense. There was a signifi cant attenuation of the pockets which hampered the visualization of the sound waves by the tumor so that only about 6– 8 mm vessels. In those type 2 lesions where vessels were of the lesion could be seen clearly, whereas tissue identifi able, there was a greater density of adenocar- outside this was seen clearly. Most of these were cinoma cells and presumably this allowed identifi ca- peripheral adenocarcinomas. Some type 3 lesions did tion of vessels because of more solid tissue surround not have any hyperechoic dots or short lines, possibly them as opposed to air pockets. because they were relatively avascular, and remnants Type 1 lesions had the unifying characteristic of of previous structures which caused such features in being homogenous. That is, the internal echoes other type 3 lesions were therefore absent. Therefore, between any visible structures such as vessels or bron- type 3 lesions could be classifi ed as either A or B chioles were homogenous. In some of these cases, the depending on the presence or absence of these hyper- vessels and bronchioles were visible and predomi- echoic dots and short lines. Overall, however, there nantly these included cases of pneumonia where there was always heterogeneity of internal echoes. was a pattern of exudates - fi lled alveoli demonstrate Type 2 lesions had a predominance of hyperechoic on histopathology. Because the pneumonia was not dots and linear arcs and these represented the residual causing any compression or stenosis of bronchi or alveoli (small points of hyperechoic air) and slightly vessels, these were well seen. There was small ultra- compressed bronchi. These lesions could be further sound attenuation because of this type of lesion which subclassifi ed as either A or B depending on whether was not particularly dense and even tissue 15 – 20 mm vessels were not, or were, visualized. The histopatho- from the probe could be seen clearly. Sometimes, logical correlate of these residual alveolar structures where the lesion was up against a fi ssure, the margins was that of well - differentiated adenocarcinomas of the lesion could be seen to be linear. There was one which grow in a lepidic fashion without destroying the case of malignancy amongst this group because the underlying alveolar parenchyma. It was thought that form of metastasis from a pancreatic carcinoma was of 82 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy a pneumonic type with respect to the CT scan and bined with concentric circles was included. The third histopathology. Some cases of homogenous type 1 characteristic was hyperechoic dots and here the spots pattern did not have vessels or bronchioles visualized; were generally bigger than normal particles. The dots however the important aspect was that mottled or may have merged several variable sized areas or hyper- linear hyperechoic areas were absent or scant. These echoic linear arcs. The presence of residual air in the included cases of organizing pneumonia and tubercu- lesions or tiny calcifi cations could have been the reason lomas; it did include one case of moderately differenti- for this pattern. Overall, more than half of all the ated squamous cell carcinoma. lesions displayed hyperechoic dots including 54% of Overall, using this classifi cation, there was an neoplastic lesions and 73.5% of non- neoplastic lesions. extremely good correlation between the presence of Therefore, it was thought not to be useful in distin- type 2 or 3 lesions and the presence of malignancy guishing lesions. Finally, the presence of concentric (99%). Furthermore, 21 of 24 type 2 lesions (87.5%) circles was analysed. There was a sense of gradation were well - differentiated adenocarcinomas. All of the from the inner to the outer parts of the lesion. It was type 3 B lesions were malignant. With respect to type thought to represent the effect of the residual intact 1 lesions, 25 (92%) were shown to be benign. architecture of the bronchioles within the lesion. In 2006, Chao et al. reported a similar study [ 27] . About one half of the non- neoplastic lesions had the They developed a classifi cation involving four particu- characteristics of concentric circles and this was only lar aspects of the ultrasound image from 20 consecu- detected in one case of malignancy. This difference was tive patients. In the following 131 patients, this highly statistically signifi cant and the signifi cance was classifi cation scheme was tested. The four points persistent even by the multivaried analysis combined described were: (1) a continuous hyperechoic margin with internal echoes. Note that it was present in only around the lesion; (2) a distinction between homoge- 53% of the benign lesions. Therefore, this classifi cation nous or heterogenous internal echoes; (3) hyperechoic system did not use the pattern of vessels or bronchioles dots in the lesion; and (4) concentric circles along the to type the lesions. In their scheme, there was unanim- echo probe . Points 2 and 3 had been a critical part of ity amongst three reviewers in the vast majority of Kurimoto’ s earlier classifi cation. With respect to the cases. The time taken to perform this analysis was less margin, the thickness of the margin varied among dif- than four minutes. Overall, the authors concluded that ferent parts of the lesion. The margin was basically the presence of concentric circles favored the periph- between the lesion and normal aerated pulmonary eral lung lesion as being benign and that the existence tissues. From 93 patients, only 16 had a continuous of a continuous hyperechoic margin was suspicious for hyperechoic margin fully around the lesion. In 13 of malignancy. The remainder of the fi ndings at this stage 16 cases of these 16 cases (81.3%) there was malig- were therefore regarded as qualitative and perhaps nancy. This did not quite reach statistical signifi cance used in support of further observation in biopsies comparing benign and malignant lesions (p = 0.09). where the histology is benign. With respect to the internal echoes of the lesion, Other authors [ 8] have used image analysis soft- homogenous internal echoes were unanimous in size, ware to determine the presence of underlying hetero- echogenicity and distribution, and the echogenicity geneity or homogeneity of the echoes within an was invariably slightly lower than that in normal lung ultrasound lesion. This would facilitate the kinds of parenchyma. Heterogenous internal echoes displayed distinctions made in both the Kurimoto and Chao a mosaic pattern in imaging particle distribution and classifi cations and has shown to be useful in a prospec- the particles varied in size. The echogenicity of the tive follow- up series. lesions comprised both hyper and hypoechogenicity. Overall, there were 16 subjects from the 93 who had homogenous internal echoes and the majority of these Side Effects and Tolerability (88%) were benign. Ninety- seven percent of neoplas- tic lesions demonstrated heterogenous internal echoes Table 8 .1 highlights the low incidence of side effects and this was statistically different (p < 0.001). This of transbronchial lung biopsy easing into bronchial signifi cance was lost after multivariant analysis com- ultrasound method. Bleeding and pneumothorax are 83 Endobronchial Ultrasonography inherent to transbronchial lung biopsy; however, in biopsy [ 29] . We demonstrated that we had an inci- all of these series, the overall incidence of these was dence of 1% pneumothorax rate from 140 cases of less than 1%. An important observation is that studies EBUS - guided sheath biopsy. This compared to a 28% that did not use a guide sheath had a slightly higher pneumothorax rate and 6% rate of intercostal catheter incidence of minor bleeding; no incidences of severe insertion in 121 retrospectively reviewed cases of CT bleeding were seen. Nonetheless, this can be discon- fi ne needle aspiration. certing for the proceduralist at the time and, as described by a number of authors, the most common scenario was to have absolutely no bleeding of any Conclusions quantity upon removal of the guide sheath and one or two minutes after the last biopsy. A paper by Chung Endobronchial ultrasound- guided sheath peripheral described EBUS guide sheath peripheral mass biopsy biopsy provides a safe, reliable, and technically simple without the use of the guide sheath, using the meas- means of extending the bronchoscopist ’ s capacity to urement of length of the lesion away from the end of obtain tissue diagnosis on small peripheral lung the bronchoscope by fl uoroscopy as the ultrasound lesions. It has an excellent safety profi le, probably probe was removed [28] . The biopsy forceps were safer than standard transbronchial lung biopsy in placed back that same distance out from the end of terms of bleeding, and probably better than usual rates the bronchoscope to take the samples. Normally, for pneumothorax compared to CT- guided fi ne needle when the guide sheath was used, the end of the guide aspiration biopsy. Not only does it allow the accurate sheath itself becomes the marker point to which the localization of very small peripheral pulmonary forceps are passed. There was a signifi cant improve- lesions, it also allows the qualitative characterization ment in the overall diagnostic yield (79% compared of the underlying lesion by way of assessment of the to 57%) in patients where this measurement was ultrasound characteristics of the lesion. In a recent used. An important fi nding from the point of view of recommendation, the American College of Chest side effects was that, from these 158 lesions, there Physicians advocated the use of endobronchial ultra- were fi ve episodes of mild bleeding. Some of the other sound in lesions less than 2 cm in diameter [30] . studies, however, suggest that the guide sheath does In many respects, the biopsy of peripheral lesions have a protective effect in terms of minimizing any larger than this can also be benefi ted by the use of bleeding. With respect to pneumothorax limitation, endobronchial ultrasound particularly in centers not the important aspect is to prevent excessive passage of frequently using standard X - ray fl uoroscopy for the biopsy forceps or brush beyond the tip of the guide such types of biopsy. Because of its safety and simplic- sheath. Most, but not all, operators use X- ray fl uoros- ity, it rapidly allows the bronchoscopist to gain access copy to manage this part of the procedure thereby to the lesion without the need to image in two planes preventing excessive lengths of the biopsy forceps by fl uoroscopy. It also provides safety advantages coming out the end of the guide sheath. Clearly, the over and above the standard transbronchial lung localization of the guide sheath at the proximal end of biopsy technique by way of the benefi ts of the guide the lesion should prevent this happening. In the sheath. author ’ s experience, one case of pneumothorax occurred because the biopsy brush was extended too The Future of EBUS Peripheral Lung Biopsy far. It is an inherent problem of using

a biopsy brush Presently, there are two aspects in development with that sometimes in taking the specimen, the brush can respect to endobronchial ultrasound. First, there is the be advanced 2 or even 3 cm and thereby breach the ongoing miniaturization of the equipment and the visceral pleura. Special care should be therefore taken greater use of the 1.4 mm diameter EBUS Miniprobe. to prevent over - excessive application of the brush This being combined with a 4 mm diameter broncho- length. In a retrospective series, we demonstrated that scopes has been demonstrated to access very small our incidence of pneumothorax with this technique lesions in two studies from Japanese centers. Better was much less than our current hospital experience biopsy forceps and brushes for use with these smaller with pneumothorax from CT - guided fi ne needle miniprobes and smaller guide sheaths are currently 84 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy allowing better diagnostic yields, particularly in very techniques have returned yields of 58– 73%, 58– 77%, small lesions of less than 1– 2 cm in diameter. Such and 63% respectively. Interestingly, there was a miniaturization can afford the bronchoscopist greater diminished lower lobe yield of 29% in the ENB alone access to very small bronchi in somewhat tortuous group and this was thought possibly due to naviga- positions as experienced with bronchoscopes of stand- tional error; navigation in the lower lobes was thought ard caliber. to be more effective by diaphragmatic movement The increasing use of CT virtual bronchoscopy will during breathing. This could have hampered the CT be an important component in the ongoing develop- images acquired in a single breath hold prior to the ment of this technique [ 31] . Many practitioners do not actual procedure, with such planning data being used have the encyclopedic knowledge of small segmental in the navigation process. The overall rate of pneu- bronchi that surgeons have, nor the knowledge held mothorax was 5% in EBUS and 5% in ENB. in some of the Japanese and European centers. Fluoroscopy was not used because earlier data had Therefore, there will probably always be a need for shown that it did not decrease the rate of the iatro- some radiological assistance of practitioners in identi- genic pneumothorax after transbronchial lung biopsy. fying the correct bronchus. The development of sim- Perhaps this was the explanation for the slightly plifi ed user interfaces for virtual bronchoscopy is increased pneumothorax rate. ongoing, and this combined with the use of small caliber miniprobes and bronchoscopes should further increase the user- friendliness of this technique. Tips for Endobronchial Ultrasound - Guided In a recent report from Eberhart et al. EBUS was Transbronchial Lung Biopsy combined with electromagnetic navigation bronchos- copy to determine their relative contribution to biopsy The techniques are not particularly different from of peripheral lung lesions [ 32] . Electromagnetic navi- standard transbronchial lung biopsy and hence the gation bronchoscopy utilizes a system of navigational procedure is accessible to many. Some simple sugges- guidance to the lesion based on specifi c hardware and tions may assist in the uptake of the technique. software interfaces, but importantly uses a steerable 1 CT anatomy: becoming more familiar with the biopsy forceps. This type of forceps has a guide sheath common appearances of the takeoff of each of the ten and is for single patient use. This study was performed subsegmental bronchi on the right and the nine sub- in lesions, once again, very small in diameter, ranging segmental bronchi on the left and their associated fi fth between 25 and 28 mm for the two techniques. In this border branchings is important. It is relatively easy to study, navigation to the lesion was fi rst performed by become familiar with this over one of two months of electromagnetic navigational bronchoscopy (ENB). repeated study of the CTs. Discussion with the radiolo- When the lesion was located, the sensor probe was gist can also be helpful as can scrolling through the withdrawn and the EBUS probe was inserted through digital images on a PC. This allows tracking of the bron- the ENB guide sheath. If the EBUS image confi rmed chial segments out to the corresponding lesion. Having that the sensor was indeed within the target, then the done this, it is necessary to make a shopping list of biopsy was performed. However, if no acceptable bronchial segments into which the guide sheath can be EBUS image was obtained, re- navigation with ENB passed starting from the most likely to the least likely. and subsequent reconfi rmation with EBUS was done. Even the most experienced bronchoscopist will do this. This combined technique had a signifi cantly higher 2 Increased familiarity with the numerical system for diagnostic yield of 88% compared to EBUS alone naming of bronchi as originally described by Boyer (69%) or electromagnetic navigational bronchoscopy and Icheda. This is much more familiar to Japanese alone (59%). The authors felt that ENB enhanced and European readers as opposed to readers in the EBUS by providing real time and subtle navigation UK, United States and Australasia. The numerical through the steering mechanism of the locatable system greatly facilitates an understanding of the guide. They felt that this navigation capability was inter - relationship of the bronchial appearance to marginally better than that afforded by either fl uoros- the CT scan appearance. Clearly, there will be varia- copy, curettes, or virtual bronchoscopy. These three tions but improving one’ s awareness of these and the 85 Endobronchial Ultrasonography 7 Use separate monitors for white light bronchoscopic fi ndings and for ultrasound fi ndings. There is the facility to have a picture display on the monitor, one showing ultrasound and the other showing bron- choscopic fi ndings, or the facility to swap between the two images on one monitor. In the author’ s experience, it is always better to have both showing constantly and simultaneously on two separate monitors. 8 In some patients, there is chronic bronchitis in the End of Transducer large airways and holding the bronchoscope in one the sheath position can occasionally lead to abrasion of the bron- chial wall over a 10 - minute period during which time ultrasound and biopsies are taken. This can lead to some bleeding from the bronchus itself due to this Figure 8.1 Set up of distal end of EBUS minprobe which is abrasion as opposed to from the lung and it is always shown exiting from the guide sheath (left). important to remain aware of the endobronchial situ- ation even though one’ s concentration is on the lesion likely expected bronchial anatomy greatly improves in the periphery of the lung. success rate. 9 Care with transbronchial brushings as mentioned 3 Probe preparation: it is important to have the ultra- above; over- extension of a bronchial brush can occa- sound part of the miniprobe just outside the end of sionally cause breach of the visceral pleura and pneu- the plastic sheath (see Figure 8.1 ). If any part of the mothorax. Lesions which are more centrally placed processor is hampered by the plastic sheath, interfer- should not pose a problem; however those lesions up ence images will appear. Sometimes as the probe is against the visceral pleura particularly in the upper passed out into the peripheral bronchi, compression lobes may have a risk of pneumothorax if the brush from bronchial structures pushes the probe back inside is extended too far. the sheath and such interference patterns can appear. 10 Once the lesion is found, withdraw the guide As such, it is important to ensure that the proximal sheath to the near end of the lesion so that the ultra- end of the probe is fi rmly taped to the guide sheath. sound image is just disappearing. Fix the guide sheath 4 The biopsy forceps and brushes need to have a tape at this point rather than within the lesion as this will mark placed at the proximal end prior to starting the facilitate better biopsy positivity as described above. procedure such that, in particular with the biopsy 11 Interpretation of ultrasound images. This need not forceps, the end corresponds to the point of the EBUS hold the procedure up and is often done following the miniprobe transducer. completion of the procedure. The decision to take 5 Use an assistant. This is important because small the biopsy is made before the procedure begins changes in position of the bronchoscope or the mini- rather than as a result of an interpretation of an image probe can affect biopsy yield and it is often helpful to at the time of the procedure. It is easy to record ultra- have an assistant hold the bronchoscope in place sound images on the hard drive of the ultrasound while the main proceduralist actually takes the processor or to record the whole ultrasound procedure biopsies. on digital video and interrogate still images from that. 6 With the use of an image intensifi er, it is often Such interpretation may be of some assistance in helpful to save the image of the point of the guide prospective evaluation of one ’ s own performance sheath on one screen and have another screen to and demonstrate for audit purposes that the procedur- show the actual live passage of the biopsy forceps. This alist is achieving reasonable diagnostic accuracy results can allow a very accurate positioning of the biopsy by comparing ultrasound image and histology forceps; however this is not essential as keeping the fi ndings. guide sheath in place once the ultrasound confi rms 12 Where a lesion appears to be a small ground glass positioning may be all that is required. opacity and to have an aerated type of appearance, 86 CHAPTER 8 EBUS-Guided Peripheral Pulmonary Nodule Biopsy transbronchial needle aspiration should be added to pulmonary nodules to assess the histology. Chest the biopsy method as described above. This would 2003 ; 124 ( suppl 4 ): 77 . increase the yield in that such lesions tend not to 9 Kurimoto N , M iyazawa T , O kimasa S , et al. Endobronchial invade the bronchus and therefore sampling outside ultrasonography using a guide sheath increases the the bronchus could improve the results; it can be done ability to diagnose peripheral pulmonary lesions endo- scopically . Chest 2004 ; 126 : 959 – 965 . without any increased risk of side effects. 10 Popvich J J r , K vale P A , E ichenhorn M S , et al. Diagnostic 13 Consider a broader range of indications than accuracy of multiple biopsies from fl exible fi beroptic simply small peripheral nodules. For example, patchy bronchoscopy: a comparison of central versus periph- subsegmental pulmonary infi ltrates can be very ame- eral carcinoma. A m Rev Respir Dis 1982 ; 125 : 521 – 523 . nable to EBUS biopsy; standard transbronchial lung 11 Radke JR , C onway WA , E yler WR , et al. Diagnostic biopsies can miss infi ltrative processes which are quite accuracy in peripheral lung lesions: factors predicting patchy such as chronic fungal infections or early cases success with fl exible fi beroptic bronchoscopy . Chest of infl ammatory alveololitis. In the author ’ s experi- 1 976 ; 76 : 176 – 179 . ence, even in these cases, it is possible to completely 12 Schreiber G , M cCrory D C . 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The probe is connected to an Endoscopic Introduction Ultrasound System (EU - M30, EU - M2000; Olympus). Guide sheaths are now available commercially under Bronchial brushing cytology and transbronchial biopsy the name of The Guide Sheath Kit (Olympus). (TBB) are used to diagnose peripheral pulmonary lesions (PPLs). Fluoroscopy is required in most cases to direct the operator to site of interest, although it is EBUS - GS Procedure often diffi cult to confi rm whether the biopsy forceps have reached the lesion. Since 1994, we have been For preparation of equipment for EBUS - GS, see able to delineate PPLs through the introduction of a Chapter 3 , p . 28 , Video clip 3.3. miniature ultrasonic probe into a peripheral bronchus For actual EBUS - GS techniques, see Chapter 3 , [1] , but this has involved withdrawing the probe after pp. 28 – 30 , Figure 3 .6 , and Video clip 3.4. the ultrasound image has been obtained, then intro- EBUS - GS procedures and images will be described ducing a brush or biopsy forceps, and obtaining the using a representative case. tissue or brushing sample. This method has made it diffi cult to be sure that the tissue or brushing sample Representative Case (Video Clip 9.1, has been accurately taken from the site of the lesion, Figure 9.1 ) however. To increase the reliability of sample collec- This 74- year - old man had a 10 × 8 mm nodular lesion tion from PPLs, we devised a technique using EBUS in segment B5a of the right lung. Bronchoscopy was with a guide sheath (EBUS - GS). performed to establish the diagnosis. A miniature probe covered by a guide sheath was introduced into the B5a bronchus of the right lung, and pulled back Equipment to obtain EBUS images. EBUS revealed heterogenous internal echoes in a lesion with an irregular margin Between 1996 and the commencement of EBUS- GS that contained almost no vessels or bronchi. These in 1999, we used a 20 MHz, mechanical- radial type fi ndings were suggestive of a solid tumor with a high miniature ultrasonic probe (UM- BS20 - 20R; Olympus cell density. The guide sheath was left at the site of Optical Co., Ltd, Tokyo, Japan) with an outer diameter the lesion identifi ed by EBUS, and the probe was with- of 1.7 mm. Since 2000, we have used a 20 MHz, drawn. A bronchial brush and biopsy forceps were mechanical - radial type thin ultrasonic probe (UM - introduced into the bronchus. Cytology of the bron- BS20 - 17R; Olympus) with an outer diameter of chial brushings revealed adenocarcinoma, and trans- 1.4 mm (see Chapter 3 , Figure 3 .5 , Procedure for bronchial biopsy (TBB) confi rmed the diagnosis of poorly differentiated adenocarcinoma. We previously reported the overall yield of EBUS Endobronchial Ultrasonography, 1st edition. using a thick guide sheath (EBUS- thick GS) to be By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. 77% (116/150), and the diagnostic yield of EBUS- Published 2011 by Blackwell Publishing Ltd. GS in malignant and benign lesions as 81% (82/101) 89 Endobronchial Ultrasonography 8 × 8mm Figure 9.1 Poorly differentiated adenocarcinoma in the left vessels or bronchi within the lesion. Bottom left: a miniature lingular segment. Top left: the lesion is diffi cult to identify on probe covered by the guide sheath introduced into the left B5a this plain chest radiograph. Top center: chest CT revealed a bronchus. Bottom center: guide sheath (arrow) left at the site of 10 × 8 mm nodular lesion in left segment B5a. Top right: The the lesion. Bottom right: bronchial biopsy forceps introduced EBUS image revealed echogenic internal echoes with almost no into the lesion. and 73% (35/49), respectively [ 2] . Lesions in which 69%), and > 20 ≤ 30 mm (33/43, 77%) were similar. In the probe was advanced to within the lesion, as other words, for lesions ≤ 30 mm, size did not affect the determined from the EBUS image, had a signifi cantly diagnostic yield using EBUS - GS, and the yield was not higher diagnostic yield (105/121, 87%) than when decreased for lesions ≤ 10 mm. It was impossible to the probe was adjacent to the lesion on the EBUS confi rm fl uoroscopically that biopsy forceps had image (8/19, 42%). The diagnostic yield using TBB reached the lesion in 54 out of 81 lesions ≤ 20 mm in for lesions in which the probe was located within size. The diagnostic yield in these lesions was 74% the lesion (85/104, 82%) was signifi cantly higher (40/54), similar to the yield when it was possible to than when the probe was adjacent to the lesion determine fl uoroscopically that the forceps had (1/15, 7%). reached the lesion (18/27, 67%). The diagnostic yield using EBUS- GS for lesions The diagnostic yield was affected by the location of defi ned as a mass ( > 30 mm; 24/26, 92%) was signifi - the lesion. Positive yield rates were as follows: right cantly higher than that for lesions defi ned as nodules upper lobe apical segment (8/13, 64%), right upper ( ≤ 30 mm; 92/124, 74%). The diagnostic yields using lobe posterior segment (8/12, 67%), left upper apical EBUS - GS for lesions ≤ 10 mm (16/21, 76%), > 10 and posterior segment (6/15, 40%), upper lobe anterior ≤ 15 mm (19/25, 76%), > 15 and ≤ 20 mm (24/35, segment (34/42, 81%), lingula (5/7, 71%), right 90 CHAPTER 9 Diagnosis of Peripheral Pulmonary Lesions middle lobe (14/14, 100%), lower lobe superior bronchi. The yield from the lower lobe basal segments segment (12/19, 63%), and lower lobe basal segment was satisfactory (22/27, 81%). EBUS - GS is therefore (22/27, 81%). The yield from the left upper apical superior to fl uoroscopy for localising lesions in the posterior segment (6/15, 40%) was signifi cantly lower lower lobe basal segments. than that from other locations. One advantage of EBUS - GS lies in the repeatability Moderate bleeding was seen in two (1%) out of 150 of access to the bronchial lesion for sampling. Without patients. Patients required bronchial intubation. There a guide sheath, it can be diffi cult at times to be certain were no deaths, pneumothoraces, or other clinically that forceps are being inserted into the same bronchial signifi cant morbidities. branch for a second biopsy. Further, the bronchial EBUS - GS increases the reliability of specimen col- mucosa becomes edematous after several attempts at lection via bronchoscopy. Reported bronchoscopic manipulation, making it diffi cult to introduce the diagnostic yields for PPLs ≤ 2 cm in size vary from 5 to forceps into the bronchus. 28% [3 – 14] .

Radlke et al. [ 6] reported a positive yield Another advantage of EBUS- GS lies in its ability to of 6/21 (28%), Stringfi eld et al. [ 7] reported a positive protect against bleeding into the bronchus proximal to yield in 4/15 (27%), Fletcher et al. reported a positive the biopsy site. Although massive hemorrhage into the yield in 4/32 (12.5%), and Wallance et al. [ 8] reported bronchus following TBB is infrequent ( < 2%) [14,15] , a positive yield in 3/65 (5%). The diagnostic yield in excessive bleeding may require wedging the tip of the this study was far superior to the earlier studies, and bronchoscope to obtain hemostasis. If bleeding occurs similar to the overall yield, even when the lesion was during EBUS - GS, blood drains through the sheath, undetectable fl uoroscopically. When a fl uoroscopically because the outer surface of the sheath is snug against undetectable lesion is in contact with the probe intro- the internal surface of the bronchus. duced into the bronchus, the lesion can be visualized The fi nal advantage of EBUS- GS is the ability to using EBUS. EBUS - GS is particularly useful for lesions obtain short - axis bronchial views of PPLs. Several ≤ 20 mm that are undetectable using fl uoroscopy. investigators have reported successful use of miniature EBUS - GS is most successful when the probe can be probes [1,2] . placed within the lesion. The yield of TBB when the Yoshikawa [16] evaluated the feasibility and effi - probe was adjacent to the lesion was very low (1/15, cacy of TBB and bronchial brushing using EBUS- GS 7%). This suggests that lesions visualized as adjacent as a guide for diagnosing PPLs without radiographic to the probe may only be in contact with the outer fl uoroscopy. Seventy - six of 123 PPLs (61.8%) were surface of the affected bronchus, and therefore sam- diagnosed by EBUS - GS guidance without fl uoroscopy. pling is unlikely to be diagnostic. In this circumstance, The diagnostic yield for PPLs > 20 mm in diameter the operator should attempt to delineate the lesion via (75.6%) was signifi cantly higher than that for those another bronchus. ≤ 20 mm in diameter. PPLs located in the middle lobe Chechani [ 13] reported fl uoroscopic localization is and the lingular segment had signifi cantly higher diag- most diffi cult when the lesion is small ( < 2 cm) and nostic yields. Multivariate analysis revealed that the located in the lower lobe basal segment or the upper diameter and location of the PPL were independent lobe apical segment. The diagnostic yield for lesions in predictors of diagnostic sensitivity by EBUS- GS - guided these two segments (58%) was lower than yields from bronchoscopy. all other locations (83%). Fletcher et al. [ 5] reported Further studies are needed to determine the diag- that the worst diagnostic yields were from the lower nostic yield of transbronchial needle aspiration under lobe basal (2/7, 28%) and superior segments (5/19, EBUS - GS guidance, and the usefulness of using a 26%). In our EBUS - GS study [ 2] , the worst diagnostic curette via the guide sheath. yields were noted for left upper lobe apical posterior segment lesions (6/15, 40%) (p = 0.003, χ 2 ) when compared with yield from all other locations (103/135, Changes in E BUS - GS Techniques 76%). The reason for the lower diagnostic yield in the left upper lobe apical posterior segment is thought to When we began EBUS- GS in 1996, we used large bore be due to diffi culty introducing a probe into the B1+ 2 guide sheaths with an outer diameter of 2.5 mm, but 91 Endobronchial Ultrasonography for almost all PPLs we now insert a narrow bore guide bronchial brachytherapy. Asano et al. [19 – 21] devel- sheaths with an outer diameter of 2.0 mm down the oped a bronchoscope insertion guidance system that working channel of a bronchoscope with an outer produces virtual images by extracting the bronchi by diameter of 4.0 mm. Large bore guide sheaths are used automatic threshold adjustment, and searching for the only in cases where relatively large specimens are bronchial route to the determined target. They used required. The use of bronchoscopes with an outer this system in combination with a thin bronchoscope diameter of 4.0 mm allows us to select fourth and fi fth and EBUS - GS. This system automatically produced order bronchi (two or three branchings more periph- virtual images to fi fth order bronchi on average. EBUS eral than the standard bronchoscopes around 6 mm in visualized 93.8% of cases successfully, providing a outer diameter). tissue diagnosis in 84.4%. Using this bronchoscope insertion guidance system, virtual images can be How to Identify the Drainage Bronchus readily produced, successfully guiding the broncho- Leading to the Target Lesion (Representative scope to the target. This method shows promise as a Case: Video Clips 9.2 – 9.8) routine part of PPL biopsy techniques (representative case: Video clips 9.6, 9.7 and 9.8). Identifi cation of the Bronchial Branch Using CT Imaging Tips for E BUS - GS On the CT scan we identify the bronchus entering the lesion, and follow the bronchial branches towards the Use of Signal Attenuation Caused by the hilum. Guide Sheath (See Chapter 3 , Figure 3 .7 and From this bronchial route, we identify the bronchial Video Clips 9.9 and 9.10) branch, its bronchial segment and subsegment, the This is a method of accurately placing the guide sheath branching directions (laterally, mediastinally, etc.), within a PPL. Once a peripheral lesion has been delin- and what are the adjacent subsegments. eated using EBUS, at the point the lesion appears at We determine the name of the branch from the CT its largest and clearest, without disturbing the guide scan, mentally transform this into the bronchoscopic sheath the assistant should withdraw the ultrasonic fi ndings in our head, and delineate the bronchial probe 1 mm at a time until the probe transducer enters branch that we should approach. the guide sheath. When the transducer completely For example, if the candidate bronchus is the right enters the guide sheath, the ultrasonic pulse will be B6c bronchus, and the B6c lesion is next to region of refl ected by the guide sheath, and the ultrasound segment B6b on the CT, at bronchoscopy we should image will suddenly become darker. If the site of this introduce the ultrasonic probe, into the bronchus phenomenon is within the lesion, the guide sheath branches of the right B6c bronchus which are closest will be placed precisely within the peripheral pulmo- to the B6b bronchi. nary lesion. Identifi cation of the Bronchial Branch Moving the Probe from Adjacent to the Using Navigation Systems Lesion to within the Lesion on the In recent years, two methods of navigation for PPLs Ultrasonic Image (See Chapter 3 , Figure 3 .8 have been developed. The electromagnetic navigation and Video Clip 9.11) system is a localization device that assists in placing When we use the bronchoscopic image to select the endobronchial equipment in the desired areas of the subsegmental bronchus into which to introduce the lung. This system uses low- frequency electromagnetic probe to delineate a lesion using EBUS, the probe is waves, which are emitted from an electromagnetic sometimes placed adjacent to the lesion. In that case, board placed under the bronchoscopy table mattress the probe should be introduced into another subseg- [17] . Harms et al. [18] introduced in a technical mental bronchus in an attempt to place the probe note a new approach to the treatment of inoperable within the lesion. When the probe has been introduced peripheral lung tumors combining an electromagnetic into the lesion, the guide sheath can be left in the navigation system and EBUS with 3 - D - planned endo- lesion, giving a 90% diagnostic yield. 92 CHAPTER 9 Diagnosis of Peripheral Pulmonary Lesions When a Lesion Can Be Identifi ed device will advance them down the drainage bron- Fluoroscopically, but Cannot Be Delineated chus. As the guiding device is advanced in this direc- Using EBUS (See Chapter 3 , Figure 3 .9 and tion the guide sheath will follow, allowing accurate Video Clip 9.12) placement of the guide sheath within the peripheral When a lesion cannot be delineated using EBUS, the pulmonary lesion. The guiding device is then removed, ultrasonic probe should be removed without moving the ultrasonic probe is reintroduced, and the lesion the guide sheath, and guide forceps introduced can be delineated. into the guide sheath until their tips protrude. The tip of the guiding device is bent in the direction of the When the Bronchus Leading to the Target lesion, and the forceps are then withdrawn slowly, Lesion Is Stenosed at the Entry to the looking for a point at which they move slightly towards Lesion (Figure 9.2 ) the lesion. A bronchus leading to the lesion branches If the ultrasonic probe is introduced as far as the entry off from this point, and the tip of the guiding device to the lesion, sometimes only part of the lesion can be have entered this branch, and advancing the guiding delineated using EBUS, and the probe cannot be Figure 9.2 When the bronchus leading to the target lesion is bronchus at the tumor entrance. The probe should be stenosed at the entry to the lesion. If the ultrasonic probe is withdrawn, and a curette introduced, allowing dilatation of introduced as far as the entry to the lesion, sometimes only part the stenosed bronchus. The probe can now be introduced as of the lesion can be delineated using EBUS, and the probe far as the interior of the lesion, allowing biopsy and other cannot be pushed any further. This is due to stenosis of the procedures. 93 Endobronchial Ultrasonography Figure 9.3 Management of post- biopsy hemorrhage. When hemorrhaging occurs following brushing or biopsy via the guide sheath, the blood usually passes back into the guide sheath rather than into the airway. This is because the outer surface of the guide sheath is snug against the bronchial lumen. If we wait around 2 min before withdrawing the guide sheath, in almost all cases it can be withdrawn without any further hemorrhage. We have experiencing a case of a large intrapulmonary hemorrhage, but thanks to the guide sheath no further treatment was necessary and only a small amount of blood escaped into the airway. pushed any further. This is due to stenosis of the multiple biopsies from the same site, protects against bronchus at the tumor entrance. The probe should be bleeding into the proximal bronchus from the biopsy withdrawn, and a curette introduced, allowing dilata- site, and can delineate the inner structure of PPLs. tion of the stenosed bronchus. The probe can now be introduced as far as the interior of the lesion, allowing biopsy and other procedures. References Management of Post - Biopsy Hemorrhage 1 Kurimoto N , M urayama M , Y oshioka S , et al. Analysis of the internal structure of peripheral pulmonary lesions (Figure 9.3 ) using endobronchial ultrasonography. C hest 2002 ; 122 : When hemorrhaging occurs following brushing or 1877 – 1894 . biopsy via the guide sheath, the blood usually passes 2 Kurimoto N , Miyazawa T , Okimasa S , et al. Endobronchial back into the guide sheath rather than into the airway. ultrasonography using a guide sheath increases the This is because the outer surface of the guide ability to diagnose peripheral pulmonary lesions endo- sheath is snug against the bronchial lumen. If we wait scopically . Chest 2004 : 126 ; 959 – 965 . around 2 min before withdrawing the guide sheath, in 3 Mori K , Y anase N , K aneko M , et al. Diagnosis of periph- almost all cases it can be withdrawn without any eral lung cancer in cases of tumors 2 cm or less in size. further hemorrhage. We have experiencing a case of Chest 1989 ; 95 : 304 – 308 . a large intrapulmonary hemorrhage, but thanks to 4 Popvich J J r , K vale P A , E ichenhorn M S , et al. D iagnostic accuracy of multiple biopsies from fl exible fi beroptic the guide sheath no

further treatment was necessary bronchoscopy – a comparison of central versus periph- and only a small amount of blood escaped into the eral carcinoma. A m Rev Respir Dis 1982 ; 125 : 521 – 523 . airway. 5 Fletcher EC , Levin DC . F lexible fi beroptic bronchoscopy and fl uoroscopically guided transbronchial biopsy in management of solitary pulmonary nodules. W est J Conclusion Med 1982 ; 135 : 477 – 483 . 6 Stringfi eld J T , M rkowitz D J , B entz R R , et al. The effect EBUS - GS permits more accurate collection of samples of tumor size and location on diagnosis by fi beroptic from PPLs than other methods. This method facilitates bronchoscopy . Chest 1977 ; 72 : 474 – 476 . 94 CHAPTER 9 Diagnosis of Peripheral Pulmonary Lesions 7 Radke J R , C onway W A , E yler W R , et al. Diagnostic 15 Ahmad M , L ivingston D R , G olish J A , et al. T he safety accuracy in peripheral lung lesions: Factors predicting of outpatient transbronchial biopsy. Chest 1986 ; 90 : 403 . success with fl exible fi beroptic bronchoscopy . C hest 16 Yoshikawa M , S ukoh N , Y amazaki K , et al. D iagnostic 1976 ; 76 : 176 – 179 . Value of Endobronchial Ultrasonography with a Guide 8 Wallace JM , D eutch AL . F lexible fi beroptic bronchos- Sheath for Peripheral Pulmonary Lesions Without X - Ray copy and percutaneous lung aspiration for evaluating the Fluoroscopy . Chest 2007 ; 131 : 1788 – 1793 . solitary pulmonary nodule. C hest 1 982 ; 81 : 665 – 671 . 17 Schwarz Y , M ehta AC , E rnst A , et al. Electromagnetic 9 Hadson RR , Zavala DC , Rhodes ML , et al. T ransbronchial navigation during fl exible bronchoscopy . R espiration biopsy via fl exible fi beroptic bronchoscope; results in 2003 ; 70 : 516 – 522 . 164 patients. A m Rev Respir Dis 1976 ; 114 : 67 – 72 . 18 Harms W , K rempien R , G rehn C , et al. Electromagnetically 10 Kvale P A , B ode F R , K ini S . Diagnostic accuracy in lung navigated brachytherapy as a new treatment option for cancer; comparison of techniques used in association peripheral pulmonary tumors. S trahlenther Onkol with fl exible fi beroptic bronchoscopy . Chest 1976 ; 69 : 2006 ; 182 ; 108 – 111 . 752 – 757 . 19 Asano F , M atsuno Y , M atsushita T , et al. T ransbronchial 11 Shiner RJ , Rosenman J , Katz I , et al. B ronchoscopic diagnosis of a pulmonary peripheral small lesion using evaluation of peripheral lung tumors. Thorax 1 988 ; an ultrathin bronchoscope with virtual bronchoscopic 43 : 887 – 889 . navigation . J Bronchol 2002 ; 9 : 108 – 111 . 12 Torrington KC , Kern JD . The utility of fi beroptic bron- 20 Asano F , M atsuno Y , S hinagawa N , et al. A virtual choscopy in the evaluation of the solitary pulmonary bronchoscopic navigation system for pulmonary periph- nodule . Chest 1993 ; 104 : 1021 – 1024 . eral lesions . Chest 2006 ; 130 : 559 – 566 . 13 Chechani V . Bronchoscopic diagnosis of solitary pulmo- 21 Asano F , Matsuno Y , Tsuzuku A , et al. D iagnosis of nary nodules and lung masses in the absence of endo- pulmonary peripheral lesions using a bronchoscope bronchial abnormality. C hest 1996 ; 109 : 620 – 625 . insertion guidance system combined with endobron- 1 4 Blasco LH , Hernandez IMS , Garrido VV , et al. S afety of chial ultrasonography with a guide sheath. L ung Cancer transbronchial biopsy in outpatients. C hest 1991 ; 99 : 562 . 2008 ; 60 : 366 – 373 . 95 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement tion. First, there was a need to analyse the laminar Introduction structure of the tracheal and bronchial wall. There are several reports by H ü rter et al. [ 2] , Baba et al. [ 3] , The clinical application of intralumenal ultrasonogra- Becker [4] , and Kurimoto et al. [ 1] on the bronchial phy using a miniature ultrasonic probe began with laminar structure as delineated by high - frequency intravascular ultrasonography. A number of reports ultrasonography. H ü rter [2] stated that the bronchial have been published concerning the use of endoscopic laminar structure is trilaminar, comprising an inner ultrasonography of the gastrointestinal tract for echodense layer and an intermediate echolucent zone delineation of the structure of the esophageal, stomach of nearly the same diameter. Baba [3] reported that and bowel walls, and determination of the depth of the intrapulmonary bronchi have six layers: 1st + 2nd tumor invasion. CT scanning has been the mainstay layers (epithelium, lamina propria, and submucosa), of tracheobronchial diagnostic imaging for invasive 3rd + 4th layers (cartilage), and 5th + 6th layers disease of the airways. CT scanning can recognize the (adventitia). The extrapulmonary bronchi were also tracheobronchial wall as the structure between the seen as having six layers, with cartilaginous and mem- lumen and the peritracheobronchial tissue, but branous portions similar to the intrapulmonary detailed evaluation of the tracheobronchial wall, only bronchi: 1st + 2nd layers (epithelium, lamina propria, 1 or 2 mm thick, requires an imaging modality with and submucosa), 3rd + 4th layers (longitudinal muscle higher resolution such as high frequency ultrasonic layer) and 5th + 6th layers (adventitia or loose con- tomography. Since 1994, we have performed endo- nective tissue. Becker [ 4] stated that the tracheobron- bronchial ultrasonography (EBUS) with a thin ultra- chial wall comprises seven layers, and the supporting sonic probe inserted through the working channel of wall, composed of cartilage and connective tissue a fl exible bronchoscope. When we commenced EBUS, which could not be distinguished, provides a triple we found that the presence of cartilage gives the tra- layer ultrasonographic image of low internal intensity cheobronchial wall a laminar structure [1] . and a strong echo at the internal and external surface of the cartilage and the adjacent structures on both Laminar Structure of the Tracheobronchial sides – the mucosa and submucosa on the inside and Wall the adventitia on the outside – each showing a ultra- With EBUS, we can visualize the laminar structure sonographic double layer with a strong echo at the of the tracheobronchial wall. The depth of tumor inva- surface and an echopoor underlying structure. sion into the tracheobronchial wall is a most impor- Based on the premise that knowledge of the differ- tant determinant of the choice of therapy, specifi cally ent anatomic layers of the bronchial walls and their bronchoscopic laser tumor ablation vs. surgical resec- ultrasonographic correlations is the basis for interpret- ing ultrasound images, we performed a needle- puncture experiment [1] (Figure 10.1 ). We fastened a Endobronchial Ultrasonography, 1st edition. resected specimen of bronchial wall to a rubber board By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. with two 23 G needles. We inserted a 29 G needle into Published 2011 by Blackwell Publishing Ltd. the cut end and immersed the assembly in water. We 96 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement Water A hole created 23G by the needle 23G needle Bronchial wall Scanning plane Probe Outermost 23C hypo.layer 29G needle 29G Rubber Rubber Slab slab Figure 10.1 Diagram of the needle - puncture experiment. A resected specimen bronchial wall was fastened to a rubber slab with two 23 G needles. A 29 G needle was inserted into the various layers from the cut end, and advanced so that it passed between the two 23 G needles. We scanned the specimen to obtain an image that included the two 23 G needles with the 29 G needle showing as a dot- like hyperechoic spot. For histopathological evaluation in the ultrasonic scanning plane, a cut was made to include the path of both 23 G needles. The hyperechoic spot of the 29 G needle on the ultrasonogram and the needle hole in the histopathological fi nding were compared to determine which layers in the tissue specimen corresponded to the ultrasonographic layers. Figure 10.2 Representative example of the needle- puncture experiment. In this specimen in which the dot - like hyperechoic scanned the plane, including both 23 G needles, com- spot produced by the needle (black arrow) was observed in the paring the hyperechoic spot of the 29 G needle with center of the outermost hypoechoic layer (white arrow) of a the hole in the pathological sample. segmental bronchus, the histopathological fi ndings were of a In Figure 1 0.2, we can see a representative speci- hole in the cartilage (black arrow), indicating that the outermost men. The dot- like hyperechoic spot from the 29 G hypoechoic layer was the cartilage. needle can be seen in the center of the outermost hypoechoic layer on the ultrasonogram of this seg- mental bronchus, where the histopathological fi nding was of a hole in the bronchial cartilage. This confi rms the marginal echo on the outer aspect of the bronchial that the outermost hypoechoic layer of the segmental cartilage. In the membranous portion, the 1st layer bronchus is the cartilage layer. (hyperechoic) is a marginal echo, the 2nd layer (hyp- Conducting this experiment on 45 specimens oechoic) represents submucosal tissue, and the 3rd yielded the following results. layer (hyperechoic) is the adventitia (Figure 10.3 ). Using a 20 MHz probe, the cartilaginous portion of A point to be borne in mind when identifying the both extrapulmonary and intrapulmonary bronchi are laminar structure of the wall ultrasonically is that mar- visualized as fi ve layers. The 1st layer (hyperechoic) is ginal echoes [5] (hyperechoic bands produced by a marginal echo, the 2nd layer (hypoechoic) repre- many reverberations) occur wherever there is an sents submucosal tissue, the 3rd layer (hyperechoic) interface between tissue types. Aibe [5] reported that is the marginal echo on the inner aspect of the bron- marginal echoes include transitional tissue, and that chial cartilage, the 4th layer (hypoechoic) represents they are high linear echoes that extend distally in the bronchial cartilage, and the 5th layer (hyperechoic) is direction of propagation of the ultrasound waves. 97 Endobronchial Ultrasonography 543 21 1 2 3 1 2 3 4 5 Figure 10.3 Bronchial wall layers delineated by endobronchial layer (hyperechoic) is a marginal echo, the second layer ultrasonography. Extrapulmonary bronchus (left): The (hypoechoic) represents smooth muscle, and the third layer cartilaginous portion of the trachea and the extrapulmonary (hyperechoic) is the adventitia. Intrapulmonary bronchus (right): bronchi is visualized as fi ve layers, and the membranous portion The intrapulmonary bronchi are visualized as fi ve layers. The 1st as three layers. The 1st layer (hyperechoic) is a marginal echo, layer (hyperechoic) is a marginal echo, the 2nd layer the 2nd layer (hypoechoic) represents smooth muscle, the 3rd (hypoechoic) represents submucosal tissue, the third layer layer (hyperechoic) is the marginal echo on the inner side of the (hyperechoic) is the marginal echo on the inner side of the bronchial cartilage, the 4th layer (hypoechoic) represents bronchial cartilage, the fourth layer (hypoechoic) represents bronchial cartilage, and the 5th layer (hyperechoic) is the bronchial cartilage, and the fi fth layer (hyperechoic) is the marginal echo on the outer side of the cartilage. In the marginal echo on the outer side of the cartilage. membranous portion of the extrapulmonary bronchi, the fi rst Marginal echoes, visualized as hyperechoic, are of the depth of invasion was the same for 23 cases observed between the lumen and the mucosal epithe- (95.8%), and different in one case (4.2%). In the case lium, between the submucosa and cartilage, and of disagreement between the EBUS and histopatho- between cartilage and the adventitia (Figure 10.4 ). logical fi ndings, lymphocytic infi ltration protruded We also compared EBUS images of resected lung between cartilages was mistakenly interpreted as cancer specimens with the histopathological fi ndings tumor invasion. to assess the

accuracy of EBUS in determining the Recently, we have encountered some cases with depth of tumor invasion [ 1] . We compared ultrasono- seven layers in the cartilage portion of the trachea and graphic measurements of the depth of tumor invasion the right and left main bronchi. An adenoid - cystic in specimens resected from 24 patients with lung carcinoma of the trachea was seen to have seven cancer with the histopathological fi ndings. Two repre- layers using a 20 MHz probe. Compared histopatho- sentative examples of squamous cell carcinoma arising logical fi ndings and the EBUS images, the 5th and 7th in the right intermediate trunk are shown in Figure hyperechoic layers were the marginal echoes at the 10.5 . The left hand picture shows a tumor in contact outer surface of the bronchial cartilage and collagen with the inner surface of the bronchial cartilage, at the fi bers outside the loose connective tissue, respectively. boundary between the membranous and cartilaginous The 6th hypoechoic layer corresponded to thick loose portions. The right hand picture of a tumor adjacent connective tissue outside the cartilage (Figure 10.6 ). to the inner surface of the smooth muscle of the mem- If the loose connective tissue outside the cartilage is branous portion shows a tumor in contact with the relatively thin, the 5th hyperechoic layer becomes second layer on the EBUS image. Comparison of the attached to the 7th hyperechoic layer, so they are EBUS images with the histopathological fi ndings in 24 visualized as one layer. We believe that in general patients with lung cancer showed that measurements the cartilaginous portion is visualized as fi ve layers, 98 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement 5th 3rd 1st 4th 2nd Marginal Marginal Marginal echo echo echo Figure 10.4 Comparison of ultrasonographic and submucosa. The marginal echo of the 3rd layer appears to histopathological layers of the bronchial wall. Marginal echoes extend from the inner margin of the bronchial cartilage to the include the transitional tissue, and are highly linear echoes that middle of the cartilage, and the marginal echo of the 5th extend distally in the direction of propagation of the ultrasound hyperechoic layer extends from the outer margin of the waves. The marginal echo (1st layer) extends from the inner bronchial cartilage to the adventitia. margin of the mucosal epithelium to the inner part of the Figure 10.5 Comparison of ultrasonographic and confi rming the ultrasonic determination of the depth of tumor histopathological fi ndings. Left: representative example of invasion. Right: representative example of invasion as far as submucosal invasion. This lesion is in contact with the inner side smooth muscle of membranous portion. This lesion is in contact of the hyperechoic third layer (inner marginal echo of cartilage: with the inner side of the hypoechoic second layer, which white arrow), and tumor in contact with the inner surface corresponds to smooth muscle (black arrow), and this was (white arrow) of the cartilage was observed histopathologically, confi rmed on histopathological examination. 99 Endobronchial Ultrasonography Figure 10.6 Seven tracheal layers demonstrated using EBUS. Left: This adenoid -c ystic carcinoma of the trachea had seven layers visualized using EBUS. Right: Comparison of the histopathological fi ndings and EBUS image showed that the 6th hypoechoic layer corresponds to thick loose connective tissue outside the cartilage, and the 7th hyperechoic layer corresponds to collagen fi bers outside the loose connective tissue. Lobar and segmental sub-segmental sub-sub-segmental bronchus bronchus bronchus Figure 10.7 Bronchial cartilage of lobar, segmental, subsegmental, and sub - subsegmental bronchi. Bronchial cartilage is visualized in fi ve layers of the segmental bronchi in these resected specimens. It is rather diffi cult to point out the bronchial cartilage beyond intact segmental 2mm bronchus. and the cartilaginous portion of the trachea and right frequency ultrasonography include marginal echoes and left main bronchi sometimes shows seven layers. (boundary echoes). Marginal echoes are the artefacts To which bronchial generation can the bronchial that high frequency ultrasound waves produce at tissue cartilage be visualized? The bronchial cartilage is boundaries, such as the cartilage surface. A shallow visualized as fi ve layers in a resected specimen of a carcinoma in situ will therefore be hidden behind the segmental bronchus. It is rather diffi cult to detect the 1st hyperechoic layer (marginal echo). Using the bronchial cartilage beyond an intact segmental bron- laminar structures of the bronchial wall, the depth of chus (Figure 1 0.7 ). However, it is easy to detect the tumor invasion of the tracheobronchial wall is classi- bronchial cartilage if a tumor invades beyond the fi ed into fi ve categories: epithelium (superfi cial subepi- bronchial cartilage, that is to say bronchial cartilage is thelium), subepithelium, cartilage, adventitia, and present within the tumor (Figure 10.8 ). beyond the adventitia (Figure 1 0.9 , Video clip 10.1). Once again we should make clear that the laminar In the next step, in order to determine the ability of structures of the bronchial wall as visualized by high EBUS to delineate the depth of tumor invasion, we 100 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement Figure 10.8 Squamous cell carcinoma (left B3 bronchus). Left: fi ndings also show this lesion to have invaded beyond the A polypoid lesion obstructing the left B3 bronchus is shown at bronchial cartilage to protrude at 12 o’ clock (arrow), confi rming bronchoscopy. Right upper: Ultrasonography shows this lesion to the ultrasonographic determination of the depth of tumor have invaded beyond the bronchial cartilage to protrude at 12 invasion. Hematoxylin and eosin: original magnifi cation × 10. o ’ clock beyond the adventitia. Right lower: The histopathological Determination of depth of tumor invasion by EBUS Epithelium Beyond Submucosa Cartilage Adventitia submucosa adventitia Figure 10.9 Depth determination using EBUS. Using the laminar structures of the bronchial wall, the depth of tumor invasion of tracheobronchial wall is classifi ed into fi ve categories: epithelium (superfi cial subepithelium), subepithelium, cartilage, adventitia, and beyond the adventitia. 101 Endobronchial Ultrasonography Figure 10.10 Typical carcinoid in the right upper bronchus. Left upper: Chest CT scanning shows a tumor located in the right upper bronchus. Left lower: Ultrasonography shows that the tumor has invaded beyond the bronchial cartilage (arrow), compressing the fi fth layer (adventitia). Right upper: The bronchoscopic fi ndings show this tumor obstructing the right upper bronchus. Right lower: Histopathologically, tumor has invaded beyond the bronchial cartilage (arrow) to compress and invade the adventitia. The histopathological fi ndings confi rm the ultrasonographic determination of the depth of tumor invasion. Hematoxylin and eosin: original magnifi cation × 10. compared preoperative EBUS fi ndings in tracheobron- shown to have invaded beyond the bronchial carti- chial tumors with the histopathological fi ndings in lage, compressing the fi fth layer (corresponding to the surgically resected lungs subjected to complete sec- adventitia, Figure 10.10 ). Histopathologically, the tioning. Histopathological examination of 42 speci- tumor compressed and invaded the adventitia. Again, mens showed the depth of tumor invasion as the histopathological fi ndings confi rmed the ultra- carcinoma in situ (epithelium) in fi ve cases, submu- sonographic determination of the depth of tumor cosal (subepithelium) in 7, bronchial cartilage in 1, invasion. adventitial in 5, and extramural (beyond the adventi- On the other hand, one misdiagnosed case was a tia) in 24. The depth of tumor invasion according to squamous cell carcinoma that histopathologically preoperative ultrasonography agreed with the his- compressed and invaded the adventitia, while ultra- topathologic fi ndings in 35 out of 42 cases (83%). The sonography showed a hypoechoic area extending accuracy of EBUS according to histological depth was beyond the adventitia (Figure 1 0.11 ). Another misdi- 0% (0/5) for carcinoma in situ, 86% (6/7) for submu- agnosed case was a squamous cell carcinoma that his- cosal, 100% (1/1) for cartilage, 80% (4/5) for adven- topathologically invaded the submucosa while titia, and 100% (24/24) for extramural lesions. ultrasonography showed a hypoechoic area extending The fi ndings in two representative cases where from the mucosa to the adventitia. While this lesion EBUS determination of the depth of tumor invasion was diagnosed by EBUS as invading the adventitia, the agreed with the histopathologic fi ndings are given hypoechoic region extending between the cartilage below. rings to the adventitia was histopathologically shown A squamous cell carcinoma was located at B3 on the to represent lymphocytic infi ltration that caused over- left. Ultrasonography showed this lesion to invade estimation of the depth of invasion by EBUS (Figure beyond the bronchial cartilage, protruding at 12 10.12 ). The other fi ve misdiagnosed cases were squa- o ’ clock; thus the ultrasonically determined depth of mous cell carcinomas that histopathologically invaded tumor invasion was extramural (Figure 1 0.8 ). The his- only the mucosa (carcinoma in situ), in three of which topathological fi ndings confi rmed this determination. ultrasonography showed fi ve layers with normal In the second case, a typical carcinoid tumor involv- appearance (Figure 10.13 ). The remaining two ing the right upper bronchus was ultrasonographically cases were carcinomas in situ where ultrasonography 102 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement Figure 10.11 Squamous cell carcinoma in the right upper invaded beyond the adventitia. Right lower: Histopathologically, bronchus. Left upper: Chest CT scanning shows a tumor located the tumor does not extend beyond the adventitia. The depth of in the right upper bronchus. Left lower: The bronchoscopic tumor invasion has therefore been overestimated. Hematoxylin fi ndings locate this tumor in the right upper bronchus and B3. and eosin: original magnifi cation × 10. Right upper: Ultrasonographically, the tumor appears to have Figure 10.12 Squamous cell carcinoma in the right B2 bronchus. Left: The bronchoscopic fi ndings locate this tumor in the right upper bronchus and B2. Right upper: Ultrasonography shows a hypoechoic area extending from the epithelium to the adventitia, indicating tumor invasion of the adventitia. Right lower: Histopathologically, this tumor invades the submucosa. The hypoechoic region extending from between the cartilages to the adventitia corresponds to lymphocytic infi ltration. The depth of tumor invasion has been overestimated. Hematoxylin and eosin: original magnifi cation × 10. 103 Endobronchial Ultrasonography Figure 10.13 Squamous cell carcinoma (left B6 bronchus). Left: The bronchoscopic fi ndings are of a dull appearance of the surface at the left B6 bifurcation. Right upper: Ultrasonography demonstrates fi ve normal - appearing layers. Right lower: Histopathologically, this tumor was observed to involve the mucosa (carcinoma in situ). The marginal echo (1st layer) extends from the luminal margin of the mucosa to the superfi cial portion of the submucosa. Carcinoma in situ thus occupies the intact- appearing fi rst layer (hyperechoic, marginal echo) as seen with a 20 MHz probe. showed a hypoechoic area extending from the epithe- ultrasonography (EUS) for oesophageal cancer was lium to the adventitia. This was diagnosed by EBUS as not able to distinguish either fi brotic change resulting tumor invasion of the adventitia, while histopatho- from esophagitis or lymphoid hyperplasia adjoining a logically most of the hypoechoic region corresponded tumor from tumor invasion. Arima et al. [6] similarly to lymphocytic infi ltration and prominent bronchial noted that changes in the tissues around a tumor such glands, leading to overestimation of the depth of as hyperplasia of lymphoid follicles, cellular infi ltra- tumor invasion (Figure 1 0.14 ). tion, and fi brosis of tumor invasion, were often mis- Unlike other diagnostic imaging methods, EBUS interpreted as tumor. Kikuchi et al. [ 8] attributed using a 20 MHz probe allows visualization of the depth misdiagnosis of the depth of invasion of colorectal of tumor invasion of the tracheobronchial wall. When cancers using EUS to attenuation of ultrasound waves the tumor has invaded beyond the bronchial cartilage, related to tumor thickness, as well as diffi culty in dif- this modality clearly shows the bronchial cartilage ferentiating between cancer invasion and lymphocytic within the tumor. infi ltration, lymphoid follicles, or submucosal fi brosis. The most important point in determination of the Menzel and Domschke [ 9] also reported that ultra- depth of tracheobronchial tumor invasion using EBUS sonographic overstaging of oesophageal cancers might is examination of the third and fourth layers, corre- involve misinterpretation of submucosal infl amma- sponding to the bronchial cartilage. An important tion. In four lesions (three carcinomas in situ, one limitation of

preoperative EBUS in determination of submucosally invading carcinoma) we also overesti- the depth of tumor invasion is diffi culty distinguishing mated the depth of tumor invasion because of lym- lymphocytic infi ltration from tumor invasion (Figure phocytic infi ltration and bronchial glands in the 10.15 ). As ultrasonography visualizes tissues accord- submucosa, and between bronchial cartilage and ing to the speed of propagation of ultrasound waves, adventitia. In recent years, we have begun to use a it would appear that the speed of ultrasound waves 30 MHz probe to obtain higher resolution images of from the 20 MHz probe passing through invasive the superfi cial layers, and a convex probe to provide cancer is similar to that through lymphocytic infi l- longitudinal images of the tracheobronchial wall. trates and hypertrophied bronchial glands. Arima et Comparison of the ultrasonographic and histopatho- al. [6] and Kawano et al. [7] reported that endoscopic logic fi ndings in this study indicated that the depth of 104 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement Figure 10.14 Squamous cell carcinoma (right B2 bronchus). Left upper: Bronchoscopic fi ndings show the right B2 to be near normal. Left lower: Ultrasonographically, the bronchial wall is thickened. A hypoechoic area extending from the epithelium to the adventitia suggests tumor invasion of the adventitia. Right: Histopathologically, this tumor is confi ned to the mucosa (carcinoma in situ). Most of the hypoechoic region corresponds to lymphocytic infi ltration and hypertrophied bronchial glands, causing overestimation of the depth of tumor invasion. Hematoxylin and eosin: original magnifi cation × 10. Figure 10.15 Lymphocytic infi ltration of the bronchus. A squamous cell carcinoma located in right B8. EBUS showed a submucosal hypoechoic area connected to the area resembling rabbit ears (arrow). This tumor was assessed as invading the adventitia. Histopathologically the tumor extends to the submucosa. Limitations of preoperative EBUS in determination of the depth of tumor invasion include diffi culty in distinguishing lymphocytic infi ltration from tumor invasion. 105 Endobronchial Ultrasonography tumor invasion of the bronchial wall can be accurately assigned by EBUS to one of fi ve levels: EP (epithelium, or minimal invasion of subepithelium), SE (subepithe- Extra- cartilagenous lium), C (cartilage), A (adventitia), and Ai (invasion beyond the adventitia). When the bronchus at the site of the lesion still shows fi ve layers, the depth of inva- 5th sion would be EP. When the lesion extends from the 4th 1st layer (hyperechoic marginal echo) to the 2nd layer 3rd Cartilage (hypoechoic, submucosa), while the third layer (hyperechoic marginal echo from the inner aspect of the cartilage) can be clearly delineated, the depth of Intra- invasion is SE. When the lesion extends from the 1st cartilagenous layer to the 4th layer, but the 5th layer (hyperechoic marginal echo at the outer aspect of the cartilage) can Figure 10.16 Intracartilaginous or extracartilaginous. be clearly delineated, the depth of invasion is C. When Tracheobronchial tumors are diagnosed as intracartilaginous or the lesion extends from the 1st layer to the 5th layer, extracartilaginous using EBUS. but the 5th layer is intact, the depth of invasion is A. Finally, when wedge- shaped interruptions are seen in layers 3, 4, and 5, the depth of invasion is Ai. An ultrasonographic depth of invasion of EP or SE allows EBUS for Infl ammatory Diseases of selection of local endobronchial therapy. the Tracheobronchial Tree We performed EBUS for the evaluation infl ammatory Photodynamic Therapy with EBUS diseases of the tracheobronchial wall, including tuber- In bronchoscopic treatment of localized lesions, avoid- culosis, relapsing polychondritis, chronic infl amma- ing tissue destruction beyond the cartilage layer is tion following tracheotomy, Wegener ’ s granulomatosis, important for success and safety [ 10 – 12]. Miyazu [ 12] and ulcerative colitis. The greatest benefi t of EBUS for reported that determination of the depth of tumor infl ammatory diseases of the tracheobronchial wall is invasion using EBUS, rather than simply measuring the ability to visualize and assess the bronchial lesion size and height, improves the chances of success cartilage. of photodynamic therapy (PDT). Eighteen patients In Figure 10.17 , we can see that in this patient with with biopsy- proven squamous cell carcinomas, consid- relapsing polychondritis, EBUS revealed thickening of ered to be appropriate candidates for PDT by conven- the tracheobronchial cartilage, containing calcifi ca- tional bronchoscopy under high- resolution computed tions, and an intact membranous portion (Figure tomography (HR - CT) control, were enrolled. Nine 10.17 ). EBUS, with its superior tissue analysis ability, lesions were diagnosed as intracartilaginous using allows us to discern the laminar structure of the mem- EBUS (Figure 10.16) , and subsequently underwent branous portion as well. In chronic infl ammatory con- PDT. Long- term complete remission has been achieved ditions such as post - tracheotomy infl ammation, in these patients, with a median follow - up term follow- Wegener ’ s granulomatosis and ulcerative colitis, the ing PDT of 32 months. infl ammatory process involves the entire circumfer- The remaining nine lesions were diagnosed as ext- ence of the trachea, and thickening of both the carti- racartilaginous using EBUS, and were considered can- laginous and membranous portions of the tracheal didates for other therapies such as surgical resection, and main bronchial walls can be seen on the EBUS chemotherapy, and radiotherapy, although two were images. This allows us to distinguish these conditions not detectable using HR - CT, three were superfi cial, from relapsing polychondritis, in which the membra- and fi ve were ≤ 1 cm in diameter at bronchoscopy. The nous portion is spared (Figure 1 0.18 ). depth of tumor invasion estimated by EBUS was con- Another advantage of EBUS in cases of bronchoma- fi rmed by histopathological fi ndings in six specimens lacia due to infl ammatory diseases of the tracheo- after surgical resection. bronchial wall is that the diameter of the infl ated 106 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement Figure 10.17 Relapsing polychondritis. In this case of relapsing polychondritis, EBUS revealed thickening of the tracheobronchial cartilage, containing calcifi cations, and an intact membranous portion. Cartilage Figure 10.18 Chronic infl ammation. In chronic infl ammatory conditions such as post - tracheotomy infl ammation, Wegener ’ s granulomatosis and ulcerative colitis, thickening of both the cartilaginous and membranous portions can be seen on the EBUS images, allowing us to distinguish these conditions from relapsing polychondritis. bronchus can be measured using the infl ated balloon the bronchial cartilage has been destroyed, a stent probe. should be inserted to maintain the patency of the Iwamoto et al. [ 13] reported the usefulness of EBUS affected bronchus. in the management of airway stenosis due to tracheo- bronchial tuberculosis. Prior to interventions for Measurement of Airway Diameters airway stenosis caused by tracheobronchial tuberculo- When performing interventions for airway stenosis, sis, EBUS was performed to evaluate whether the such as stent placement, it is important to accurately bronchial cartilages were destroyed or intact. When measure the internal diameters of the normal bronchus 107 Endobronchial Ultrasonography proximal and distal to the lesion, and of the lesion itself. when there is a discontinuity of this interface echo. This will aid in the selection of the optimum diameter This is particularly useful in determining whether stent, and the best size balloon for balloon dilatation. there is tracheal invasion by a thyroid cancer, or direct Similarly, when laser ablation is to be performed, Using invasion of the left main bronchus by oesophageal EBUS we measure the distance between the luminal cancer. Herth et al. [ 15] investigated whether EBUS surface of the lesion to the inner surface of the bron- can reliably differentiate between airway infi ltration chial cartilage, so the laser depth of penetration can and compression by tumor. The ability of chest CT and be set. EBUS to distinguish between compression and infi l- I conducted an experiment to evaluate the accuracy tration was measured against the histological results. of measurements using EBUS. I measured the inner They found that EBUS is a highly accurate diagnostic diameter of a syringe using EBUS, comparing these tool, and superior to chest CT in evaluating the ques- fi ndings with the actual diameter. The syringe tion of airway involvement by central intrathoracic diameter as measured using EBUS was 0.1 mm greater tumors. than the actual diameter. When performing EBUS for central lesions in the clinical setting, a balloon sheath 30 MHz Versus 20 MHz is necessary to exclude air over the target lesion. Shaw Radial probes operating at 20 MHz have been used et al. [ 14] evaluated whether infl ation of a fl uid- fi lled since EBUS fi rst began, and now 30 MHz radial probes balloon sheath over the transducer infl uenced i n vitro are available. As the ultrasound frequency increases, measurements. In vivo comparison of EBUS with high the resolution is higher but the depth of penetration resolution computed tomography scanning (HRCT), decreases (Figure 10.19 ). Radial probes operating at statistical analysis of measurements of airway internal 30 MHz show more differentiated 2nd and 4th layers diameter and wall thickness with and without the than 20 MHz radial probes. At 30 MHz, the submucosal balloon sheath showed agreement between EBUS and tissue is more echo intense, and the cartilage more HRCT. We believe that the accuracy of measurements hypoechoic. Nakamura et al. [16] compared 20 MHz using EBUS is acceptable. and 30 MHz probes using a plot profi le derived from CT scanning is also used to measure the internal the image analysis software NIH Image. A normal diameters of the normal bronchus proximal and distal bronchial wall image consists of fi ve layers, and the to the lesion, and of the lesion itself. Measurements plot profi le shows a W - shape curve. The differences in using EBUS are necessary in the following cases: (1) mean echo intensity between the 3rd and 4th layers, when tracheobronchomalacia is present; (2) when a and the 2nd and 4th layers, were found to be signifi - build -u p of secretions or sputum is present distal to the cantly greater with the 30 MHz probe than with the stenosis; and (3) when CT scanning cannot be per- 20 MHz probe. The 30 MHz probe was found to be formed, e.g. the patient is unable to hold their breath. more useful than the 20 MHz probe in delineating the In cases of tracheobronchomalacia, as typifi ed by laminar structures of the bronchial wall. relapsing polychondritis, the tracheobronchial lumen In the future, higher probe frequencies, electrical is narrowed during both the inspiratory and expiratory scanning, and linear probes will allow higher resolu- phases. Accurate measurement of the inner diameter tion EBUS images of the tracheobronchial wall. We with the lumen expanded is necessary, a requirement believe that both cross- sectional and longitudinal met by EBUS with the balloon fi lled with fl uid. images are necessary for accurate diagnosis of the depth of tracheobronchial wall invasion. Diagnosis of Invasion of the Bronchial Tree from Outside The tracheobronchial laminar structure delineated by Conclusions EBUS using high frequency ultrasonic waves is made up of interface echoes generated at the interfaces 1 EBUS using a high - frequency ultrasonic probe between the submucosa and cartilage, and cartilage allows visualization of the depth of invasion of tra- and serosa. Diagnosis of direct invasion of the tracheo- cheobronchial tumors, not possible with other diag- bronchial wall from outside can therefore be made nostic imaging methods. 108 CHAPTER 10 Endobronchial Ultrasonographic Analysis of Airway Wall Integrity and Tumor Involvement 20MHz 30MHz Figure 10.19 30 MHz vs. 20 MHz. The differences in the mean echo intensity between the 3rd and 4th layers, and the 2nd and 4th layers were found to be signifi cantly greater with the 30 MHz probe than with the 20 MHz probe. 2 Preoperative EBUS using a 20 MHz probe clearly 4 Becker H . E ndobronchialer Ultraschall – eine Neue visualizes bronchial cartilage within the tumor when Perspektive in der Bronchologie. Ultraschall In Med the adventitia has been invaded. 1996 ; 17 : 106 – 112 [in German]. 3 Some problems persist with EBUS using a 20 MHz 5 Aibe T . A study on the structure of layers of the gas- probe for the determination of the depth of tumor trointestinal wall

visualized by means of the ultrasonic endoscope. The structure of layers of the esophageal invasion, particularly its inability to visualize carci- wall and the colonic wall. G astroenterol Endosc noma in situ and diffi culty in distinguishing tumor 1984 ; 26 : 1465 – 1473 . invasion from lymphocytic infi ltration and hypertro- 6 Arima M , T ada M . Endosonographic assessment of phied bronchial glands. the depth of tumor invasion by superfi cial esophageal cancer, using a high- frequency miniature US probe: diffi culties in interpretation and misleading factors. Stomach and Intestine (Tokyo) 2004 ; 39 : 901 – 913 . References 7 Kawano T , N agai Y , I noue H , et al. E ndoscopic ultrasonography for patients with esophageal cancer . 1 Kurimoto N , Murayama M , Yoshioka S , Nishisaka T , Stomach and Intestine (Tokyo) 2001 ; 36 : 307 – 314 . Inai K , D ohi K . Assessment of the usefulness of endo- 8 Kikuchi Y , Tsuda S , Yurioka M , et al. D iagnosis of bronchial ultrasonography in tracheobronchial depth the depth infi ltration in colorectal cancer- diagnosis and diagnosis . Chest 1999 ; 115 : 1500 – 1506 . issues of the depth of infi ltration investigated by endo- 2 H ü rter T , H anarath P . E ndobronchiale Sonographie scopic ultrasonography (EUS) . Stomach and Intestine zur Diagnostik Pulmonaler und Mediastinaler Tumoren . 2001 ; 36 : 392 – 402 . Dtsch Med Wschr 1990 ; 105(50) : 1899 – 1905 [in German]. 9 Menzel J , D omschke W . Gastrointestinal miniprobe 3 Baba M , Sekine Y , S uzuki M , et al. Correlation between sonography: the current status. A m J Gastroenterol endobronchial ultrasonography (EBUS) images and his- 2000 ; 95 : 605 – 616 . tological fi ndings in normal and tumor invaded bron- 10 Konaka C , Okunaka T , Kato H . C ombined use of photody- chial wall. L ung Cancer 2002 ; 35 : 65 – 71 . namic therapy . Ann Thorac Cardiovasc Surg 1 995 ; 1 : 55– 59 . 109 Endobronchial Ultrasonography 11 Okunaka T , K ato H , K onaka C , et al. P hotodynamic 14 Shaw T J , W akely S L , P eebles C R , et al. E ndobronchial therapy for multiple primary bronchogenic carcinoma . ultrasound to assess airway wall thickening: validation Cancer 1991 ; 68 : 253 – 258 . in vitro and i n vivo . E ur Respir J 2004 ; 23 : 813 – 817 . 12 Miyazu Y , M iyazawa T , K urimoto N , et al. E ndobronchial 15 Herth F J , E rnst A , S chulz M , et al. Endobronchial ultra- ultrasonography in the assessment of centrally located sound reliably differentiates between airway infi ltration early - stage lung cancer before photodynamic therapy . and compression by tumor. C hest 2003 ; 123 : 458 – 462 . Am J Respir Crit Care Med 2002 ; 165 : 832 – 837 . 16 Nakamura Y , Endo C , Sato M , et al. A new technique 13 Iwamoto Y , M iyazawa T , K urimoto N , et al. Interventional for endobronchial ultrasonography and comparison of bronchoscopy in the management of airway stenosis two ultrasonic probes. Analysis with a plot profi le of the due to tracheobronchial tuberculosis. C hest 2004 ; 126 : image analysis software NIH Image. Chest 2004 ; 1344 – 1352 . 126 : 192 – 197 . 110 11 EBUS in Interventional Bronchoscopy assessment for the degree of external compression Introduction versus true invasion are described, particularly with reference to surgical decision making in lesions adja- Some of the earliest applications of EBUS were in cent to the trachea. These techniques have not been interventional bronchoscopy techniques [1] . These evaluated in multicenter studies; however, in the techniques continue to be used in selected centers, description of these techniques, a better understand- particularly where there is a high throughput of large ing of the benefi ts of ultrasound can be obtained. airway obstructive lesions. The largest series and greatest variety of applications of EBUS has been described by Becker and Herth in Heidelberg [ 2] .To a Technique large extent, this refl ects the huge experience of these authors with rigid bronchoscopy and management of In contrast to the miniprobe used for peripheral lesions obstructing large airway lesions. It also refl ects their a saline fi lled balloon is required to obtain EBUS pioneering role of the use of EBUS in these different images in the large airways (Olympus XMAJ - 643R). clinical situations. The techniques predominantly use The probe (XUM - BS20 - 26R) is passed through the the 360 ° radial probe. In this situation EBUS attempts biopsy channel (2.8 mm or greater) of a bronchoscope to carefully scrutinize the layers of the bronchial wall and placed next to the wall at the site for evaluation. and determine whether these layers are invaded either The balloon is slowly infl ated until by bronchoscopic from the inside by endobronchial tumors or from the evaluation, it is seen to fi ll the bronchus. The EBUS outside. Conventional bronchoscopic inspection of the image of the bronchial wall is most detailed where bronchial mucosa can only give a superfi cial impres- there is approximately 1 cm distance from the probe sion of the underlying pathology. EBUS enhances the (inside the balloon) to the wall; however structures at bronchoscopists ’ evaluation particularly with refer- a depth of 4 cm from the bronchus can be visualized ence to tumor staging of both early and advanced [3] . To view the wall over a length it is usual to place tumors. EBUS provides unique information and a the balloon distally fi rst and infl ate at that point number of different studies have been shown greater then gently pull back along the wall of the bronchus sensitivity than any other diagnostic modality particu- as imaging occurs. Becker et al. report that, in terms larly in comparison with CT or MRI [ 2] . of the technique of applying the balloon ultrasound The early studies as discussed in previous chapters probe, the balloon is fi lled until there is close relating to depth diagnosis of small endobronchial contact with the bronchial wall. Clearly, this can mean lesions are a case in point. In this chapter, large airway obstruction of one or other of the main bronchi; however, in terms of ventilating the patient, this is rarely a problem. Sometimes there is complete occlusion even of the trachea; however even this Endobronchial Ultrasonography, 1st edition. can be well - tolerated for short periods under By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. suffi cient sedation and with careful preoxygenation. Published 2011 by Blackwell Publishing Ltd. Although it is very uncommon to require it, it is safe 111 Endobronchial Ultrasonography for the patient to undergo 3 or 4 minutes of apnea carcinomas and adenocarcinomas of the lung. On CT for the investigation of mediastinal structures in this scans in these patients, 81 patients (77%) were way [4] . reported to have tumor invasion of the airway while The method is well - suited for studying compressed 24 patients (23%) were considered to have extrinsic airways in that distal access is easily achieved by tumor compression of the airway. In contrast, when passing the uninfl ated balloon probe through the EBUS was performed, it was considered that 49 region of bronchial stricture or tumor, then gently patients (47%) had large airway tumor invasion and infl ating until the balloon image on the monitor shows 56 patients (53%) had tumor compression. On the some “ molding” by the bronchial wall. surgical resected specimens, 55 patients (52%) had The mucosa on the inner surface immediately adja- tumor invasion and tumor compression was seen in cent to the balloon shows a very bright echo. Next to 50 patients (48%). Therefore, all patients that did this, the submucosa is comparatively hypoechoic. have tumor invasion as proved by surgical resection There is a strong echo of the endochondrium and had been diagnosed by EBUS. EBUS had six false- perichondrium (hyperechoic) and this can sometimes negative examinations for tumor invasion within the reduce the visualization of the outside layers (support- trachea. Comparing EBUS and chest CT for infi ltration ing connective tissue and adventitia). Vessels can be by a central tumor of the tracheobronchial tree, accu- seen by both their pulsations and by their low internal racies were 94% and 51%, sensitivity 89% and 75%, echoes and constant reference to anatomical diagrams and specifi city 100% and 28% respectively. The cor- assist the proceduralist in becoming familiar with this relation between EBUS classifi cation and the surgical 360 ° image. Lymph nodes tend to be more hypere- classifi cation of airway involvement was very high at choic than blood vessels. Adjacent to the left main 0.89 (p < 0.01). Importantly, this was a simple safe bronchus, the important structures are the pulmonary technique and only took 3.5 minutes on average to trunk and left and right main pulmonary arteries as perform. EBUS therefore had been demonstrated as well as the ascending aorta and aortic arch. Posteriorly, an effective unique means of anatomically staging a it is easy to see the multilayered structure of the patient. Where there were six false- negative results esophagus. In orienting the radial probe, artifacts from from the EBUS alone, that is, infi ltration was present bronchial openings can also be helpful, for example, on surgery but not detected by EBUS, it was thought the apical segment bronchus. Important structures on due to poor contact of the probe with the wall because the right main bronchus are the pulmonary trunk and of the large tracheal diameter. It was felt to represent right pulmonary artery, and adjacent the lower trachea an accurate means of staging; however the clinical the vena cava and aortic root. The azygous vein crosses relevance in terms of changes in surgical management at the level of the right tracheobronchial angle. remains to be determined by long - term studies. A similar study was reported by Wakamatsu in 2006 [6] , however, the subjects had primary tumors of the Studies of Tracheal Compression Versus esophagus and thyroid. The study aimed to compare Tracheal Wall Invasion the utility of EBUS to assess this invasion as compared to the standard diagnostic techniques of CT and MRI. In 2003, Herth et al. reported on the ability of EBUS The fi ndings of bronchoscopy with EBUS regarding to reliably differentiate between airway infi ltration direct invasion of the airway lumen were used to and compression by tumor [5] . These tumors were determine indications for surgical exploration or defi ned as a mass next to the trachea or within the resection. That is, EBUS was used to change manage- tracheobronchial angles. From 131 patients referred ment and where invasion was evident, those with for evaluation, there were obvious factors which pre- direct invasion underwent chemoradiotherapy. Fifty- cluded them from subsequent surgery. These included four patients were included and from CT, MRI and visible tumor growth into the trachea, contralateral EBUS, invasion was suspected in 29, 28 and 25 endobronchial tumor, N3 node positivity and meta- patients respectively. It is important to note that the static disease. This left 105 patients who did undergo fi nal diagnosis was an intact trachea or bronchial surgery. The majority of these were squamous cell adventitia in 26 patients and invasion in 28 patients, 112 CHAPTER 11 EBUS in Interventional Bronchoscopy but that the invasion was not always proven by sound layers roughly corresponding to the mucosa, surgery. Nonetheless, the sensitivity and specifi city of submucosa, cartilage and adventitia as described in CT, MRI and EBUS for invasion were 59 and 56%; 75 previous chapters. The software determined the differ- and 73%; and 92 and 83% respectively. With respect ences in the mean echo intensity particularly between to the surgically treated patients, the accuracy of EBUS the third and fourth layers and second and fourth was signifi cantly different from that of CT

and MRI. A layers as a means of plotting the extent of involve- total of 37 patients underwent surgery and direct inva- ment. From 10 normal bronchi and 10 patients with sion was seen in 11 and intact trachea was seen in 26. lung cancer, the ultrasound images were analysed for EBUS correctly identifi ed direct invasion in 10 of these the intensity of ultrasound in each of the fi ve layers. 11 patients (91%), compared to 5 (45%) and 6 (55%) There were fi ve peaks and troughs demonstrable. in CT and MRI respectively. In the intact trachea, Given the greater resolution of the 30 MHz probe com- EBUS correctly identifi ed this in 22 of 26 patients pared to the 20 MHz probe, there were greater differ- (85%) compared to 15 (60%) and 17 (68%) in CT and ences between the peaks and troughs of the echo MRI respectively. The success of this study relates to intensity comparing the two probes. Importantly, the careful inspection of the adventitial layer seen by using the package to digitize the ultrasound image, a radial probe ultrasound. Importantly, the adventitia normal w - shaped curve of the ultrasound intensities was too thin to identify on MRI scan whereas the wall was demonstrated; however, when there was a tumor of the trachea was approximately 2 mm thick by MRI infi ltration, this typical w- shaped curve was absent with two layers, an inner layer corresponding to the with a fl at ultrasound intensity through all of the mucous membrane and submucosa, and an outer fi ve layers where previously there had been peaks layer of cartilage and adventitia. EBUS, on the other and troughs. There was a statistically signifi cant supe- hand, revealed good resolution and imaging of the riority of the 30 MHz probe in this type of imaging. outer most layer of the trachea and bronchial wall as Higher frequency ultrasound allows higher resolution reported by Shirakawa [ 7] . It was common for ultra- of the structures but less in terms of depth of tissue sound depth of diagnosis to go out to 1.5 to 2 cm penetration. allowing good visualization of the total bronchial wall thickness as well as lymph nodes and vessels. In this study, a fi ve- layered system for classifying the tracheal Relapsing Polychondritis with wall was used. When the outermost hyperechoic layer Tracheobronchial Malacia of the trachea was indistinguishable, a diagnosis of tracheobronchial invasion by the tumor was made. This condition is well described in Japan and provides The membranous portion of the extrapulmonary a fascinating insight into the potential applications of bronchi has three layers on EBUS. Esophageal cancer radial probe endobronchial ultrasound. Miyazawa et al. is located in the membranous portion of the trachea [9,10] have demonstrated the qualitative aspects of and the outer hyperechoic layer in this region is the ultrasound interpretation which were important in adventitia. At this point, an interruption of the third supporting a diagnosis of this problem. In a case series layer indicates invasion of the membranous portion. in 2003, a patient who had presented requiring emer- In general, where the cartilage layer was infi ltrated by gency tracheotomy fi ve years previously presented the tumor on EBUS, tumor invasion could be seen with breathlessness and at bronchoscopy there was easily; however, it was considered diffi cult for those malacia of the tracheobronchial tree with collapse of not experienced in the interpretation of the image to the trachea on expiration [ 10] . There was diffuse thick- be confi dent of the invasion of the adventitia. ening of the tracheobronchial wall with severely nar- Some authors such as Nakamura [ 8] have used rowed lumen on CT images. EBUS showed thickening 30 MHz probe to improve the resolution of images for of the bronchial wall due to submucosal edema and the this indication. In 2004, Nakamura described an image cartilage layer appeared ill- defi ned and absent in places. analysis software package to determine the depth of This was present in the trachea and in both main invasion of a tumor through the tracheobronchial bronchi. Biopsy of the tracheal cartilage showed degen- wall. The study confi rmed the presence of fi ve ultra- eration with fi brous changes and infl ammatory cell 113 Endobronchial Ultrasonography infi ltrate. In another case, the hyperechoic third and the evaluation of the airway wall proximal to sites of fi fth layers of the bronchial wall were indistinct on obvious obstruction in patients prior to stenting at the ultrasound and the hypoechoic fourth layer was mark- area of the obstruction [ 9,12] . It was possible to iden- edly swollen indicating cartilage degeneration. In that tify areas of cartilaginous malacia by the tumor on case, biopsy of the tracheal cartilage confi rmed chronic EBUS even though this was not obvious by standard chondritis with infl ammatory cell infi ltrate. Normally, bronchoscopic inspection. In these patients, there there would be more clear images of the third and fi fth tended to be a proximal migration of the large airway hyperechoic layer if the cartilage was intact. Therefore, choke point after the stenting of the original site. there were two patterns of cartilage damage identifi ed Secondary stenting at these subsequent migrated by EBUS, namely fragmentation and edema. These choke points resulted in signifi cant improvement in could be used to distinguish patients with relapsing peak fl ows over the initial stenting and supported the polychondritis from other patients who had tracheo- weakened airway wall. The use of EBUS was therefore bronchial malacia and tracheomegaly who would have able to demonstrate the cause of this choke point intact tracheobronchial cartilages by EBUS. migration. In particular, absence of supporting carti- lage on EBUS images due to external tumor damage was an important cause of this choke point migration. Endobronchial Stenting This type of identifi cation of tracheal or major bron- chial wall is not possible by CT scan. The dynamic changes in airway diameter in patients Herth et al. report that the utility of EBUS in stent with either severe tracheobronchial malacia or malig- placement [ 13] . An important attribute of EBUS is nant airway compression can make it diffi cult to detection of mucosal disease proximal to an area of determine what size stent will be required. CT and obvious tumor involvement and hence the placement MRI are limited because of the static nature of images. of longer tracheobronchial stents to include these EBUS gives a real time image and simply by infl ating involved areas and overcome this problem. In 235 the water- fi lled balloon and measuring the size of the cases of stent placement, EBUS assisted in stent place- balloon on the ultrasound monitor when the probe is ment parameters in 121 cases (51%). In addition to comfortably infl ated, accurate sizing of the stent the identifi cation of submucosal disease, extrinsic required can be obtained. In the report of Miyazu with tumor application to the tracheal wall was a reason to relapsing polychondritis, both patients were stented use a longer stent. using prior EBUS measurement which was particu- larly useful given the complete collapse of the airway and the diffi culty of judging diameter [9] . Iwamoto et Brachytherapy al. reported in 2004 the utility of the EBUS images to demonstrate tracheobronchial wall changes in evalu- EBUS can be used to confi rm staging prior to endo- ating airway stenosis from tracheobronchial tubercu- bronchial brachytherapy. In Herth et al.’ s series of 134 losis [ 11] . In a series of 30 patients, EBUS was patients with endobronchial carcinoma, EBUS revealed performed in four patients and demonstrated the 69 (51%) cases which required some form of changed destruction of the bronchial cartilage or the thickening management [ 13] . In cases where brachytherapy was of the bronchial wall. One of these patients had local to be used for curative treatment of early carcinoma, interruption of the tracheal cartilages demonstrated by 28% had local disease extension or lymph node ultrasound and this gave qualitative information sup- metastasis which escaped all other imaging methods. porting the use of an endobronchial stent. In two of Very small lesions can demonstrate quite signifi cant the four cases, the demonstration of absence or inter- invasion through the tracheobronchial wall (through ruption of tracheal cartilage supported the decision to the cartilage and adventitia) despite relatively minor performed endobronchial stenting. mucosal changes and hence require some other form Similar qualitative information with respect to of therapy, namely, surgery or external beam radio- mural involvement can be obtained for stent evalua- therapy. This was described in detail in the series of tion in patients with lung cancer. Miyazawa reported photodynamic therapy by Miyazu and Kurimoto [ 14] . 114 CHAPTER 11 EBUS in Interventional Bronchoscopy parathyroid function. Also because of a large blood Thermal Applications vessel next to the cyst, it was not possible to aspirate via an external CT- guided technique and therefore the Herth et al. reported the use of EBUS in the perform- EBUS - TBNA was performed. This was done under ance of thermal applications such as laser and argon local anesthetic with mild conscious sedation using plasma coagulation for endobronchial obstructing 2 mg midazolam. The EBUS image would be of the tumors [13] . This use of EBUS in patients having homogenous low echo mass with multiple septae mechanical tumor destruction changed management inside the cyst. 80 mL of fl uid was removed after punc- in 123 of 346 patients (36%). The signifi cant way that ture of the cyst by the needle. Repeated punctures it achieved this was to demonstrate the proximity of were used to allow the overall aspiration to be per- the area being treated to the tumor and external large formed because of septation of the lesion. There was blood vessels. Debridement with laser or APC was immediate relief of dyspnea. stopped when EBUS demonstrated close relationships We have reported the use of convex probe EBUS in with blood vessels. No patient undergoing EBUS- the identifi cation of pericardial recesses which mimic guided tumor destruction demonstrated severe bleed- paratracheal lymph nodes [16] . Characteristic EBUS ing or fi stula formation. Images could demonstrate images show hypodensity and complete loss of any tumors growing through the wall of the bronchus in vascularity adjacent to the trachea in the typical right close proximity to the pulmonary arteries on the ante- lower paratracheal node position (4R) in between the rior wall of the obstructed bronchus. On the left side, azygous vein and the lower part of the superior vena it was easy to demonstrate proximity to the descend- cava. If necessary, cyst fluid can be aspirated for diag- ing aorta. In these cases, the ultrasound images nosis, followed by antibiotics. obtained by placing the miniprobe in the main bron- Shaw et al. reported an interesting application of chus adjacent to the tumor sometimes required only EBUS, namely the accurate measurement of airway small infl ation volumes of the balloon, given the direct wall thickness with the aim of using this to demon- application of the tumor to the probe. The authors strate changes in patients receiving treatment for commented that they used this method in all cases of airways diseases such as asthma [ 17] . In their study of total airway obstruction before and during thermal an animal model of 24 cartilaginous airways, the tumor destruction. ultrasound and actual airway diameter and wall thick- ness were calculated. Subsequent to that, 12 control- led subjects underwent both EBUS imaging of the Miscellaneous Applications posterior basal bronchus of the right lower lobe and this was compared to the airway wall thickness as Nakajima reported the use of EBUS- guided transbron- demonstrated by high resolution CT scanning. In the chial needle aspiration to treat central airway stenosis animal in vitro studies in 24 airways, there was a from a mediastinal cyst [15] . Whereas such an applica- mean internal diameter of 4.3 mm and wall thickness tion had been reported for non - EBUS guided trans- of 1.4 mm without balloon infl ation and 4.2 and bronchial needle aspiration previously, the real time 1.5 mm respectively after infl ation. Signifi cant agree- imaging afforded a means of providing great control ment was

seen between the two approaches of actual during this delicate procedure. The cyst was compress- measurement and ultrasound (intra- class coeffi cient ing the membranous portion of the trachea with 0.97 (p < 0.001) and for wall thickness 0.88 airway narrowing and arose from the upper mediasti- (p < 0.001). For the in vitro human airways studies, num. The dimensions were 65 × 57 × 49 mm. The there was a mean internal diameter of 4.9 mm and patient has previously had a left thyroid lobectomy for wall thickness of 1.3 mm using EBUS and these were a goiter and previously had had a diagnostic aspirate measured to be 5.2 mm and 1.2 mm respectively by performed confi rming serous fl uid without any malig- HRCT. Using gland and Altman plots to compare nant cells. There was progressive dyspnea due to measurements without balloon infl ation on the airway the increasing size of this cyst and surgical resection parameters, the mean difference was close to 0 and was not possible due to the risk of loss of thyroid and there was no obvious relationship between the meas- 115 Endobronchial Ultrasonography urement error and the airway parameter. There were area of the second layer of the autologous airways, the no obvious differences when the measurements were relative area of the second layer of the autologous made by different observers. The important aspect of airways was statistically signifi cantly smaller in the this study was the implication that studies done in this rejection group (p = 0.04); however there was no dif- way would not require the radiation exposure of high ference in the absolute values between the two groups. resolution CT scanning. Importantly, the balloon With respect to infection, there was a statistically sig- sheath did not cause any increase in the airway diam- nifi cant difference between the groups in the relative eter or alter the airway wall measurements. area of layer two in the autologous part of the airway Irani et al. reported the use of quantitative assess- (p = 0.02). There were some problems in interpreting ment of the bronchial mural structures in lung trans- data, given that full histologic examination of the plant recipients using EBUS [ 18] . The objective was to central airway walls in vivo is not possible and, there- determine whether EBUS analysis could allow the fore, comparison between the EBUS and true macro- detection of airway anastomosis, infection or rejec- scopic fi ndings could not be done. Overall, it was tion. There were 10 lung transplant recipients and found to be a safe procedure and the multilayered EBUS images were obtained from proximal to the structure of the allogeneic and autologous wall was anastomosis and distal to the anastomosis. Two well - imaged and was felt to represent a possible future hundred images were obtained for qualitative assess- means for surveillance of lung transplant recipients ment. The important fi nding was that the relative although further study was required. thickness of the second layer (hyperechoic submu- cosal tissue) of the transplanted airway was signifi - cantly smaller in patients with graft rejection (p = 0.04) References compared to patients without rejection. Conversely, this was signifi cantly larger in patients with graft 1 Becker H D . Endobronchial Ultrasound – Expensive Toy infection. An ultrasound miniprobe UMBS 20- 26R or Useful Tool? Proc 8th World Congress for Bronchology Olympus was used with a balloon sheath. The Olympus and 8th World Congress for Bronchoesophagology, BUM30 processor and MH240 driving unit were used. Munich 1994, abstr No 237 . After digital recording, the fi lm was screened for at 2 Becker H D , H erth F . Endobronchial ultrasound of the least fi ve representative slides from each autologous airways and the mediastinum In: Bolliger C T , M athur and allogeneic bronchial portion. The slides which PN , eds. P rogress in Respiratory Research, Vol. 30. showed the most obvious and well- defi ned lamina Interventional Bronchoscopy. S. Karger, Basel - Freiburg , 2000 : 80 – 93 . structure were selected by a blinded investigator. 3 Becker H D. T he role of endobronchial ultrasound These fi les were saved in tagged image fi le format and (EBUS) in diagnosis and treatment of centrally located the image was measured using AnalySIS software; soft early lung cancer. In Hirsh FR , Bunn PA , Kato H , imaging system; (Munster Germany). The image size Mulshine JL , eds. T extbook of Prevention and Detection was calibrated and then the largest possible sector of Early Lung Cancer . L ondon : T aylor & Francis , starting at the center of the bronchus containing car- 2005 : 168 – 175 . tilage was defi ned. Then, the absolute values of 4 Frietsch T , Becker HD , Bulzebruck H , Wiedemann K . the thickness of each layer and the relative value of Capnometry for rigid bronchoscopy and high frequency the area of each layer were measured. Because of the jet ventilation compared to arterial pCO 2 . Acta anatomic inconsistency of the diameter of the carti- Anaesthesiol Scand 2000 ; 44 : 391 – 397 . lage, the relative values of the other four layers were 5 Herth , FJ , Ernst , A , Schulz , M , et al. Endobronchial ultrasound reliably differentiates between airway infi l- also calculated after exclusion of the area of the carti- tration and compression by tumor. Chest 2003 ; 123 : lage. As expected, there was a statistically signifi cant 458 – 462 . correlation found for layer three, that is, the inner 6 Wakamatsu T , Tsushima K , Yasuo M , Yamazaki Y , hyperechoic marginal echo of the cartilage between Yoshikawa S , Koide N , et al. U sefulness of preoperative the autologous and allogeneic airways, given that endobronchial ultrasound for airway invasion around there was no change in the cartilage expected due to the trachea: oesophageal cancer and thyroid cancer . either infection or rejection. Conversely, the relative Respiration 2006 ; 73 : 651 – 657 . 116 CHAPTER 11 EBUS in Interventional Bronchoscopy 7 Shirakawa T , Tanaka F , Becker HD : L ayer structure of 13 Herth F , Becker HD , LoCicero J , Ernst A . Endobronchial the central airways viewed using endobronchial ultra- ultrasound in therapeutic bronchoscopy. Eur Respir J sonography (EBUS). In Yoshimura H , Kida A , Arai T , 2002 ; 20 : 118 – 121 . Niimi S , Kaneko M , Kitahara S , eds. B ronchology and 14 Miyazu Y , Miyazawa T , Kurimoto N , Iwamoto Y , Kanoh Bronchoesophagology . S tate of the Art. Amsterdam , K , Kohno N. Endobronchial ultrasonography in the Elsevier , 2001 : 921 – 923 . assessment of centrally located early - stage lung cancer 8 Nakamura Y , E ndo C , S ato M , S akurada A , W atanabe before photodynamic therapy. A m J Respir Crit Care S , S akata R , et al. New technique for endobronchial Med 2001 ; 165 : 832 – 837 . ultrasonography and comparison of two ultrasonic 15 Nakajima T , Y asufuku K , S hibuya K , F ujisawa T . probes: analysis with a plot profi le of the image analysis Endobronchial ultrasound guided transbronchial needle software NIH image. Chest 2004 ; 126 : 192 –1 97 . aspiration for the treatment of central airway stenosis 9 Miyazawa T , Miyazu Y , Iwamoto Y , Ishida A , Kanoh K , caused by a mediastinal cyst . Eur J Cardiothoracic Surg Sumiyoshi H , Doi M , Kurimoto N . S tenting of the 2007 ; 32 : 538 – 540 . fl ow limiting segment in tracheobronchial stenosis 16 Fielding D , Hundloe J , Windsor M , Plit M , Haverick A , due to lung cancer. Am J Crit Care Med 2 004 ; 169 : Pearson R . H igh riding pericardial recess; fi ndings on 1096 – 1102 . EBUS TBNA. J Bronchol 2008 ; 15 : 182 – 184 . 10 Miyazu Y , Miyazawa T , Kurimoto N. , Iwamoto Y , Ishida 17 Shaw TJ , W akely SL , P eebles CR , M ehta RL , T urner JM , A , K anoh K , K ohno N . Endobronchial ultrasonography Wilson SJ , Howarth PH . E ndobronchial ultrasound to in the diagnosis and treatment of relapsing polychon- assess airway wall thickening: validation in vitro and in dritis with tracheobronchial malacia . Chest 2 003 ; 124 : vivo . E ur Repir J 2004 ; 23 : 813 – 817 . 2393 – 2395 . 18 Irani S , Hess T , Hofer M , Gaspert A , Bachmann L , Russi 11 Iwamoto Y , M iyazawa T , K urimoto N , M iyazu Y , I shida E , B oehler A . E ndobronchial ultrasonography for A , Matsuo K , Watanabe Y . I nterventional bronchoscopy the quantitative assessment of bronchial mural struc- in the management of airway stenosis due to tracheo- tures in lung transplant recipients . Chest 2 006 ; 129 : bronchial tuberculosis. C hest 2004 ; 126 : 1344 – 1352 . 349 – 355 . 12 Miyazawa T , Yamakido M , Ikeda S , et al. Implantation of Ultrafl ex nitinol stents in malignant tracheobronchial stenoses . Chest 2000 ; 118 : 959 – 965 . 117 12 Future Directions for Endobronchial Ultrasonography quency of 7.5 MHz, identifi cation of cartilage is just Evaluation of the Depth of Invasion of possible, but delineation of the layer structure is dif- Tracheobronchial Tumors fi cult. Once higher frequencies of 20 or 30 MHz are achieved, the bronchial wall will be much more clearly Endotracheal therapies are indicated for tracheobron- delineated, allowing considerable progress. chial tumors that have not invaded as far as the tra- cheobronchial cartilage, in other words are confi ned to the mucosa or submucosal tissue. Endobronchial EBUS -G uided Transbronchial Needle ultrasonography (EBUS) is presently the most useful Aspiration (E BUS - TBNA ) method of determining the depth of tumor invasion. Tissue resolution improves as the frequency of the B mode images obtained using a convex probe remain ultrasonic transducer increases, providing clear and poor in quality, so we await improvements in ultra- detailed ultrasonic images. Ultrasonic probes are pres- sonographic equipment that will provide better quality ently available at two frequencies, 20 and 30 MHz, but ultrasonic images. The main advantage of using in the future we anticipate the development of even convex probes is the ability to utilize Doppler mode, higher frequency probes. Radial probes now in use are at present only power Doppler, although in the near mechanical radial probes, meaning that images are future the introduction of pulse Doppler is expected obtained by physically rotating the probe through to allow Fast Fourier Transform (FFT) analysis of 360 ° . The development of electronic scanning will bloodfl ow. provide even better images, giving a 360° profi le It is diffi cult to retrieve large tissue samples using without having to move the probe. EBUS - TBNA, but this problem may come close to Radial scanning provides a two- dimensional image, resolution with the development of larger needles. but we can now obtain three - dimensional images by There are limitations to the size of the endoscope withdrawing the probe at a constant speed while scan- working channel, however, that are diffi cult to recon- ning. Large balloons required to make this method cile with the need for larger diameter needles. more practical do not exist at present, but we antici- pate that they will become available in the future. Expectations are also high for evaluation of the Peripheral Pulmonary Lesions depth of invasion of tracheobronchial tumors using bronchial long axial cross - section images obtained At present, we use a 4 mm diameter endoscope with with convex probes. At present, due to the low fre- a 2 mm working channel, through which we pass a guide sheath and ultrasonic probe, 2 mm in outer diameter, into the bronchial tree. In the

future, we hope to pass even narrower bronchoscopes into Endobronchial Ultrasonography, 1st edition. ever more peripheral bronchi, detecting early lesions By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. using narrower gauge guide sheaths and ultrasonic Published 2011 by Blackwell Publishing Ltd. probes. 118 CHAPTER 12 Future Directions for Endobronchial Ultrasonography Cytology and tissue biopsies are presently taken through textbooks such as this one, and through inter- under fl uoroscopic control, but we would like to be net sites such as “ The Essential Bronchoscopist © ” able to watch the real - time EBUS image as we take (h ttp://www.essential- b ronchoscopy.org/intro_en. specimens. asp ). Keeping up with the latest developments in EBUS through sources such as these can provide the basis of self - learning activities. Hands - on training in Training in E BUS EBUS is also available in Japan and other countries. A number of bronchoscopists have participated in train- Continuous education in EBUS techniques is essential ing programs under the aegis of the Japan Society for for bronchoscopists wishing to improve their results. Respiratory Endoscopy, upgrading their skills in Ongoing education in bronchology is presently avail- EBUS - TBNA and other EBUS techniques. able for medical practitioners throughout the world 119 13 Case Reports on EBUS represented lymphocytic infi ltration, passing Introduction through the cartilage layer and showing exactly the same morphology as seen on EBUS (arrows). A case of overestimation of the depth of tumor pen- EBUS was unable to differentiate between tumor etration using EBUS – comparison of EBUS images invasion and lymphocytic infi ltration, although very and histopathological fi ndings (Figure 1 ). similar looking images are obtained with EBUS as with Upper right: In this EBUS image of the resected low magnifi cation light microscopy. specimen, an open V - shaped hypoechoic area can be The fi rst patient on whom I ever performed EBUS seen continuous with the tumor and extending in 1994 was this case of overestimation of the depth beyond the cartilage layer (arrows). of tumor penetration. I recall how I struggled for 2 Lower right: Histopathological examination (low hours to obtain the above image from the resected magnifi cation) revealed that the depth of invasion is specimen immersed in water. I consider myself lucky from the bronchial lumen only to the submucosal to have learned such a useful lesson so early, and I am layer, and not as far as the cartilage. The open V - shaped grateful to the cooperation of the pathologist who hypoechoic area extending beyond the cartilage layer sliced up the entire specimen for me. Figure 1 Endobronchial Ultrasonography, 1st edition. By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. Published 2011 by Blackwell Publishing Ltd. 120 CHAPTER 13 Case Reports Preoperative EUS fi ndings (Figures 2 , 3) : We used Case 1 an UM - 3R ultrasonic probe. The target lesion was delineated as a hypoechoic mass extending from 3 Squamous cell carcinoma in the right basal bronchus o ’ clock to 9 o ’ clock, containing triangular and island - (cartilage islands seen within the tumor). shaped areas of cartilage (arrows: high, low, high Moderately differentiated squamous cell carcinoma in echo areas). This tumor was thereby shown to have the right basal bronchus. invaded past the bronchial cartilage layer, beyond the adventitia. Presenting Complaint: Hemoptysis Histopathological examination (low magnifi cation, History: Presented to previous doctor with hemoptysis, Figures 2 , 3 ): This is a squamous cell carcinoma with abnormal opacity seen on plain chest radiograph. CT a defi nite tendency towards keratinisation, forming scanning and bronchoscopy revealed a nodular lesion invasive nests if large and small irregular sheets as in the right basal bronchus. A class V squamous cell it proliferates. These specimens, sliced in the same carcinoma was diagnosed from the endobronchial plane as the EBUS images, show cartilage fragments brushing cytology. The patient underwent right lower (arrows) of the same shape and in the same position lobectomy + R 2 a: t1n0m0, stage IA. as in the EBUS images (arrows: high, low, high echo Macroscopic examination of the resected specimen areas). (Figure 1 ): A nodular invasive squamous cell carci- Bronchial cartilage fragments within tumors are noma can be seen in the right basal bronchus distal to delineated as high, low, high echo areas (3rd, 4th and the B 6 bifurcation. 5th layers in the needle - puncture experiment). Figure 1 Figure 2 Figure 3 121 Endobronchial Ultrasonography seen to invade the membranous portion of the inter- Case 2 mediate bronchus. Bronchoscopic fi ndings (Figure 2 ): The target Squamous cell carcinoma in the right S 6 region (car- lesion is compressing the right intermediate bron- tilage detected within the tumor). chus from behind, and breaking through the mucosa. Moderately differentiated squamous cell carcinoma in Preoperative EBUS fi ndings (Figure 3 ): We used the right S 6 region. an UM - 3R ultrasonic probe + balloon. The right 35 × 30 × 30 mm. pulmonary artery can be seen anterior to the right intermediate bronchus. The target lesion, extending from 3 o’ clock to 9 o ’ clock, has invaded from outside Presenting Complaint: Cough the bronchial wall, past the bronchial cartilage layer History: Presented to previous doctor with cough, (arrow: high, low, high echo area) as far as the abnormal opacity seen on plain chest radiograph. CT submucosa. scanning and bronchoscopy revealed a nodular lesion Histopathological examination (low magnifi cation, in the right B6 directly invading the intermediate Figure 4 ): This specimen, sliced in the same plane as bronchus. A class V squamous cell carcinoma was the EBUS image, shows a cartilage fragment (arrow) diagnosed from the endobronchial brushing cytology. of the same shape and in the same position as in the The patient underwent right lower and middle lobec- EBUS image (arrow: high, low, high echo area). tomy + R2 a: t2n0m0, stage IB. Bronchial cartilage fragments within tumors are delin- CT scan chest (Figure 1 ): A nodular mass largest eated as high, low, high echo areas (3rd, 4th and 5th diameter 35 mm arising in the right B6 bronchus is layers in the needle - puncture experiment). Figure 1 Figure 3 Figure 2 Figure 4 122 CHAPTER 13 Case Reports bronchi, intimately associated with the pulmonary Case 3 artery. Bronchoscopic fi ndings (Figure 2 ): A white- coated Squamous cell carcinoma in the right B8 bronchus polypoid lesion is seen occluding the right B 8 (tumor invading beyond cartilage and adjacent to bronchus. the pulmonary arteries). EBUS fi ndings: We used an UM - 3R ultrasonic probe. Moderately differentiated squamous cell carcinoma in The probe was passed down what was thought to be the right B8 bronchus. the right B 8 b bronchus, readily passing the target lesion, which was shown to be attached in the direction of the bifurcation (Figure 3 ). Passing the probe down what Presenting Complaint: Class V on was thought to be the right B8 a bronchus, it came up Sputum Cytology against the target lesion, and the hypoechoic tumor History: During follow- up for heart disease, sputum was delineated. The target lesion was compressing the cytology in this heavy smoker was class V. Bronchoscopy adjacent pulmonary artery, and had invaded past the revealed a polypoid lesion occluding the right B 8 bronchial cartilage layer (arrow: high, low, high echo bronchus. area) and beyond the bronchial wall (Figure 4 ). CT scan chest (Figure 1 ): A nodular mass can be seen Bronchial cartilage fragments within tumors are just distal to the bifurcation of the right B8 a and B 8 b delineated as high, low, high echo areas (3rd, 4th and 5th layers in the needle - puncture experiment). Figure 1 Figure 2 Figure 3 Figure 4 123 Endobronchial Ultrasonography Bronchoscopic fi ndings (Figure 1 ): Erosions can be Case 4 seen extending from the left main bronchus to the left lower bronchus. Squamous cell carcinoma in the left main and lower CT scan chest (Figure 2 ): Thickening of the medias- bronchi (irregularly shaped cartilage seen within tinal aspect of the left main bronchus can be seen. the tumor). Preoperative EBUS fi ndings (Figure 3 ): We used an Squamous cell carcinoma in the left main and lower UM - 3R ultrasonic probe + balloon. The target lesion bronchi. was delineated as a hypoechoic mass extending from 4 o ’ clock to 9 o’ clock, extending from the bron- Presenting Complaint: Hemoptysis chial lumen through the cartilage layer (arrows: high, History: Presented to previous doctor with hemoptysis, low, high echo areas) beyond the adventitia. The car- abnormal opacity seen on plain chest radiograph. CT tilage has been deformed, becoming convex to the scanning and bronchoscopy revealed thickening of the lumen. left main bronchus. A class V squamous cell carcinoma Bronchial cartilage fragments within tumors are was diagnosed from the endobronchial brushing delineated as high, low, high echo areas (3rd, 4th and cytology. 5th layers in the needle - puncture experiment). Figure 1 Figure 2 Figure 3 124 CHAPTER 13 Case Reports narrowed from this point until the left B 3 bronchus, Case 5 with erythema and erosions of the mucosa. EBUS fi ndings (Figure 3 ): We used an UM- 3R ultra- Squamous cell carcinoma in the left B 3 bronchus sonic probe + balloon. The balloon was infl ated at the (invasion beyond the bronchial wall, beyond the origin of the left B3 bronchus to allow scanning. The 5th layer (hyperechoic) can be seen). target lesion was delineated as a hypoechoic mass Squamous cell carcinoma in the left upper B3 extending from 5 o’ clock to 10 o’ clock, containing a bronchus. hyperechoic line (arrow), representing the marginal echo at the outer margin of the cartilage (5th layer). The adventitia cannot be identifi ed outside this hyper- Presenting Complaint: E Result from echoic line, indicating extramural invasion. (If we Sputum Cytology at Routine Health Check follow the hyperechoic line around to the 11 o’ clock History: Bronchoscopy revealed erythema and thick- to 2 o’ clock arc, outside it we can see two small blood ening of the left upper B 3 bronchus. EBUS was vessels (bronchial arteries) 2 – 3 mm in diameter.) performed to assist selection of treatment modality, Histopathological examination (low magnifi cation, (photodynamic therapy) PDT or surgery. Figure 4 ): This squamous cell carcinoma has passed CT scan chest (Figure 1 ): No abnormality seen on between the bronchial cartilages, invading beyond the CT scanning, in particular at the bifurcation of the left bronchial wall. B3 and B1 + 2 bronchi. Bronchial cartilage fragments within tumors are Bronchoscopic fi ndings (Figure 2 ): Here we can see delineated as high, low, high echo areas (3rd, 4th and the origin of the left upper bronchus. The lumen is 5th layers in the needle - puncture experiment). Figure 1 Figure 2 Figure 3 Figure 4 125 Endobronchial Ultrasonography EBUS fi ndings (Figures 2 , 3 ): We used an UM - 4R Case 6 ultrasonic probe, introducing it into the right B5 bron- chus, which was completely occluded by the target Squamous cell carcinoma in the right middle bron- lesion. The tumor extended from the bronchial lumen chus (irregularly shaped cartilage seen within the through the hyperechoic cartilage layer and invaded tumor). beyond the adventitia (arrow). Moderately differentiated squamous cell carcinoma in the right middle bronchus. Points of Advice When evaluating the depth of tumor invasion, the Presenting Complaint: Abnormal Opacity following points need to be elucidated: (1) At what Seen on Plain Chest Radiograph angle is the tumor to be found? (2) What is the length History: Abnormal opacity seen on plain chest of the lesion? (3) Where is its deepest extent? (4) radiograph by previous doctor. CT scanning and bron- Where is the bronchial cartilage, the outermost hyp- choscopy revealed nodular lesion in the right middle oechoic layer? (5) Can the adventitia be delineated bronchus. A class V squamous cell carcinoma was diag- around the entire circumference? and (6) What has nosed from the endobronchial brushing cytology. happened to the peribronchial vasculature? CT scan chest (Figure 1 ): A mass can be seen in the right middle bronchus at the bifurcation of the right B4 and B 5 bronchi. Figure 1 Figure 2 Figure

3 126 CHAPTER 13 Case Reports Bronchoscopic fi ndings (Figure 1 ): A polypoid lesion Case 7 obstructs the left B3 bronchus. Preoperative EBUS fi ndings (Figure 2 ): We used an Squamous cell carcinoma in the left B 3 bronchus UM - 3R ultrasonic probe + balloon. Cartilage can be (observation of the 5th layer shows invasion beyond clearly seen within the polypoid lesion (black arrow). the bronchial wall in one area). This hypoechoic mass extends from the bronchial Squamous cell carcinoma in the left B3 bronchus. lumen to beyond the cartilage. The 5th layer can be discerned almost around the entire circumference, Presenting Complaint: Class III Sputum although the hypoechoic mass does protrude beyond Cytology During Follow - Up for Pulmonary the bronchial wall in one area (red arrow), indicating Emphysema extramural invasion. History: During follow - up for pulmonary emphysema, Histopathological examination (low magnifi cation, sputum cytology yielded a class III result. Bronchoscopy Figures 3 , 4) : In this slice that corresponds to the plane revealed an intraepithelial cancer involving the bifur- of the EBUS image, we see a cartilage fragment (black cation of the left upper and lingual bronchi and the arrow) of the same shape and in the same position as origin of the left upper bronchus. PDT was performed in the EBUS images (arrows: high, low, high echo for this tumor. Follow - up bronchoscopy 4 weeks later areas), with hypoechoic cancer cells beyond it. In one revealed a polypoid lesion at the origin of the left B3 area tumor invades beyond the adventitia into the bronchus. Biopsy showed this to be a moderately dif- lung parenchyma (red arrow), corresponding to the ferentiated squamous cell carcinoma, for which the hypoechoic area on the EBUS image. patient underwent surgery. We compared the preop- When the hypoechoic area continues beyond the erative EBUS images and the histopathological fi nd- bronchial cartilage, observation of the 5th hyperechoic ings for this polypoid lesion arising from the origin of layer (including the adventitia) will help distinguish the left B 3 bronchus. between intramural disease and extramural invasion. Figure 1 Figure 2 Figure 3 Figure 4 127 Endobronchial Ultrasonography Preoperative EBUS fi ndings (Figure 4 ): We used an Case 8 UM - 3R ultrasonic probe + balloon. Cartilage can be clearly seen within the polypoid lesion (arrow), and a Squamous cell carcinoma in the right upper bronchus hypoechoic area extends from the bronchial lumen to (observation of the 5th layer the key to determina- beyond the cartilage. The hyperechoic 5th layer tion of the depth of tumor invasion = adventitia). (including the adventitia) is continuous with the outer Moderately differentiated squamous cell carcinoma in edge of the hypoechoic area inferiorly (arrow). This the right upper lobe B3 bronchus. was interpreted as the tumor compressing the adven- titia, and the depth of tumor invasion was assessed as Presenting Complaint: “ Positive ” Result from “ to the adventitia” . Sputum Cytology at Routine Health Check Histopathological examination (low magnifi cation, History: A t routine health check, sputum cytology Figure 5 ): This specimen of the origin of the right yielded an E result. CT scanning and bronchoscopy upper lobe bronchus, sliced in the same plane as the revealed a polypoid lesion in the right upper lobe B3 EBUS image, shows a cartilage fragment (arrow) of bronchus. A class V squamous cell carcinoma was the same shape and in the same position as in the diagnosed from the endobronchial brushing cytology. EBUS image (arrow: high, low, high echo area). The patient underwent right upper lobectomy + R 2 a. Tumor has invaded beyond the cartilage, correspond- Bronchoscopic fi ndings (Figures 1 , 2) : A polypoid ing to the hypoechoic area, pressing up against the mass, lacking a mucosal surface, extends from the adventitia, but not extending beyond it. right upper lobe bronchus to the right B3 bronchus. When the hypoechoic area continues beyond Squamous cell carcinoma was strongly suspected. the bronchial cartilage, observation of the 5th hyper- CT scan chest (Figure 3 ): A nodular mass is present echoic layer (including the adventitia) will help dis- in the bronchial wall, extending from the right upper tinguish between intramural disease and extramural lobe bronchus to the right B 3 bronchus. invasion. Figure 2 Figure 3 Figure 1 Figure 4 Figure 5 128 CHAPTER 13 Case Reports Bronchoscopic fi ndings (Figure 2 ): A fl at polypoid Case 9 mass extends from the origin of the right B6 bronchus to the right lower lobe and intermediate bronchi. A Squamous cell carcinoma in the right intermediate superfi cial spreading squamous cell carcinoma with no bronchus (hyperechoic line corresponds to submu- mucosal cover was strongly suspected. cosal collagen fi bers, depth of tumor invasion = car- Preoperative EBUS fi ndings (Figure 3 ): We used an tilage layer). UM - 3R ultrasonic probe + balloon. Thickening of the Moderately differentiated squamous cell carcinoma in bronchial wall extends from 1 o ’ clock to 11 o’ clock, the right intermediate bronchus nearly circumferential. The tumor has invaded deep enough to contain cartilage between 2 o ’ clock and 3 Presenting Complaint: Cough o ’ clock (arrow: high, low, high echo area), but does History: Presented to previous doctor with cough, not compress the adventitia, and the depth of tumor abnormal opacity seen on plain chest radiograph and invasion was assessed as “ to the cartilage layer ” . CT scan. CT scanning and bronchoscopy revealed a Histopathological examination (low magnifi cation, nodular lesion in the right B6 bronchus, continuous Figure 4 ): This lesion is a squamous cell carcinoma with thickening of the membranous portion of the forming villous projections into the lumen. This speci- right intermediate bronchus. A class V squamous cell men, sliced in the same plane as the EBUS image, carcinoma was diagnosed from the endobronchial show a cartilage fragment (arrow) of the same shape brushing cytology. The patient underwent right lower and in the same position as in the EBUS image (arrow: and middle lobectomy + R 2 a: t2n0m0, stage IB. We high, low, high echo area). Tumor infi ltrates between compared the preoperative EBUS images and the his- cartilages, giving a depth of tumor invasion to the topathological fi ndings for this tumor. cartilage layer. CT scan chest (Figure 1 ): We can see thickening of Hyperechoic lines can be seen in the thickened the membranous portion of the right intermediate bronchial wall (arrow at 5 o ’ clock), corresponding to bronchus, but cannot discern the bronchial wall hyperplastic collagen fi bers (arrow) within the squa- structure. mous cell carcinoma forming villous projections. Figure 1 Figure 2 Figure 3 Figure 4 129 Endobronchial Ultrasonography and B 3 bronchi (arrow). Biopsy showed poorly dif- Case 10 ferentiated squamous cell carcinoma. CT scan chest (Figure 2 ): No abnormality can be Squamous cell carcinoma in the left upper segmental seen at the bifurcation of the left B 1 + 2 and B3 bronchi. bronchus (cartilage compressed by tumor, depth of EBUS fi ndings (Figures 3 , 4 ): We used an UM - 3R tumor invasion = submucosa). ultrasonic probe + balloon. The tumor is delineated as Poorly differentiated squamous cell carcinoma at the a polypoid lesion at 6 o ’ clock. The leading edge of the bifurcation of the left B 1 + 2 and B 3 bronchi. tumor compresses the cartilage (high, low, high echo area), making it convex to the outside. The depth of Presenting Complaint: Polypoid Lesion tumor invasion was assessed as “ to the submucosa ” . Detected at Bronchoscopy Complete remission was achieved with PDT. History: Polypoid lesion at the bronchial spur between In this case of a lesion near a bronchial spur, we had the left B 1 + 2 and B 3 bronchi detected at bronchoscopy diffi culty obtaining a usable images due to the ten- by previous doctor for assessment of interstitial pneu- dency of the balloon to slip past. We blew up the monitis. Biopsy confi rmed squamous cell carcinoma. balloon so that it completely occluded the bifurcation, Bronchoscopic fi ndings (Figure 1 ): A polypoid lesion and achieved a good image by moving the probe back can be seen at the bronchial spur between the left B1 + 2 and forth. Figure 1 Figure 2 Figure 3 Figure 4 130 CHAPTER 13 Case Reports Bronchoscopic fi ndings (Figures 1 , 2) : An erythema- Case 11 tous polypoid lesion can be seen at the origin of the left B6 bronchus (arrow, at 1 o’ clock near the spur with the Squamous cell carcinoma at the origin of the left B 6 basal bronchus). bronchus (cartilage loss detected using EBUS, depth CT scan chest (Figure 3 ): No abnormality can be of tumor invasion = adventitia). seen at the origin of the left B 6 bronchus. Squamous cell carcinoma at the origin of the left B6 EBUS fi ndings (Figure 4 ): We used an UM- 3R ultra- bronchus. sonic probe + balloon. The tumor is delineated as a hypoechoic lesion between 10 o ’ clock and 2 o ’ clock. Presenting Complaint: E Result from Cartilage (red arrow, high, low, high echo area) can Sputum Cytology At Routine Health Check be clearly seen at the periphery of the polypoid lesion. History: This patient underwent left partial upper The submucosal layer of the lesion is thickened (the lobectomy 3 years previously for squamous cell carci- tumor itself). The cartilage tapers and disappears at 12 noma. At follow - up the previous year, an area of ery- o ’ clock, with only the adventitia preserved (yellow thema on the upper wall of the origin of the left B 6 arrow). The depth of tumor invasion was assessed as bronchus was diagnosed as early squamous cell carci- “ to the adventitia” . noma. Although complete remission was achieved with When cartilage visible at the periphery of a PDT, a biopsy of the same site (arrow) approximately 1 lesion trappers and disappears within the lesion, the year later yielded squamous cell carcinoma. EBUS was tumor is assessed as invading beyond the cartilage performed to evaluate the depth of tumor invasion. layer. Figure 2 Figure 1 Figure 3 Figure 4 131 Endobronchial Ultrasonography It appeared to be submucosal in origin, and biopsy Case 12 yielded a diagnosis of adenoid cystic carcinoma. Preoperative EBUS fi ndings (Figures 2 , 4) : We used Adenoid cystic carcinoma of the trachea (important an UM- 3R ultrasonic probe. The target lesion is deline- fi nding of tumor invasion between cartilage rings, ated as a hypoechoic lesion between 7 o ’ clock and 11 depth of tumor invasion = adventitia). o ’ clock. At the cartilaginous portion (Figure 2 ), the Adenoid cystic carcinoma of the trachea. hypoechoic layer corresponding to the tracheal ring (arrow, 4th layer) is preserved, and the lesion can be Presenting Complaint: Cough seen in contact with the marginal echo on the inner History: Presented with cough, polypoid lesion of the side of the tracheal cartilage (3rd layer). Tumor can be trachea on CT scan chest. seen protruding between tracheal rings, adjacent to Reversed CT scan chest (Figure 1 ): For comparison the hyperechoic layer corresponding to the adventitia with the EBUS images, we reversed the image so it (arrow). From the above, the target lesion has invaded appears that we are looking down from above. past the line between neighboring tracheal rings, up Endoscopic examinations and treatments are, of course, to but not beyond the adventitia, so the depth of conducted looking down from above. A polypoid lesion tumor invasion was assessed as “ to the adventitia” . can be seen arising form the left tracheal wall. In the extrapulmonary tracheobronchial tree with Bronchoscopic fi ndings (Figure 3 ): A polypoid lesion cartilage rings, the depth of tumor invasion must be can be seen on the left tracheal wall, protruding assessed in both the cartilaginous portion and in the through the mucosa with a white stripe on its apex. membranous portion between cartilage rings. Figure 1 Figure 2 Figure 3 Figure 4 132 CHAPTER 13 Case Reports not be determined whether the right middle lobe Case 13 bronchial wall was thickened. Bronchoscopic fi ndings (Figures 3, 4 ): Erythema of Squamous cell

carcinoma of the right lower lobe the bronchial mucosa and narrowing of the lumen (thickening of the right intermediate bronchial sub- extended from the right intermediate bronchus as far mucosa (2nd layer) due to tumor invasion). as could be seen down the lower lobe bronchus. A Squamous cell carcinoma at the origin of the right polypoid lesion was seen at the origin of the right lower lobe bronchus. lower lobe bronchus. EBUS fi ndings: Although the right main bronchial Presenting Complaint: Exertional Dyspnea wall was normal, thickening of the right intermediate History: Presented to previous doctor with exertional bronchus is seen from the bifurcation with right upper dyspnea, abnormal opacity seen on plain chest lobe bronchus distally, strongly suggestive of tumor radiograph. invasion (Figure 5 ). Having passed the probe as far as CT scan chest (Figures 1, 2 ): A cavity - containing the B 8 bronchus, we see destruction of cartilage within tumor was seen at the origin of the right lower lobe the tumor (arrow), representing extramural invasion bronchus. Stenosis of the right intermediate bronchus from the right lower lobe tumor (Figure 6 ). was seen on 1 cm slice CT scanning, although it could Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 133 Endobronchial Ultrasonography the thickened wall of the esophagus was seen to Case 14 compress the left main bronchus from behind. Bronchoscopic fi ndings (Figure 2 ): External com- Esophageal carcinoma (EBUS to determine if the pression of the dorsal aspect of the membranous tumor had invaded the membranous portion of the portion is seen from the left main bronchus to the left main bronchus). left lower lobe bronchus. No abnormality of the Squamous cell carcinoma of the esophagus. mucosa of the membranous portion is seen. Preoperative EBUS fi ndings (Figures 3 , 4) : We used Presenting Complaint: Diffi culty Swallowing an UM- 3R ultrasonic probe + balloon. The esophageal History: Presented to previous doctor with diffi culty carcinoma is delineated as a hypoechoic lesion from 4 swallowing, esophageal stricture at 25 cm from the o ’ clock to 8 o’ clock. No abnormality is seen in the incisors. Biopsy yielded the diagnosis of squamous cell laminar structure of the membranous portion of the carcinoma. EBUS was performed to determine if the left main bronchus, so we concluded that there was tumor had invaded the membranous portion of the no tumor invasion. At operation, it was confi rmed left main bronchus. that the esophageal carcinoma had not invaded the CT scan chest (Figure 1 ): In the slice showing the membranous portion. bifurcation of the left upper and lower lobe bronchi, Figure 1 Figure 2 Figure 3 Figure 4 134 CHAPTER 13 Case Reports CT scan chest (Figure 1 ): We could see enlargement Case 15 of the #10 lymph node is seen, and suspected meta- static squamous cell carcinoma. We could not deter- A metastatic peribronchial lymph node that directly mine whether the #10 lymph node invaded the right invaded the right intermediate bronchial wall. intermediate bronchus. Invasion of the right intermediate bronchial wall by #10 Bronchoscopic fi ndings (Figure 2 ): External com- metastatic lymph node (squamous cell carcinoma). pression of the dorsal aspect of the membranous portion is seen from the left main bronchus to the left Presenting Complaint: Feeling of Things lower lobe bronchus. No abnormality of the mucosa Getting Stuck in the Throat of the membranous portion is seen. History: Abnormal opacity seen in the left upper lobe Preoperative EBUS fi ndings (Figures 3 , 4) : We used on plain chest radiograph. Bronchoscopy revealed an UM- 3R ultrasonic probe + balloon. The target squamous cell carcinomas in two positions, in the left lesion is delineated as a hypoechoic lesion from 8 B3 bronchus and the origin of the right intermediate o ’ clock to 10 o ’ clock. Looking at the site of the poly- bronchus. EBUS was performed to determine if the poid lesion, we see the #10 lymph node invades past latter lesion was the result of invasion by the #10 the cartilage (arrow, high, low, high echo area) as far metastatic lymph node. as the submucosa. Figure 1 Figure 2 Figure 3 Figure 4 135 Endobronchial Ultrasonography Bronchoscopic fi ndings: A submucosal (breaking Case 16 through the mucosa) polypoid lesion was seen pro- truding in to the dorsal aspect of the membranous Small cell carcinoma (metastatic right #11i lymph node portion of the right middle lobe bronchus (Figure 2 ). directly invaded the right middle lobe bronchus). EBUS fi ndings: We positioned an UM- 3R ultrasonic probe directly against the polypoid lesion in the mem- Presenting Complaint: Abnormal Opacity branous portion of the right middle lobe bronchus. Seen on Plain Chest Radiograph at The intramural submucosal polypoid lesion was het- Routine Health Check erogenous but relatively highly echogenic, with loss History: Referred in May 1997 after an abnormal of cartilage within (Figure 3 ). The relatively highly opacity was seen on plain chest radiography at a routine echogenic submucosal polypoid lesion was continuous health check. with the extramural enlarged lymph node (Figure 4 ). CT scan chest (Figure 1 ): A subpleural 1.8 × 1.7 cm This was considered to be small cell carcinoma primary tumor is located at the right S8a region. that had metastasised to the right #11i lymph node, Enlargement of the #12l, #11i, #7 and #3 lymph nodes and then invaded the right middle lobe bronchus led to staging as cT1N2M0, stage IIIA. directly. Figure 1 Figure 2 Figure 3 Figure 4 136 CHAPTER 13 Case Reports chus to the bifurcation of the left upper and lower lobe Case 17 bronchi. Metastatic breast cancer was diagnosed from the endobronchial brushing cytology. Breast cancer (V - shaped bronchial cartilage fragment CT scan chest (Figure 2 ): An enlarged left #11 lymph caused by metastatic left #11 lymph node compress- node was seen to compress the bifurcation of the left ing the bronchial wall from outside). upper and lower lobe bronchi. Left #11 metastatic lymph node (breast cancer). EBUS fi ndings (Figure 3 ): We introduced an UM - 3R ultrasonic probe + balloon into the left B6 bronchus. Presenting Complaint: Abnormal Opacity on The target lesion is delineated as a circumferential CT Scan Chest at Follow- Up after Surgery hypoechoic lesion. The left #11 lymph node is enlarged, for Breast Cancer and directly invades bronchial wall submucosal History: Referred after abnormal opacity seen on layer. Observation of a deformed section of bronchial follow- up CT scan chest 2 years after surgery for breast cartilage allows us to determine whether it is cancer. compressed by proliferating extramural tumor or Bronchoscopic fi ndings (Figure 1 ): Erythema and compressed by proliferating tumor on the mucosal erosions were seen extending from the left main bron- side. Figure 2 Figure 1 Figure 3 137 Endobronchial Ultrasonography EBUS fi ndings: We used an UM - 3R ultrasonic probe. Case 18 The laminar structure of the bronchial wall was diffi cult to visualize in this case because the tumor was located Mucoepidermoid carcinoma arising from the origin of in the right intermediate bronchus obstructing the right the right lower lobe bronchus (diffi cult evaluation lower lobe bronchus, thereby attenuating the ultra- of the depth of tumor invasion). sound pulse before it reached the bronchial wall Mucoepidermoid carcinoma at the origin of the right (Figures 3 , 4 , 5) . This tumor in fact arose from the lower lobe bronchus. bronchial spur between B7 and B1 0 bronchi, invading the right intermediate bronchus from outside. An ane- Presenting Complaint: Abnormal Opacity choic region within the tumor was thought to represent Seen on Plain Chest Radiograph During an area of necrosis (red arrow, Figure 3 ). An extramu- Hospital Admission ral area of different echodensity to the intrabronchial History: Transferred after right lower lobe atelectasis tumor (red arrow, Figure 4 ) was though to correspond seen by previous doctor in plain chest radiograph to the atelectasis. during hospital admission. In cases such as this where a tumor obstructs a large CT scan chest (Figure 1 ): A tumor can be seen bronchus, attenuation of the ultrasound waves makes almost completely obstructing the lumen at the origin it diffi cult to visualize the laminar structure of the of the right intermediate bronchus. bronchial wall, or evaluate the depth of tumor Bronchoscopic fi ndings (Figure 2 ): A pale tumor can invasion. be seen obstructing the right intermediate bronchus. Biopsy showed mucoepidermoid carcinoma. Figure 2 Figure 1 Figure 3 Figure 4 Figure 5 138 CHAPTER 13 Case Reports The patient underwent right lower lobectomy + R 2 a: Case 19 t2n0m0, stage IB. CT scan chest: A mass can be seen in the right lower Comparison of EBUS fi ndings of right #11i lymph lobe S1 0 region (Figure 1 ). Although it measures less node with intraperative fi ndings. than 1 cm on its minor axis, the right #11i lymph node Poorly differentiated squamous cell carcinoma of the can be identifi ed (Figure 2 ). right lower lobe. Preoperative EBUS fi ndings (Figure 3 ): We used an UM - 3R ultrasonic probe + balloon, infl ating the balloon in the right lower lobe bronchus. The pulmo- Presenting Complaint: Abnormal Opacity nary artery (PA) 7 - 10 can be seen between 12 o’ clock Seen on Plain Chest Radiography at a and 3 o’ clock, and to its left the right #11i lymph node Routine Health Check (arrow), measuring 11.9 × 10.4 mm. History: Abnormal opacity seen on plain chest radiog- Intraoperative fi ndings (Figure 4 ): The lower part of raphy at a routine health check. CT scanning and this photograph is the caudal direction. Somewhat bronchoscopy revealed a poorly differentiated squa- distally placed outside the right middle lobe bronchus, mous cell carcinoma in the right lower lobe S1 0 region. we can see the #11i lymph node, next to PA 7- 10, in A class V squamous cell carcinoma was diagnosed agreement with the EBUS fi ndings. The #11i lymph from the endobronchial brushing cytology. node was negative for metastasis. Figure 1 Figure 2 Figure 3 Figure 4 139 Endobronchial Ultrasonography CT scan chest: Although it measures less than 1 cm Case 20 on its minor axis, the right #10 lymph node can be identifi ed (Figure 1 ). Right #10 lymph node and bronchial artery identifi ed Preoperative EBUS fi ndings (Figures 2 , 3) : We used using EBUS. an UM- 3R ultrasonic probe + balloon, infl ating the Poorly differentiated squamous cell carcinoma of the balloon in the right intermediate bronchus. The pul- right lower lobe. monary artery can be seen at 12 o’ clock. The right #10 lymph node can be seen at 9 o’ clock, measuring Presenting Complaint: Abnormal Opacity 8.4 × 6.4 mm, triangular in shape. Two blood vessels on CT Scan Chest Following Surgery for are delineated running anterior to this lymph node Colorectal Cancer (arrow), and a blood vessel running parallel to the History: Abnormal opacity seen on follow- up CT scan bronchus can be seen in the vicinity. chest 4 years after surgery for rectal cancer. CT scan- Intraoperative fi ndings (Figure 4 ): The lower part ning and bronchoscopy revealed a poorly differenti- of this photograph is the caudal direction. The #10 ated squamous cell carcinoma in the right lower lobe lymph node can be seen attached to the right inter- S 6 region. A class V squamous cell carcinoma was mediate bronchus. This bronchial artery (arrow) diagnosed from the endobronchial brushing cytology. seen intraperatively corresponds to the vessel seen The patient underwent right lower lobectomy + R 2 a: using EBUS. The #10 lymph node was negative for t1n0m0, stage IA. metastasis. Figure 1 Figure 2 Figure 3 Figure 4 140 CHAPTER 13 Case Reports responded to oral antimicrobial therapy, with no abnor- Case 21 mality on follow- up radiography 2 months later. CT scan chest (Figure 1 ): A nodular opacity 18 mm Subpleural organizing pneumonia (blood vessels in greatest diameter, containing an air bronchogram, delineated within the lesion). can be seen at the right S9 b region. Organizing pneumonia in the right S 9 b region. EBUS fi ndings (Figure 2 ): This lesion has a clearly delineated

border, and patent blood vessels can be seen Presenting Complaint: Cough in several places. Hyperechoic points running alongside History: Presented to previous doctor with cough, blood vessels represent patent bronchioles (arrow). abnormal opacity seen on plain chest radiograph. CT Findings of patent blood vessels distributed scanning and bronchoscopy confi rmed an opacity in the regularly throughout the lesion are characteristic right S9 b region. Transbronchial lung biopsy (TBLB) of soft lesions such as pneumonia or organizing yielded the diagnosis of organizing pneumonia. Patient pneumonia. Figure 1 Figure 2 141 Endobronchial Ultrasonography CT scan chest (Figure 2 ): A round nodular opacity Case 22 50 mm in greatest diameter can be seen in the left S1 0 c region. Organizing pneumonia (regularly distributed patent EBUS fi ndings (Figure 3 ): Although we were unable blood vessels). to defi ne the boundaries of this lesion due to its size, Left S1 0 organizing pneumonia. blood vessels remained patent (arrow) throughout the lesion. No hyperechoic air - containing dots are seen, Presenting Complaint: Fever, Cough differentiating this lesion from a highly differentiated History: Presented to previous doctor with fever and adenocarcinoma. cough, abnormal opacity seen on plain chest radio- Findings of patent blood vessels distributed regu- graph. CT scanning and bronchoscopy confi rmed an larly throughout the lesion, and no hyperechoic air- opacity in the left S 10 c region. TBLB yielded the diag- containing dots, are characteristic of pneumonia or nosis of organizing pneumonia. organizing pneumonia. Fluoroscopy at the time of EBUS (Figure 1 ): The UM - 3R probe has passed down the bronchoscope instrument channel into the left B10c bronchus. Figure 1 Figure 2 Figure 3 142 CHAPTER 13 Case Reports CT scan chest (Figure 1 ): A thin elongated nodular Case 23 opacity 30 mm in greatest diameter can be seen in the left S1 + 2 a region. Tuberculoma (homogenous echo pattern with no EBUS fi ndings (Figure 2 ): This thin elongated lesion patent vessels or bronchioles). has a clearly delineated border. No blood vessels can Tuberculoma in the left S1 + 2 a region. be seen within the lesion, and the internal echoes are homogeneous with no hyperechoic points. Presenting Complaint: Abnormal Opacity Seen on Plain Chest Radiograph at Points of Advice Routine Health Check The EBUS fi ndings for tuberculomas are varied, History: Abnormal opacity seen on plain chest radio- including the following possibilities: (1) no patent graph at company health check 3 months earlier. blood vessels, no hyperechoic points and homogene- Tuberculosis was diagnosed on the basis of a Gaffky ous internal echoes; (2) microcalcifi cations; and (3) rating 1 from bronchial washings obtained at bron- patent blood vessels and bronchioles as with choscopy. Near resolution of the radiographic changes pneumonia. was achieved with antituberculosis therapy. Figure 1 Figure 2 143 Endobronchial Ultrasonography ographic changes was achieved with 2 months anti- Case 24 microbial therapy. CT scan chest (Figure 1 ): A nodular opacity 30 mm Cryptococcosis (regular distribution of blood vessels in greatest diameter can be seen at the right S6 and bronchioles throughout the lesion). region, with associated pleural indentation and air Cryptococcosis in the right S 6 region. bronchogram. EBUS fi ndings (Figure 2 ): This lesion has a clearly delineated border, linear in places. Patent blood vessels Presenting Complaint: Abnormal Opacity can be seen throughout the lesion, accompanied by Seen on Plain Chest Radiograph at Routine hyperechoic points corresponding to patent bronchi- Health Check oles. The internal echoes are homogenous. History: Abnormal opacity seen on plain chest radio- Findings of patent blood vessels distributed regularly graph at company health check 1 month earlier. throughout the lesion, hyperechoic corresponding to Cryptococcosis was diagnosed on the basis of TBLB patent bronchioles, and homogeneous internal echoes, obtained at bronchoscopy. Near resolution of the radi- are characteristic of infl ammatory conditions. Figure 1 Figure 2 144 CHAPTER 13 Case Reports TBLB yielded the diagnosis of organizing pneumonia. Case 25 Near resolution of the radiographic changes was con- fi rmed 1 month later without treatment. Organizing pneumonia (lesion with star - shaped CT scan chest (Figure 1 ): A nodular opacity 15 mm border). in greatest diameter can be seen at the right S4 a Organizing pneumonia in the right S 4 a region. region. EBUS fi ndings (Figure 2 ): This lesion has a clearly Presenting Complaint: Abnormal Opacity delineated border, linear in places, forming a star- Seen on Plain Chest Radiograph at Routine shape centred on the bronchus. Health Check An irregular star - shaped pattern centred on a bron- History: Abnormal opacity seen on plain chest radio- chus is characteristic of a peribronchial infl ammatory graph at municipal health check 1 month earlier. condition such as organizing pneumonia. Figure 1 Figure 2 145 Endobronchial Ultrasonography CT scan chest (Figure 1 ): A nodular opacity 25 mm Case 26 in greatest diameter can be seen at the left S4 region, with an infi ltrative pattern distally. Organizing pneumonia (lesion with star - shaped EBUS fi ndings (Figure 2 ): This round lesion has a border). clearly delineated border, and contains a star - shaped Infl ammatory pseudotumor in the right S 4 region. anechoic area. Histopathological examination (Figure 3 ): A fl uid collection within the lesion, corresponding to the star- Presenting Complaint: Fever shaped anechoic area seen using EBUS, is the dilated History: Presented to previous doctor with fever of 1 bronchial lumen itself. month ’ s duration, referred with abnormal opacity An irregular star - shaped anechoic area seen on seen on plain chest radiograph. Investigations EBUS sometimes corresponds to dilatation of a bron- including bronchoscopy TBLB failed to yield a defi ni- chus. We have also experienced some cases where an tive diagnosis. Due to persistent pyrexia and enlarge- anechoic area corresponded to a necrotic area within ment of the lesion, the patient underwent left a squamous cell carcinoma. lingulectomy. Figure 1 Figure 2 Figure 3 146 CHAPTER 13 Case Reports CT scan chest (Figure 1 ): A localized ground - glass Case 27 opacity of largest diameter 17 mm, with increased density centrally, can be seen in the left S9 a region. Well -d ifferentiated adenocarcinoma containing air Preoperative EBUS fi ndings (Figure 2 ): The target and blood vessels. lesion was rounded with well - defi ned margins. It con- Well -d ifferentiated adenocarcinoma (papillary type, tains a ribbon - like hypoechoic structure, thought to Noguchi C 17 mm) of the left S9 region. be a blood vessel (arrow). Multiple hyperechoic points are scattered irregularly throughout the lesion. Presenting Complaint: Abnormal Opacity Histopathological examination (low magnifi cation, Seen on Chest CT Scan Figure 3 ): The target lesion is a well - differentiated History: Ground -g lass opacity detected in the left adenocarcinoma (papillary type, Noguchi C) of the left lower lobe on CT scan chest at the time of surgery for S 9 bronchus, with central fi brosis, and growing out esophageal cancer. Priority was given to the surgery, replacing the alveolar mucosa. In this specimen, sliced as the esophageal cancer was advanced, and the in the same plane as the EBUS image, we can see a abnormal opacity was observed with CT scanning. The bronchial artery, 0.7 mm in diameter, passing through left lower lobe ground - glass opacity had increased in the lesion corresponding to the ribbon- like hypoechoic size from 15 mm to 17 mm after 1 year, so the patient structure in the EBUS image (arrow). The hyperechoic then underwent left lower lobectomy + R 1 : sT1N0M0, points in the EBUS image correspond to alveolar air, P0, D0, E0, PM0: c - stage IA. trapped within the tumor as it invades the alveoli. Figure 1 Figure 2 Figure 3 147 Endobronchial Ultrasonography ular. It contains a ribbon - like hypoechoic structure, Case 28 thought to be a blood vessel passing through the lesion (arrow). Multiple hyperechoic points are scattered Well -d ifferentiated adenocarcinoma (blood vessels irregularly throughout the lesion. and hyperechoic points distributed irregularly Histopathological examination (low magnifi ca- through the lesion). tion): The target lesion is a well - differentiated Well -d ifferentiated adenocarcinoma (papillary type) adenocarcinoma (papillary type). In this specimen, of the right S1 region. sliced in the same plane as the EBUS image, we can see a bronchial artery, 0.65 mm in diameter, corre- Presenting Complaint: Abnormal Opacity sponding to the ribbon - like hypoechoic structure in Seen on Plain Chest Radiograph the EBUS image (Figure 2 , arrow). The hyperechoic History: Nodular opacity detected in the right upper points in the EBUS image correspond to alveolar air, lobe on plain chest radiograph at company health trapped within the tumor as it invades the alveoli check. The patient underwent right upper lobec- (Figure 3 , arrow). tomy + R 2 a: sT1N0M0, P0, D0, E0, PM0: c - stage IA. Hyperechoic lines and points are also seen in EBUS We compared the preoperative EBUS images and the images of infl ammatory conditions, but they are regu- histopathological fi ndings. larly distributed in infl ammatory conditions, and tend CT scan chest (Figure 1 ): A nodular opacity of to be irregularly distributed in neoplastic lesions. largest diameter 20 mm, with a central air broncho- When a patent blood vessel is seen passing through a gram, can be seen in the right S1 region. tumor in the EBUS image, this indicates that the Preoperative EBUS fi ndings (Figures 2 , 3) : The tumor is relatively soft, and suggests it is likely to be margins of the target lesion are well - defi ned but irreg- well - differentiated. Figure 1 Figure 2 Figure 3 148 CHAPTER 13 Case Reports CT scan chest (Figure 1 ): A nodular opacity of Case 29 largest diameter 18 mm can be seen in the left S5 region, associated with pleural indentation. Well -d ifferentiated adenocarcinoma with indistinct Preoperative EBUS fi ndings (Figure 2 ): The margins margins. of the target lesion are indistinct. Multiple hypere- Well -d ifferentiated adenocarcinoma (papillary type) choic points are scattered irregularly throughout the of the left S5 region. lesion. 19 × 18 × 18 mm. Histopathological examination (low magnifi cation, Figure 3 ): The target lesion is a well - differentiated Presenting Complaint: Abnormal Opacity adenocarcinoma (papillary type) with central fi brosis. Seen on Plain Chest Radiograph The hyperechoic points in the EBUS image correspond History: Nodular opacity detected in the left middle to alveolar air, trapped within the tumor as it invades lungfi eld on plain chest radiograph at company health the alveoli. check. The patient underwent left upper lobec- The reason the margins of this tumor were indistinct tomy + R 2 a: sT1N0M0, P0, D0, E0, PM0: s - stage IA. We is because it invades by replacing alveolar mucosa, compared the preoperative EBUS images and the his- trapping alveolar air as it spreads peripherally. topathological fi ndings. Figure 1 Figure 2 Figure 3 149 Endobronchial Ultrasonography E0, PM0: s - stage IA. We compared the preoperative Case 30 EBUS images and the histopathological fi ndings. Plain chest radiograph, CT scan chest (Figures 1 , 2) : Moderately differentiated adenocarcinoma (with A nodular opacity of largest diameter 15 mm can be indistinct margins and hyperechoic points distrib- seen at the boundary of the left S 3 a and b regions, uted irregularly through the lesion). some areas containing air. Moderately differentiated adenocarcinoma of the left Preoperative EBUS fi ndings (Figures 3 , 4) : The S3 a region. margins of the target lesion are well - defi ned but irreg- 1.5 × 1.5 × 1.0 cm. ular. Multiple hyperechoic lines and points are scat- tered irregularly throughout the lesion. Histopathological examination (low magnifi cation, Presenting Complaint: Abnormal Opacity Figure 5 ): The target lesion is a moderately differenti- Seen on Plain Chest Radiograph at ated adenocarcinoma (papillary type) with central Municipal Health Check fi brosis, invades by replacing alveolar mucosa as it History: Abnormal opacity seen on plain chest radio- spreads peripherally. graph at company health check. TBLB yielded the The hyperechoic lines and points in the EBUS image diagnosis of adenocarcinoma, and the patient under- correspond to air trapped inside bronchioles and went left upper lobectomy + R 2 a: sT1N0M0, P0, D0, alveoli within the tumor. Figure 1 Figure 2 Figure

3 Figure 4 Figure 5 150 CHAPTER 13 Case Reports could not be obtained. At the second attempt, we were Case 31 able to vizualize the lesion using a UM - 3R probe with a guide sheath. The margins of the target lesion are Moderately differentiated adenocarcinoma (two blood well - defi ned but irregular. At the edge of the lesion, vessels entering the lesion detected). we can see two round hypoechoic structures, thought Moderately differentiated adenocarcinoma of the right to be blood vessel passing through the lesion (yellow S5 b region. arrows). Leaving the guide sheath in position, we removed the ultrasonic probe, introduced an endo- Presenting Complaint: E Result from bronchial cytology brush into the guide sheath, and Sputum Cytology at Municipal Health Check we were able to identify adenocarcinoma cells from History: Adenocarcinoma cells detected on sputum the brushings. cytology at municipal health check. The patient Histopathological examination (low magnifi cation, underwent right middle lobectomy + R2 a: sT1N0M0, Figure 3 ): The target lesion is a moderately differenti- P0, D0, E0, PM0: s - stage IA. We compared the preop- ated adenocarcinoma. In this specimen, sliced in the erative EBUS images and the histopathological same plane as the EBUS image, we can see two bron- fi ndings. chial arteries in the periphery of the tumor, corre- CT scan chest (Figure 1 ): A nodular opacity of largest sponding to the two round hypoechoic structures in diameter 15 mm can be seen in the right S 5 b region. the EBUS image (yellow arrows). Preoperative EBUS fi ndings (Figure 2 ): At the fi rst One of the merits of EBUS for periphery pulmonary bronchoscopy, the endobronchial cytology brush lesions is that it can be used in the place of fl uoroscopy passed through the lesion, and a defi nitive diagnosis to identify the location of a lesion. Figure 2 Figure 1 Figure 3 151 Endobronchial Ultrasonography from the tumor that had been taken up by the nearby Case 32 alveoli. Fluoroscopy at the time of EBUS (Figure 2 ): Although Moderately differentiated adenocarcinoma (detectable the nodular opacity could not be seen under fl uoros- using EBUS, but not fl uoroscopy). copy, the probe introduced into the left B3 a bronchus Moderately differentiated adenocarcinoma of the left was successful in delineating the target lesion. S3 a region. Preoperative EBUS fi ndings (Figure 3 ): The margins of the target lesion are well - defi ned but irregular. A Presenting Complaint: Abnormal Opacity plaque - shaped hyperechoic area can be seen in one Seen on Plain Chest Radiograph at part of the lesion, but the majority of the target lesion Municipal Health Check shows an irregular heterogeneous internal echo History: A nodular opacity was seen in the left S 3 a pattern, with no blood vessels or hyperechoic areas. region on plain chest radiograph at municipal health Histopathological examination (low magnifi cation, check. A class V adenocarcinoma was diagnosed from Figure 4 ): The target lesion is a moderately differenti- the endobronchial brushing cytology. The patient ated adenocarcinoma. It is a highly cellular tumor, underwent left upper lobectomy + R 2 a: sT1N0M0, P0, with only one air- containing area. The plaque - shaped D0, E0, PM0: s - stage IA. We compared the preopera- hyperechoic area corresponded to compressed blood tive EBUS images and the histopathological fi ndings. vessels and bronchioles. CT scan chest (Figure 1 ): A nodular opacity of One of the merits of EBUS for periphery pulmonary largest diameter 20 mm can be seen in the left S 3 a lesions is that it can be used in the place of fl uoroscopy region. The tumor was surrounded by hemorrhage to identify the location of a lesion. Figure 1 Figure 3 Figure 2 Figure 4 152 CHAPTER 13 Case Reports compared the preoperative EBUS images and the his- Case 33 topathological fi ndings. CT scan chest (Figure 1 ): A nodular opacity of Poorly differentiated adenocarcinoma (no blood vessels largest diameter 8 mm can be seen in the right S5 b or bronchioles detectable within the lesion). region, drawing in the adjacent pleura. Poorly differentiated adenocarcinoma of the right S 5 b Preoperative EBUS fi ndings (Figure 2 ): We intro- region. duced an UM- 3R ultrasonic probe into the right S5 b bronchus, and visualized the target lesion. The margins of the target lesion are well - defi ned but irregular. Presenting Complaint: Abnormal Opacity Collapse of the pleural surface has been delineated on CT Scan Chest During Follow- Up after (arrow). No blood vessels, hyperechoic spots or lines Surgery for Left Lower Lobe Moderately can be seen. Differentiated Adenocarcinoma Histopathological examination (low magnifi cation, History: The patient underwent left lower lobectomy Figure 3 ): The target lesion is a poorly differentiated (t2n0m0, stage IB) for left lower lobe moderately dif- adenocarcinoma. It is a solid tumor, with no air- ferentiated adenocarcinoma. An 8 mm opacity was containing areas. seen in the right S 5 b region on follow- up CT scan chest EBUS fi ndings of no blood vessels or hyperechoic 3 years 6 months after surgery. The patient underwent spots within a lesion are characteristic of poorly dif- right middle lobectomy + R 2 a: t1n2m0, stage IIIA. We ferentiated adenocarcinoma. Figure 1 Figure 3 Figure 2 153 Endobronchial Ultrasonography diameter 30 mm can be seen in the right S3 b Case 34 region. EBUS fi ndings (Figure 2 ): We introduced an UM - 3R Poorly differentiated adenocarcinoma (no blood ultrasonic probe into the right S 3 b bronchus, and vessels or bronchioles detectable within the lesion). vizualized the target lesion. The margins of the target Poorly differentiated adenocarcinoma of the right S3 b lesion are well - defi ned. No blood vessels, hyperechoic region. spots or lines can be seen. EBUS fi ndings of no blood vessels or hyperechoic Presenting Complaint: Abnormal Opacity spots within a lesion are characteristic of poorly dif- on CT Scan Chest ferentiated adenocarcinoma. CT scan chest (Figure 1 ): A nodular opacity of largest Figure 1 Figure 2 154 CHAPTER 13 Case Reports pared the preoperative EBUS images and the his- Case 35 topathological fi ndings. CT scan chest (Figures 1 , 2) : A nodular opacity of Moderately differentiated squamous cell carcinoma largest diameter 25 mm can be seen in the left S9 a (hyperechoic spots caused by tumor invasion of region, invading the adjacent emphysematous lung. emphysematous area). Preoperative EBUS fi ndings (Figure 3 ): The margins Moderately differentiated squamous cell carcinoma in of the target lesion are indistinct, with no identifi able the left S 9 region. border. A few hyperechoic points, refl ecting the pres- 25 × 22 × 20 mm. ence of air, can be seen in the central part of the lesion, and some hyperechoic points are scattered Presenting Complaint: Abnormal Opacity irregularly around the tumor margins. Seen on Plain Chest Radiograph at Histopathological examination (low magnifi cation, Municipal Health Check Figure 4 ): This is a squamous cell carcinoma with a History: Abnormal opacity seen on plain chest radio- tendency in one area towards keratinisation, forming graph at municipal health check. CT scanning and invasive nests if large and small irregular sheets as it bronchoscopy revealed a nodular lesion in the left S 9 proliferates. At its periphery, it invades the adjacent region. A class V squamous cell carcinoma was diag- emphysematous lung. nosed from the endobronchial brushing cytology. The The hyperechoic points in the EBUS image corre- patient underwent left lower lobectomy + R 2 a: spond to air contained in emphysematous lung that sT1N1M0, P0, D0, E0, PxM0: c - stage IIA. We com- has been invaded at the periphery of the tumor. Figure 1 Figure 2 Figure 3 Figure 4 155 Endobronchial Ultrasonography We compared the preoperative EBUS images and the Case 36 histopathological fi ndings. CT scan chest (Figure 1 ): A nodular opacity of Metastatic squamous cell carcinoma (areas of cystic largest diameter 45 mm can be seen in the left lower change within the tumor). lobe, compressing the pulmonary artery at its edge. Metastatic squamous cell carcinoma in the left lower Preoperative EBUS fi ndings (Figures 2 , 3) : The lobe. margins of the target lesion are well - defi ned but irreg- ular. Multiple round anechoic areas are seen within Presenting Complaint: Abnormal Opacity the lesion. Seen on Plain Chest Radiograph after Histopathological examination (low magnifi cation, Surgery for Cancer of the Floor of Figure 4 ): This is a squamous cell carcinoma with a the Mouth tendency in one area towards keratinization, forming History: Abnormal opacity seen on plain chest radio- invasive nests if large and small irregular sheets as it graph during follow- up after surgery for cancer of proliferates, consistent with metastatic oral cancer. the fl oor of the mouth. Bronchoscopy revealed a Multiple necrotic fl uid fi lled cysts are seen within this nodular lesion in the left S 9 region. Class V squamous tumor. cell carcinoma, thought to be metastatic oral cancer, The multiple round anechoic areas in the EBUS was diagnosed from the endobronchial brushing cytol- image correspond to the histopathological fi nding of ogy. The patient underwent left lower lobectomy + R2 . necrotic fl uid- fi lled cysts. Figure 1 Figure 2 Figure 3 Figure 4 156 CHAPTER 13 Case Reports CT scan chest (Figure 1 ): An elongated nodular Case 37 opacity of largest diameter 15 mm can be seen in the left S 8 a region. Small cell carcinoma in a peripheral bronchus (direct Preoperative EBUS fi ndings (Figure 2 ): The target invasion of adjacent pulmonary artery). lesion was rounded with well - defi ned margins. At its Small cell carcinoma (intermediate type) in the left periphery it contains a ribbon - like hypoechoic struc- S8 a region. ture, thought to be a blood vessel passing through the 15 × 10 × 5 mm lesion (arrow). Histopathological examination (low magnifi cation, Figure 3 ): The target lesion is a small cell carcinoma, Presenting Complaint: Abnormal Opacity intermediate type. In this specimen, sliced in the same Seen on Plain Chest Radiograph At plane as the EBUS image, we can see a pulmonary Municipal Health Check artery corresponding to the ribbon - like hypoechoic History: Abnormal opacity seen on plain chest radio- structure in the EBUS image (arrow). graph at municipal health check. The patient then The fi ndings in this case were of a small cell carci- underwent left lower lobectomy + R2 a: s- T1N0M0, noma, arising in the bronchial wall, directly invading s - stage IA. a pulmonary artery running beside the bronchus. Figure 1 Figure 2 Figure 3 157 Endobronchial Ultrasonography CT scan chest (Figure 1 ): A snowman - shaped Case 38 nodular opacity can be seen in the left S 1 + 2 c region. Bronchoscopic fi ndings (Figure 2 ): A polypoid lesion A snowman - shaped carcinoid tumor. is seen obstructing the right B1 + 2 c bronchus. Typical carcinoid in the left S1 + 2 c region. Preoperative EBUS fi ndings (Figures 3, 4 ): We intro- duced an UM- 3R ultrasonic probe into the left B1 + 2c Presenting Complaint: Enlargement of bronchus between the polypoid lesion and the bron- Abnormal Opacity Seen on Plain Chest chial wall. The tumor is snowman- shaped (Figure 4 ), Radiograph During Follow- Up for with a hyperechoic line at the snowman ’ s neck corre- Diabetes Mellitus sponding to the bronchial cartilage (Figure 3 ). History: Abnormal opacity seen on plain chest radio- Hyperechoic plaques are seen within the lesion (arrow). graph during follow- up for diabetes mellitus with Histopathological examination (Figure 5 ): The target previous doctor 2 years earlier. Referred this year with lesion is snowman - shaped. Bronchial cartilage corre- enlargement of the opacity. Bronchoscopy and biopsy sponds to the hyperechoic line at the snowman ’ s neck, yielded the diagnosis of typical carcinoid in the left indicating that the tumor has invaded the bronchial S1 + 2 c region. The patient then underwent left upper wall from the lumen. The hyperechoic plaques cor- lobectomy + R2 a: t1n0m0, stage IB. respond to hemorrhagic foci. Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 158 CHAPTER 13

Case Reports Conclusion Analysis of internal structures in peripheral Bleeding pulmonary lesions using EBUS Calcification Bronchiole Our experience with a large number of cases has Dilatation of shown us that with EBUS we can visualize the internal Vessel bronchus structures in peripheral pulmonary lesions. Analysis of WD the cases where we were able to compare EBUS images Multiple cysts Adenoca with the histopathological fi ndings showed that EBUS can delineate the following structures (Figure 1 ): 1 Blood vessels (with diameters greater than 0.65 mm as measured histopathologically). 2 Normal bronchioles. Figure 1 3 Intratumor hemorrhage (carcinoid tumors). 4 Calcifi cation (moderately differentiated adenocarci- noma, papillary thyroid carcinoma metastases). 5 Dilated bronchi (infl ammatory pseudotumor). 6 Multiple necrotic cysts (squamous cell carcinoma). 7 Alveolar air (well- differentiated adenocarcinoma). blood vessels. The internal echoes are heterogenous. The following characteristics were seen in EBUS 4 Squamous cell carcinoma: Multiple necrotic cysts images related to the histological type and degree of are seen. When a tumor is located between the hilum differentiation of lung cancers: and pleura, the probe can be passed through the 1 Well - differentiated adenocarcinoma: Hyperechoic middle of the lesion (bronchial lumen) and the tumor dots and lines (usually less than 1 mm in size), repre- can be seen to compress the bronchial cartilage and senting alveolar air, are irregularly distributed though adventitia as it proliferates. these lesions. Patent blood vessels may or may not be 5 Small cell carcinoma: Thickening of the submucosal present. tissue is seen due to tumor infi ltration. Tumor some- 2 Moderately differentiated adenocarcinoma: Hypere- times involves a bronchial artery running alongside choic dots and lines (greater than 1 mm in size), repre- the affected bronchus. senting compressed blood vessels and bronchioles, are With its superior tissue resolution, EBUS can deline- see within these lesions. The internal echoes are het- ate structures that cannot be visualized using CT or erogeneous. Patent blood vessels are rarely seen. other imaging modalities. EBUS is a tool that can 3 Poorly differentiated adenocarcinoma: No hypere- provide new information to the fi eld of diagnostic choic dots or lines are seen within lesions, nor patent imaging. 159 Appendix: Videos Video clip A1: EBUS - TBNA for No.4L lymph node. 1:07 –1 :17 seconds 0 – 0:6 seconds After puncturing, the stylet was advanced into the end of the A lymph node of No.4L was enlarged. needle to prevent plugging of the bronchial wall. 0:6 – 0:19 seconds 1:17 –1 :31 seconds A lymph node of about 2cm in diameter was observed at A - P The needle was moved back and forth in the lesion. window between aortic arch and left pulmonary artery. 0:19 – 0:28 seconds Power Doppler mode revealed vessels in the lymph node. Video clip A3: EBUS - TBNA for left No.10 lymph node 0:28 – 0:42 seconds with the Navigation System. The TBNA needle was advanced into the tracheal wall. 0 – 0:6 seconds 0:42 – 0:53 seconds A lymph node of left No.10 was enlarged. We could see the real- time movement of the needle in the lymph 0:6 –0 :35 seconds node. The Navigation System (Olympus) showed the location of the 0:53 – 1:20 seconds target lymph node beside the left main bronchus. Seven or eight strokes of the movement of needle were 0:35 –0 :55 seconds performed. The probe of the bronchoscope was attached at the inner surface beside the lymph node. 0:55 –1 :09 seconds The lymph node was located between left main pulmonary artery Video clip A2: EBUS - TBNA for No.12m lymph node. and descending aorta. 0 – 0:7 seconds 1:09 –1 :20 seconds A lymph node of No.12m was enlarged. The bronchoscopist decided the angle of the scope providing the 0:7 – 0:13 seconds largest area of the lymph node. The lymph node was located just beside the middle lobe 1:20 –1 :55 seconds bronchus. Using power Doppler mode, we should not puncture the bronchial 0:13 – 0:28 seconds artery outside the lymph node. The tip of the bronchoscope was introduced into the middle lobe bronchus. 0:28 – 0:51 seconds Video clip A4: Lesion “ peripheral ” to EBUS miniprobe. The EBUS image revealed the enlarged lymph node beside the 70 - year - old man with lesion in RS10. The EBUS- GS appearance vessel. is of a lesion “ peripheral ” to the probe. This would be expected 0:51 – 1:07 seconds to some extent based on the CT appearance. Biopsies showed Power Doppler mode revealed vessels in the lymph node. adenocarcinoma. Video clip A5: Large white points on EBUS due to air Endobronchial Ultrasonography, 1st edition. spaces within consolidated lung. By Noriaki Kurimoto, David I. K. Fielding and Ali I. Musani. 65 - year - old man. EBUS GS biopsy showed bronchiolitis obliterans Published 2011 by Blackwell Publishing Ltd. organizing pneumonia. Resolved with steroid treatment. Note the 160 Appendix: Videos large white areas around the probe at 1– 2 o’ clock, corresponding Video clip A7: Respiratory movement of EBUS to the air spaces seen on CT. probe in RB10a. (see enclosed JPEG) 55 - year - old man with rounded lesion in S10. note on video there Video clip A6: Changing placement of miniprobe. is a lot of respiratory movement, moving the EBUS probe (in RB10) Lesion in LUL. Notice fi rst entry of EBUS miniprobe shows only the in and out of the lesion. The lesion is homogenous and at the probe next to a pulmonary vessel (at 3 o’ clock in relation to bottom of the lesion open vessels can be seen. Biopsies showed probe.) Probe then removed and placed in 1 subsegment laterally benign atelectasis; no change on CT with 4 years follow - up. and clear difference in EBUS appearance is apparent with probe See accompanying CT. well - centered in 2 cm lesion. 161 Index Note: The following abbreviations are used in the index: EBUS: endobronchial ultrasonography; EUS-FNA: endoscopic ultrasound-guided fi ne needle aspiration; GS: guide sheath; PPL: peripheral pulmonary lesion; TBNA: transbronchial needle aspiration adenocarcinoma 159 Boyer and Icheda’s numerical biopsy forceps 29, 30, 36, 86 case reports system 85–6 bleeding left S3a region 150, 152 EBUS-TBNA 20–5, 53–4 conventional transbronchial lung left S5 region 149 frequently asked questions 25 biopsy 74, 75, 84 left S9 region 147 left bronchi 18–19 EBUS-GS 30, 32, 93, 96, 98 right S1 region 148 lymph nodes 20–5, 36, 37, 53–4 EBUS-guided PPL biopsy 76, 84, 86 right S3b region 154 radiological 53–4 clinical trials 77, 78, 79 right S5b region 151, 153 right bronchi 16–18 EBUS-TBNA 25, 58 EBUS and histopathological anesthesia 12, 27 post-biopsy 97–8 examination, correlation EBUS-TBNA 55–6 TBNA 36, 41, 58 between 63–4, 65–8 aortic arch 24, 25, 38, 54, 112 B-mode ultrasonography 3, 34, 118 EBUS-GS 91–2 aortic root 112 brachiocephalic vein 54 echo strength 73 argon plasma coagulation (APC) 115 brachytherapy 114 endobronchial brushing 28 ascending aorta 36, 112 breast cancer 137 Type II 72, 83 asthma 115–6 brightness (gain) 5, 6–7 IIa 69 atrium 18 bronchi, anatomy IIb 69 attenuation of ultrasound waves left 18–19, 25 Type III 82 31, 96 right 16–18, 25 IIIa 69, 72 axial resolution 3–4 bronchioalveolar carcinoma 73 IIIb 72 azygous vein 54, 112 bronchiolitis obliterans organizing adenoid cystic carcinoma of the pneumonia 160–1 trachea 132 bacteremia 58 bronchitis, chronic 86 adenopathy 59–60 balloon method of examination 7 bronchoscopes 8–10 airway wall assembling the balloon probe 10–11 compatibility with ultrasound probes 9 bronchial tree invasion from outside, equipment 8, 9, 10, 26 EBUS-TBNA 14, 55–6 diagnosis 112 frequently asked questions 15, 36 depth of tumour invasion 98, 99, 100–6, preparation 26–7 carcinoid tumours 118 procedure 26–8 case report 158 diameters, measurement of 106–12, tips 27–8 depth of invasion 102 114, 115 video clips 26, 27 EBUS and histopathological frequency of probes 112–3 benign versus malignant PPLs 72–3, 83 examination, correlation infl ammatory diseases 106–7 biopsy between 68 integrity and tumor involvement 96, peripheral lung 75–6 central airway stenosis 115 113 clinical trials 76–81 children, EBUS-guided PPL biopsy 76 interventional bronchoscopy 112–3 conventional 73–5 cisatracurium 56 laminar structure 96–106 future 84–5 colorectal cancers 104 photodynamic therapy 106 side effects and tolerability 84 computed tomography (CT) thickness, measurement of 115 tips 85–7 abnormal opacities on chest scans alveolitis, infl ammatory 87 transbronchial (TBB) 63, 73–5 adenocarcinoma 147, 153, 154 anatomy of mediastinal and hilar area 16, EBUS-GS 28, 29, 30, 93 breast cancer 137 36, 37 side effects 74, 75, 83–4 squamous cell carcinoma 140 162 Index airway diameters, measurement of 108 future 84–85 image orientation 12 airway involvement by tumors 108, internal structure, analysis of 81–83 pancreas 62 112–13 side effects and tolerability 84 endoscopic ultrasound-guided fi ne anatomy 52, 53 tips 85–87 needle aspiration (EUS-FNA) EBUS-GS 95 PPLs 89, 92, 94 59, 61 EBUS-guided PPL biopsy 75, 79–80, changes in techniques 91–92 endotracheal tubes (ETTs) 33, 54 84, 85 equipment 89 equipment 7–10 EBUS-TBNA 52, 60 procedure 89 balloon probes for central lesions 26 lung cancer diagnosis 60–61 tips 92 EBUS-GS 29, 89 orientation 27 video clip 160 EBUS-guided PPL biopsy 75–76 TBNA 39 preparation 28 EBUS-TBNA 14–15, 32 tracheobronchial wall 96 procedure 29 EUS-FNA 59 contrast, image quality adjustment 5–7 tips 30–32 operation 12–14 cough EBUS-TBNA 42–5 preparations 10–12 adenoid cystic carcinoma of the anatomy 36, 37, 38–39 TBNA 37–39, 40 trachea 132 anesthesia 54 esophageal carcinoma 104, 112–13 needle breakage due to 57 bronchoscope case report 134 organizing pneumonia 141, 142 passing the 54–55 esophagus prevention 26, 56 reach 55 anatomy 18 squamous cell carcinoma 122, 129 set-up 53–54 avoiding the 35 cough technique, TBNA 40, 42 equipment 14–15, 32 interventional bronchoscopy 112 cryptococcosis 144 frequently asked questions 25, 35 etomidate 56 cyst, mediastinal 115 future 118 EUS-FNA 59, 61 cytology, on-site 35, 42, 51, 57 interventional bronchoscopy 115 exertional dyspnea 133 lymph nodes 20–25 depth of tumor invasion, assessment 98, accessible 59, 61 fentanyl 54 99, 100–6, 126 aspirations per target lymph node fever 58, 142, 146 case report 120 station 56 fl uoroscopy 73 future directions 118 most commonly sampled 53 conventional transbronchial lung optimum image quality 13–14 sampling for lung cancer diagnosis biopsy 73–74 depth penetration 5 and staging 59–61 EBUS-GS 91, 92 descending aorta 18 on-site pathology 57 EBUS-guided PPL biopsy 76, 84 diagnostic yields procedure 33, 45–51 clinical trials 77–78, 80 conventional transbronchial lung passing the bronchoscope 54 frequently asked questions 35 biopsy 74 passing the needle through limitations 28 EBUS-GS 29–30, 90–91 the wall 55 frequency 2 EBUS-guided PPL biopsy 77–78, 80–81, radiological anatomy 52 30 MHz versus 20 MHz 112–13 84, 85 samples, obtaining 56 future directions 118 EBUS-TBNA 56 side effects and risks 56 fungal infections, chronic 87 diameters, measurement of airway 106–8, tips 52 future directions 114, 115 electromagnetic navigation bronchoscopy depth of tumor invasion, direct contact method of examination 8, 9, (ENB) 85, 92 evaluation of 118 27 electronic scanning 3, 118 EBUS-guided PPL biopsy 84–85 Doppler mode scanning 33, 118 endobronchial brushing 28, 29, 30, EBUS-TBNA 118 drainage bronchus leading to target lesion, 62, 93 PPLs 84–85, 118–19 identifying the 92 diagnostic yield 30 training 119 dynamic magnetic resonance imaging 71 frequently asked questions 35 dysphagia 134 risks 84 gain (brightness) 5, 6–7 dyspnea, exertional 133 tips 86 gray scale bar 6–7 endobronchial stenting 107, 114 EBUS-GS endobronchial ultrasonography (EBUS) hemomediastinum 58 advantages and benefi ts 32, 91 transbronchial needle aspiration see hemoptysis 121, 124 diagnostic yield 30 EBUS-TBNA hemorrhage see bleeding equipment 9, 28 guide sheath see EBUS-GS hertz (Hz) 2 frequently asked questions 35 endoscopic ultrasonic probes see probes histopathological and ultrasonography history 73, 74 endoscopic ultrasonography (EUS) 1, 59 fi ndings, comparison of peripheral lung biopsy 75–76 advantages 72 depth of tumor invasion 98, 99, 101, clinical trials 76–81 equipment 10 102–4 163 Index laminar structure of airway wall 98, 100 EBUS and intraoperative fi ndings pediatrics, EBUS-guided PPL biopsy 76 PPLs, examination of 62–7, 81 compared 139 penetration, depth 5 history small cell carcinoma 136 performing EBUS 26 of EBUS 1–2 squamous cell carcinoma 135, 140 balloon probes for central lesions 26–8 of EBUS-GS 73, 74 EBUS-TBNA 20–5, 45, 47–51, 52, 54–6 EBUS-TBNA 32–5 hub technique, TBNA 40, 41 video clips 160 frequently asked questions 35 frequently asked questions 25, 35 guide sheath method for peripheral image interventional bronchoscopy 112 pulmonary lesions 28–32

and reinforcing the meanings of the terms. Use the other side of the paper in the same way (Fig. 1.3). Snatching Moments Carry your flash cards with you at all times. During most days, there are times when you can snatch a moment to use your flash cards. You will feel less stress when wait- ing in a line or for an appointment if you know that you can use that time for study (Fig. 1.4). Remember to use your good senses: SEE IT Employ your visual sense by making and repeatedly reviewing flash cards. SAY IT Pronounce each component out loud three times as you flash each card to reinforce your auditory sense. WRITE IT Make each flash card by hand using pleasant colored paper and ink to satisfy your kinesthetic sense. DON’T HESITATE TO ANNOTATE! Annotating simply refers to making notes as you read. Learning and reading research indicates that students retain information best after reflecting on what they’ve read and physically making notes with a pen or pencil that organize the material, clarify questions, and link new information to old. It is not enough to highlight or underline. As you read each chapter, and during lecture on related material, make notes in the Chapter 1 • Building a Medical Vocabulary: Getting Started 5 EPI- Figure 1.4 Snatching moments. margins and look carefully at every new term or definition you encounter. Draw lines to separate the component parts of key terms, and write out their meanings. MNEMONICS CAN HELP Mnemonics, referring to any device for aiding memory, is named for the goddess of memory in Greek mythology. Mnemonic techniques link things to be remembered with clues for their recall using the stimulus of images, sounds, smell, touch, etc. Con- sider the following applications: Draw pictures of word components for reinforcement. Often the most absurd as- sociations can help you to remember. It does not matter if they make sense to no one but you (Fig. 1.5). Make up rhymes or stories that help to differentiate between meanings. For exam- ple, “peri-,” the prefix meaning around, is often confused with “para-,” the prefix mean- ing alongside of. Use the two components in a sentence to compare their meanings; e.g., I sat “para” (alongside of) Sarah on the merry “peri” go-around. Figure 1.5 Draw pictures of word components for reinforce- ment. 6 Medical Terminology: The Language of Health Care Make up songs and rhythms to help remember facts. Take a song you are familiar with like “Row, row, row, your boat” and insert words with definitions that are in tune with the song. Other Study Tips Give yourself a memory drill by listing word components, symbols, or terms on one side of a paper and then filling in the definitions from memory. Write corrections in red ink. List the incorrectly defined components on a separate paper, and repeat the drill. Repeat this process until you have identified a list of those most continually found incorrect. Spend additional time on those troublesome terms. Tape record lectures, and listen to pronunciations included in the CD-ROM that accompanies the text. Find a study “buddy” or group from class. Compare notes, study techniques, quiz each other, and enjoy healthy competition. Take advantage of the many fun and interactive learning activities this text pro- vides in the CD-ROM, including: • A pronunciation glossary with audio pronunciations • Spelling bees to help you recognize and correctly spell terms • Labeling exercises to reinforce and test your knowledge of medical terms and anatomy • Games in which you match terms or components with definitions • Scored and unscored chapter quizzes for knowledge assessment • Interactive medical record exercises Let your imagination be your guide. Be creative and make learning fun! Chapter 1 • Building a Medical Vocabulary: Getting Started 7 PRACTICE EXERCISES 1. Name the personal aspect that is key to developing a solid knowledge of medical language. __________________________________________________________________ ___________________________________________________________________________ 2. Identify your personal prime time. ___________________________________________ 3. Identify at least three methods for confronting procrastination._________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4. How can a positive attitude help you with learning? ___________________________ ___________________________________________________________________________ ___________________________________________________________________________ 5. Give an example of a positive affirmation. ____________________________________ ___________________________________________________________________________ 6. List at least three ways you can provide a relaxed environment in which to study. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 7. How can a healthy diet and regular exercise help you learn? ___________________ ___________________________________________________________________________ ___________________________________________________________________________ 8. List the three basic sensory rules for memorizing facts. ________________________ ___________________________________________________________________________ ___________________________________________________________________________ 9. Describe the usefulness of preparing flash cards. ______________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 8 Medical Terminology: The Language of Health Care 10. Explain what it means to annotate text material. ______________________________ ___________________________________________________________________________ ___________________________________________________________________________ 11. Identify at least three other study tips described in Chapter 1. __________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Chapter 2 Basic Term Components OBJECTIVES After completion of this chapter you will be able to Describe the origin of medical language Analyze the component parts of a medical term List basic prefixes, suffixes, and combining forms Use basic prefixes, suffixes, and combining forms to build medical terms Explain common rules for proper medical term formation, pronunciation, and spelling Most medical terms stem from Greek or Latin origins. These date to the founding of ETYMOLOGY. modern medicine by the Greeks and the influence of Latin when it was the universal The Greek root language in the Western world. Other languages, such as German and French, have etymon refers also influenced medical terms, and many new terms are derived from English, which to that which is true or is considered the universal language. Most terms related to diagnosis and surgery have genuine. Etymology is the Greek origin, and most anatomical terms can be traced to Latin. study of the origin and development of words from Once you learn the basic medical term structure and memorize the most common the source language, term components (prefixes, suffixes, and combining forms), you can get the meaning original meaning, and of most medical terms by defining their parts. Those mysterious words, which are al- history of usage. most frightening at first, will soon no longer be a concern. You will analyze each term with your newly acquired knowledge and the help of a good medical dictionary. This chapter lists common prefixes, suffixes, and a selected number of common combining forms. More combining forms and other pertinent prefixes and suffixes will be added in following chapters as you learn terms related to the body systems. The ba- sic rules for proper medical term formation, pronunciation, and spelling are also pre- sented here. The key to success in building a medical vocabulary is the groundwork you do now by making flash cards and memorizing the basic term components in this chapter. The work will pay big dividends if you do. Analysis of Term Components ROOT PREFIX SUFFIX Most medical terms have three components: root, suffix, and prefix. 9 10 Medical Terminology: The Language of Health Care ROOT AND SUFFIX Each term is formed by combining at least one root, the foundation or subject of the word, and a suffix, the ending that modifies and gives essential meaning to the root. For example, in lipemia, l i p / e m i a   ROOT SUFFIX   fat blood condition Lip (fat), the root, is the subject. It is modified by the suffix (emia) to indicate a condition of fat in the blood. Note that each component is dependent on the other to express meaning. Note: lipemia is synonymous with lipidemia (formed from lip, oid, and emia) PREFIX The prefix is a word structure placed at the beginning of a term when needed to further modify the root or roots. For example, in hyperlipemia h y p e r / l i p / e m i a    PREFIX ROOT SUFFIX    excessive fat blood condition The addition of the prefix, hyper, modifies the root to denote excessive fat in the blood. ADDITIONAL ROOTS Often a medical term is formed of two or more roots. For example, in hyperlipoproteinemia h y p e r / l i p / o / p r o t e i n / e m i a      PREFIX ROOT VOWEL ROOT SUFFIX     excessive fat protein blood condition In this term, the additional root, protein (joined to lip by the vowel “o”), further defines the word to indicate an excessive amount of fat and protein in the blood. COMBINING VOWELS AND COMBINING FORMS When a medical term has more than one root, each is joined by a vowel, usually an o. As shown in the term hyper/lip/o/protein/emia, the o links the two roots and fosters eas- ier pronunciation. This vowel is known as a combining vowel; o is the most common combining vowel (i is the second most common) and is used so frequently to join root to root or root to suffix that it is routinely attached to the root and presented as a combining form: l i p ROOT l i p / o COMBINING FORM (ROOT WITH COMBINING VOWEL ATTACHED) This text lists combining forms for easier term formation and analysis. Chapter 2 • Basic Term Components 11 QUICK REVIEW Complete the following sentences: 1. Most medical terms have three basic parts: the _______________________________, ___________________________________, and ____________________. 2. The root is the _________________________ of the term. 3. The _________________________ is the word ending that modifies and gives essential meaning to the root. 4. The _________________________ is a word structure at the beginning of a term that further modifies the root. 5. Often a medical term is formed of _________________________ or more roots. 6. When a medical term has more than one root, it is joined together by a _________________________ (usually an _____). 7. A combining form is a _________________________ with a ______________________ attached. QUICK REVIEW ANSWERS 1. root, suffix, prefix 4. prefix 7. root, vowel 2. foundation or subject 5. two 3. suffix 6. combining vowel, o Required Activity Using the guidelines found in Chapter 1 (see “Flash Cards for Prefixes, Suffixes, and Combining Forms”, page 3), prepare flash cards for the basic term components listed in this chapter: prefixes (pages 20–22), combining forms (pages 23–25), and suffixes (pages 25–28). Memorize them in preparation for analysis of medical term formations, spelling considerations, and rules of pronunciation. Rules for Forming and Spelling Medical Terms Memorizing and spelling basic medical word components are the first steps for learn- ing how to form medical terms. The next step is to construct the words using the fol- lowing rules: 1. A combining vowel is used to join root to root as well as root to any suffix beginning with a consonant: e l e c t r  c a r d i  - g r a m    ROOT ROOT SUFFIX    electric heart record e l e c t r / o / c a r d i / o / g r a m e l e c t r o c a r d i o g r a m (ELECTRICAL RECORD OF THE HEART) 12 Medical Terminology: The Language of Health Care 2. A combining vowel is not used before a suffix that begins with a vowel: v a s  e c t o m y   ROOT SUFFIX   vessel excision v a s / e c t o m y v a s e c t o m y (EXCISION OF A VESSEL) 3. If the root ends in a vowel and the suffix begins with the same vowel, drop the final vowel from the root and do not use a combining vowel: c a r d i  i t i s   ROOT SUFFIX   heart inflammation c a r d / i t i s c a r d i t i s (INFLAMMATION OF THE HEART) 4. Most often, a combining vowel is inserted between two roots even when the second root begins with a vowel: c a r d i  e s o p h a g  e a l    ROOT ROOT SUFFIX    heart esophagus pertaining to c a r d i / o

/ e s o p h a g e a l c a r d i o e s o p h a g e a l (PERTAINING TO THE HEART AND ESOPHAGUS) 5. Occasionally, when a prefix ends in a vowel and the root begins with a vowel, the final vowel is dropped from the prefix: p a r a  e n t e r  a l    PREFIX ROOT SUFFIX    alongside of intestine pertaining to p a r / e n t e r / a l p a r e n t e r a l (PERTAINING TO ALONGSIDE OF THE INTESTINE) Breaking down and defining the components in a term often clues you to its mean- ing. Frequently, however, you must consult a medical dictionary to obtain a precise definition. Take a moment to look up parenteral, so you understand the complete meaning. Note: There are many exceptions to these rules. Follow the basic guidelines, but be prepared to accept exceptions as you encounter them. Rely on your medical dictionary for additional guidance. Chapter 2 • Basic Term Components 13 Defining Medical Terms Through Word Structure Analysis You can usually define a term by interpreting the suffix first, then the prefix (if pres- ent), then the succeeding root or roots. For example, in pericarditis, p e r i / c a r d / i t i s    PREFIX ROOT SUFFIX    2 3 1    around heart inflammation p e r i c a r d i t i s (INFLAMMATION AROUND THE HEART) You sense the basic meaning of this term by understanding its components; how- ever, the dictionary clarifies that the term refers to inflammation of the pericardium, the sac that encloses the heart. Note: Beginning students often have difficulty differentiating between prefixes and roots (or combining forms) because the root appears first in a medical term when a prefix is not used. It is important to memorize the most common prefixes so that you can tell the difference. Also, keep in mind that a prefix is only used as needed to fur- ther modify the root or roots. QUICK REVIEW 1. A combining vowel is used to join root to root as well as root to any suffix begin- ning with a consonant. 2. A combining vowel is not used before a suffix that begins with a vowel. 3. If the root ends in a vowel and the suffix begins with the same vowel, drop the final vowel from the root and do not use a combining vowel. 4. Most often, a combining vowel is inserted between two roots even when the second root begins with a vowel. 5. Occasionally, when a prefix ends in a vowel and the root begins with a vowel, the final vowel is dropped from the prefix. Identify which of the rules listed above were applied when forming the following terms: 1. angi  -ectasis  angi/ectasis _____ 2. hemat  -logy  hemato/logy _____ 3. oste  -ectomy  ost/ectomy _____ 4. electr  encephal  -gram  electro/encephalo/gram _____ 5. para-  umbilic  -al  par/umbilic/al _____ 6. vas  -ectomy  vas/ectomy _____ 7. arteri  -itis  arter/itis _____ 8. gastr  enter  -cele  gastro/entero/cele _____ 9. gastr  -tomy  gastro/tomy _____ 10. hypo  ox  -ia  hyp/ox/ia _____ 14 Medical Terminology: The Language of Health Care QUICK REVIEW ANSWERS 1. 2 5. 5, 2 9. 1 2. 1 6. 2 10. 5, 2 3. 3 7. 3 4. 4, 1 8. 4, 1 Formation of Medical Terms Most medical terms build from the root. Prefixes and suffixes are attached to the root to modify its meaning. Often two or more roots are linked before being modified. The following are examples of the various patterns of medical term formation using the root cardi (heart) as a base. Note the rules used for forming each term. Root/Suffix c a r d i / a c   HEART PERTAINING TO (pertaining to the heart) Prefix/Root/Suffix e p i / c a r d / i u m    UPON HEART TISSUE (tissue upon the heart, i.e., external lining of the heart) Prefix/Prefix/Root/Suffix s u b / e n d o / c a r d i / a l     BENEATH WITHIN HEART PERTAINING TO (pertaining to beneath and within the heart) Root/Combining Vowel/Suffix c a r d i / o / l o g y   HEART STUDY OF (study of the heart) Root/Combining Vowel/Root/Suffix c a r d i / o / p u l m o n / a r y    HEART LUNG PERTAINING TO (pertaining to the heart and lungs) Root/Combining Vowel/Suffix (symptomatic) c a r d i / o / d y n i a   HEART PAIN (pain in the heart) Root/Combining Vowel/Suffix (diagnostic) c a r d i / o / r r h e x i s   HEART RUPTURE (a rupture of the heart) Chapter 2 • Basic Term Components 15 Root/Combining Vowel/Suffix (operative) c a r d i / o / r r h a p h y   HEART SUTURE (a suture of the heart) A FEW EXCEPTIONS As noted above, most medical terms are formed by the combination of a root or roots modified by suffixes and prefixes. Occasionally, terms are formed by a root alone or a combination of roots. EXAMPLES d u c t  ROOT  to lead o v i / d u c t   ROOT ROOT   egg to lead Oviduct refers to the uterine tube. Sometimes, you will find a term formed from the combination of a prefix and a suffix. EXAMPLE m e t a / s t a s i s   PREFIX SUFFIX   beyond, after, stop or stand or change Metastasis refers to the spread of a disease, such as cancer, from one location to another. QUICK REVIEW Analyze the following terms by separating each component, and then define the in- dividual elements: 1. gastric _____________________________________________________ 2. epigastric __________________________________________________ 3. gastrocardiac ______________________________________________ 4. epigastralgia _______________________________________________ 5. gastroscopy ________________________________________________ 6. epigastrocele _______________________________________________ 7. gastrotomy ________________________________________________ 8. epigastrorrhaphy ___________________________________________ 16 Medical Terminology: The Language of Health Care QUICK REVIEW ANSWERS 1. gastr/ic pertaining to the stomach 2. epi/gastr/ic pertaining to upon the stomach 3. gastr/o/cardi/ac or gastro/cardi/ac pertaining to the stomach and heart 4. epi/gastr/algia pain upon the stomach 5. gastr/o/scopy or gastro/scopy examination of the stomach 6. epi/gastr/o/cele or epi/gastro/cele pouching or hernia upon the stomach 7. gastr/o/tomy or gastro/tomy incision in the stomach 8. epi/gastr/o/rrhaphy or epi/gastro/rrhaphy suture upon the stomach Spelling Medical Terms Correct spelling of medical terms is crucial for communication among health care pro- fessionals. Careless spelling causes misunderstandings that can have serious conse- quences. The following are some of the pitfalls to avoid. 1. Some words sound exactly the same but are spelled differently and have different meanings. Context is the clue to spelling. For example, i l e u m (PART OF THE INTESTINE) i l i u m (PART OF THE HIP BONE) s i t o l o g y (STUDY OF FOOD) c y t o l o g y (STUDY OF CELLS) 2. Other words sound similar but are spelled differently and have different meanings. For example, a b d u c t i o n (TO DRAW AWAY FROM) a d d u c t i o n (TO DRAW TOWARD) h e p a t o m a (LIVER TUMOR) h e m a t o m a (BLOOD TUMOR) a p h a g i a (INABILITY TO SWALLOW) a p h a s i a (INABILITY TO SPEAK) 3. When letters are silent in a term, they risk being omitted when spelling the word. For example, pt has a “t” sound if found at the beginning of a term [e.g., pterygium, but both the “p” and “t” are pronounced when found within a term [e.g., nephroptosis (nef-rop-tō’sis)] ph has an “f” sound (e.g., diaphragm) ps has an “s” sound (e.g., psychology) 4. Some words have more than one accepted spelling. For example, o r t h o p e d i c ORTHOPAEDIC (BRITISH) l e u k o c y t e LEUCOCYTE (BRITISH) Chapter 2 • Basic Term Components 17 5. Some combining forms have the same meaning but different origins that compete for usage. For example, there are three combining forms referring to the uterus: h y s t e r / o (GREEK) m e t r / o (GREEK) u t e r / o (LATIN) ACCEPTABLE TERM FORMATIONS As you learn medical terms, you can have fun experimenting with creating words, such as glyco (sweet)  cardio (heart)  sweetheart! However, in the real medical world, the word is formed when the term is coined. Often there seems to be no reason why a par- ticular word form became acceptable. That is why you should check your medical dic- tionary when in doubt about the spelling, formation, or precise meaning. Rules of Pronunciation When you first learn to pronounce medical terms, the task can seem insurmountable. The first time you open your mouth to say a term is a tense moment for those who want to get it right! The best preparation is to study the basic rules of pronunciation, repeat the words after hearing them pronounced on the CD-ROM accompanying this text and/or after your instructor has said them, and try to keep the company of others who use medical language. There is nothing like the validation you get from the fact that no one laughed or snarled at you when you said something “medical” for the very first time! Your confidence will build with every word you use. Following are some helpful shortcuts: Shortcuts to Pronunciation Consonant Example c (before a, o, u)  k cavity colon cure c (before e, i)  s cephalic cirrhosis ch  k cholesterol g (before a, o, u)  g gallstone gonad gurney g (before e, i)  j generic giant ph  f phase pn  n pneumonia ps  s psychology pt  t ptosis pterygium 18 Medical Terminology: The Language of Health Care Consonant Example rh  r rhythm rrh  r hemorrhoid x  z (as first letter) xerosis THE PHONETIC SYSTEM Phonetic spelling for pronunciation of most medical terms in this text is in parenthe- ses below the term (beginning with Chapter 3). The phonetic system used is basic and has only a few standard rules. The macron and breve are the two diacritical marks used. The macron (¯) is placed over vowels that have a long sound: ā day ē be ı̄ kite ō no ū unit The breve (ˇ) is placed over vowels that have a short sound: ǎ alone ě ever ı̌ pit ǒ ton ǔ sun The primary accent (´ ) is placed after the syllable that is stressed when saying the word. Monosyllables do not have a stress mark. Other syllables are separated by hyphens. QUICK REVIEW 1. The pt in pterygium has a/an ____ sound. 2. The ch in the word chronic has a/an ____ sound. 3. The c in the word cirrhosis has a/an ____ sound. 4. The x in xerosis has a/an ___ sound. 5. The g in genital has a/an ___ sound. 6. The pn in pneumatic has a/an ___ sound. QUICK REVIEW ANSWERS 1. t 4. z 2. k 5. j 3. s 6. n Chapter 2 • Basic Term Components 19 Singular and Plural Forms Most often, plurals are formed by adding -s or -es to the end of a singular form. The following are common exceptions. Singular Plural ENDING EXAMPLE ENDING EXAMPLE -a vertebra -ae vertebrae -is diagnosis -es diagnoses -ma condyloma -mata condylomata -on phenomenon -a phenomena -um bacterium -a bacteria -usa fungus -i fungi -ax thorax -aces thoraces -ex apex -ices apices -ix appendix -ices appendices -y myopathy -ies myopathies aViruses and sinuses are not exceptions. QUICK REVIEW Convert the following singular forms to plural: 1.

bulla___________________________________ 2. speculum ______________________________ 3. fungus _________________________________ 4. stoma__________________________________ 5. anomaly _______________________________ 6. prognosis ______________________________ QUICK REVIEW ANSWERS 1. bullae 4. stomata 2. specula 5. anomalies 3. fungi 6. prognoses 20 Medical Terminology: The Language of Health Care Common Prefixes A list of commonly used prefixes organized within categories follows. A hyphen is placed after each prefix to indicate its link at the beginning of a medical term. Each includes a term example. Appendix A and the Quick Study Reference include a summary list of prefixes in alphabetical order. Prefix Meaning Example NEGATION a-, an- without aphonia (without voice or sound) anaerobic (pertaining to without air) anti-, contra- against or opposed to anticoagulant (against clotting) contraception (opposed to becoming pregnant) de- from, down, or not decapitate [separation of the head (caput) from the body] POSITION/DIRECTION ab- away from abnormal (pertaining to away from normal) ad- to, toward, or near adhesion (to stick to) circum-, peri- around circumvascular (pertaining to around a vessel) periosteum (pertaining to around bone) dia-, trans- across or through dialysis [dissolution across or through (a membrane)] transmission (to send across or through) e-, ec-, ex- out or away edentia (condition of teeth out) [dent/oteeth] eccentric (pertaining to away from center) excise (to cut out) [cis/oto cut] ecto-, exo-, extra- outside ectopic (pertaining to a place outside) exocrine (denoting secretion outside) extravascular (pertaining to outside a vessel) en-, endo-, intra- within encapsulate (within little box) endoscope (instrument for examination within) intradermal (pertaining to within skin) Chapter 2 • Basic Term Components 21 Prefix Meaning Example epi- upon epidermal (pertaining to upon the skin) inter- between intercostal (pertaining to between the ribs) [cost/orib] meso- middle mesomorphic (pertaining to middle form) meta- beyond, after, or metastasis [beyond stopping or change standing (spread of disease from one part of the body to another)] metamorphosis (condition of change in form) para- alongside of or paramedic (pertaining to abnormal alongside of medicine) paranoia (condition of abnormal thinking) retro- backward or behind retrograde (going backward) sub-, infra- below or under infraumbilical (pertaining to below the navel) [umbilic/onavel] sublingual (pertaining to under the tongue) [lingu/otongue] QUANTITY OR MEASUREMENT bi- two or both bilateral (pertaining to two or both sides) hemi-, semi- half hemicephalic (pertaining to half of the head) semilunar (pertaining to half moon) [lunamoon] hyper- above or excessive hyperlipemia (excessive fat in blood) hypo- below or deficient hypothermia (condition of below normal temperature) [therm/oheat] macro- large or long macrocyte (large cell) micro- small microlith (small stone) mono-, uni- one monochromatic (pertaining to one color) [chromat/ocolor] unilateral (pertaining to one side) oligo- few or deficient oliguria (condition of deficient urine) pan- all panacea (a cure-all) 22 Medical Terminology: The Language of Health Care Prefix Meaning Example poly-, multi- many polyphobia (condition of many fears) multicellular (pertaining to many cells) quadri- four quadriplegia (paralysis of all four limbs) super-, supra- above or excessive suprarenal (pertaining to above the kidney) supernumerary [excessive numbers (too many to count)] tri- three triangle (three angles) ultra- beyond or excessive ultrasonic (pertaining to beyond sound) TIME ante-, pre-, pro- before antepartum (before labor) premature (before ripe) prognosis [before knowing (prediction of course and outcome of a disease)] brady- slow bradycardia (condition of slow heart) tachy- fast tachycardia (condition of fast heart) post- after or behind postoperative [after operation (surgery)] re- again or back reactivate (to make active again) GENERAL con-, syn-, sym- together or with syndactylism (webbing together of toes or fingers) [dactyl/o finger or toe] symbiosis (presence of life together) [biolife] congenital (pertaining to being born with) dys- painful, difficult, dysphonia [condition of difficult or faulty voice or sound (hoarseness)] eu- good or normal eugenic (pertaining to good production) neo- new neoplasia [a new (abnormal) formation] Chapter 2 • Basic Term Components 23 Common Combining Forms Following are selected combining forms (roots with combining vowels attached) to give you a start toward building medical terms. Additional combining forms are intro- duced at the beginning of Chapters 5 to 17 on body systems. Each is presented with a slash between the root and the combining vowel along with a term example. Appendix A and the Quick Study Reference include a summary list of combining forms in al- phabetical order. Combining Forms Combining Form Meaning Example abdomin/o abdomen abdominal (pertaining to abdomen) lapar/o laparotomy (incision into the abdomen) acr/o extremity or topmost acrodynia (pain in an extremity) acrophobia [exaggerated fear of topmost places (heights)] aden/o gland adenoma (gland tumor) aer/o air or gas aerobic (pertaining to air) angi/o vessel angioplasty (surgical repair of a blood vessel) vas/o vasectomy (excision of a vessel) vascul/o vascular (pertaining to a vessel) carcin/o cancer carcinogenic (pertaining to CANCER. production of cancer) Cancer is Latin for crab. The cardi/o heart cardiologist (one who specializes word is derived from the in treatment of the heart) Greek word karkinos that was used by Hippocrates cephal/o head cephalic (pertaining to the head) and other early writers and cyan/o blue cyanotic (pertaining to blue) also means crab. Some authorities say the word was cyt/o cell cytology (study of cells) used because it describes the appearance of the derm/o skin dermal (pertaining to the skin) disease; i.e., just as the dermat/o dermatology (study of the skin) crab’s feet extend in all directions from its body, so cutane/o cutaneous (pertaining to the skin) can the disease extend in the human. Other authorities dextr/o right or on the right side dextrocardia (condition of the relate the term to the heart on the right side) obstinacy of a crab in erythr/o red erythrocyte (red cell) pursuing prey. fibr/o fiber fibroma ( fiber tumor) gastr/o stomach gastric (pertaining to the stomach) gen/o origin or production osteogenic (pertaining to origin or production in bone) 24 Medical Terminology: The Language of Health Care Combining Form Meaning Example gluc/o sugar glucogenesis (origin or production of sugar) glucos/o glucose (sugar) glyc/o glycolysis (breakdown or dissolution of sugar) hem/o blood hemogram (record of blood) hemat/o hematology (study of blood) hepat/o liver hepatoma (tumor of the liver) hydr/o water hydrophobia (exaggerated fear of water) leuk/o white leukocyte (white cell) lip/o fat lipoid (resembling fat) lith/o stone lithiasis (formation or presence of a stone) melan/o black melanoma (black tumor) morph/o form morphology (study of form) nas/o nose nasal (pertaining to the nose) rhin/o rhinitis (inflammation of the nose) necr/o death necrocytosis (condition or increase of cell death) or/o mouth oral (pertaining to the mouth) orth/o straight, normal, orthostatic (pertaining to standing or correct straight) oste/o bone osteal (pertaining to bone) path/o disease pathology (study of disease) ped/o child or foot pediatrics (treatment of child) pedal (pertaining to the foot) phob/o exaggerated fear or hydrophobia (exaggerated fear sensitivity of water) photophobia (sensitivity to light) phon/o voice or sound phonic (pertaining to voice or sound) plas/o formation dysplasia (condition of faulty formation) pod/o foot podiatry (treatment of the foot) psych/o mind psychology (study of the mind) py/o pus pyopoiesis (formation of pus) ren/o kidney renal (pertaining to the kidney) nephr/o nephrosis (condition of the kidney) Chapter 2 • Basic Term Components 25 Combining Form Meaning Example scler/o hard sclerosis (a condition of hardness) sinistr/o left or on the left side sinistropedal (pertaining to the left foot) son/o sound sonometer (an instrument to measure sound) sten/o narrow stenosis (a condition of narrow) therm/o heat thermometer (instrument for measuring heat) tox/o poison toxemia (poison in blood) TOXIN. The Greek root toxic/o toxicology (study of poison) toxicon means troph/o nourishment or trophocyte (a cell that arrow poison and is derived development provides nourishment) from the word for the archer’s bow. The Greeks hypertrophy (condition of often used darts and arrows excessive development) coated with a poisonous substance. ur/o urine urology (study of urine) urin/o urinary (pertaining to urine) Common Suffixes Suffixes are endings that modify the root. They give the root essential meaning by forming a noun, verb, or adjective. There are two types of suffixes: simple and compound. Simple suffixes form basic terms. For example, ic (pertaining to), a simple suffix, combined with the root gastr (stomach) forms the term gastric (pertaining to the stomach). Compound suffixes are formed by a combination of basic term components. For example, the root tom (to cut) combined with the simple suffix y (denoting a process of) forms the compound suffix tomy (incision); the compound suffix ectomy (excision or removal) is formed by a combination of the prefix ec (out) with the root tom (to cut) and the simple suffix y (a process of). Compound suffixes are added to the roots to provide a specific meaning. For example, hyster (a root meaning uterus) combined with ectomy forms hysterec- tomy (excision of the uterus). Noting the differences between simple and compound suffixes will help you analyze medical terms. Suffixes in this text are divided into four categories: • Symptomatic suffixes, which describe the evidence of illness • Diagnostic suffixes, which provide the name of a medical condition • Operative (surgical) suffixes, which describe a surgical treatment • General suffixes, which have general application Commonly used suffixes follow in alphabetical order except for groups with the same meaning. A hyphen is placed before each to indicate their link at the end of a term. Appendix A and the Quick Study Reference include a summary list of suffixes in alphabetical order. 26 Medical Terminology: The Language of Health Care Suffix Meaning Example SYMPTOMATIC SUFFIXES (WORD ENDINGS THAT DESCRIBE EVIDENCE OF ILLNESS) -algia pain cephalalgia [pain in the head (headache)] -dynia cephalodynia [pain in the head (headache)] -genesis origin or production pathogenesis (origin or production of disease) -lysis breaking down or dissolution hemolysis (breakdown of blood) -megaly enlargement hepatomegaly (enlargement of the liver) -oid resembling lipoid (resembling fat) -penia abnormal reduction leukopenia [abnormal reduction of white (blood cells)] -rrhea discharge rhinorrhea (runny discharge from nose) -spasm involuntary contraction vasospasm (involuntary contraction of a blood vessel) DIAGNOSTIC SUFFIXES (WORD ENDINGS THAT DESCRIBE A CONDITION OR DISEASE) -cele pouching or hernia gastrocele ( pouching of the stomach) -ectasis expansion or dilation angiectasis (expansion or dilation of a blood vessel) -emia blood condition hyperlipemia (blood condition of excessive fat) -iasis formation or presence of lithiasis (formation or presence of a stone or stones) -itis inflammation hepatitis (inflammation of the liver) -malacia softening osteomalacia (softening of bone) -oma tumor carcinoma (cancer tumor) -osis condition or increase sclerosis (condition of hard) leukocytosis (increase of white cells) -phil attraction for basophil (cell with an attraction for basic dyes) -philia pneumophilia (condition that has an attraction for the lungs) Chapter 2 • Basic Term Components 27 Suffix Meaning Example -ptosis falling or downward gastroptosis (downward displacement displacement of the stomach) -rrhage to burst forth (usually blood) hemorrhage (to burst forth blood) -rrhagia -rrhexis rupture hepatorrhexis (rupture of the liver) OPERATIVE SUFFIXES [WORD ENDINGS THAT DESCRIBE A SURGICAL (OPERATIVE) TREATMENT] -centesis puncture for aspiration abdominocentesis (puncture for aspiration of the abdomen) -desis binding arthrodesis (binding together of a joint) [arthr/ojoint] -ectomy excision or removal nephrectomy (excision or removal of a kidney) -pexy suspension or fixation gastropexy [fixation of the stomach (to the abdominal wall)] -plasty surgical repair or rhinoplasty (surgical repair of the reconstruction nose) -rrhaphy suture osteorrhaphy (suture of bone) -tomy incision laparotomy (incision into the abdomen) -stomy creation of an opening gastrostomy (creation of an opening in the stomach) -tripsy crushing lithotripsy (crushing of stone) GENERAL SUFFIXES (SUFFIXES THAT HAVE GENERAL APPLICATIONS) Noun Endings (suffixes that form a noun when combined with a root) -e noun marker erythrocyte (a red blood cell) -ia condition of phobia (condition of an exaggerated fear or sensitivity) -ism alcoholism (condition of alcohol abuse) -ium structure or tissue epigastrium [structure upon the stomach (region in the abdomen)] pericardium [tissue around the heart (sac enclosing the heart)] -ation condition or process of starvation (condition or process of starving) -y adenopathy (condition or process of gland disease) 28 Medical Terminology: The Language of Health Care Suffix Meaning Example Adjective Endings (suffixes that mean “pertaining to” and form an adjective when com- bined with a root) -ac cardiac (pertaining to the heart) -al pedal (pertaining to the foot) -ar glandular (pertaining to a gland) -ary pulmonary (pertaining to the lung) -eal esophageal (pertaining to the esophagus) -ic toxic (pertaining to poison) -ous fibrous (pertaining to fiber) -tic cyanotic (pertaining to blue) Diminutive Endings (suffixes meaning “small”) -icle ventricle (small belly or pouch) -ole bronchiole (small airway) -ula

macula (small spot) -ule pustule (small pimple) Other General Suffixes -gram record sonogram (record of sound) -graph instrument for recording sonograph (instrument for recording sound) -graphy process of recording sonography (process of recording sound) -iatrics treatment pediatrics (treatment of children) -iatry psychiatry (treatment of the mind) -logy study of cytology (study of cells) -logist one who specializes in the psychologist (one who specializes study or treatment of in the study or treatment of the mind) -ist one who specializes in pharmacist (one who specializes in drugs) -meter instrument for measuring spirometer (instrument for measuring breathing) [spir/o breathing] -metry process of measuring spirometry (process of measuring breathing) -poiesis formation hemopoiesis ( formation of blood) -scope instrument for examination endoscope (instrument for examination within) -scopy examination endoscopy (examination within) -stasis stop or stand hemostasis (stop blood) orthostasis (stand straight) Chapter 2 • Basic Term Components 29 Don’t Be Rolled Over by the We have the Greeks to thank for the suffixes with double rr’s. Take a careful look at each so that you rr will spell them correctly in a term! Suffix Meaning Example 's -rrhea discharge pyorrhea—a discharge of pus -rrhage or to burst forth hemorrhage—a -rrhagia (usually blood) bursting forth of blood menorrhagia—a bursting forth of blood during menstruation -rrhexis rupture angiorrhexis— rupture of a vessel -rrhaphy suture nephrorrhaphy— suture of the kidney Also note that each component also has an h and -rrhaphy has two! 30 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following words, draw a line or lines to separate prefixes, roots, combining forms, and suffixes. Then define the word according to the meaning of: Pprefix; Rroot; CFcombining form; Ssuffix. EXAMPLE hyperlipemia _______ / _______ / _______ P R S hyper/lip/emia P R S DEFINITION: above or excessive/fat/blood condition 1. pancytopenia __________________ / __________________ / __________________ P CF S DEFINITION: _________________________________________________________________ 2. leukemia __________________ / __________________ R S DEFINITION: _________________________________________________________________ 3. toxoid __________________ / __________________ R S DEFINITION: _________________________________________________________________ 4. mesomorphic __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 5. acrodynia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 6. metastasis __________________ / __________________ P S DEFINITION: _________________________________________________________________ Chapter 2 • Basic Term Components 31 7. ultrasonography __________________ / __________________ / __________________ P CF S DEFINITION: _________________________________________________________________ 8. tachycardia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 9. pyopoiesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 10. adenitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 11. macrocephalous __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 12. paracentesis __________________ / __________________ P S DEFINITION: _________________________________________________________________ 13. microlithiasis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 14. orthopedic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 15. angiomegaly __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 16. psychiatry __________________ / __________________ R S DEFINITION: _________________________________________________________________ 32 Medical Terminology: The Language of Health Care 17. carcinogenesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 18. nephrologist __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. rhinostenosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 20. hypohydration __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 21. aerogastralgia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 22. fibroma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 23. necrophilia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 24. sclerosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 25. hemolysis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 26. acrophobia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 2 • Basic Term Components 33 27. cytometer __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 28. cyanotic __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 29. extravascular __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 30. hypertrophy __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ Write in the appropriate prefix to complete the following terms: 31. ________ nasal  above the nose a. para b. peri c. supra d. infra e. sub 32. ________ activate  make active again a. de b. retro c. pro d. re e. hyper 33. ________ operative  before surgery a. intra b. post c. pre d. peri e. circum 34. ________ hydrated  not watered a. anti b. de c. ec d. dys e. contra 35. ________ dermal  across or through the skin a. ecto b. endo c. intra d. epi e. trans 36. ________ acute  excessively severe a. sub b. hypo c. super d. oligo e. pan 37. ________ umbilical  below or under the navel a. hyper b. infra c. peri d. para e. pre 38. ________ cardia  outside the heart a. exo b. endo c. retro d. para e. peri 39. ________ phonia  difficult voice a. ab b. dys c. a d. eu e. para 40. ________ duction  to turn away from a. ad b. ab c. ecto d. pro e. ante 41. ________ phylaxis  to guard before a. retro b. pro c. post d. peri e. anti 34 Medical Terminology: The Language of Health Care 42. ________ vascular  around a blood vessel a. intra b. inter c. para d. circum e. endo 43. ________ plegia  half paralysis a. quadri b. peri c. hemi d. bi e. mono Match the following: 44. ________ away from a. retro- 45. ________ between b. peri- 46. ________ alongside of c. anti- 47. ________ around d. ecto- 48. ________ behind e. dia- 49. ________ within f. ab- 50. ________ against or opposed to g. inter- 51. ________ without h. para- 52. ________ outside i. an- 53. ________ across or through j. intra- Give the meaning of the following prefixes: 54. poly- ________ 60. bi- ________ 55. hypo- ________ 61. quadri- ________ 56. oligo- ________ 62. semi- ________ 57. mono- ________ 63. infra- ________ 58. pan- ________ 64. hyper- ________ 59. ultra- ________ Match the following: 65. ________ before a. brady- 66. ________ after b. re- 67. ________ fast c. ante- 68. ________ slow d. post- 69. ________ again e. tachy- Chapter 2 • Basic Term Components 35 Circle the correct meaning for the following term components: 70. a- a. double b. both c. two d. without e. against 71. pod/o a. child b. foot c. voice d. sound e. pus 72. or/o a. lip b. nourishment c. gland d. mouth e. normal 73. neo- a. birth b. death c. origin d. new e. disease 74. -plasty a. surgical repair b. cancer c. tumor d. excision e. incision 75. -ation a. measure b. disease c. tissue d. pain e. process 76. -tripsy a. nourishment b. poison c. crushing d. incision e. stone 77. -ectasis a. blood condition b. formation of c. expansion d. rupture e. discharge 78. dextr/o a. hard b. straight c. right d. left e. long Match the following: 79. ________ black a. tri- 80. ________ three b. leuk/o 81. ________ red c. cyan/o 82. ________ four d. dextr/o 83. ________ white e. uni- 84. ________ one f. melan/o 85. ________ blue g. quadri- 86. ________ two h. sinistr/o 87. ________ few i. oligo- 88. ________ right j. erythr/o 89. ________ left k. bi- 36 Medical Terminology: The Language of Health Care Circle the appropriate suffix for each of the following meanings: 90. record a. -meter b. -metry c. -gram d. -graph e. graphy 91. condition or increase a. -itis b. -iasis c. -osis d. -ium e. -ous 92. excision a. -tomy b. -stomy c. -ectomy d. -centesis e. cele 93. pertaining to a. -ia b. -ar c. -ism d. -ium e. -icle 94. rupture a. -rrhagia b. -rrhea c. -rrhagia d. -rrhexis e. -megaly 95. small a. -ous b. -eal c. -ula d. -ia e. -ary 96. condition of a. -ism b. -ium c. -ule d. -ic e. al Match the following terms related to the kidney with the definitions listed below: nephrolysis nephrostomy nephroptosis nephrotomy nephritis nephropexy nephroma nephrocele nephrogenous nephrolithiasis nephrorrhaphy nephrectomy 97. inflammation of the kidney_________________________________________________ 98. dissolution or breakdown of the kidney______________________________________ 99. incision in the kidney ______________________________________________________ 100. developing from the kidney ________________________________________________ 101. surgical fixation of the kidney ______________________________________________ 102. creation of an opening in the kidney ________________________________________ 103. excision of the kidney______________________________________________________ 104. presence of kidney stones __________________________________________________ 105. kidney tumor _____________________________________________________________ 106. hernia of the kidney _______________________________________________________ 107. suture of the kidney _______________________________________________________ 108. downward displacement of the kidney ______________________________________ Chapter 2 • Basic Term Components 37 Circle the operative term in each of the following lists: 109. a. nephroptosis b. hemolysis c. angiectasis d. colostomy e. necrosis 110. a. vasorrhaphy b. hematoma c. gastrocele d. endoscope e. cardiorrhexis 111. a. morphologic b. adenolysis c. abdominocentesis d. osteomalacia e. polyrrhea Fill in the blanks for the following regarding singular/plural forms: 112. An ovum is an egg produced by an ovary. There are two ________________ in the female that produce eggs or ________________. 113. The spread of cancer to a distant organ is called metastasis. The spread of cancer to more than one organ is ________________. 114. A verruca is a wart. The term for several warts is ________________. 115. Condylomata are genital warts. One genital wart is a ________________. 116. Indices is a plural form of ________________. 117. A thrombus is a clot. Several clots are termed ________. Circle the correct spelling: 118. a. nephoraphy b. nephorrapy c. nephrorrhaphy d. nephorrhapy 119. a. abdominoscopy b. abdemenoscopi c. abdomenscopy d. abdominoschope 120. a. perrycardium b. pericardium c. periocardium d. parcardium Chapter 3 Fields of Medical Practice OBJECTIVES After completion of this chapter you will be able to Define combining forms used in naming medical specialties Trace the evolution of medicine Identify the purpose of the American Board of Medical Specialties Define diplomate and fellow Describe the scope of medical practice for the medical specialties recognized by the American Board of Medical Specialties Identify other medical practitioners with the title of doctor and list their scope of practice List titles of other health professionals Combining Forms Combining Form Meaning Example cardi/o heart cardiology kar-dē-olō-jē chir/o hand chiropractic kı̄-rō-praktik crin/o to secrete endocrinology endō-kri-nolō-jē dent/i teeth dentist dentist dermat/o skin dermatology der-mă-tolō-jē enter/o small intestine gastroenterology gastrō-en-ter-olō-jē esthesi/o sensation anesthesiology anes-thē-zē-olō-jē gastr/o stomach gastroenterology gastrō-en-ter-olō-jē 38 Chapter 3 • Fields of Medical Practice 39 Combining Form Meaning Example gen/o origin or production gene jēn ger/o old age geriatric jer-ē-atrik gynec/o woman gynecology gı̄-nĕ-kolō-jē hemat/o blood hematology hēmă-tolō-jē immun/o safe immunology imyū-nolō-jē laryng/o voicebox otolaryngology ōtō-lar-ing-golō-jē nephr/o kidney nephrology ne-frolō-jē neur/o nerve neurologist noo-rolō-jist obstetr/o midwife obstetric ob-stetrik onc/o tumor oncology ong-kolō-jē ophthalm/o eye ophthalmology of-thal-molō-jē opt/o eye optometry op-tomĕ-trē orth/o straight, normal, or correct orthopedics ōr-thō-pēdiks ot/o ear otolaryngologist ōtō-lar-ing-golō-jist path/o disease pathologist pa-tholō-jist ped/o child or foot pediatrics pē-dē-atriks orthopedics ōr-thō-pēdiks physi/o physical physiatrist fiz-ı̄ă-trist plas/o formation plastic surgery plastik serjer-ē pod/o foot podiatry pō-dı̄ă-trē psych/o mind psychiatry sı̄-kı̄ă-trē 40 Medical Terminology: The Language of Health Care Combining Form Meaning Example radi/o x-ray radiology rā-dē-olō-jē vascul/o vessel vascular vaskyu-lăr The Evolution of Medicine Today’s practice of medicine evolved from the customs of ancient times. Care for the patient (one who suffers) was often given by priests who gave homage to mythological gods and performed rituals designed to appease those gods to rid the body of disease. Hippocrates, the ancient Greek physician who lived about 400 B.C., is known as the “Father of Medicine.” He was the first to attempt to separate medicine from myth, and his writings include the first rational documentation of disease. He also wrote the Hippocratic Oath, which was the standard of medical ethics for physicians in his day and is the basis of modern ethical codes (Fig. 3.1). Curiosity about the body and the causes of disease led to the study of anatomy and physiology and the art of healing practiced by medieval physicians. Scientific progress led to the development of surgery, pharmacy, pathology, and other aspects of medi- cine. Hospitals were built to care for the sick and dying, and universities were estab- lished to study disease (Fig. 3.2). Medieval methods have evolved into the modern sophisticated health care system that provides comprehensive care. Physicians have branched out into many specialties of medicine and have been joined by a team of other health care professionals with highly developed training and skills. The Physician Today, health care is delivered by a complicated system involving many types of pro- fessionals. The most

prominent professional responsible for meeting the medical needs of the patient is the physician, also called a medical doctor (Fig. 3.3). HIPPOCRATES. Born on the island of Cos about 400 B.C. and known as the founder of medicine, this Greek physician created the art and science of medicine and removed it from the realm of superstition and magic. Our medical terminology really begins with Hippocrates because he was the first to write terms. Figure 3.1 Hippocrates. Chapter 3 • Fields of Medical Practice 41 HOSPITAL. Hospital is derived from the Latin word meaning guest house. The words hospital, hospice, host, hostel, and hotel have the same origin but now have different meanings. It is unknown where special institutions for sick people originated. The Romans had military hospitals by 100 A.D. Christian hospitals seem to have originated from the tradition of a guest house for travelers. In 6th century France, an institution for the sick was called hostel Dieu Figure 3.2 Three photographs (God’s hotel). Most hospitals of Hostel-Dieu, Beaune, France, a were run by religious orders medieval hospital founded in 1443; whose members devoted it is now a museum. A. Entrance. themselves to the care of the B. Grand salle (“great room”—com- bination hospital ward and church). sick. In the 19th century, C. Bedsides. hospitals became centers for treating disease for all classes of society, and they operated for both profit and The Doctor of Medicine (M.D.) degree is earned by successfully completing nonprofit. medical school. To practice medicine, however, the graduate with an M.D. must be li- censed. The license to practice medicine is granted after the applicant passes a speci- fied medical licensing examination and meets any other requirements established by the medical board in the state where the applicant wants to practice. The Doctor of Osteopathic Medicine (D.O.) is a medical practitioner similar to an M.D. but with a traditional emphasis on the role of the musculoskeletal system in Figure 3.3 Luke Fildes’ The Doctor. 42 Medical Terminology: The Language of Health Care maintaining function and balance in the body. Osteopathic physicians are trained at osteopathic colleges and are often affiliated with osteopathic hospitals. The licensing requirements for the osteopath are also similar to the M.D. and are established by med- ical boards in each state. American Board of Medical Specialties The licensed physician in the past was often both physician and surgeon. Today, with the rapid expansion of technology and the greater knowledge required to be proficient in treating patients, physicians have entered various nonsurgical and surgical specialty PHYSICIAN. areas. Physician is With increasing medical specialties, standards and monitoring of specialty prac- derived from a tices were required. The American Board of Medical Specialties (ABMS) was founded Greek word for natural or in 1933 for this purpose. The 24 individual specialty boards recognized by ABMS have according to the laws of established criteria for specific training after medical school (3 to 7 years depending nature. In ancient Greece, on the specialty). After the specialty training (called a residency or fellowship), the natural science, which physician gains eligibility to take the specified board examination. A physician who included biology and has completed specialty requirements and passed the board examination is designated medicine, was concerned with speculation about the “board certified” and referred to as a “diplomate” (e.g., Joan Jones, M.D., Diplomate, origin and existence of American Board of Family Practice). A board’s standards extend beyond the usual re- things. Physic, in the sense quirement for licensure. of drug, especially a Other organizations, such as the American College of Physicians (ACP) and the laxative made from herbs American College of Surgeons (ACS), recognize members who have met set published and natural sources, has criteria for standards of distinction. These include Fellow of the American College the same origin. The of Physicians (F.A.C.P.) and Fellow of the American College of Surgeons (F.A.C.S.) teaching of medicine came (Fig. 3.4). under the general heading ABMS-approved specialty boards of the United States follow: of physicus, and practitioners were called American Board of Allergy and Immunology physicians. American Board of Anesthesiology Figure 3.4 The early days of surgery and anesthesiology. Thomas Eakins’ The Agnew Clinic. Chapter 3 • Fields of Medical Practice 43 American Board of Colon and Rectal Surgery American Board of Dermatology American Board of Emergency Medicine American Board of Family Practice American Board of Internal Medicine American Board of Medical Genetics American Board of Neurological Surgery American Board of Nuclear Medicine American Board of Obstetrics and Gynecology American Board of Ophthalmology American Board of Orthopaedic Surgery American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Physical Medicine and Rehabilitation American Board of Plastic Surgery American Board of Preventive Medicine American Board of Psychiatry and Neurology American Board of Radiology American Board of Surgery CADUCEUS. The word for the American Board of Thoracic Surgery staff of Mercury, American Board of Urology an emblem in Greek mythology represented by Each specialty or subspecialty has its own scope of practice as follows. All earn the two serpents twined around M.D. or D.O. degree. Ph.D. degrees are accepted by a few specialties/subspecialties, a staff, is the most common e.g., medical genetics, public health. symbol of the medical Special note: The American Osteopathic Association (AOA) also provides certi- profession. From earliest fication of osteopaths who have expertise in the following approved specialty and sub- history, serpents have been specialty areas: anesthesiology, dermatology, emergency medicine, family practice, symbols of wisdom and internal medicine, neurology and psychiatry, neuromusculoskeletal medicine, nuclear health and objects of medicine, obstetrics and gynecology, ophthalmology and otolaryngology, orthopedic worship. They appear as surgery, pathology, pediatrics, preventive medicine, proctology, radiology, rehabilita- regular shrine equipment tion medicine, and surgery. and were involved in ancient healing rituals. The significance of the caduceus for the medical profession is said to lie in the fact that the serpent symbolizes healing—some say because of its long life, others because the annual shedding of its skin suggests a renewal of youth and health, others because of its keen eyesight. The earliest representation of serpent and staff was the rod of Aesculapius, the god of medicine, which shows a single serpent twining A B around a rod or stick. Some argue that it is the Figure 3.5 The caduceus. A. Staff of Mercury. true symbol of the medical B. Rod of Aesculapius. profession (Fig. 3.5). 44 Medical Terminology: The Language of Health Care Physicians’ Specialty Fields of Medical Practice Specialty and Specialist Scope of Practice allergy and immunology diagnosis, treatment, and prevention of allergic aler-jē and imyū-nolō-jē diseases, including asthma, and diagnosis, management, and therapy of immunologic diseases, e.g., autoimmune disorders allergist/immunologist ANESTHESIA. anesthesiology comprehensive medical management and Anesthesia is a condition in anes-thē-zē-olō-jē anesthetic care before, during, and after which there is an absence surgery and long-term pain management and of sensation [an critical care related to cardiac and respiratory (without)/esthesio emergencies (sensation)/ia (condition)]. anesthesiologist The inhalation of various vapors to produce a sort of colon and rectal surgery diagnosis, medical care, and surgical treatment intoxication or stupefaction of conditions related to the small intestine, is an ancient practice. By colon, and rectum the 14th century, methods of inducing sleep for colon and rectal surgeon surgical operations included the inhalation of hemlock, dermatology medical and surgical treatment of disorders of mandrake, and lettuce. der-mă-tolō-jē the skin and its appendages, e.g., hair, nails, Other attempts to produce including cosmetic care anesthesia included the use dermatologist of snow and ice. Interest in chemistry at the end of the emergency medicine prehospital emergency medical care of acutely 18th century resulted in the ill or injured patients; most commonly rendered investigation of various in an emergency department of a hospital or a chemicals that could be free-standing urgent care facility used for inhalation anesthesia. Early anesthetics emergency physician included nitrous oxide, ether, and chloroform. family practice comprehensive general medical care of individuals of all ages and their families, with emphasis on disease prevention and health promotion family physician internal medicine nonsurgical care centered around prevention, diagnosis, and treatment of diseases of adults internist COMMON SUBSPECIALTIES OF INTERNAL MEDICINE cardiology diagnosis and management of conditions kar-de-olō-jē related to the heart and blood vessels (cardiovascular disease) cardiologist endocrinology diagnosis and management of diseases of the endō-kri-nolō-jē endocrine glands, e.g., diabetes, obesity, thyroid dysfunction endocrinologist Chapter 3 • Fields of Medical Practice 45 Specialty and Specialist Scope of Practice gastroenterology diagnosis and management of conditions related gastrō-en-ter-olō-jē to the digestive system gastroenterologist geriatric medicine diagnosis and medical management of conditions affecting the elderly; also a subspecialty of family practice geriatrician jer-ē-ă-trishŭn hematology diagnosis and treatment of blood disorders hē-mă-tolō-jē hematologist nephrology nonsurgical treatment of kidney disorders ne-frolō-jē nephrologist oncology treatment of tumors and cancer ong-kolō-jē oncologist rheumatology treatment of arthritis and related disorders rū-mă-tolō-jē rheumatologist medical genetics diagnosis, treatment, and prevention of genetic jĕ-netiks (inherited) disorders; includes research, laboratory testing, and counseling geneticist jĕ-neti-sist neurology nonsurgical treatment of diseases of the nervous nū-rolō-jē system neurologist SURGEON. The Greek word neurological surgery surgical and nonsurgical treatment of diseases chirurgeon of the nervous system and supportive (chiro, the hand; urgeon, to structures, including blood vessels work) refers to one who neurosurgeon works with the hands. The earliest conception of nuclear medicine use of radioactive substances to diagnose and surgery was that diseases treat disease; a dual specialty in other fields of an external nature were such as radiology, internal medicine, neurology, suitable for treatment by and cardiology is common manual operations, as opposed to internal nuclear medicine physician conditions that were treated obstetrics and gynecology with drugs, etc. The name surgeon has been in English (OB/GYN) since the 14th century. obstetrics care and treatment of mother and fetus There was no distinction ob-stetriks throughout pregnancy, childbirth, and between barbers and immediate postpartum period surgeons until 1745 when the barbers and surgeons of obstetrician London were separated and ob-stĕ-trishŭn given individual charters. 46 Medical Terminology: The Language of Health Care Specialty and Specialist Scope of Practice gynecology medical and surgical treatment of disorders of gı̄-nĕ-kolō-jē the female reproductive and urinary system gynecologist ophthalmology medical and surgical treatment of the eye, of-thal-molō-jē including vision care and services ophthalmologist orthopedic surgery medical, surgical, and rehabilitative treatment ōr-thō-pēdik of disorders of the musculoskeletal system, including the bones, joints, muscles, ligaments, tendons, and nerves orthopedic surgeon orthopedist (orthopaedist) otolaryngology medical and surgical treatment of diseases and ōtō-lar-ing-golō-jē disorders of the ear, nose, throat, and adjoining structures of the head and neck otolaryngologist ōtō-lar-ing-golō-jist ENT (ear, nose, throat) physician pathology study of disease emphasizing examination of pa-tholō-jē tissue for diagnosis, e.g., biopsy, autopsy pathologist pediatrics comprehensive medical care of infants, children, pē-dē-atriks and adolescents, with emphasis on disease prevention and healthful physical and mental development pediatrician physical medicine and treatment of patients suffering from rehabilitation physiatry neuromusculoskeletal disorders caused by fi-zı̄ă-trē illness or injury, e.g., stroke, spinal cord injury physiatrist fiz-ı̄ă-trist plastic surgery surgery for restoration, repair, or reconstruction of body structures, e.g., body contouring, skin grafting plastic surgeon preventive medicine medical care that focuses on prevention of disease and health maintenance; specialty areas include: aerospace medicine, occupational medicine, public health, and general preventive medicine psychiatry diagnosis, treatment, and prevention of mental, sı̄-kı̄ă-trē emotional, and behavioral disorders psychiatrist Chapter 3 • Fields of Medical Practice 47 Specialty and Specialist Scope of Practice radiology use of ionizing and nonionizing imaging rā-dē-olō-jē modalities, including x-ray, radionuclides, magnetic resonance, and ultrasound, to diagnose disease, or in therapies that involve imaging guidance; primary fields include diagnostic radiology, radiation oncology, and radiation physics radiologist surgery treatment of diseases and trauma requiring an operation;—subspecialty areas include vascular, pediatric, hand, and critical care surgery general surgeon thoracic surgery treatment of diseases, deformities, and trauma thō-rasik requiring an operation within the chest, including the heart and lungs thoracic surgeon urology surgical and nonsurgical treatment of the male yū-rolō-jē urinary and reproductive system and the female urinary system urologist Other Fields of Medical Practice Many other medical specialists are called doctors, even though they do not have an M.D. or D.O. degree. They have graduated from a college of podiatry, chiropractic, op- tometry, or dentistry and are licensed to practice. Because they commonly provide health care services in hospitals and/or medical clinics, you need a basic knowledge of their scope of practice. Degree Field of Practice

Scope of Practice doctor of chiropractic chiropractic treatment centered on manipulation medicine (D.C.) medicine of the spine to maintain function kı̄-rō-praktik and balance in the body chiropractor (chir/o  hand; prattein  to do) kı̄-rō-praktor doctor of dental oral surgery treatment of dental disorders surgery (D.D.S.) requiring surgery oral surgeon (or/o  mouth; dent/i  teeth) doctor of podiatric podiatry diagnosis and treatment (including medicine (D.P.M.) pō-dı̄ă-trē surgery) of disorders of the foot pō-dı̄ă-trik podiatrist doctor of optometry optometry diagnosis and nonsurgical (O.D.) op-tomĕ-trē treatment of the eye, including vision care and services optometrist op-tomĕ-trist 48 Medical Terminology: The Language of Health Care Degree Field of Practice Scope of Practice doctor of psychology psychology counsel of patients with mental (Psy.D. or Ph.D.) or emotional disorders sı̄-kolō-jist sı̄-kolō-jē clinical psychologist sı̄-kolō-jist Other Health Care Professions As a result of the major advances in health care technology, various licensed and non- licensed allied health professionals with specialized training and skill have emerged to meet the increasing needs of the population. They are integral to today’s health care team. The following is a list of professions for which formal training is available. acupuncturist massage therapist anesthesiologist assistant medical assistant art therapist medical coding specialist athletic trainer medical illustrator audiologist medical laboratory technician cardiovascular technologist medical technologist clinical exercise specialist medical transcriptionist clinical laboratory scientist medical unit coordinator (unit clerk/ cytogenetic technologist secretary or ward clerk/secretary) cytotechnologist mental health counselor dental assistant mobility specialist dental hygienist music therapist dental laboratory technologist nephrology technician diagnostic medical sonographer nuclear medicine technologist diagnostic molecular scientist nurse, licensed vocational or practical dialysis technician nurse, registered dietetic technician nurse anesthetist dietitian/nutritionist nurse assistant electrocardiography technician nurse midwife electroencephalographic technologist nurse practitioner electroneurodiagnostic technologist nutrition care technologist emergency medical technician occupational therapist fitness therapist occupational therapy assistant genetic counselor operating room technician geriatric home aide ophthalmic dispensing optician NURSE. gerontologist ophthalmic laboratory technician/ Derived from the health and fitness specialist technologist Latin word nutrix, a nurse, from nutrire, to health information administrator optician suckle or nourish, originally health information technician orthoptist described one who suckled histotechnician/histologic technician orthotist/prosthetist or cared for an infant, and home health aide paramedic by extension, now describes one who cares for any sick kinesiotherapy pathologist assistant or helpless person. marriage and family counselor/therapist perfusionist Chapter 3 • Fields of Medical Practice 49 pharmacist recreational therapist pharmacologist rehabilitation counselor pharmacy technician/assistant rehabilitation technologist phlebotomy technician/phlebotomist respiratory therapist physical therapist specialist in blood bank technology physical therapist assistant speech-language pathologist physician assistant speech therapist polysomnographic technologist surgeon assistant psychiatric technician surgical technologist radiation therapy technologist/ therapeutic recreation specialist radiation therapist veterinarian radiologic technologist/radiographer veterinary assistant Summary of Chapter 3 Acronyms/Abbreviations ABMS ............American Board of Medical Specialties D.O. .................Doctor of Osteopathic Medicine ACP .................American College of Physicians ENT.................ear, nose, throat ACS .................American College of Surgeons M.D. ................Doctor of Medicine AOA.................American Osteopathic Association OB/GYN.......obstetrics and gynecology D.C. .................Doctor of Chiropractic Medicine O.D. .................Doctor of Optometry D.D.S. ............Doctor of Dental Surgery Ph.D. ..............Doctor of Psychology D.P.M. ...........Doctor of Podiatric Medicine 50 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following words, draw a line or lines to separate prefixes, roots, combining forms, and suffixes. Then define the word according to the meaning of: Pprefix; Rroot; CFcombining form; Ssuffix. EXAMPLE psychiatry _______ / _______ R S psych/iatry R S DEFINITION: mind/treatment 1. oncology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 2. immunologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 3. otolaryngology _____________________ / _____________________ / _____________________ CF CF S DEFINITION: _________________________________________________________________ 4. optometry _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 5. gynecology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 6. pathology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 7. orthopedic _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ Chapter 3 • Fields of Medical Practice 51 8. urologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 9. neurology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 10. psychologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 11. osteopathy _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ 12. ophthalmologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 13. obstetric _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 14. anesthesiology _____________________ / _____________________ / _____________________ P CF S DEFINITION: _________________________________________________________________ 15. cardiology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 16. dermatology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 17. pediatrics _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 52 Medical Terminology: The Language of Health Care 18. endocrinologist _____________________ / _____________________ / _____________________ P CF S DEFINITION: _________________________________________________________________ 19. nephrologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 20. gastroenterology _____________________ / _____________________ / _____________________ CF CF S DEFINITION: _________________________________________________________________ 21. hematologist _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ Match the following specialists or specialties with the definition: 22. ________ emergency physician a. doctor for adults 23. ________ chiropractor b. treats foot disorders 24. ________ neurosurgeon c. provides emotional counsel 25. ________ physiatrist d. performs dental surgery 26. ________ radiologist e. operates on heart and lungs 27. ________ plastic surgeon f. interprets x-rays 28. ________ rheumatologist g. uses radioactive isotopes 29. ________ thoracic surgeon h. nonsurgical care of brain and spinal cord 30. ________ podiatrist i. treats disease of the mind 31. ________ oral surgeon j. cares for acutely ill 32. ________ psychiatrist k. general practice 33. ________ neurology l. performs brain surgery 34. ________ nuclear medicine m. specialty for treatment of the elderly 35. ________ internist n. performs reconstructive surgical repairs 36. ________ family practice o. treats arthritis Chapter 3 • Fields of Medical Practice 53 37. ________ psychologist p. rehabilitation specialist 38. ________ geriatrics q. manipulates the spine Write the full medical term for the following abbreviations: 39. OB/GYN ___________________________________________________________________ 40. D.D.S. _____________________________________________________________________ 41. ENT_______________________________________________________________________ 42. ABMS _____________________________________________________________________ 43. O.D. ______________________________________________________________________ 44. F.A.C.S. ___________________________________________________________________ 45. ACP _______________________________________________________________________ 46. D.C. _______________________________________________________________________ 47. D.P.M. ____________________________________________________________________ 48. D.O. ______________________________________________________________________ 49–53. From the following list, identify the five specialists who perform surgery: gynecologist cardiologist gastroenterologist neurologist otolaryngologist orthopaedist allergist rheumatologist nephrologist ophthalmologist geneticist endocrinologist internist pediatrician urologist Match the type of school with the degree it grants: 54. ________ dental a. Ph.D. 55. ________ graduate b. O.D. 56. ________ podiatric c. D.D.S. 57. ________ medical d. D.O. 58. ________ chiropractic e. D.P.M. 59. ________ optometric f. D.C. 60. ________ osteopathic g. M.D. Chapter 4 The Medical Record OBJECTIVES After completion of this chapter you will be able to Define basic terms and abbreviations used in documenting a history and physical Explain the concept of problem oriented medical record keeping and common format for documenting SOAP progress notes Identify common hospital records and patient care abbreviations Recognize types of diagnostic imaging modalities Define common terms related to disease Define common pharmacological terms Recognize abbreviations and symbols deemed error prone Define the symbols used in documenting a prescription or physician’s order Record military date and time Follow legal guidelines when making corrections to a medical record entry Explain the terms used in documenting a medical history and physical record Common Records Used in Documenting Care of a Patient To put your knowledge of medical terminology to practical use, you need to see how this language is used in everyday communication about patients. Learning the com- mon abbreviations, symbols, forms, and formats used in recording patient care will help you comprehend medical record documentation. HISTORY AND PHYSICAL CHART. The The record that serves as a cornerstone for patient care is the history and physical. It doc- word originates uments the patient’s medical history and findings from the physical examination. It is from the Latin usually the first document generated when a patient presents for care, most often charta, a kind of paper recorded at the time of a new patient visit (Fig. 4.1), or as part of a consultation (Fig. 4.2). made from papyrus. Charta Subjective information is obtained from the patient and documented in the patient came to mean any leaf or thin sheet of fine paper on history, starting with the chief complaint (the reason for seeking care) along with the his- which graphic illustrations tory of present illness (indicating duration and severity of the complaint) and any other were made. In medicine, the symptoms that the patient is experiencing. Information about the patient’s past medical chart most often refers to history, family history, social history, and occupational history is then noted. The history patient record is complete after documenting the patient’s answers to questions related to the review documentations. of systems, which is intended to uncover any other significant evidence of disease. 54 Chapter 4 • The Medical Record 55 Once subjective data have been recorded, the provider begins a physical examina- tion to obtain objective information, facts that can be seen or detected by testing. Signs, or objective evidence of disease, are documented, and selected diagnostic tests are per- formed or ordered when further evaluation is necessary. The impression, diagnosis, or assessment is made after evaluation of all subjective and objective data, including the results of the physical examination and diagnostic test findings. R/O (rule out) is the abbreviation used to indicate a differential diagno- sis when two or more possible diagnoses are in question. Further tests are then neces- sary to rule out or eliminate these possibilities and verify the final diagnosis. Final notations include the provider’s plan, also called a recommendation or dispo- sition, which outlines strategies designed to remedy the patient’s condition. Further documentation in the form of progress notes is made as care continues. Most often, physicians are required to submit a current history and physical before admitting a patient to the hospital. When the patient is to have surgery, this report is often called a “preoperative” history and physical (see Figure 4.6). Following are common terms and abbreviations used in documenting a history and physical examination. Abbreviation Meaning/Explanation H & P History and Physical documentation of patient history and physical examination findings Hx History record of subjective information regarding the patient’s personal medical history, including past injuries, illnesses, operations, defects, and habits subjective information information obtained from the patient including his or her personal perceptions CC Chief Complaint c/o complains of patient’s description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patient’s own words indicated within quotes For example: CC: left lower back pain; patient states, “I feel like I swallowed a stick and it got stuck in my back” HPI (PI) History of Present Illness (Present Illness) amplification of the chief complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad it is) For example: HPI: the patient has had left lower back pain for the past 2 weeks since slipping on a rug and landing on her left side; the pain worsens after sitting upright for any extended period but gradually subsides after lying in a supine position 56 Medical Terminology: The Language of Health Care Abbreviation Meaning/Explanation Sx symptom subjective evidence (from the patient) that indicates an abnormality PMH (PH) Past Medical History (Past History) a record of information about the patient’s past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies UCHD usual childhood diseases an abbreviation used to note that the patient had the “usual” or commonly contracted illnesses during childhood (e.g., measles, chickenpox, mumps) NKA no known allergies NKDA no known drug allergies FH Family History state of health of immediate family members A & W alive and well L & W living and well For example: FH: father, age 92, L & W; mother, age 91, died, stroke SH Social History a record of the patient’s recreational interests, hobbies, and use of tobacco and drugs, including alcohol For example: SH: plays tennis twice/wk; tobacco—none; alcohol—drinks 1–2 beers per day OH Occupational History a record of work habits that may involve work- related risks For example: OH: the patient has been employed as a heavy equipment operator for the past 6 years ROS (SR) Review Of Systems (Systems Review) a documentation of the patient’s response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned) Chapter 4 • The Medical Record 57 Abbreviation Meaning/Explanation objective information facts and observations noted PE (Px) Physical Examination

documentation of a physical examination of a patient, including notations of positive and negative objective findings HEENT head, eyes, ears, nose, throat NAD no acute distress, no appreciable disease PERRLA pupils equal, round, and reactive to light and accommodation WNL within normal limits Dx Diagnosis IMP Impression A Assessment identification of a disease or condition after evaluation of the patient’s history, symptoms, signs, and results of laboratory tests and diagnostic procedures R/O Rule Out used to indicate a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed For example: Diagnosis: R/O pancreatitis R/O gastroenteritis this indicates that either of these two diagnoses is suspected and further testing is required to verify or eliminate one or both possibilities P Plan (also referred to as recommendation or disposition) outline of the treatment plan designed to remedy the patient’s condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies 58 Medical Terminology: The Language of Health Care H&P Hx CC HPI c/o UCHD PMH NKDA FH L&W SH OH ROS PE NAD PERRLA A IMP DX P Figure 4.1 History and physical. Chapter 4 • The Medical Record 59 Figure 4.2 History and physical documented as part of a consultation for a patient with an upper respiratory infection. 60 Medical Terminology: The Language of Health Care PROBLEM-ORIENTED MEDICAL RECORD The problem-oriented medical record (POMR) is a method of record keeping intro- duced in the 1960s. It is a highly organized approach that encourages a precise method of documenting the logical thought processes of health care professionals. Data are organized so that information can be accessed readily at a glance, with a focus on the patient’s health problem. The use of POMR and its adaptations has grown in many areas of medicine. The approach is often used in medical schools, hospitals, clinics, and private practices (Fig. 4.3). The central concept is a medical record in which all information is linked to spe- cific problems. The record has four sections: • Database patient’s history, physical examinations, and diagnostic test results; from the database, the problem is identified and a plan is developed to address it • Problem list directory of the patient’s problems; each problem is listed and often assigned a number; problems include 1. a specific diagnosis 2. a sign or symptom 3. an abnormal diagnostic test result 4. any other problem that may influence health or well-being Once identified, each problem is evaluated, and a plan for treating it is written. When a problem is resolved, a notation is made to show its resolution, but the problem remains on the summary list. The original problem list is maintained in the record so that per- sonnel can easily orient themselves to the patient’s prior medical history. • Initial plan the strategy employed to resolve each problem is listed. There are three subdivisions: 1. Diagnostic plan orders are given for specific diagnostic testing to confirm suspicions 2. Therapeutic plan goals for therapy are specified 3. Patient education instructions communicated to the patient are notated Database S Follow-up O Problems Progress A Notes P Plans Orders Patient Therapies education Meds Figure 4.3 Problem-oriented medical record (POMR) diagram. Chapter 4 • The Medical Record 61 • Progress notes documentations of the progress concerning each problem are organized using the SOAP format (Figs. 4.4 and 4.5). S—subjective that which the patient describes O—objective observable information, e.g., test results, blood pressure readings A—assessment patient’s progress and evaluation of the plan’s effectiveness (note: any new problem identified is added to the problem list, and a separate plan for its treatment is recorded) P—plan decision to proceed or alter the plan strategy The SOAP method of documenting a patient’s progress appears to be the most popular adaptation to the entire system, and it is commonly utilized with or without assigning a number to the problem. Subjective WNL Objective Assessment (Impression, Diagnosis) Rule out Plan (Disposition, Recommendation) Figure 4.4 Progress note using SOAP format, representing follow-up visit after history and physical recorded in Figure 4.1. 62 Medical Terminology: The Language of Health Care Figure 4.5 SOAP progress notes following consultation of a patient with an upper respiratory infection (Fig. 4.2). Chapter 4 • The Medical Record 63 HOSPITAL RECORDS The history and physical is usually the first document entered into the patient’s hospi- tal record on admission. Physician’s orders list the directives for care prescribed by the doctor attending the patient. The nurse’s notes and physician’s progress notes chronicle the care throughout the patient’s stay, and ancillary reports note the various procedures and therapies, including diagnostic tests and pathology reports. In a difficult case, a spe- cialist may be called in by the attending physician, and a consultation report is filed. If a surgical remedy is indicated, a narrative operative report is required of the primary surgeon. The anesthesiologist, who is in charge of life support during surgery, must file the anesthesiologist’s report. The final document, which is recorded at the time of dis- charge from the hospital, is the discharge summary. The following are descriptions of common forms used in documenting the care of a hospital patient. history and physical documentation of the patient’s recent medical history and results of a physical examination required before hospital admission (e.g., before admission for surgery) (Fig. 4.6) consent form document signed by the patient or legal guardian giving permission for medical or surgical care informed consent consent of a patient after being informed of the risks and benefits of a procedure and alternatives—often required by law when a reasonable risk is involved (e.g., surgery) physician’s orders a record of all orders directed by the attending physician (Fig. 4.7) diagnostic tests/laboratory records of results of various tests and procedures reports used in evaluating and treating a patient (e.g., laboratory tests, x-rays) (Fig. 4.8) nurse’s notes documentation of patient care by the nursing staff (note: flow sheets and graphs are often used to display recordings of vital signs and other monitored procedures) (Fig. 4.9) physician’s progress notes physician’s daily account of patient’s response to treatment, including results of tests, assessment, and future treatment plans (Fig. 4.10) ancillary reports miscellaneous records of procedures or therapies provided during a patient’s care (e.g., physical therapy, respiratory therapy) consultation report report filed by a specialist asked by the attending physician to evaluate a difficult case; note: a patient may also see another physician in consultation as an outpatient (in a medical office or clinic) 64 Medical Terminology: The Language of Health Care operative report (op report) surgeon’s detailed account of the operation including the method of incision, technique, instruments used, types of sutures, method of closure, and the patient’s responses during the procedure and at the time of transfer to recovery (Fig. 4.11) pathology report report of the findings of a pathologist after the study of tissue (e.g., a biopsy) (Fig. 4.12) anesthesiologist’s report anesthesiologist’s or anesthetist’s report of the details of anesthesia during surgery, including the drugs used, dose and time given, and records indicating monitoring of the patient’s vital status throughout the procedure discharge summary, four terms that describe an outline summary of clinical resume, the patient’s hospital care, including date of clinical summary, admission, diagnosis, course of treatment, final discharge abstract diagnosis, and date of discharge (Fig. 4.13) The sample medical records in Figures 4.6 to 4.13 chronicle the hospital care of Carleen Perron, a 28-year-old woman who was seen in consultation by Dr. Patrick Rod- den, an ENT specialist, who recommended a surgical remedy for the repeated infec- tions she has had over the past 6 months. Chapter 4 • The Medical Record 65 Figure 4.6 Preoperative history and physical. A documentation of a patient’s presurgical history and physical, dic- tated and transcribed for the hospital record before admission. 66 Medical Terminology: The Language of Health Care Figure 4.6 Continued. Chapter 4 • The Medical Record 67 Figure 4.7 Preoperative surgical admitting orders. A form completed by the admitting physician that is forwarded to the hos- pital before the date of surgery. 68 Medical Terminology: The Language of Health Care Figure 4.7 Continued. Physician’s orders. Orders written by the anesthesiologist and surgeon and noted by the nurs- ing staff during the patient’s surgical care. Chapter 4 • The Medical Record 69 Figure 4.7 Continued. 70 Medical Terminology: The Language of Health Care Figure 4.7 Continued. Chapter 4 • The Medical Record 71 Figure 4.8 Diagnostic tests/laboratory reports. Reporting forms with results of blood and urine studies ordered before surgery. 72 Medical Terminology: The Language of Health Care Figure 4.8 Continued. Chapter 4 • The Medical Record 73 Figure 4.9 Nurse’s notes. A recording by the nursing staff of the patient’s progress made during general care and treat- ment. 74 Medical Terminology: The Language of Health Care Figure 4.9 Continued. Vital signs record. A chart recording of the patient’s vital signs documented by the nursing staff. Chapter 4 • The Medical Record 75 Figure 4.10 Physician’s progress notes. Physician’s notations of the patient’s progress throughout care. 76 Medical Terminology: The Language of Health Care Figure 4.11 Operative report. Surgeon’s account of a surgical procedure. Chapter 4 • The Medical Record 77 Figure 4.12 Pathology report. 78 Medical Terminology: The Language of Health Care Figure 4.13 Discharge summary (abstract). Final report documented at the time of discharge that includes the diagnostic record and di- agnosis-related group (DRG)—the number assigned to the individual hospitalization based on the patient’s diagnoses, complications, age, etc.—and that translates to a fixed dollar amount payable from a third-party payer, e.g., Medicare. Chapter 4 • The Medical Record 79 Medical Record Abbreviations Following are common medical record abbreviations used in patient care documenta- tions. They represent the “acceptable” terms used extensively throughout this text. It is important to note that individual medical facilities provide their own list of acceptable terms and abbreviations that may differ from site to site. Memorize the terms and ab- breviations from this list, and plan on adapting them to the variations you encounter in the workplace. ERROR-PRONE ABBREVIATIONS AND SYMBOLS Medical errors caused by illegible entries and misinterpretations of medical ab- breviations and symbols have led health care agencies, such as the Joint Commis- sion on Accreditation of Healthcare Organizations (JCAHO), to require that med- ical facilities publish lists of authorized abbreviations for use by all personnel, including a list of those that are unacceptable. In this text, the abbreviations and symbols that have been identified as error prone are bolded red. Depending on the medical facility, their use may or may not be deemed acceptable; therefore, it is very important to study them, too, so that you can properly interpret their meaning if they have been used in a medical record. Abbreviation Meaning MEDICAL CARE FACILITIES CCU coronary (cardiac) care unit ECU emergency care unit ER emergency room ICU intensive care unit IP inpatient (a registered bed patient) OP outpatient OR operating room PACU postanesthetic care unit PAR postanesthetic recovery post-op/postop postoperative (after surgery) pre-op/preop preoperative (before surgery) RTC return to clinic RTO return to office PATIENT CARE BRP bathroom privileges CP chest pain DC, D/C discharge, discontinue ETOH ethyl alcohol 80 Medical Terminology: The Language of Health Care Abbreviation Meaning L left R right pt patient RRR regular rate and rhythm SOB shortness of breath Tr treatment Tx treatment or traction VS vital signs T temperature P pulse R respiration BP blood pressure Ht height Wt weight WDWN well-developed and well-nourished y.o. year old # number or pound: if before the numeral, it means number (e.g., #2  number two); if after the nu- meral, it means pound (e.g., 150#  150 pounds)  female  male ° degree or hour ↑ increased ↓ decreased none or negative standing sitting lying Chapter 4 • The Medical Record 81 Common Diagnostic Tests and Procedures Diagnostic tests and procedures are an integral part of patient care. Analyses of urine, stool, and blood specimens are recorded among the earliest efforts to under- stand conditions of disease. The advance of technology has led to the development of a myriad of highly sophisticated laboratory testing, examples of which will be fea- tured in this text as they pertain to a specific body system. The two most common laboratory tests performed as part

of a general health inquiry or to rule out a par- ticular condition are the complete blood count, or CBC (see Fig. 4.8, Hematology, and Fig. 8.6 in Chapter 8) and urinalysis, or UA (see Fig. 4.8 Continued and Fig. 15.9 in Chapter 15). It is valuable for health care professionals to recognize common diagnostic tests and procedures and the types of technology used to produce them. Diagnostic Imaging Modalities Methods of diagnostic imaging have rapidly expanded in the years since the discovery of x-rays by Wilhelm Roentgen in 1895. Radiation from x-rays, which pass through the body to produce images of the skeleton and other body structures, was found to be ion- izing, a process that changes the electrical charge of atoms with a possible effect on body cells. Overexposure to ionizing radiation can have harmful side effects, e.g., can- cer; however, technological advances have produced images requiring significantly lower doses of radiation to minimize risk. Further advancement has led to the discovery and use of other imaging modalities (techniques) under the umbrella of the medical specialty known as radiology. Com- mon ionizing modalities include radiography (x-ray), computed tomography, and nu- clear medicine. Common nonionizing modalities that present no apparent risk include magnetic resonance imaging and sonography. IONIZING IMAGING Radiography (X-ray) Radiography is a modality using x-rays (ionizing radiation) to provide images of the body’s anatomy to diagnose a condition or impairment. An image is produced when a small amount of radiation is passed through the body to expose a sensitive film. The image is called a radiograph. (Note: -graph is the preferred suffix used in radiology to refer to an x-ray record. It is taken by a radiologic technologist [also known as a radi- ographer] and interpreted or read by a radiologist, a physician specializing in the study of radiology.) (See Figure 4.14.) Computed Tomography or Computed Axial Tomography Computed tomography (CT), also known as computed axial tomography (CAT), is a ra- diologic procedure that uses a machine (called a scanner) to examine a body site by taking a series of cross-sectional (tomographic) x-ray films in a full circle rotation. A computer then calculates and converts the rates of absorption and density of the x-rays into a three-dimensional picture on a screen (Fig. 4.15). Nuclear Medicine Imaging or Radionuclide Organ Imaging This diagnostic imaging technique uses an injected or ingested radioactive isotope, also called a radionuclide (a chemical that has been tagged with radioactive com- pounds that emit gamma rays). A gamma camera detects and produces an image of the 82 Medical Terminology: The Language of Health Care Figure 4.14 The first published x-ray image of the hand and signet ring of Professor Roentgen’s wife. It was produced December 22, 1895. X-ray source moving around a stationary patient Patient X-ray detector moving around the patient A B Figure 4.15 A. Principles of computed tomography (CT). Inset, CT showing multiple open fractures (arrows) of skull. B. CT imaging process. Chapter 4 • The Medical Record 83 Figure 4.16 Nuclear medicine image. A. Gamma camera used to produce image. B. Radionuclide whole-body bone scan. 84 Medical Terminology: The Language of Health Care distribution of the gamma rays in the body. This is useful in determining the size, shape, location, and function of body organs such as the brain, lungs, bones, and heart (Fig. 4.16). NONIONIZING IMAGING Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is a nonionizing imaging technique using mag- netic fields and radiofrequency waves to visualize anatomical structures within the body. A large magnet surrounds the patient as a scanner subjects the body to a radio signal that temporarily alters the alignment of the hydrogen atoms in the patient’s tis- sue. As the radiowave signal is turned off, the atoms realign and the energy produced is absorbed by detectors and interpreted using computers to provide detailed anatom- ical images of the body part. MRI is particularly useful in examining soft tissues, joints, and the brain and spinal cord (Fig. 4.17). Magnetic resonance angiography (MRA) applies MR technology in the study of blood flow (see Diagnostic Tests and Procedures in Chapters 7 and 10). Sonography Sonography (diagnostic ultrasound)[U/S or US] is the use of high-frequency sound waves (ultrasound) to visualize body tissues. Ultrasound waves sent through a scan- ning device, called a transducer, are reflected off structures within the body and ana- lyzed by a computer to produce moving images on a monitor. Sonography is used to examine many parts of the body, including the abdomen, male and female reproduc- tive organs, thyroid and parathyroid glands, and the cardiovascular system (Fig. 4.18). USE OF CONTRAST Some imaging procedures require the internal administration of a contrast medium to enhance the visualization of anatomical structures. There are many different kinds of contrast media, including barium, iodinated compounds, gasses (air, carbon dioxide), and other chemicals known to increase visual clarity. Depending on the medium, it may be injected, swallowed, or introduced through an enema or catheter. Compare Figures 15.5 and 15.8 (x-rays of the urinary tract) in Chapter 15, which show images taken with and without contrast. Chapter 4 • The Medical Record 85 Radiowave detector Radiowave pulses Magnet A Figure 4.17 A. Principles of magnetic resonance imaging (MRI). Patient is positioned within a magnetic field as radiowave sig- nals are conducted through the selected body part. Energy is absorbed by tissues and then released. A computer processes the re- leased energy and formulates the image. Inset, MRI of the knee (lateral view) identifying a torn meniscus. B. MRI unit. 86 Medical Terminology: The Language of Health Care Transducer Skin surface Internal Sound organ waves or fetus Energy in the form of sound waves is reflected off internal organs or, during pregnancy, the fetus and transformed into an image on a A B TV-type monitor. Figure 4.18 A. Principles of sonography. B. Obstetric sonography. Common Medical Record Terms Related to Disease NORMAL. The The following terms related to disease are common in medical records. Learn them as word stems from a foundation on which you will build as your vocabulary expands. the Latin word normalis, referring to that which is made according to a carpenter’s square, from Term Meaning norma, a carpenter’s square; thus, normal refers to acute sharp; having intense, often severe symptoms and a rule or pattern. Abnormal ă-kyūt a short course is out of line, not conforming chronic a condition developing slowly and persisting over to the rule of pattern. kronı̄k time benign mild or noncancerous BENIGN bi-nı̄n VERSUS MALIGNANT. malignant harmful or cancerous These antonyms, stemming mă-lignănt from the Latin words benignus, meaning kind degeneration gradual deterioration of normal cells and body origin, and malignus, dē-jen-er-āshŭn functions meaning bad origin, were first used to refer to degenerative disease any disease in which there is deterioration of conditions that were kind or structure or function of tissue mild as opposed to those diagnosis determination of the presence of a disease based on that were bad or severe. dı̄ -ag-nōsis an evaluation of symptoms, signs, and test findings Galen is credited for using (results) (dia  through; gnosis  knowing) the terms in reference to tumors. A tumor is etiology cause of a disease (etio  cause) considered malignant if ē-tē-olō-jē cancerous and benign if not. exacerbation increase in severity of a disease with aggravation eg-zas-er-bāshŭn of symptoms (ex  out; acerbo  harsh) remission a period in which symptoms and signs stop or rē-mishŭn abate Chapter 4 • The Medical Record 87 Term Meaning febrile relating to a fever (elevated temperature) FEBRILE. Febrile febrı̄ l is derived from the Latin febris, gross large; visible to the naked eye meaning “I am warm.” In idiopathic a condition occurring without a clearly identified the ancient world, fever was idē-ō-pathik cause (idio  one’s own) considered a favorable symptom, and the origin of localized limited to a definite area or part the word is associated with lōkăl-ı̄zd February (the month for cleansing or purifying). systemic relating to the whole body rather than only a part Before the clinical sis-temik thermometer was developed, the method of malaise a feeling of unwellness, often the first indication of estimating fever was to lay mă-lāz illness the hand on the skin. marked significant equivocal vague, questionable ē-kwı̄vō-kl morbidity sick; a state of disease mor-bidi-tē morbidity rate the number of cases of a disease in a given year; the ratio of sick to well individuals in a given population mortality the state of being subject to death mor-tali-tē mortality rate death rate; ratio of total number of deaths to total number in a given population prognosis foreknowledge; prediction of the likely outcome of prog-nōsis a disease based on the general health status of the patient along with knowledge of the usual course of the disease progressive the advance of a condition as signs and symptoms prō-gresiv increase in severity prophylaxis a process or measure that prevents disease prō-fi-laksis (pro  before; phylassein  to guard) recurrent to occur again; describes a return of symptoms rē-kŭrent and signs after a period of quiescence (rest or inactivity) sequela a disorder or condition after, and usually resulting sē-kwelă from, a previous disease or injury sign a mark; objective evidence of disease that can be seen or verified by an examiner symptom occurrence; subjective evidence of disease that is simptŏm perceived by the patient and often noted in his or her own words syndrome a running together; combination of symptoms and sindrōm signs that give a distinct clinical picture indicating a particular condition or disease, e.g., menopausal syndrome 88 Medical Terminology: The Language of Health Care Term Meaning noncontributory not involved in bringing on the condition or result unremarkable not significant or worthy of noting Pharmaceutical Abbreviations and Symbols Pharmaceutical abbreviations and symbols are frequently used in documenting pa- tient care. They are found throughout the medical record. Efficient medical record keeping and effective communication among health care workers depend on knowl- edge of commonly used pharmaceutical abbreviations and symbols. UNITS OF MEASURE The following are common metric and apothecary units of measurement. Consult your medical dictionary for a complete listing of units of measurement and conversion formulas. Metric System Metric is the most commonly used system of measurement in health care. It is a deci- mal system based on the following units. meter (m) length 39.37 inches liter (L) volume 1.0567 U.S. quarts gram (g or gm) weight 15.432 grains Apothecary System The apothecary system is an outdated method of liquid and weight measure used by the earliest chemists and pharmacists. The liquid measure was based on one drop. The weight measure was based on one grain of wheat. Although the small apothecary measures are rarely used, the larger ones, e.g., fluid ounces, are still common. DRUG. The Middle English Common Abbreviations and Symbols drogge or Abbreviation Meaning drugge is derived from the Old French drogue, all METRIC meaning drug. Earlier origin is uncertain, possibly either cc cubic centimeter (1 cc  1 mL) a Teutonic root meaning dry cm centimeter (2.5 cm  1 inch) or the Persian droa meaning odor because many drugs g or gm gram had a strong odor. Although the ancients listed the use of kg kilogram [1,000 grams (2.2 pounds)] various medicines, the term L liter drug did not appear until the end of the medieval mg milligram [one-thousandth (0.001) of a gram] period. The word druggist did not appear until the ml, mL milliliter [one-thousandth (0.001) of a liter] 16th century. mm millimeter [one-thousandth (0.001) of a meter] cu mm cubic millimeter Chapter 4 • The Medical Record 89 Abbreviation Meaning APOTHECARY fl oz fluid ounce gr grain gt drop (L. gutta  drop) gtt drops dr dram (1/8 ounce) oz ounce lb or # pound (16 ounces) qt quart (32 ounces) MEDICATION ADMINISTRATION Prescribed medications can be administered to patients in various ways, depending on the indication for the drug and the status of the patient. The following is an overview of forms of drugs and routes of administration, including abbreviations and symbols. Drug Form Route of Administration SOLID AND SEMISOLID FORMS tablet (tab) oral [per os (p.o.)] by mouth capsule (cap) sublingual (SL) under the tongue buccal in the cheek suppository (suppos) vaginal [per vagina (PV)] inserted in vagina rectal [per rectum (PR)] inserted in rectum LIQUID FORMS fluid inhalation

inhaled through nose or mouth [e.g., aerosol (spray) or neblizer (device used to produce a fine spray or mist, often in a metered dose)] parenteral by injection (Fig. 4.19) intradermal (ID) within the skin intramuscular (IM) within the muscle intravenous (IV) within the vein subcutaneous (Sub-Q, SC, SQ) under the skin cream, lotion, topical applied to the ointment surface of the skin other delivery transdermal absorption of a drug systems through unbroken skin implant a drug reservoir imbedded in the body to provide continual infusion of a medication (see Chapter 11, Fig. 11.9) 90 Medical Terminology: The Language of Health Care Intramuscular Subcutaneous Muscle Vein Intradermal Intravenous Figure 4.19 Parenteral drug administration. The Prescription Rx. The symbol found at the A prescription is a written direction by a physician for dispensing or administering a beginning of a medication to a patient. It is an order to supply a named patient with a particular drug prescription stands for of a specific strength and quantity along with specific instructions for administration. recipe. The cross on the tail of the Rx incorporates the The prescription is a legal document that must be written in a specific format (Fig. 4.20). astrological sign of Jupiter, which has no connection DRUG NAMES with the word recipe. The sign of Jupiter was placed at The chemical name is assigned to a drug in the laboratory at the time it is invented. It the top of a formula to is the formula for the drug, which is written exactly according to its chemical struc- appease the chief Roman ture. The generic name is the official, nonproprietary name given a drug. The trade or god so that the compound brand is the manufacturer’s name for a drug. For example: might act favorably. The period during the chemical name 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1H-pyra- ascendancy of the planet zolo[4,3-d]pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]- Jupiter was considered a favorable time for the 4-methylpiperazine citrate collection of herbs and the generic name sildenafil preparation of medicines. trade or brand Viagra (Pfizer Pharmaceutical Company) Chapter 4 • The Medical Record 91 Figure 4.20 Sample prescription. PRESCRIPTION ABBREVIATIONS Many Latin abbreviations and symbols are commonly used in prescription writing as well as in physicians’ orders. Being familiar with these symbols makes it possible to read a prescription or physician’s order. Historically, prescriptions were written in Latin. The words were abbreviated for convenience. For example, quater in die, Latin for four times a day, is abbreviated q.i.d. The periods were included to indicate the abbreviation of three words; if not carefully documented, however, they can be interpreted with drastic implications. For example, the period in q.d (meaning once a day) can be misinterpreted as q.i.d (four times a day) when handwritten. For the purpose of proper recognition, the periods were included in the abbreviations in this text, but the trend is to discourage their use, especially in writing, because they can be misinterpreted. In practice, you will find variations in- cluding or excluding the periods and the use of uppercase instead of lowercase letters, e.g., QID versus qid. Roman numerals were used exclusively in the early days and are still used today; however, most pharmacy organizations now promote the use of Arabic numerals only. 92 Medical Terminology: The Language of Health Care Error-Prone Abbreviations and Symbols Listed is a sampling of abbreviations and symbols deemed most error prone, including the risk for misin- terpretation and preferred use. Error-Prone Abbreviation Meaning Risk Preferred Use q.d every day mistaken for q.i.d. when spell out “daily” the period after the “q” is sloppily written to look like an “i” q.o.d. every other day mistaken for q.d when the spell out “every other “o” is mistaken for a period day” DC, D/C discharge, when used to mean “dis- spell out “discon- discontinue charge,” mistaken for tinue” or “discontinue” when “discharge” followed by medications prescribed at the time of discharge AS, AD, AU left ear, right ear, mistaken for each other spell out both ears OS, OD, OU left eye, right eye, mistaken for each other spell out both eyes SC or SQ subcutaneous mistaken for SL spell out “subcuta- (sublingual) or “5 every” neously” or use Sub-Q ,  greater than, mistaken for each other spell out less than Chapter 4 • The Medical Record 93 Common Abbreviations and Symbols DEXTER AND SINISTER. Abbreviation Meaning Latina Dexter is Latin for right, and sinister is Latin for TIME AND FREQUENCY left. The origin of these terms, however, is earlier ā before ante than ancient Rome. Sun a.c. before meals ante cibum worshippers facing the morning sun had the south a.m. before noon ante meridiem on their right hand. The Sanskrit word for south is b.i.d. twice a day bis in die dekkan, allied to dhu, d day shining; thus, the right hand was the south or warm h hour hora shining hand. The left hand h.s. at hour of sleep (bedtime) hora somni was the north or cold hand. Therefore, dexterity or right- noc. night noctis handedness was skill, whereas sinister was p̄ after post ill-omened. Among the p.c. after meals post cibum Romans, sinisteritas (left- handedness) meant p.m. after noon post meridiem awkwardness. p.r.n. as needed pro re nata q every quaque q d every day quaque die q h every hour quaque hora q 2 h every 2 hours q.i.d. four times a day quater in die q.o.d. every other day quaque altera die STAT immediately statim t.i.d. three times a day ter in die wk week yr year MISCELLANEOUS AD right ear auris dextra AS left ear auris sinistra AU both ears aures unitas ad lib. as desired ad libitum amt amount aq water aqua B bilateral C Celsius, centigrade c̄ with cum 94 Medical Terminology: The Language of Health Care Abbreviation Meaning Latina F Fahrenheit m murmur NPO nothing by mouth non per os OD right eye oculus dexter OS left eye oculus sinister OU both eyes oculi unitas per by or through p.o. by mouth per os PR through rectum per rectum PV through vagina per vagina q.n.s. quantity not sufficient q.s. quantity sufficient Rx recipe; prescription Sig: label; instruction to the patient signa s̄ without sine ss̄ one-half semis w.a. while awake  times or for [e.g.,  6 (six times),  2 d (for 2 days)] > greater than < less than one (modified lowercase Roman numeral i) two (modified lowercase Roman numeral ii) three (modified lowercase Roman numeral iii) four (modified lowercase Roman numeral iv) I, II, III, IV, V, uppercase Roman numerals 1–10 (Note: Arabic numerals are VI, VII, VIII, IX, X preferred) aOriginal Latin given when it is deemed helpful. Chapter 4 • The Medical Record 95 Recording Date and Time The date and time are usually required in entries in a medical record. Always include the month, day of the month, and the year (e.g., 12/25/xx); sometimes eight digits are required (e.g., 01/08/20xx). Often military time is used (Fig. 4.21). Standard Military Standard Military 1:00 a.m. 0100 zero one hundred 1:00 p.m. 1300 thirteen hundred 2:00 a.m. 0200 zero two hundred 2:00 p.m. 1400 fourteen hundred 2:15 a.m. 0215 zero two fifteen 3:00 p.m. 1500 fifteen hundred 3:00 a.m. 0300 zero three hundred 4:00 p.m. 1600 sixteen hundred 4:00 a.m. 0400 zero four hundred 5:00 p.m. 1700 seventeen hundred 4:30 a.m. 0430 zero four thirty 6:00 p.m. 1800 eighteen hundred 5:00 a.m. 0500 zero five hundred 7:00 p.m. 1900 nineteen hundred 6:00 a.m. 0600 zero six hundred 8:00 p.m. 2000 twenty hundred 7:00 a.m. 0700 zero seven hundred 9:00 p.m. 2100 twenty-one hundred 8:00 a.m. 0800 zero eight hundred 10:00 p.m. 2200 twenty-two hundred 9:00 a.m. 0900 zero nine hundred 11:00 p.m. 2300 twenty-three hundred 10:00 a.m. 1000 ten hundred 12:00 a.m. 2400 twenty-four 11:00 a.m. 1100 eleven hundred (midnight) hundred hours 12:00 p.m. 1200 twelve hundred hours (noon) 2400 2300 1300 2200 1400 2100 1500 2000 1600 1900 1700 1800 Figure 4.21 Military and standard time. 96 Medical Terminology: The Language of Health Care Regulations and Legal Considerations Medical record documentations are made by physicians caring for the patient as well as other authorized health care professionals involved with care. State, federal, and private accrediting agencies, e.g., the Joint Commission on Ac- creditation of Healthcare Organizations (JCAHO), provide specific guidelines that reg- ulate how medical records are kept, including proper format for all forms, use of ap- propriate terminology and accepted abbreviations, protocol for personnel having access to records, and responsibilities for documentation. Corrections Sometimes mistakes are made when making an entry in a medical record. Careful clar- ification of the error is essential. If a mistake is made in a handwritten entry, it should be identified by drawing a single line through it, and the correction written in the mar- gin above or immediately after. Include the date, the abbreviation “corr.,” and the ini- tials of the person making the correction. The use of correction fluid, e.g., Wite-Out, is forbidden! The medical record often becomes evidence in medical malpractice cases. Obliter- ations and signs of possible tampering can be construed as trying to withhold infor- mation or covering up negligent wrongdoing. Complete and accurate record keeping is your best defense against any possible legal action (Fig. 4.22). Wrong Right Figure 4.22 Proper correction of a medical record. Chapter 4 • The Medical Record 97 PRACTICE EXERCISES Write the full medical term for the following abbreviations and symbols, and put an asterisk (*) next to those that are error prone: 1. CC ________________________________________________________________________ 2. OH ________________________________________________________________________ 3. PR ________________________________________________________________________ 4. BRP ______________________________________________________________________ 5. PACU _____________________________________________________________________ 6. PH ________________________________________________________________________ 7. D/C _______________________________________________________________________ 8. Sig: _______________________________________________________________________ 9. ER ________________________________________________________________________ 10. ICU _______________________________________________________________________ 11. R/O _______________________________________________________________________ 12. NPO ______________________________________________________________________ 13. L&W ______________________________________________________________________ 14. BP ________________________________________________________________________ 15. AU ________________________________________________________________________ 16. Sx ________________________________________________________________________ 17. VS ________________________________________________________________________ 18. ROS ______________________________________________________________________ 19. pt _________________________________________________________________________ 20. OD _______________________________________________________________________ 21. Sub-Q _____________________________________________________________________ 22. H&P ______________________________________________________________________ 23. Tx ________________________________________________________________________ 24. Dx ________________________________________________________________________ 25. HPI _______________________________________________________________________ 98 Medical Terminology: The Language of Health Care 26.  _________________________________________________________________________ 27. ↓ _________________________________________________________________________ Match the following terms with their meanings: 28. ________ febrile a. period in which symptoms stop 29. ________ syndrome b. probable outcome of a disease 30. ________ chronic c. name of a disease based on history, exam, and testing 31. ________ remission d. elevated temperature 32. ________ etiology e. set of symptoms characteristic of a par- ticular disease or condition 33. ________ malignant f. increase in severity with aggravation of symptoms 34. ________ prognosis g. developing slowly over time 35. ________ diagnosis h. limited to a definite area or part 36. ________ exacerbation i. cancerous 37. ________ localized j. the study of the cause of a disease Match the following definitions with their abbreviation or symbol: 38. ________ route of oral medications a. pre-op 39. ________ place for surgery b. prn 40. ________ as desired c.parenteral 41. ________ progress note d. po 42. ________ after surgery e. STAT 43. ________ pound f. ad lib 44. ________ as needed g. post op 45. ________ by injection h. OR 46. ________ before surgery i. SOAP 47. ________ immediately j. # Write the meaning for the following pharmaceutical phrases: 48. VS q h  4 h, then q 2 h ____________________________________________________ 49. po qid pc hs _____________________________________________________________ 50. aspirin (ASA) gr ss _______________________________________________________ Chapter 4 • The Medical Record 99 51. 650 mg po q 4 h prn temp 101° ____________________________________________ 52. suppos PR q noc prn _____________________________________________________ 53. gt OU tid  7 d __________________________________________________________ 54. cap STAT, then q 6 h __________________________________________________ Write the standard pharmaceutical abbreviations for the following: 55. one tablet by mouth three times a day for 7 days ___________________________________________________________________________ 56. one suppository in the vagina at bedtime ___________________________________________________________________________ 57. five milliliters by mouth four times a day ___________________________________________________________________________ 58. one or two by mouth every 3 to 4 hours as needed ___________________________________________________________________________ 59. two drops in left ear every 3 hours ___________________________________________________________________________ 60. one capsule by mouth two times a day, morning and evening ___________________________________________________________________________ 61. two by mouth immediately, then one by mouth every 6 hours ___________________________________________________________________________ 62. thirty milligrams by mouth at bedtime as needed ___________________________________________________________________________ Give the military time for the following: 63. 1:00 a.m. 64. 2:30 p.m. 65. midnight 66. 1:00 p.m. 67. 7:00 p.m. 68. 4:50 a.m. 100 Medical Terminology: The Language of Health Care Match the

following chart entries with the corresponding health record abbreviations: 69. ________ works as a security officer a. UCHD 70. ________ advised to lower salt intake b. HPI 71. ________ father, age 88, L&W; mother, age 78, died, stroke c. PE 72. ________ quit smoking 2 years ago, drinks alcohol socially d. CC 73. ________ diagnosis: tonsillitis e. OH 74. ________ c/o lower back pain f. SH 75. ________ pain in lower back for 2 weeks, worse at night g. FH 76. ________ no reaction to any previously administered drug h. P 77. ________ had all commonly contracted childhood diseases i. A 78. ________ lungs: clear; heart: regular rate and rhythm j. NKA Give the meaning for the following abbreviations deemed error prone, and list the preferred term for each: Abbreviation Meaning Preferred Term 79. q.d ________________ ___________________ 80. q.o.d. ________________ ___________________ 81. OS ________________ ___________________ 82. AD ________________ ___________________ 83. AU ________________ ___________________ 84.  ________________ ___________________ 85. D/C ________________ ___________________ From the following list of diagnostic imaging modalities, circle those that use ion- izing radiation: 86. computed tomography 87. magnetic resonance imaging 88. radiology 89. radionuclide organ imaging 90. sonography Chapter 4 • The Medical Record 101 Match the following imaging modalities with the type of radiation used: 91. ________ computed tomography a. standard x-rays 92. ________ magnetic resonance imaging b. gamma rays 93. ________ radiology c. ultrasound waves 94. ________ radionuclide organ imaging d. radio waves 95. ________ sonography e. 3-D x-rays 102 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 4 . 1 Progress Note CC: 37 y.o.  c̄ diabetes c / o swelling of the R foot and calf  3d S: There is no Hx of trauma, pain, SOB, or cardiac Sx, smoker  12 yr, ss̄ pkg q d, denies ETOH consumption Meds: parenteral insulin qd, NKDA O: Pt is afebrile, BP 140/84, P 72, R 16, lungs are clear; abdomen is benign s organomegaly; muscle tone and strength are WNL; there is swelling of the R calf but s erythema or tenderness A: Edema of R calf of unknown etiology P: Schedule STAT vascular sonogram of lower extremities; pt is to keep the leg elevated  d, then RTC for follow-up and test results on Thursday (or sooner if ↑ edema, SOB, or CP) 1. What is the sex of the patient? 5. How is the patient’s insulin administered? a. male a. orally b. female b. transdermally c. infusion through implant 2. Where was the patient seen? d. by injection a. emergency room b. outpatient office of clinic 6. What is the cause of the patient’s complaint? c. inpatient hospital a. unknown d. not stated b. fever c. shortness of breath 3. What was the condition of the patient’s ab- d. trauma domen? a. shows signs of cancer 7. When should the sonogram be performed? b. internal organs are enlarged a. immediately c. internal organs are not enlarged b. within two days d. muscle tone and strength are weak c. at the time of follow-up d. only if symptoms persist 4. How much does the patient smoke per day? a. one package 8. How long should the patient’s leg be kept b. two packages elevated? c. half a package a. one week d. none; patient quit smoking 12 years ago b. two weeks c. one day d. two days Chapter 4 • The Medical Record 103 M E D I C A L R E C O R D 4 . 2 Postop Meds for Laparotomy 1. Vicodin, tab p.o. q 3 h prn mild pain, or tab p.o. q 3 h prn moderate pain 2. Demerol, 100 mg IM q 3 h prn severe pain 3. Tylenol (acetaminophen) 650 mg p.o. q 4 h prn oral temp ↑ 100.4°F 4. Dalmane (flurazepam) 30 mg p.o. h.s. prn sleep 5. Mylicon (simethicone) 80 mg, tab chewed and swallowed q.i.d. 6. Ducolax (bisacodyl) suppos, PR in a.m. 1. How is the Demerol to be administered? 5. What are the instructions for administering the a. by mouth Vicodin in the case of moderate pain? b. within the vein a. one tablet every three hours c. under the skin b. three tablets every hour d. within the muscle c. two tablets every three hours d. three tablets every three hours 2. What is the Sig: on the Mylicon? a. one every other day 6. How should the Tylenol be administered? b. one twice a day a. one dose every four hours as needed c. one three times a day b. one dose every four hours only if patient has a temperature of 100.4°F or higher d. one four times a day c. one dose every four hours as long as the pa- 3. What is the Sig: on the Ducolax? tient’s temperature does not go over 100.4° a. one suppository in the rectum in the morning d. one dose every hour up to four per day b. one suppository taken orally before noon c. two suppositories before breakfast 7. Laparotomy refers to d. one suppository as needed in the morning a. a puncture of the abdomen b. excision of the stomach 4. When should the Dalmane be administered? c. a puncture of the stomach a. each night d. an incision in the abdomen b. at bedtime c. as needed d. every hour 104 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 4 . 3 Michael Marsi has had chronic health problems in the past 2 years and has been see- ing Dr. Spaulding, his personal physician, regularly in recent months. Dr. Spaulding uses problem-oriented medical records and writes a new SOAP progress note at each patient visit. Mr. Marsi has come to see Dr. Spaulding today because he feels worse than usual. DIRECTIONS Read Medical Record 4.3 (page 105) for Michael Marsi, and answer the following ques- tions. This record is the progress note for today’s visit, part of Dr. Spaulding’s POMR for Mr. Marsi. Dr. Spaulding handwrote it herself during the patient’s visit. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 4 . 3 Write your answers in the spaces provided. 1. How old is Mr. Marsi? _______________________________________________________ 2. Where was the treatment rendered? ___________________________________________ 3. List the three elements of the patient’s complaint a. __________________________________________________________________________ b. __________________________________________________________________________ c. __________________________________________________________________________ 4. In your own words, not using medical terminology, briefly summarize Mr. Marsi’s history: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. Which of the following is not mentioned at all in this history? a. The prescription medication Mr. Marsi takes b. Mr. Marsi’s smoking habit c. Mr. Marsi’s activity level at work d. Mr. Marsi’s consumption of alcohol 6. Dr. Spaulding and Mr. Marsi talked at length about Mr. Marsi’s symptoms and how they’ve changed recently, and then Dr. Spaulding examined him. List three objective findings she noted in this examination. a. __________________________________________________________________________ b. __________________________________________________________________________ c. __________________________________________________________________________ Chapter 4 • The Medical Record 105 Medical Record 4.3 106 Medical Terminology: The Language of Health Care 7. Dr. Spaulding’s assessment is that Mr. Marsi has ______________________________. But she also wants to make sure he does not have ______________________________ ____________________________________________________________________________. 8. Dr. Spaulding’s treatment plan involves four areas. List the specific plan(s) for each of these. Diagnostic tests ordered: _____________________________________________________ ____________________________________________________________________________ Instruct patient to change (and how) these personal habits: _____________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Drug prescribed (and how much and when): __________________________________ ____________________________________________________________________________ Future diagnostic check and/or action to take: _________________________________ ____________________________________________________________________________ 9. When is Dr. Spaulding expecting to see Mr. Marsi again? _______________________ ____________________________________________________________________________ Chapter 5 Integumentary System OBJECTIVES After completion of this chapter you will be able to Define common combining forms used in relation to the integumentary system Describe the basic functions of the integumentary system Define basic anatomical terms related to the integumentary system Identify common symptomatic terms related to the integumentary system Identify common diagnostic terms related to the integumentary system List common diagnostic tests and procedures related to the integumentary system Identify common operative terms referring to the integumentary system Identify common therapeutic terms including drug classifications related to the integumentary system Explain common terms and abbreviations used in documenting medical records involving the integumentary system Combining Forms Combining Form Meaning Example adip/o fat adiposis ad-i-pōsis lip/o lipoma li-pōma steat/o steatoma stē-ā-tōmă derm/o skin hypodermic hı̄pō-dermik dermat/o dermatology der-mă-tolō-jē cutane/o subcutaneous sŭb-kyū-tānē-ŭs erythr/o red erythrodermatitis ĕ-rith-rō-dermā-tı̄tis hidr/o sweat anhidrosis an-hı̄-drōsis 107 108 Medical Terminology: The Language of Health Care Combining Form Meaning Example hist/o tissue histology his-tolō-jē histi/o histiogenic histē-ō-jenik ichthy/o fish ichthyoid ikthē-oyd kerat/o hard keratosis ker-ă-tōsis scler/o scleroderma sklĕr- ō-dermă leuk/o white leukonychia lū-kō-nikē-ă melan/o black melanocyte melă-nō-sı̄t myc/o fungus mycosis mı̄-kōsis onych/o nail onychodystrophy oni-kō-distrō-fē plas/o formation dysplastic dis-plastik purpur/o purple purpuric pŭrpūrik seb/o sebum (oil) seborrhea seb-ō-rēă squam/o scale squamous skwāmūs trich/o hair trichorrhexis trik-ō-reksis xanth/o yellow xanthoma zan-thōmă xer/o dry xerosis zē-rōsis Integumentary System Overview The integumentary system is composed of the skin (also called the integument) and its appendages, including hair, nails, sweat glands, and sebaceous glands. It protects the body from injury or intrusion of microorganisms, helps regulate body tempera- ture, and houses the receptors for the sense of touch, including pain and sensation (Fig. 5.1). The skin is the largest organ in the body. Skin layers are divided into an outer layer called the epidermis, an inner layer called the dermis, and a subcutaneous tissue layer beneath the dermis. Chapter 5 • Integumentary System 109 Squamous cell carcinoma Hair shaft Squamous layer Receptor for (stratum corneum) touch Basal layer Pore (stratum germinativum) Epidermis Dermis Pilomotor muscle Sebaceous gland Subcutaneous tissue Sweat gland Basal cell carcinoma Hair follicle Free nerve ending Adipose tissue Receptor for pressure Venule Arteriole Nerve Normal nevus (mole) (Fig. 1) Malignant melanoma showing asymmetry (Fig. 2) Signs of melanoma Malignant melanoma showing Malignant melanoma showing A Asymmetry: One half does not match the other half border irregularity (Fig. 3) uneven pigmentation (Fig. 4) (Fig. 2). B Border irregularity: The edges are ragged, notched, or blurred (Fig. 3). C Color: The pigmentation is not uniform. Shades of tan, brown, and black are present. Red, white, and blue may add to the mottled appearance (Fig. 4). D Diameter greater than 6 millimeters: Any sudden or continuing increase in size should be of special concern (not shown). Figure 5.1 The skin. 110 Medical Terminology: The Language of Health Care Epidermis The epidermis consists of several layers of stratified squamous (scale-like) epithelium. The two significant layers are the innermost layer, known as the basal layer (stratum germinativum), and the outermost layer, called the squamous layer (stratum corneum). The cells of the basal layer are constantly being produced, moving the older cells up to- ward the surface. As these cells are being pushed up, they flatten, become filled with a hard protein substance called keratin, and soon die. As a result, many layers of tightly packed dead cells accumulate in the outermost squamous layer, where they are sloughed off from the surface of the skin. Melanocytes, which produce the pigment called melanin that gives color to the skin, are found in the basal layer. Dermis The dermis, also called the corium, is the connective tissue layer; it contains blood and lymphatic vessels, nerves and nerve endings, glands, and hair follicles within a network of elastic and collagen fibers. Collagen is a fibrous protein material that is tough and resistant. These fibers give the skin its qualities of toughness and elasticity. Subcutaneous Tissue The subcutaneous layer is below the dermis and is composed of loose connective tis- sue and adipose (fatty) tissue. Anatomical Terms Term Meaning epithelium cells covering external and internal surfaces of the body ep-i-thēlē-ŭm epidermis thin, cellular outer layer of the skin ep-i-dermis squamous cell layer flat, scale-like epithelial cells comprising the outermost skwāmŭs layers of the epidermis basal layer deepest region of the epidermis bāsăl melanocyte a cell found in the basal layer that gives color to the skin melă-nō-sı̄t melanin dark brown to black pigment contained in melanocytes melă-nin dermis dense, fibrous connective tissue layer of the skin (also known as the corium) sebaceous

glands oil glands in the skin sē-bāshŭs sebum oily substance secreted by the sebaceous glands sēbŭm sudoriferous glands sweat glands (sudor  sweat; ferre  to bear) sū-dō-rifer-ŭs Chapter 5 • Integumentary System 111 Term Meaning subcutaneous tissue connective and adipose tissue layer just under the dermis sŭb-kyū-tānē-ŭs collagen protein substance found in skin and connective tissue kollă-jen (koila  glue; gen  producing) hair outgrowth of the skin composed of keratin nail outgrowth of the skin attached to the distal end of each finger and toe, composed of keratin keratin hard protein material found in the epidermis, hair, and nails keră-tin Symptomatic Terms Term Meaning lesion an area of pathologically altered tissue (two types: primary lēzhŭn and secondary) (Fig. 5.2) primary lesions lesions arising from previously normal skin flat, nonpalpable changes in skin color macule (macula) a flat, discolored spot on the skin up to 1 cm across (e.g., a makyūl freckle) (Fig. 5.3A) patch a flat, discolored area on the skin larger than 1 cm (e.g., vitiligo) (Fig. 5.3B) elevated, palpable, solid masses papule a solid mass on the skin up to 0.5 cm in diameter [e.g., a nevus papyūl (mole)] (Fig. 5.3C) plaque a solid mass greater than 1 cm in diameter, limited to the plāk surface of the skin (Fig. 5.3D) nodule a solid mass greater than 1 cm, which extends deeper into nodyūl the epidermis (Fig. 5.3E) tumor a solid mass larger than 1–2 cm (Fig. 5.3F) tumŏr wheal an area of localized skin edema (swelling) (e.g., a hive) hwēl (Fig. 5.3G) elevation formed by fluid within a cavity vesicle little bladder; an elevated, fluid-filled sac (blister) within or vesı̆-kl under the epidermis up to 0.5 cm in diameter (e.g., a fever blister) (Fig. 5.3H) bulla a blister larger than 0.5 cm (e.g., a second-degree burn) bulă (bulla  bubble) (Fig. 5.3I) pustule a pus-filled sac (e.g., a pimple) (Fig. 5.3J) pŭschūl 112 Medical Terminology: The Language of Health Care PRIMARY LESIONS Flat discolored, nonpalpable changes in skin color Macule Patch Elevated, palpable solid masses Papule Plaque Nodule Tumor Wheal Elevation formed by fluid in a cavity Vesicle Bulla Pustule SECONDARY LESIONS Loss of skin surface Erosion Ulcer Excoriation Fissure Material on skin surface Scale Crust Keloid VASCULAR LESIONS Cherry angioma Telangiectasia Petechia Ecchymosis Figure 5.2 Types of primary, secondary, and vascular lesions. Term Meaning secondary lesions lesions that result in changes in primary lesions loss of skin surface erosion to gnaw away; loss of superficial epidermis leaving an ēr-ōzhŭn area of moisture but no bleeding (e.g., area of moisture after rupture of a vesicle) (Fig. 5.3K) Chapter 5 • Integumentary System 113 PRIMARY LESIONS A Macule B Patch C Papule D Plaque E Nodule F Tumor G Wheal H Vesicle SECONDARY LESIONS I Bulla J Pustule K Erosion L Ulcer M Excoriation N Fissure O Scale P Crust VASCULAR LESIONS Q Keloid R Cherry angioma S Telangiectasia T Petechia Figure 5.3 Skin lesions. Term Meaning ulcer an open sore on the skin or mucous membrane that can bleed and scar and is sometimes accompanied by infection (e.g., decubitus ulcer) (Fig. 5.3L) excoriation a scratch mark (e.g., from a cat scratch) (Fig. 5.3M) eks-kōrē-āshŭn fissure a linear crack in the skin (Fig. 5.3N) fishŭr 114 Medical Terminology: The Language of Health Care Term Meaning material on skin surface scale a thin flake of exfoliated epidermis (e.g., dandruff) (Fig. 5.3O) crust dried residue of serum (body liquid), pus, or blood on the skin (e.g., in impetigo) (Fig. 5.3P) other secondary lesions cicatrix of the skin a mark left by the healing of a sore or wound showing sikă-triks the replacement of destroyed tissue by fibrous tissue (cicatrix  scar) keloid an abnormal overgrowth of scar tissue that is thick and kēloyd irregular (kele  tumor) (Fig. 5.3Q) vascular lesions lesions of a blood vessel cherry angioma a small, round, bright-red blood vessel tumor on the chārē an-jē-ōmă skin, often on the trunk of the elderly ((Fig. 5.3R) telangiectasia a tiny, red blood vessel lesion formed by the dilation of a tel-anjē-ek-tāzē-ă group of blood vessels radiating from a central arteriole, spider angioma most commonly seen on the face, neck, or chest spı̄der an-jē-ōmă (telos  end) (Fig. 5.3S) purpuric lesions purpura; lesions as a result of hemorrhages into the skin pŭrpū-rik petechia spot; a reddish-brown, minute hemorrhagic spot on the pe-tēkē-ă skin that indicates a bleeding tendency—small purpura (Fig. 5.3T) ecchymosis bruise; a black and blue mark—large purpura (chymo  ek-i-mōsis juice) epidermal tumors skin tumors arising from the epidermis nevus a congenital malformation on the skin that can be nēvŭs epidermal or vascular—also called a mole (see Fig. 5.1) dysplastic nevus a mole with precancerous changes dis-plastik nēvŭs verruca an epidermal tumor caused by a papilloma virus—also vĕ-rūkă called a wart (Fig. 5.4) GENERAL SYMPTOMATIC TERMS COMEDO, a alopecia baldness; natural or unnatural deficiency of hair plug of sebum al-ō-pēshē-ă within the opening of a hair follicle, comedo a plug of sebum (oil) within the opening of a hair follicle also known as whitehead or (pl. comedos, (Fig. 5.5) blackhead, is derived from comedones) the Latin word meaning to komē-dō eat up or consume. The material when expressed closed comedo below the skin surface with a white center has a worm-like (whitehead) appearance, and ancient writers thought there was an open comedo open to the skin surface with a black center caused actual worm eating into the (blackhead) by the presence of melanin exposed to air flesh. Chapter 5 • Integumentary System 115 Figure 5.4 Verrucae on a knee. (From Dr. Barankin Figure 5.5 Open and closed comedones. Dermatology Collection.) Term Meaning eruption appearance of a skin lesion ē-rŭpshŭn erythema redness of skin er-i-thēmă pruritus severe itching prū-rı̄tŭs rash a general term for skin eruption, most often associated with communicable disease skin pigmentation skin color due to the presence of melanin depigmentation loss of melanin pigment in the skin hypopigmentation areas of skin lacking color due to deficient amounts of melanin hyperpigmentation darkened areas of skin caused by excessive amounts of melanin suppuration production of purulent matter (pus) sŭpyŭ-rāshŭn urticaria hives; an eruption of wheals on the skin accompanied by erti-kari-a itch (urtica  stinging nettle) (see Fig. 5.3G) xeroderma dry skin zērō-dermă Diagnostic Terms Term Meaning acne an inflammation of the sebaceous glands and hair aknē follicles of the skin evidenced by comedones, pustules, or nodules on the skin (acne  point) (Fig. 5.6) albinism a hereditary condition characterized by a partial or total albi-nizm lack of melanin pigment (particularly in the eyes, skin, and hair) 116 Medical Terminology: The Language of Health Care Term Meaning burn any injury to body tissue caused by heat, chemicals, electricity, radiation, or gases first-degree burn a burn involving only the epidermis, characterized by erythema (redness) and hyperesthesia (excessive sensation) second-degree burn a burn involving the epidermis and the dermis, characterized by erythema, hyperesthesia, and vesications (blisters) third-degree burn a burn involving all layers of the skin, characterized by the destruction of the epidermis and dermis with damage or destruction of the subcutaneous tissue cellulitis an acute inflammation of subcutaneous tissue resulting from a bacterial invasion through a break in the skin (cellula  small storeroom) dermatitis (eczema) an inflammation of the skin characterized by redness, der-mă-tı̄tis pruritus (itching), and various lesions common types: atopic dermatitis a chronic skin inflammation characterized by the (atopic eczema) appearance of inflamed, swollen papules and vesicles that crust and scale, with severe itching and burning; most outbreaks begin in infancy and are marked by exacerbations and remissions that usually clear up before adulthood; occurs in persons with atopy (a genetic hypersensitivity to environmental irritants or allergens) contact dermatitis an inflammation of the skin resulting from contact with a substance to which one is allergic (e.g., chemicals in dyes, preservatives, fragrances, rubber; allergic dermatitis); or one that is a known skin irritant (e.g., acid, solvent; irritant dermatitis) (Fig. 5.7) seborrheic redness of the skin covered by a yellow, oily, itchy scale dermatitis most commonly at the hairline, forehead, and around the nose, ears, or eyelashes and developing at any age; referred to as “cradle cap” in infants Figure 5.6 Acne lesions. Inflammatory papules, Figure 5.7 Contact dermatitis. This eczematous pustules, and closed comedones are present on the dermatitis on the dorsa of the hands was caused by face of a patient diagnosed with acne vulgaris. exposure to lanolin. Chapter 5 • Integumentary System 117 Term Meaning dermatosis any disorder of the skin der-mă-tōsis exanthematous eruption of the skin caused by a viral disease (exanthema  viral disease eruption) eg-zan-themă-tŭs rubella reddish; German measles rū-belă rubeola reddish; 14-day measles rū-bēō-lă varicella a tiny spot; chickenpox var-ı̆-selă eczema to boil out; the term is often used interchangeably with ekzĕ-mă dermatitis to denote a skin condition characterized by the appearance of inflamed, swollen papules and vesicles that crust and scale, often with sensations of itching and burning furuncle a boil; a painful nodule formed in the skin by inflammation fyūrŭng-kl originating in a hair follicle—caused by staphylococcosis carbuncle a skin infection consisting of clusters of furuncles (carbo  karbŭng-kl small, glowing embers) abscess a localized collection of pus in a cavity formed by the abses inflammation of surrounding tissues that heals when drained or excised (abscessus  a going away) gangrene an eating sore; death of tissue associated with a loss of ganggrēn blood supply resulting from trauma or an inflammatory or infectious process such as seen in complications of frostbite, severe burns, and conditions that affect circulation (e.g., diabetes) herpes simplex virus transient viral vesicles (e.g., cold sores, fever blisters) type 1 (HSV-1) that infect the facial area, especially the mouth and nose herpēz (herpes  creeping skin disease) herpes simplex virus sexually transmitted ulcer-like lesions of the genital and type 2 (HSV-2) anorectal skin and mucosa; after initial infection, the virus lies dormant in the nerve cell root and may recur at times of stress (see Chapter 17, Fig. 17.9) herpes zoster a viral disease affecting the peripheral nerves characterized herpēz zoster by painful blisters that spread over the skin following the affected nerves; usually unilateral—also known as shingles (zoster  girdle) (see Chapter 10, Fig. 10.10) ichthyosis a skin condition caused by a gene defect that results in dry, ik-thē-ōsis thick, scaly skin; ichthyosis vulgaris is the most common of the many types (vulgaris is a Greek word meaning common) impetigo highly contagious, bacterial skin inflammation marked im-pe-tı̄gō by pustules that rupture and become crusted—most often occurs around the mouth and nostrils 118 Medical Terminology: The Language of Health Care Term Meaning keratoses thickened areas of epidermis ker-ă-tōsez actinic keratoses localized thickening of the skin caused by ak-tinik excessive exposure to sunlight; a known solar keratoses precursor to cancer (actinic  ray; solar  sun) (Fig. 5.8) seborrheic keratoses benign wart-like lesions (seen especially seb-ō-rēik on elderly skin) (Fig. 5.9) lupus a chronic autoimmune disease characterized lūpŭs by inflammation of various parts of the body (lupus  wolf) cutaneous lupus limited to the skin; evidenced by a kyū-tānē-ŭs characteristic rash especially on the face, neck, and scalp systemic lupus erythematosus a more severe form of lupus involving the (SLE) skin, joints, and often the vital organs (e.g., sis-temik lūpŭs er-i-themă-tō-sis lungs, kidneys) malignant cutaneous neoplasm skin cancer mă-lignănt kyū-tānē-ŭs nēō-plazm squamous cell carcinoma (SCC) a malignant tumor of squamous epithelium skwāmŭs sel kar-si-nōmă (see Fig. 5.1) basal cell carcinoma (BCC) a malignant tumor of the basal layer of the bāsăl sel kar-si-nōmă epidermis [the most common type of skin cancer (see Fig. 5.1)] malignant melanoma a malignant tumor composed of mă-lignănt melă-nōmă melanocytes—most develop from a pigmented nevus over time (see Signs of Melanoma in Fig. 5.1) Kaposi sarcoma a malignant tumor of the walls of blood kăpō-sē sar-kōmă vessels appearing as painless, dark bluish- purple plaques on the skin; often spreads to lymph nodes and internal organs (Fig. 5.10) onychia inflammation of the fingernail or toenail ō-nikē-ă Figure 5.9 Seborrheic keratoses. A. Lesion with warty, stuck-on appearance. B. Multiple lesions showing various colors and sizes. Figure 5.8 Actinic (solar) keratoses. Chapter 5 • Integumentary System 119 Figure 5.10 Skin lesions associated with Kaposi sarcoma. Term Meaning paronychia inflammation of the nail fold (Fig. 5.11) par-ō-nikē-ă pediculosis infestation with lice that causes itching and pĕ-dikyū-lōsis dermatitis (pediculo  louse) (Fig. 5.12)

pediculosis capitis head lice (capitis  head) pĕ-dikyū-lōsis kapi-tis pediculosis pubis lice that generally infect the pubic region, but hair of pĕ-dikyū-lōsis pyūbis the axilla, eyebrows, lashes, beard, or other hairy body surfaces may also be involved—also called crabs (pubis  groin) psoriasis an itching; a chronic, recurrent skin disease marked sō-rı̄ă-sis by silver-gray scales covering red patches on the skin that result from overproduction and thickening of skin cells—elbows, knees, genitals, arms, legs, scalp, and nails are common sites of involvement (Fig. 5.13) scabies a contagious disease caused by a parasite (mite) that skābēz invades the skin, causing an intense itch—most often found at articulations between the fingers or toes, elbow, etc. (scabo  to scratch) seborrhea a skin condition marked by the hypersecretion of seb-ō-rēă sebum from the sebaceous glands tinea a group of fungal skin diseases identified by the TINEA. Tinea is tinē-ă body part that is affected, including tinea corporis Latin for a grub, (body), commonly called ringworm, and tinea pedis a gnawing (foot), also called athlete’s foot worm; it is used to describe the gnawed or moth-eaten vitiligo a condition caused by the destruction of melanin that appearance of the skin in vit-i-lı̄gō results inthe appearance of white patches on the this condition. skin, commonly the face, hands, legs, and genital areas (see Fig. 5.3B) Figure 5.11 Chronic paronychia. 120 Medical Terminology: The Language of Health Care Pubic louse Head louse Figure 5.13 Psoriasis of the scalp. Figure 5.12 Pediculosis. Diagnostic Tests and Procedures Term Meaning SUTURE. Suture biopsy (Bx) removal of a small piece of tissue for microscopic pathological is derived from bı̄op-sē examination (Fig. 5.14) the Latin sutura, meaning a seam, a sewing excisional Bx removal of an entire lesion together. In surgery, a suture is a thread or other material incisional Bx removal of a selected portion of a lesion used for sewing. Also, to shave Bx a technique using a surgical blade to “shave” tissue from the suture is to sew up or stitch epidermis and upper dermis together. Numbers indicate thickness of the thread (i.e., culture and a technique of isolating and growing colonies of lower numbers denote sensitivity (C&S) microorganisms to identify a pathogen and to determine thicker thread; higher which drugs might be effective in combating the infection numbers denote thinner it has caused thread). frozen section (FS) a surgical method involving cutting a thin piece of tissue from a frozen specimen for immediate pathological examination Figure 5.14 Collection of a biopsy specimen. Chapter 5 • Integumentary System 121 Term Meaning skin tests methods for determining the reaction of the body to a given substance by applying it to, or injecting it into, the skin—commonly seen in treating allergy scratch test the substance is applied to the skin through a scratch patch test the substance is applied topically to the skin on a small piece of blotting paper or wet cloth Operative Terms (Fig. 5.15) Term Meaning chemosurgery a technique for restoring wrinkled, scarred, or blemished kemō-ser-jer-ē skin by application of an acid solution to “peel” away chemical peel the top layers of the skin cryosurgery destruction of tissue by freezing—involves application krı̄-ō-serjer-ē of an extremely cold chemical (e.g., liquid nitrogen) dermabrasion surgical removal of frozen epidermis using wire brushes der-mă-brāzhŭn and emery papers to remove scars, tattoos, and/or wrinkles; aerosol spray is used to freeze the skin debridement removal of dead tissue from a wound or burn site to dā-brēd-mon promote healing and prevent infection curettage to clean; scraping of a wound using a spoon-like cutting kyū-rĕ-tahzh instrument called a curette; this technique is used in debridement electrosurgical use of electric currents to destroy tissue—the type and procedures strength of the current and method of application varies electrocautery use of an instrument heated by electric current (cautery) CAUTERY. A ē-lektrō-cawter-ē to coagulate bleeding areas by burning the tissue (e.g., Greek word to sear a blood vessel) (Fig. 5.16) meaning branding iron refers to the electrodesiccation use of short, high-frequency, electric currents to destroy surgical use of flame or heat ē-lektrō-des-i-kāshŭn tissue by drying—the active electrode makes direct to destroy tissue, control contact with the skin lesion (desicco  to dry up) bleeding of wound sites, etc. The ancients used fulguration to lighten; use of long, high-frequency, electric sparks to actual cautery with a ful-gŭ-rāshŭn destroy tissue; the active electrode does not touch the skin metallic instrument heated in incision and incision and drainage of an infected skin lesion (e.g., an a flame and potential drainage (I&D) abscess) cautery with a caustic chemical. laser surgery surgery using a laser in various dermatological lāzer procedures to remove lesions, scars, tattoos, etc. laser an acronym for light amplification by stimulated emission of radiation; an instrument that concentrates high frequencies of light into a small, extremely intense beam that is precise in depth and diameter; it is applied to body tissues to destroy lesions or for dissection (cutting of parts for study) 122 Medical Terminology: The Language of Health Care Jagged tears OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Complex lacerations of the nose and upper lip due to a dog bite. POSTOPERATIVE DIAGNOSIS: Complex lacerations of the nose and upper lip due to a dog bite. OPERATION: Revision and closure of complex lacerations of the nose and upper lip. Agents used to clean the wound ANESTHESIOLOGIST: H. Vaughn, M.D. INDICATIONS: Anesthetic This 33-year-old female sustained a dog bite to her face while she was handling a dog at a veterinary clinic. Because of the complexity of her injuries, a plastic surgery consultation was requested. PROCEDURE: A type of absorbable Dead tissue The patient’s face was prepped and draped in the usual sterile fashion. A copious amount of dilute Betadine and saline were used to irrigate out all the lacerations. Subcutaneous tissues in the vicinity of the lacerations thread used to removed from were infiltrated with 0.5% Xylocaine with 1:200,000 concentration epinephrine. Attention was directed to the sew up deeper the wound patient’s upper lip. There was a laceration approximately 1.5 cm oriented parallel to the mucocutaneous layers of junction. There was another diagonal laceration measuring approximately 1.0 cm. The devitalized tissues were debrided sharply. The laceration was closed in layers with 5-0 Vicryl sutures and then with 6-0 and 7-0 tissue Prolene on the skin. Attention was directed to the patient’s nose. There are two major lacerations. There is a 2 cm laceration to the left ala. This was a full thickness laceration through the entire alar cartilage into the A type of nose as well as the entire alar rim. First, the devitalized cartilage was debrided sharply. The intranasal Absorbable nonabsorbable incision was closed with 4-0 chromic catgut suture. The alar rim was meticulously reapproximated with a few suture made of tacking sutures to produce perfect anatomic continuity. The remainder of the laceration was closed with 6-0 thread used to and 7-0 Prolene sutures in interrrupted and running fashion. At this time, attention was directed to another sheep or beef sew up surface laceration measuring approximately 2.5 cm located in the right nasal sill area extending to the columella and intestine coated layers of tissue, lip junction. The columella was detached. Again, all devitalized tissues were debrided sharply. Deep with salt to removed after subcutaneous tissues were approximated with 5-0 chromic catgut sutures in such a fashion so as to meticulously reapproximate the columella into its normal anatomic position. The nasal sill was prolong holding healing reapproximated with 6-0 Prolene sutures meticulously reapproximating the detailed anatomy of this area. strength The remainder of the wounds were closed with 6-0 and 7-0 Prolene sutures in a running and interrupted fashion. A few smaller lacerations were closed with Prolene sutures on the bridge of the nose. All the wounds were covered with Neosporin ointment, Adaptic, and appropriate bandages. Brought Oral together again The patient was given intravenous antibiotics; and she will be started on Keflex 250 mg p.o. t.i.d. The patient will be seen in my office in 24 hours for follow-up. antibiotic Topical TR:kf T. Romero, M.D. antibiotic D: 10/19/20xx T: 10/20/20xx OPERATIVE REPORT PT. NAME: SMITH, WILMA ID NO: OPS-167480621 SURGEON: T. ROMERO, M.D. A B C PER TA T-7 C d gjh J K glfk JL hlfk lK jd f jd hfd jd flf g JL SK K JL SK K N O IC ETH Removing suture from sterile Continuous sutures are several stitches Interrupted sutures are groups of package with needle holder from a single length of suture material, individual stitches, each of which knotted at each end is knotted Figure 5.15 Typical documentation of a surgical procedure. Suturing is also depicted. Chapter 5 • Integumentary System 123 Figure 5.16 Electrocautery. A cautery device is used to perform hemostasis during a surgical procedure. Term Meaning Mohs surgery a technique used to excise tumors of the skin by removing mōz fresh tissue layer by layer until a tumor-free plane is reached skin grafting transfer of skin from one body site to another to replace skin lost through burns or injury autograft transfer to a new position in the body of the same person awto-graft (auto  self) homograft donor transfer between individuals of the same species such as hōmō-graft human to human (homo  same; alloother) allograft alō-graft xenograft a graft transfer from one animal species to one of another zenō-graft species (xeno  strange; hetero  different) heterograft heter-ō-graft Therapeutic Terms Term Meaning chemotherapy treatment of malignancies, infections, and other diseases with kēmō-ther-ă-pē chemical agents that destroy selected cells or impair their ability to reproduce radiation therapy treatment of neoplastic disease by using ionizing radiation to rādē-āshŭn deter proliferation of malignant cells sclerotherapy use of sclerosing agents in treating diseases (e.g., injection of a sklēr-ō-theră-pē saline solution into a dilated blood vessel tumor in the skin, resulting in hardening of the tissue within and eventual sloughing away of the lesion) ultraviolet therapy use of ultraviolet light to promote healing of a skin lesion (e.g., ŭl-tră-vı̄ō-let an ulcer) COMMON THERAPEUTIC DRUG CLASSIFICATIONS anesthetic a drug that temporarily blocks transmission of nerve an-es-thetik conduction to produce a loss of sensations (e.g., pain) antibiotic a drug that kills or inhibits the growth of microorganisms antē-bı̄-otik 124 Medical Terminology: The Language of Health Care Term Meaning antifungal a drug that kills or prevents the growth of fungi an-tē-fŭngăl antihistamine a drug that blocks the effects of histamine in the body an-tē-histă-mēn histamine a regulating body substance released in excess during allergic histă-mēn reactions causing swelling and inflammation of tissues [e.g., in urticaria (hives), hay fever] anti-inflammatory a drug that reduces inflammation antē-in-flamă- tor-ē antipruritic a drug that relieves itching antē-prū-ritik antiseptic an agent that inhibits the growth of infectious microorgan- isms an-tă-septik Summary of Chapter 5 Acronyms/Abbreviations BCC ....................basal cell carcinoma HSV-2 ...............herpes simplex virus type 2 Bx ........................biopsy I&D.....................incision and drainage C&S ....................culture and sensitivity SCC.....................squamous cell carcinoma FS ........................frozen section SLE.....................systemic lupus erythematosus HSV-1 ...............herpes simplex virus type 1 Chapter 5 • Integumentary System 125 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE hypodermic _______ / _______ / _______ P R S hypo/derm/ic P R S DEFINITION: below or deficient/skin/pertaining to 1. dermatologist __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 2. ichthyoid __________________ / __________________ R S DEFINITION: _________________________________________________________________ 3. onycholysis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 4. histotrophic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 5. dysplasia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 6. hyperkeratosis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 126 Medical Terminology: The Language of Health Care 7. leukotrichia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 8. mycology __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 9. epidermal __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 10. lipoma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 11. subcutaneous __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 12. anhidrosis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 13. histopathology __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 14. paronychia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 15. adiposis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 16. squamous __________________ /

__________________ R S DEFINITION: _________________________________________________________________ Chapter 5 • Integumentary System 127 17. erythrodermatitis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 18. desquamation __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 19. histotoxic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 20. melanocyte __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 21. xerosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 22. purpuric __________________ / __________________ R S DEFINITION: _________________________________________________________________ 23. seborrhea __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 24. xanthoma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 25. asteatosis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 26. ________ oma  black tumor 27. ________ dermic  pertaining to below the skin 128 Medical Terminology: The Language of Health Care 28. ________ angioma  bright-red, round blood vessel tumor 29. ________ coriation  scratch mark on the skin 30. ________ section  type of microscopic study of fresh tissue 31. ________ comedo  whitehead 32. anti________  a drug that relieves itching 33. ______________ mycosis  condition of fungus of the fingernail or toenail 34. ______________ biopsy  removal of an entire lesion for microscopic examination 35. ________ graft  transfer of skin to a new position in the body of the same person 36. ____________ therapy  method of eliminating a dilated blood vessel tumor of the skin by injection of a hardening solution 37. ____________ pigmentation  darkened areas of skin caused by excessive amounts of melanin For each of the following, circle the combining form that corresponds to the meaning given: 38. fat leuk/o steat/o seb/o 39. black necr/o trich/o melan/o 40. fungus seb/o myc/o onych/o 41. nail onych/o trich/o squam/o 42. red xanth/o purpur/o erythr/o 43. hair trich/o histi/o fibr/o 44. dry ichthy/o xer/o xanth/o 45. oil py/o hidr/o seb/o Write the correct medical term for each of the following definitions: 46. death of tissue associated with a loss of blood supply as a result of trauma or inflammatory or infectious process __________________________________________ 47. severe itching ______________________________________________________________ 48. skin infection consisting of a cluster of furuncles _____________________________ 49. baldness ___________________________________________________________________ 50. use of a spoon-like instrument to scrape tissue, such as that used in debridement of a wound ________________________________________________________________ Chapter 5 • Integumentary System 129 51. inflammation of the sebaceous glands and hair follicles of the skin evidenced by comedones, pustules, or nodules on the skin __________________________________ 52. chronic, recurrent skin disease marked by silver-gray scales covering red patches on the skin ________________________________________________________________ 53. acute inflammation of subcutaneous tissue as the result of bacterial invasion through a break in the skin (derived using the Latin word meaning small storeroom) _________________________________________________________________ Match the lay terms with the appropriate medical terms: 54. ________ mole a. pediculosis capitis 55. ________ black and blue mark b. cicatrix 56. ________ blackhead c. seborrheic dermatitis 57. ________ boil d. urticaria 58. ________ crabs e. verruca 59. ________ cradle cap f. nevus 60. ________ head lice g. furuncle 61. ________ hives h. comedo 62. ________ scar i. ecchymosis 63. ________ wart j. pediculosis pubis Using the suffix -derma, name the following conditions of the skin: 64. ____________________ white skin 65. ____________________ yellow skin 66. ____________________ dry skin 67. ____________________ red skin 68. ____________________ hard skin Give the medical terms for the following exanthematous viral diseases: 69. German measles____________________________________________________________ 70. chickenpox_________________________________________________________________ 71. 14-day measles _____________________________________________________________ 130 Medical Terminology: The Language of Health Care Match the following primary lesions with their descriptions: 72. ________ vesicle a. tiny, flat discolored spot on the skin, up to 1 cm diameter 73. ________ pustule b. large, flat discolored area on the skin, larger than 1 cm diameter 74. ________ papule c. solid mass on skin less than 0.5 cm diameter 75. ________ bulla d. solid mass greater than 1 cm that extends into the epidermis 76. ________ nodule e. solid mass greater than 1 cm limited to the skin’s surface 77. ________ wheal f. small blister 78. ________ macule g. area of localized skin edema, such as a hive 79. ________ tumor h. large blister 80. ________ patch i. pus-filled sac 81. ________ plaque j. solid mass larger than 1–2 cm diameter Write the abbreviation used to identify the following terms: 82. biopsy ____________________________________________________________________ 83. incision and drainage ______________________________________________________ 84. basal cell carcinoma ________________________________________________________ 85. herpes virus that causes cold sores ___________________________________________ 86. culture and sensitivity ______________________________________________________ 87. systemic lupus erythematosus _______________________________________________ Match the following terms: 88. ________ scabies a. chemical peel 89. ________ cryosurgery b. purpuric lesion 90. ________ telangiectasia c. eczema 91. ________ tinea d. xenograft 92. ________ heterograft e. intense light 93. ________ actinic keratoses f. desiccation 94. ________ radiation therapy g. spider angioma 95. ________ petechia h. solar keratoses 96. ________ homograft i. allograft Chapter 5 • Integumentary System 131 97. ________ laser j. cancer treatment 98. ________ chemosurgery k. freezing treatment 99. ________ electrosurgery l. mycosis 100. ________ dermatitis m. mites Write the plural forms of the following terms: 101. keratosis _________________________________________________________________ 102. bulla _____________________________________________________________________ 103. nevus ____________________________________________________________________ 104. macula ___________________________________________________________________ 105. ecchymosis _______________________________________________________________ Briefly describe the difference between the following terms: 106. electrodesiccation/fulguration ______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 107. actinic keratoses/seborrheic keratoses _______________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 108. vitiligo/albinism ___________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 109. cicatrix/keloid _____________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 110. dermatosis/dermatitis______________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 111. incisional biopsy/excisional biopsy __________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 132 Medical Terminology: The Language of Health Care 112. heterograft/allograft _______________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 113. closed comedo/open comedo _______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 114. cutaneous lupus/systemic lupus erythematosus_______________________________ _______________________________________________________________________________ _______________________________________________________________________________ 115. dysplastic nevus/malignant melanoma_______________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Write in the missing words on the blank lines in the following illustration of the skin. 116–120. Hair shaft 116. layer Receptor for (stratum corneum) touch 117. layer Pore (stratum germinativum) 118. 119. Pilomotor muscle Sebaceous gland 120. tissue Sweat gland Hair follicle Free nerve ending Adipose tissue Receptor for pressure Venule Arteriole Nerve Chapter 5 • Integumentary System 133 For each of the following, circle the correct spelling of the term: 121. cicatrix scicatrix cicatrex 122. pruritis purritis pruritus 123. petechia patechia petecchia 124. veruca verucca verruca 125. eckamosis ecchymosis eckemyosis 126. excission excisison excision 127. soriasis psoreyeasis psoriasis 128. impetigo infantiego impatiego 129. eggszema eczema ecczema 130. debridemant debridement debreedment Give the noun that was used to form the following adjectives: 131. __________ keratotic 132. __________ bullous 133. __________ nodular 134. __________ seborrheic 135. __________ petechial 136. __________ ecchymotic 137. __________ urticarial 138. __________ eczematous 139. __________ macular 140. __________ suppurative 134 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 5 . 1 Progress Note S: This is a 30 y.o.  presenting with an erythematous and scaly eruption on the face and ears  6 mo. Stress and emotional tensions aggravate the rash. Over-the- counter remedies provide no relief. O: Patchy erythema with greasy, yellowish scaling appears over the nose and along the eyebrows. The external ears are similarly affected. Erythematous papules are scattered across the face, and there is ↑oiliness around the nose. A: Seborrheic dermatitis P: Rx: hydrocortisone cream, ss̄ oz tube Sig: apply to affected areas t.i.d. 1. What is the sex of the patient? 4. How much hydrocortisone cream was pre- a. male scribed? b. female a. one ounce c. not stated b. two ounces c. one-half dram 2. What is the patient’s CC? d. one dram a. stress and emotional tension e. one-half ounce b. appearance of raised, yellow, pus-filled lesions on the skin 5. What is the Sig: on the prescription? c. appearance of red areas on the skin with flak- a. apply to affected areas twice a day ing of the outer layers of the skin b. apply to affected areas three times a day d. appearance of red areas on the skin with open c. apply to affected areas four times a day sores d. apply to affected areas every 2 hours e. appearance of a communicable rash on the e. apply to affected areas every 3 hours face and ear 3. What is the diagnosis? a. inflammation of the sebaceous glands and hair follicles of the skin evidenced by comedones b. fungus of the skin c. inflammation of the skin with excessive secre- tion of sebum from the sebaceous glands d. highly contagious bacterial skin inflammation marked by pustules that rupture and become crusted e. transient, viral cold sores that infect the facial area Chapter 5 • Integumentary System 135 M E D I C A L R E C O R D 5 . 2 After ignoring various skin problems for months, Robert Fuller consulted his doctor in October when he became alarmed by what he saw happening on his right hand. His doctor referred him to Dr. Luong, a dermatologist, who then diagnosed and treated Mr. Fuller. Directions Read Medical Record 5.2 for Robert Fuller (page 136) and answer the following ques- tions. This record is a SOAP progress note dictated by Dr. Luong immediately after the treatment of Mr. Fuller and transcribed the next day by his assistant. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 5 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record that you have not yet encountered in this text. Underline each where it appears in the record and define below: vulgaris ___________________________________________________________________ verruciform ________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe Mr. Fuller’s complaint. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. In your own words, not using medical terminology, briefly describe Dr. Luong’s three objective findings. a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 4. Define the three diagnoses for those three objective findings. a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 5. Briefly describe the treatments for those three diagnoses: a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 136 Medical Terminology: The Language of Health Care 6. What did Dr. Luong tell Mr. Fuller might occur in the future? Check all that apply: _____ scarring where the lesions were _____ nausea and possible vomiting from the nitrogen _____ red, freckle-like spots appearing on the right hand _____ possible regrowth of lesions _____ self-desiccating tissue destruction Medical Record 5.2 Chapter 5 • Integumentary System 137 M E D I C A L R E C O R D 5 . 3 About 5 months ago, Patricia Brown saw Dr. Luong, the dermatologist, and was treated for a skin problem. Since she was told then that there was a chance of recur- rence, she has watched that area of her skin carefully. When what looked to her like a small dot appeared in the same area, she called Dr. Luong for another appointment. Directions Read Medical Record 5.3 for Patricia Brown (page 138) and answer the following ques- tions. This record is the progress note dictated by Dr. Luong after treating her and tran- scribed the next day by his assistant. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 5 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: pigmented __________________________________________________________________ margin _____________________________________________________________________ defect ______________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe what Dr. Lu- ong found in the first visit 5 months ago and the treatment he then gave: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Dr. Malloy analyzed a tissue sample for Dr. Luong 5 months ago and diagnosed the lesion marked C. Translate her diagnosis into lay language: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. Before initiating treatment of the recurrent lesion in this visit, Dr. Luong fully ex- plained to Ms. Brown the likely and possible results. What three specific things (in nonmedical language) did she agree to accept as possible risks? a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 138 Medical Terminology: The Language of Health Care Medical Record 5.3 Chapter 5 • Integumentary System 139 5. Treatment of the recurrent lesion involved several steps. Put the following actions in correct order by numbering them 1 to 5: _____ sample sent to lab _____ suture removal _____ excision of tumor

and surrounding area _____ patient’s permission given _____ suturing the wound 6. What, briefly, is Dr. Malloy’s role this time? Is this the same as or different from her role in Ms. Brown’s first treatment? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 140 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 5 . 4 Mary Chen’s physician, Dr. Ogawa, treated her for a skin lesion more than 2 months ago and more recently did a biopsy after that carcinoma apparently recurred. Dr. Ogawa then referred Mary to Dr. Volkman, a dermatologic surgeon. Directions Read Medical Record 5.4 (pages 141–142) for Mary Chen and answer the following questions. This record is the operative report dictated by Dr. Volkman after perform- ing the surgery. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 5 . 4 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: supine ______________________________________________________________________ gentian (crystal) violet _______________________________________________________ hemostasis _________________________________________________________________ flap (full thickness) __________________________________________________________ 2. In your own words, not using medical terminology, briefly describe Ms. Chen’s preoperative diagnosis. ____________________________________________________________________________ Now describe the meaning of the addition to that diagnosis in the postoperative diagnosis. ____________________________________________________________________________ 3. In your own words, describe Dr. Ogawa’s earlier treatment of Ms. Chen’s lesion. ____________________________________________________________________________ ____________________________________________________________________________ 4. The surgery was performed with Ms. Chen in what position? a. lying flat, face down b. lying flat, face up c. lying on her side d. sitting Chapter 5 • Integumentary System 141 Medical Record 5.4 142 Medical Terminology: The Language of Health Care Medical Record 5.4 Continued. Chapter 5 • Integumentary System 143 5. Put the following surgical actions in correct order to describe the surgery by num- bering them 1 to 8: _____ removing the gross tumor _____ stopping the bleeding _____ applying antibiotics _____ outlining clinical margins of the tumor _____ removing first underlying layer _____ evaluating tissues microscopically _____ administering local anesthetic _____ removing second and third layers 6. Translate the surgeon’s phrase “Hemostasis was obtained with electrocautery”: ____________________________________________________________________________ ____________________________________________________________________________ 7. Describe a “frozen section”: __________________________________________________ ____________________________________________________________________________ How many frozen sections were analyzed in this surgery? ______________________ 8. For the other two physicians mentioned, give their specializations and their roles in treating Ms. Chen now and in the future: Dr. O’Connor’s specialization _________________________________________________ role in treatment ____________________________________________________________ Dr. Jensen’s specialization ___________________________________________________ role in treatment ____________________________________________________________ 9. Translate the instructions for the two medications Ms. Chen will be taking postop- eratively: Drug Name Route of Administration Dose Frequency of Dose ____________ ______________________ _________ _________________ ____________ ______________________ _________ _________________ 10. In your own words, not using medical terminology, briefly describe the addi- tional treatment to be considered for Ms. Chen. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Chapter 6 Musculoskeletal System OBJECTIVES After completion of this chapter you will be able to Define common combining forms used in relation to the musculoskeletal system Describe the basic functions of the musculoskeletal system Define the basic anatomical terms referring to the musculoskeletal system Describe the anatomical position List the planes of the body Define positional and directional terms Define the terms related to body movements Define common symptomatic and diagnostic terms related to the musculoskeletal system List common diagnostic tests and procedures related to the musculoskeletal system Identify common operative terms referring to the musculoskeletal system Identify common therapeutic terms including drug classifications related to the muscu- loskeletal system Explain the terms and abbreviations used in documenting medical records involving the musculoskeletal system Combining Forms Combining Form Meaning Example ankyl/o crooked or stiff ankylotic ang-ki-lotik arthr/o joint (articulation) arthritis ar-thrı̄tis articul/o articular ar-tikyū-lăr brachi/o arm brachium brākē-ŭm cervic/o neck cervical servı̆-kal chondr/o cartilage (gristle) chondral kondrăl 144 Chapter 6 • Musculoskeletal System 145 Combining Form Meaning Example cost/o rib intercostal in-ter-kostăl crani/o skull cranial krānē-ăl dactyl/o digit (finger or toe) dactylomegaly DIGIT. The Latin daktil-ō-megă-lē term for finger or toe. Digit in the fasci/o fascia (a band) fasciodesis sense of a number was fas-ē-odĕ-sis derived from the habit of femor/o femur femoral counting on the fingers, femŏ-răl which probably accounts for the decimal system. fibr/o fiber fibrous Digitalis, the heart drug, is fibrŭs an extract of the purple foxglove plant, also known kyph/o humpback kyphosis as ladies fingers. kı̄-fōsis lei/o smooth leiomyoma lı̄o-mı̄-ōmă lord/o bent lordosis lŏr-dōsis lumb/o loin (lower back) lumbar lŭmbar myel/o bone marrow or spinal cord myelitis mı̄-ĕ-lı̄tis my/o muscle myalgia mı̄-aljē-ă myos/o myositis mı̄-ō-sı̄tis muscul/o muscular mŭskyū-lăr oste/o bone osteomyelitis ostē-o-mı̄-ĕ-lı̄tis patell/o knee cap patellar pa-telăr pelv/i hip bone or pelvic cavity pelvimeter pel-vimĕ-ter pelv/o pelvic pelvik radi/o radius radial rādē-ăl rhabd/o rod shaped or striated (skeletal) rhabdomyoma rabdō-mı̄-ōmă sarc/o flesh sarcoma sar-kōmă scoli/o twisted scoliosis skō-lē-ōsis 146 Medical Terminology: The Language of Health Care Combining Form Meaning Example spondyl/o vertebra spondylitis spon-di-lı̄tis vertebr/o vertebral vertĕ-brăl stern/o sternum (breastbone) sternocostal sternō-kostăl ten/o tendon (to stretch) tenodesis tĕ-nodē-sis tend/o tendolysis ten-doli-sis tendin/o tendinitis ten-di-nı̄tis thorac/o chest thoracic thō-rasik ton/o tone or tension myotonia mı̄-ō-tōnē-ă uln/o ulna ulnar ŭlnăr Musculoskeletal System Overview The musculoskeletal system provides support and gives shape to the body. The skele- SKELETON. ton gives structure to the body by providing a framework of bones and cartilage. Also, Skeleton is the bones store calcium and other minerals and produce certain blood cells within the derived from a bone marrow (Figs. 6.1 to 6.4). Greek word meaning “dried The muscles cover the bones where they hinge (articulate) and supply the forces up.” The Greeks used the that make movement possible. They also provide a protective covering for internal or- term in reference to a mummy or dried-up body. gans and produce body heat (Figs. 6.5 and 6.6). They never used the word in the modern meaning of the bony framework of the Anatomical Terms Related to Bones (Figs. 6.1 to 6.4) body. The first recorded use Term Meaning of the modern term in English occurred in 1578. appendicular skeleton bones of shoulder, pelvis, and upper and lower apen-dikyū-lăr extremities ELBOW. Many terms referring to axial skeleton bones of skull, vertebral column, chest, and hyoid the elbow are aksē-ăl bone (U-shaped bone lying at the base of the based on the L-shape tongue); refer to Figure 6.4 for abbreviated formed at the joint. This is identification and numbering of cervical, thoracic, the basis of the “el” of and lumbar vertebrae elbow. It is also the root of the Latin term ulna. An “ell” bone specialized connective tissue composed of was an old measure of osteocytes (bone cells) forming the skeleton length, particularly of cloth, being the amount from the TYPES OF BONE TISSUE elbow (or shoulder) to the compact bone tightly solid, strong bone tissue resistant to fingers, which was a convenient way of rapidly bending measuring lengths. Boga spongy (cancellous) bone mesh-like bone tissue containing marrow and fine was a bending or a bow. spŭnjē kansĕ-lŭs branching canals through which blood vessels run Chapter 6 • Musculoskeletal System 147 Cranium Skull Face Hyoid 1 Clavicle 2 Manubrium 3 Scapula 4 Sternum 5 Ribs 6 7 Xiphoid process 8 Humerus 9 10 Vertebral column 11 Iliac crest 12 Ilium Ischium Ulna Radius Carpals Metacarpals Trochanter Phalanges Pubic bone Femur Sacrum Coccyx Patella Tibia Fibula Tarsals Metatarsals Calcaneus Phalanges Anterior view Posterior view Color key: Appendicular skeleton Axial skeleton Figure 6.1 The skeleton. Term Meaning CLASSIFICATION OF BONES long bones bones of arms and legs short bones bones of wrists and ankles flat bones bones of ribs, shoulder blades, pelvis, and skull irregular bones bones of vertebrae and face sesamoid bones round bones found near joints (e.g., patella) sesă-moyd Anatomy of a long bone Joints of lower limb Hip joint Epiphysis Articular Head cartilage Greater Spongy (cancellous) trochanter bone Neck Epiphyseal disk (plate) Lesser trochanter Red marrow Linea aspera Compact bone Medullary cavity containing marrow Nutrient artery Knee joint Diaphysis Head Neck Yellow marrow Tibial tuberosity Periosteum Interosseous ligament Medial malleolus Lateral malleolus Articular cartilage Ankle joint Talus Epiphysis Calcaneus Anterior view Posterior view Anatomy of joints Lateral view (hip joint) Lateral view (knee joint) Extension Flexion Lateral Patellar condyle ligament Extension Flexion Lateral view (ankle joint) Talus Calcaneus Dorsiflexion Plantarflexion Figure 6.2 Anatomy of bone and joints. 148 Anterior view Frontal bone Parietal bone Supraorbital foramen Greater wing of Lacrimal bone sphenoid bone Ethmoid bone Temporal bone Nasal bones Zygomatic bone Infraorbital foramen Maxilla bone Median nasal septum Mandible Inferior nasal concha Mental foramen THE SKULL: Lateral view Coronal suture Frontal bone Parietal bone Sphenoid bone Lacrimal bone Nasal bone Occipital bone Maxilla Temporal bone Zygomatic bone External auditory Mandible meatus Superior view Lambdoidal suture Occipital bone Sagittal Parietal bone suture Coronal suture Frontal bone Nasal bone Three-dimensional CT reconstruction of a skull showing traumatic injury to facial bones suffered as the result of a motor vehicle accident. Figure 6.3 The skull. 149 150 Medical Terminology: The Language of Health Care THE VERTEBRAE: Lateral view C1 C2 Cervical C3 C4 C1–C7 C5 C6 C7 T1 T2 T3 T4 T5 T6 Thoracic T7 T1–T12 T8 T9 T10 T11 T12 L1 L2 Lumbar L1–L5 L3 L4 L5 Sacrum (5 fused pieces) Coccyx (3–4 fused pieces) Superior view (L2) Magnetic resonance image of portions of the lower vertebrae (lower thoracic, lumbar, sacrum, Spinous process and coccyx) demonstrating normal anatomy. Lamina of vertebral arch Inferior articular process Lateral view Transverse process Spinal cord in neural canal Superior articular facet Pedicle of vertebral arch L3 Vertebral foramen Vertebral body Spinous Lateral view (L2) process L4 Intervertebral Superior articular Superior vertebral notch Transverse disk (disc) process Pedicle process Transverse process Nucleus L5 Spinous process Vertebral pulposus body Laminae Lamina Inferior vertebral notch Inferior articular facet Figure 6.4 The vertebrae. Chapter 6 • Musculoskeletal System 151 Frontalis Galea aponeurotica Temporalis Occipitalis Orbicularis oculi Zygomaticus Sternocleidomastoid Orbicularis oris Trapezius Masseter Deltoid Buccinator Pectoralis major Coracobrachialis Latissimus dorsi Teres minor Serratus Triceps brachii anterior External oblique Teres major Biceps Brachialis under biceps brachii Anconeus Rectus Flexor carpi radialis abdominis Flexor carpi ulnaris Linea Brachioradialis alba Removed Extensor carpi external radialis longus oblique Extensor digitorum Internal Extensor carpi oblique radialis brevis Extensor carpi ulnaris Palmar aponeurosis Transversus Iliotibial band Gluteus abdominis medius Tensor fasciae Iliopsoas Gluteus latae Pectineus maximus Gracilis Adductor longus Sartorius Adductor magnus Vastus lateralis Rectus femoris Peroneus longus Vastus medialis Tibialis anterior Biceps femoris Calcaneus tendon Adductor magnus Soleus Semimembranosus Peroneus longus Semitendinosus Extensor hallucis Peroneus brevis longus Plantaris Gastrocnemius Anterior view Posterior view Figure 6.5 Muscles of the body. 152 Medical Terminology: The Language of Health Care Skeletal muscle tissue Striations Nucleus Muscle fiber Cardiac muscle tissue Striations Muscle fiber Intercalated disk Nucleus Smooth muscle tissue Muscle fiber Nucleus Figure 6.6 Architecture of the three types of muscle. Chapter 6 • Musculoskeletal System 153 Term Meaning PARTS OF A LONG BONE (SEE FIG. 6.2) epiphysis wide ends of a long bone (physis  growth) e-pifi-sis diaphysis shaft of a long bone dı̄-afi-sis metaphysis growth zone between epiphysis and diaphysis mĕ-tafi-sis during development of a long bone endosteum membrane lining the medullary cavity of a bone en-dostē-ŭm medullary cavity cavity within the shaft of the long bones filled with medŭ-lār-ē bone marrow bone marrow soft connective tissue within the medullary cavities marō of bones red bone marrow found in cavities of most bones in infants; functions in formation of red blood cells, some white blood cells, and platelets; in adults, red bone marrow is found most often in the flat bones yellow bone marrow gradually replaces red bone marrow in adult bones, functions as storage for fat tissue, and is inactive in formation of blood cells periosteum a fibrous, vascular membrane that covers the bone per-ē-ostē-ŭm articular cartilage a gristle-like substance found on bones where they ar-tikyū-lăr karti-lij articulate Anatomical Terms Related to Joints and Muscles (Figs. 6.2 to 6.7) Term Meaning ANKLE. Ank, a very old Greek articulation a joint; the point where two bones come together root meaning artik-yū-lāshŭn (Fig. 6.7) bend or angle, is the origin of the term for the ankle joint. bursa a fibrous sac between certain tendons and bones It is also associated with bersă that is lined with a synovial membrane that ankyl/o, a

combining form secretes synovial fluid meaning crooked or bent. disk (disc) a flat, plate-like structure composed of fibrocartilaginous tissue found between the vertebrae to reduce friction (see Fig. 6.4) BURSA. A Latin word for a purse nucleus pulposus the soft, fibrocartilaginous, central portion of was given to the nuklē-ŭs pŭl-pōsŭs intervertebral disk small synovial pouch associated with a joint. The ligament a flexible band of fibrous tissue that connects bone meaning stems from the use ligă-ment to bone (Fig. 6.8) of a purse by the bursar, the man who holds the purse in synovial membrane membrane lining the capsule of a joint order to pay out of it. Most si-nōvē-ăl membrān anatomical terms come from synovial fluid lubricating fluid secreted by the synovial the names of familiar objects si-nōvē-ăl flūid membrane [e.g., patella (dish), acetabulum (bowl)]. 154 Medical Terminology: The Language of Health Care Bursa Joint cavity filled with synovial fluid Patella Extracapsular ligament Joint capsule Intracapsular ligament Fat pad Meniscus Figure 6.7 Lateral view of the knee joint. Term Meaning muscle tissue composed of fibers that can contract, mŭsĕl causing movement of an organ or part of the body (see Figs. 6.5 and 6.6) striated (skeletal) muscle voluntary striated muscle attached to the skeleton striā-ted (skele-tăl) smooth muscle involuntary muscle found in internal organs cardiac muscle muscle of the heart origin of a muscle muscle end attached to the bone that does not move when the muscle contracts Lower end Posterior of femur cruciate ligament Medial condyle Lateral condyle Anterior cruciate Lateral ligament meniscus Medial meniscus Lateral (fibular) Medial (tibial) collateral collateral ligament ligament Fibula Tibia Figure 6.8 Posterior view of the knee and ligaments. Chapter 6 • Musculoskeletal System 155 Term Meaning insertion of a muscle muscle end attached to the bone that moves when the muscle contracts tendon a band of fibrous tissue that connects muscle to tendŏn bone fascia a band or sheet of fibrous connective tissue that FASCIA. Fascia fashē-ă covers, supports, and separates muscle is derived from a Latin word for a band or bandage derived Anatomical Position and Terms of Reference from fascis, a bundle (the bandage that ties up a bundle, especially a band To communicate effectively about the body, health professionals use terms with spe- around a bundle of sticks). cific meanings to refer to body positions, directions, and planes. These terms of refer- Fasces were bundles of ence are based on the body being in anatomical position, in which the person is sticks from which an ax assumed to be standing upright (erect), facing forward, feet pointed forward and projected; they were carried slightly apart, arms at the sides with palms facing forward. The patient is visualized in by Roman officials. In the this pose before applying any other term of reference. 20th century, fasces were With the body in an anatomical position, three different imaginary lines divide the adopted in Italy as a body in half, forming body planes. In addition to the three body planes, positional and political party badge, hence directional terms are used to indicate the location or direction of body parts in respect the term “fascist.” In to each other (Fig. 6.9). anatomy, the sheets of connective tissue that wrap the muscles or other parts Term Meaning are called fascia. Many are named for those who first BODY PLANES described them, such as Camper, Scarpa, Colles. coronal (frontal) plane vertical division of the body into front (anterior) kōrŏ-năl (frŭntăl) and back (posterior) portions sagittal plane vertical division of the body into right and left saji-tăl portions transverse plane horizontal division of the body into upper and trans-vers lower portions TERMS OF POSITION AND DIRECTION anterior (A) (ventral) front of the body an-tērē-ōr (ventrăl) posterior (P) (dorsal) back of the body pos-tērē-ōr (dorsăl) anterior-posterior (AP) from front to back; commonly associated with the direction of an x-ray beam posterior-anterior (PA) from back to front; commonly associated with the direction of an x-ray beam superior (cephalic) situated above another structure, toward the head su-pērē-ōr (se-falik) inferior (caudal) situated below another structure, away from the in-fērē-ōr (kawdăl) head 156 Medical Terminology: The Language of Health Care Body planes Superior (cephalic) Lateral Anterior Posterior (ventral) (dorsal) Medial Inferior (caudal) Sagittal plane Coronal or frontal plane Transverse plane Body cavities Thoracic cavity Cranial Esophagus Dorsal Trachea Pleural cavity Pleura Spinal Thoracic Abdominal Lung Lung Bronchial tubes Ventral Abdomino- pelvic Pelvic Mediastinum Diaphragm Figure 6.9 Body planes and cavities. Chapter 6 • Musculoskeletal System 157 Term Meaning proximal toward the beginning or origin of a structure [e.g., proksi-măl the proximal aspect of the femur (thigh bone) is the area closest to where it attaches to the hip] distal away from the beginning or origin of a structure distăl [e.g., the distal aspect of the femur (thigh bone) is the area at the end of the bone near the knee] medial toward the middle (midline) mēdē-ăl lateral toward the side later-ăl axis line that runs through the center of the body or a aksis body part BODY POSITIONS erect normal standing position ĕ-rĕkt decubitus lying down, especially in bed; i.e., lateral decubitus dē-kyūbi-tŭs is lying on the side (decumbo  to lie down) prone lying face down and flat prōn recumbent lying down rē-kŭmbent supine horizontal recumbent; lying flat on the back— sū-pı̄n “on the spine” (Fig. 6.10) BODY MOVEMENTS (FIG. 6.11) flexion bending at the joint so that the angle between the flekshŭn bones is decreased extension straightening at the joint so that the angle between eks-tenshŭn the bones is increased abduction movement away from the body ab-dŭkshŭn adduction movement toward the body ă-dukshŭn rotation circular movement around an axis rō-tāshŭn eversion turning outward, i.e., of a foot ē-verzhŭn inversion turning inward, i.e., of a foot in-verzhŭn Figure 6.10 Supine (horizontal re- cumbent position). Patient lies on back with the legs extended. 158 Medical Terminology: The Language of Health Care Flexion Extension Abduction Adduction Rotation Additional movements of the feet Additional movements of the hands and arm Eversion Inversion Pronation Supination Additional movements of the feet Dorsiflexion Plantar flexion Figure 6.11 Body movements. Term Meaning supination turning upward or forward of the palmar surface sūpi-nāshŭn (palm of the hand) or plantar surface (sole of the foot) pronation turning downward or backward of the palmar prō-nāshŭn surface (palm of the hand) or plantar surface (sole of the foot) dorsiflexion bending of the foot or the toes upward dōr-si-flekshŭn plantar flexion bending of the sole of the foot by curling the toes plantăr toward the ground range of motion (ROM) total motion possible in a joint, described by the terms related to body movements, i.e., ability to flex, extend, abduct, or adduct; measured in degrees goniometer instrument used to measure joint angles (gonio  gō-nē-omĕ-ter angle) (Fig. 6.12) Chapter 6 • Musculoskeletal System 159 Figure 6.12 Dorsal placement of goniometer used when measuring digital motion. Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC arthralgia joint pain ar-thraljē-ă atrophy shrinking of tissue such as muscle atrō-fē crepitation grating sound made by movement of some joints or krep-i-tāshŭn broken bones crepitus krep-i-tŭs exostosis a projection arising from a bone that develops from eks-os-tōsis cartilage flaccid flabby, relaxed, or having defective or absent muscle flasid tone hypertrophy increase in the size of tissue such as muscle hı̄-pertrō-fē hypotonia reduced muscle tone or tension hı̄pō-tōne-ă myalgia muscle pain mı̄-aljē-ă myodynia mı̄ō-dinē-ă ostealgia bone pain os-tē-aljē-ă osteodynia os-tē-o-dinē-ă rigor or rigidity stiffness; stiff muscle riger or ri-jidi-tē 160 Medical Terminology: The Language of Health Care Term Meaning spasm drawing in; involuntary contraction of muscle spazm spastic uncontrolled contractions of skeletal muscles causing spastik stiff and awkward movements (resembles spasm) tetany tension; prolonged, continuous muscle contraction tetă-nē tremor shaking; rhythmic muscular movement tremer DIAGNOSTIC ankylosis stiff joint condition angki-lōsis arthritis inflammation of the joints characterized by pain, ar-thrı̄tis swelling, redness, warmth, and limitation of motion— there are more than 100 different types of arthritis osteoarthritis (OA) most common form of arthritis that especially affects ostē-ō-ar-thrı̄tis weight-bearing joints (e.g., knee, hip); characterized by the erosion of articular cartilage (Fig. 6.13) degenerative arthritis dē-jener-ă-tiv ar-thrı̄tis degenerative joint disease (DJD) dē-jener-ă-tiv joynt di-zēz Normal hip Hip with mild arthritis Spine Cartilage Shoulder Hip Hip with moderate arthritis Hip with severe arthritis Knee A B Figure 6.13 Osteoarthritis. A. Common sites of osteoarthritis. B. How osteoarthritis affects the hip. Chapter 6 • Musculoskeletal System 161 Term Meaning rheumatoid arthritis (RA) most crippling form of arthritis characterized by a rūmă-toyd ar-thrı̄tis chronic, systemic inflammation most often affecting joints and synovial membranes (especially in the hands and feet) causing ankylosis (stiff joints) and de- formity (Fig. 6.14) gouty arthritis acute attacks of arthritis usually in a single joint GOUT. The term gowtē ar-thrı̄tis (especially the great toe) caused by hyperuricemia for gout stems (an excessive level of uric acid in the blood) from the Latin word meaning a drop. Known to the ancients, the condition was thought to be caused by a liquid secretion that was distilled drop by drop on the diseased part. Cartilage Synovial membrane Bone atrophy Figure 6.14 Joints of the hand affected by rheumatoid arthritis. A. X-ray of normal hand. B. X-ray of hand with rheumatoid arthritis. 162 Medical Terminology: The Language of Health Care Term Meaning bony necrosis dead bone tissue from loss of blood supply such as nĕ-krōsis can occur after a fracture (sequestrum  something sequestrum laid aside) sē-kwestrŭm bunion swelling of the joint at the base of the great toe caused bŭnyŭn by inflammation of the bursa bursitis inflammation of a bursa ber-sı̄tis carpal tunnel syndrome condition that results from compression of the karpăl median nerve within the carpal tunnel at the wrist, characterized by pain, numbness, and tingling in the wrist and fingers and weak grip; commonly seen as a result of cumulative trauma of surrounding tendons (Fig. 6.15) chondromalacia softening of cartilage kondrō-mă-lāshē-ă epiphysitis inflammation of epiphyseal regions of the long bone e-pif-i-sı̄tis Figure 6.15 Carpal tunnel con- taining the median nerve and the flexor tendons of the fingers and thumb. Chapter 6 • Musculoskeletal System 163 Term Meaning fracture (Fx) a broken or cracked bone (Fig. 6.16) frakchūr closed fracture a broken bone with no open wound open fracture compound fracture; a broken bone with an open wound simple fracture a nondisplaced fracture involving one fracture line that does not require extensive treatment to repair (e.g., hairline Fx, stress Fx, or crack) complex fracture a displaced fracture that requires manipulation or surgery to repair fracture line line made by broken bone (e.g., oblique, spiral, or transverse) comminuted fracture broken in many little pieces komi-nū-ted greenstick fracture bending and incomplete break of a bone—most often seen in children herniated disk or disc protrusion of a degenerated or fragmented hernē-ā-ted intervertebral disk so that the nucleus pulposus protrudes, causing compression on the nerve root (see Chapter 10, Fig. 10.9) myeloma bone marrow tumor mı̄-ĕ-lōmă myositis inflammation of muscle mı̄-ō-sı̄tis myoma muscle tumor mı̄-ōmă leiomyoma smooth muscle tumor lı̄ō-mı̄-ōmă leiomyosarcoma malignant smooth muscle tumor lı̄ō-mı̄ō-sar-kōmă rhabdomyoma skeletal muscle tumor rabdō-mı̄-omă rhabdomyosarcoma malignant skeletal muscle tumor rabdō-mı̄-ō-sar-kōmă muscular dystrophy a category of genetically transmitted diseases mŭskyū-lăr distrō-fē characterized by progressive atrophy of skeletal muscles (Duchenne’s type is most common) osteoma bone tumor os-tē-ōmă osteosarcoma type of malignant bone tumor ostē-ō-sar-kōmă osteomalacia disease marked by softening of the bone caused ostē-ō-mă-lāshē-ă by calcium and vitamin D deficiency rickets osteomalacia in children (causes bone deformity) rikets 164 Medical Terminology: The Language of Health Care A Comminuted Greenstick Oblique Spiral Transverse B C Figure 6.16 A. Types of common fracture. B. AP radiograph of lower leg demonstrating open fractures of the tibia and fibula (ar- rows). C. Lateral view radiograph demonstrating a closed spiral fracture of the tibia (arrows). (Note: -graph is the preferred suffix used in radiology to refer to an x-ray record.) Chapter 6 • Musculoskeletal System 165 Term Meaning osteomyelitis infection of bone and bone marrow causing ostē-ō-mı̄-ĕ-lı̄tis inflammation osteoporosis condition of decreased bone density and increased ostē-ō-pō-rōsis porosity, causing bones to become brittle and liable to fracture (porosis  passage) (Fig. 6.17) spinal curvatures (Fig. 6.18) spı̄năl kyphosis abnormal posterior curvature of the thoracic spine kı̄-fōsis (humpback condition) lordosis abnormal anterior curvature of the lumbar spine lōr-dōsis (sway-back condition) scoliosis abnormal lateral curvature of the spine (S-shaped skō-lē-ōsis curve) (Fig. 6.19) Normal bone Osteoporotic bone Normal

spine in premenopausal Spine compression and loss woman of height due to osteoporosis in postmenopausal woman Figure 6.17 Osteoporosis. 166 Medical Terminology: The Language of Health Care Normal Kyphosis Lordosis Scoliosis Figure 6.18 Spinal curvatures. Figure 6.19 AP thoracic spine radiograph demonstrating scoliosis. Chapter 6 • Musculoskeletal System 167 L3 Defect L4 Anterior displacement of L5 vertebra Sacral 5 canal L5 S1 S2 S3 Dotted line follows posterior vertebral margins of L5 and the sacrum A B Figure 6.20 Spondylolisthesis. A. Drawing illustrates forward slipping of L5 vertebra. B. X-ray showing displacement. Term Meaning spondylolisthesis forward slipping of a lumbar vertebra (listhesis  spondi-lō-lis-thēsis slipping) (Fig 6.20) spondylosis stiff, immobile condition of vertebrae due to joint spon-di-lōsis degeneration sprain injury to a ligament caused by joint trauma but sprān without joint dislocation or fracture subluxation a partial dislocation (luxation  dislocation) sŭb-lŭk-sāshŭn (Fig. 6.21) tendinitis inflammation of a tendon ten-di-nı̄tis tendonitis ten-dō-nı̄tis Diagnostic Tests and Procedures Test or Procedure Explanation electromyogram (EMG) a neurodiagnostic graphic record of the ē-lek-trō-mı̄ō-gram electrical activity of muscle at rest and during contraction to diagnose neuromusculoskeletal disorders (e.g., muscular dystrophy); usually performed by a neurologist 168 Medical Terminology: The Language of Health Care Subluxation of jaw in open mouth position Normal jaw position of open mouth Figure 6.21 Subluxation. Test or Procedure Explanation magnetic resonance imaging a nonionizing imaging technique using (MRI) magnetic fields and radiofrequency waves măg-nĕtik rezō-nans imă-jing to visualize anatomical structures—useful in orthopedics to detect joint, tendon, and vertebral disk disorders (see MRI of spine in Fig. 6.4 and MRI of knee in Chapter 4, Fig. 4.17A) nuclear medicine ionizing imaging technique using radioactive nūklē-er isotopes radionuclide organ imaging rādē-ō-nūklı̄d bone scan radionuclide image of bone tissue to detect tumor, malignancy, etc. (see whole-body bone scan in Chapter 4, Fig. 4.16B) X-RAYS. Wilhelm radiography (x-ray) x-ray imaging; an ionizing technique commonly Roentgen rādē-ogră-fē used in orthopedics to visualize the extremities, discovered x-rays in 1895. ribs, back, shoulders, joints, etc. (see Fig. 6.19 and He used the expression rays first radiograph in Chapter 4, Fig. 4.14) for the sake of brevity and named them x-rays to arthrogram an x-ray of a joint taken after injection of a contrast distinguish them from others arthrō-gram medium of the same name. The first diskogram an x-ray of an intervertebral disk after injection of a x-ray image was made of diskō-gram contrast medium Roentgen’s wife’s hand. Chapter 6 • Musculoskeletal System 169 Test or Procedure Explanation dual-energy x-ray an x-ray scan that measures bone mineral density of absorptiometry the spine and extremities to diagnose osteoporosis, (DEXA) determine fracture risk, and monitor treatment; ab-sōrptomĕ-trē classifications of bone mass include normal, osteopenic, or osteoporotic as indicated by a T score (amount of bone mass of the patient compared to that of a normal young adult) computed tomography a specialized x-ray procedure producing a series of (CT) cross-sectional images that are processed by a tō-mogră-fē computer into a 2-dimensional or 3-dimensional computed axial image (see Fig. 6.3) tomography (CAT) sonography ultrasound imaging; a nonionizing technique useful sŏ-nogră-fē in orthopedics to visualize muscles, ligaments, displacements, and dislocations or to guide a therapeutic intervention such as that performed during arthroscopy Operative Terms Term Meaning amputation partial or complete removal of a limb; AKA, am-pyū-tāshŭn above-knee amputation; BKA, below-knee amputation arthrocentesis puncture for aspiration of a joint arthrō-sen-tēsis arthrodesis binding or fusing of joint surfaces ăr-thrō-dēsĭs arthroplasty repair or reconstruction of a joint arthrō-plas-tē arthroscopy procedure using an arthroscope to examine, ar-throskă-pē diagnose, and repair a joint from within (Fig. 6.22) bone grafting transplantation of a piece of bone from one site to another to repair a skeletal defect bursectomy excision of a bursa ber-sektō-mē myoplasty repair of muscle mı̄ō-plas-tē open reduction, internal internal surgical repair of a fracture by bringing fixation (ORIF) of a fracture bones back into alignment and fixing them into place, often utilizing plates, screws, pins, etc. (Fig. 6.23) osteoplasty repair of bone ostē-ō-plas-tē 170 Medical Terminology: The Language of Health Care Tiny incisions, known as portals, are made for insertion Portal for insertion of a of arthroscope and other cannula for flow of saline instruments solution to expand joint space or rinse away blood or debris Operating portal for Insertion of fiberoptic, insertion of specialized camera-equipped arthroscope instruments and motorized provides illumination and equipment used to repair magnified examination of structures and remove joint interior, which is also damaged tissue projected on a video monitor Figure 6.22 Scene of arthroscopic knee surgery with projection of surgeon’s view on a video monitor. Term Meaning osteotomy an incision into bone os-tē-otō-mē spondylosyndesis spinal fusion (see Chapter 10, Fig. 10.24B) spondi-lō-sin-dēsis tenotomy division by incision of a tendon to repair a te-notō-mē deformity caused by shortening of a muscle Chapter 6 • Musculoskeletal System 171 Figure 6.23 An x-ray image taken after open reduction, internal fixation (ORIF) of the right ankle (see Medical Record 6.2). Therapeutic Terms Term Meaning closed reduction, external external manipulation of a fracture to regain fixation of a fracture alignment along with application of an external device to protect and hold the bone in place while healing casting use of a stiff, solid dressing around a limb or other body part to immobilize it during healing (Fig. 6.24) splinting use of a rigid device to immobilize or restrain a broken bone or injured body part; provides less support than a cast, but can be adjusted easier to accommodate for swelling from an injury (Fig. 6.25) traction (Tx) application of a pulling force to a fractured trakshŭn bone or dislocated joint to maintain proper position during healing (Fig. 6.26) closed reduction, external manipulation of a fracture to regain percutaneous fixation of alignment, followed by insertion of one or more a fracture pins through the skin to maintain position—often includes use of an external device called a fixator to keep the fracture immobilized during healing (Fig. 6.27) 172 Medical Terminology: The Language of Health Care Figure 6.24 Applying a short arm cast. Figure 6.25 Finger splint. BRACE. A Latin Term Meaning word from brachia, the orthosis use of an orthopedic appliance to maintain a arms, was originally used as ōr-thōsis bone’s position or provide limb support (e.g., back, a measure of length (the two knee, or wrist brace) (Fig. 6.28) extended arms), or a pair. The meaning was expanded physical therapy (PT) treatment to rehabilitate patients disabled by to the idea of two arms that fizi-kăl theră-pē illness or injury, involving many different connect, support, or modalities (methods), such as exercise, hydrother- strengthen, i.e., to brace. apy, diathermy, and ultrasound Braces in the form of splints were used in ancient Egypt prosthesis an artificial replacement for a diseased or and by most surgeons prosthē-sis missing body part such as a hip, joint, or limb throughout the centuries. (Fig. 6.29) Figure 6.26 Cervical traction. Chapter 6 • Musculoskeletal System 173 Figure 6.27 This radiograph, taken after closed re- Figure 6.28 Examples of orthoses: back, knee, and wrist. duction, percutaneous fixation of an open comminuted distal tibia/fibula fracture, shows placement of an exter- nal fixator to maintain pin placement during the healing process. The injury was the result of a gunshot to the right lower extremity. A B Figure 6.29 A. Prosthetist holding an above-the-knee prosthesis with an array of prostheses on the table in the fore- ground. B. A prosthetic leg makes it possible for an above-the-knee amputee to lead an active life. 174 Medical Terminology: The Language of Health Care COMMON THERAPEUTIC DRUG CLASSIFICATIONS analgesic a drug that relieves pain an-ăl-jēzik narcotic a potent analgesic that has addictive properties nar-kotik anti-inflammatory a drug that reduces inflammation antē-in-flamă-tō-rē antipyretic a drug that relieves fever antē-pı̄-retik nonsteroidal anti-inflammatory a group of drugs with analgesic, anti- drug (NSAID) inflammatory, and antipyretic properties non-stēroy-dăl (e.g., ibuprofen, aspirin) commonly used to treat arthritis Summary of Chapter 6 Acronyms/Abbreviations A .................anterior MRI...........magnetic resonance imaging AKA ..........above-knee amputation NSAID.....nonsteroidal anti-inflammatory drug AP...............anterior-posterior OA .............osteoarthritis BKA ..........below-knee amputation ORIF ........open reduction, internal fixation CAT ...........computed axial tomography P ..................posterior CT...............computed tomography PT ...............physical therapy DEXA ......dual-energy x-ray absorptiometry RA ..............rheumatoid arthritis DJD ..........degenerative joint disease ROM.........range of motion EMG .........electromyogram Tx ..............traction Fx ..............fracture x-ray .........radiography Chapter 6 • Musculoskeletal System 175 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE hypertrophy _______ / _______ / _______ P R S hyper/troph/y P R S DEFINITION: above or excessive/nourishment or development/condition or process of 1. thoracic __________________ / __________________ R S DEFINITION: _________________________________________________________________ 2. myofascial __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 3. arthropathy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 4. spondylolysis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. osteopenia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 6. achondroplasia __________________ / __________________ / __________________ / __________________ P CF R S DEFINITION: _________________________________________________________________ 7. ostealgia __________________ / __________________ R S DEFINITION: _________________________________________________________________ 176 Medical Terminology: The Language of Health Care 8. polymyositis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 9. leiomyosarcoma __________________ / __________________ / __________________ / __________________ CF CF R S DEFINITION: _________________________________________________________________ 10. myelocyte __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 11. costovertebral __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 12. musculotendinous __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 13. orthosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 14. kyphoplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 15. craniectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 16. arthrodesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 17. fibromyalgia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 6 • Musculoskeletal System 177 18. rhabdomyoma __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 19. sternocostal __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 20. intra-articular __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 21. syndactylism __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 22. lumbodynia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 23. cervicobrachial __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 24. arthroscopy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 25. lordosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 26. inter __________________ al  pertaining to between the ribs 27. __________________ algia  joint pain 28. myo __________________  incision in a muscle 29. spondylosyn __________________  binding together of vertebrae 178 Medical Terminology: The Language of Health Care 30. __________________ myoma  smooth muscle tumor 31. osteo __________________  softening of bone 32. __________________ listhesis  slipping of a vertebra 33. arthro __________________  x-ray of a joint 34. __________________ tomy  incision into bone 35. epiphys __________________  inflammation of the ends of the long bones 36. __________________ al  pertaining to the neck 37. bony __________________ osis  dead bone tissue 38. __________________ oma  tumor of cartilage 39. arthro __________________  puncture for aspiration of a joint 40. osteo __________________  repair or reconstruction of bone For each of the following, circle the combining form that corresponds to the meaning given: 41. cartilage crani/o cost/o chondr/o 42. vertebra myel/o spondyl/o lumb/o 43. bone marrow my/o myel/o muscul/o 44. neck thorac/o crani/o cervic/o 45. joint oste/o arthr/o ankyl/o 46. chest thorac/o cervic/o spondyl/o 47. muscle my/o myel/o lei/o 48. rib stern/o chondr/o cost/o Write the correct medical term for each of the following: 49. lateral curvature of the spine ________________________________________________ 50. bone tumor ________________________________________________________________ 51. grating sound made by movement of broken bones ____________________________ 52. synonym for bony necrosis __________________________________________________ 53. plane that divides the body into right and left portions _________________________ 54. application of a pulling force to a fractured or dislocated joint to maintain proper position during healing _____________________________________________________ Chapter 6 • Musculoskeletal System 179 55. arthritis caused by hyperuricemia____________________________________________ 56. a partial dislocation ________________________________________________________ 57. toward the beginning of a structure __________________________________________ 58. osteomalacia in children ____________________________________________________ 59. physician specializing in x-ray technology ____________________________________ Match the following terms related to muscles with their meaning: 60. ________ atrophy a. uncontrolled, stiff, and awkward muscle contractions 61. ________ tremor b. flabby muscle 62. ________ spasm c. involuntary muscle contraction 63. ________ rigidity d. prolonged, continuous muscle contraction

64. ________ spastic e. stiff muscle 65. ________ hypertrophy f. rhythmic muscle movement 66. ________ flaccid g. increase in the size of a muscle 67. ________ tetany h. shrinking of muscle size Briefly describe the difference between the following terms: 68. arthrogram/arthroscopy_____________________________________________________ _______________________________________________________________________________ 69. rhabdomyoma/rhabdomyosarcoma __________________________________________ _______________________________________________________________________________ 70. osteoarthritis/rheumatoid arthritis ___________________________________________ _______________________________________________________________________________ 71. osteomalacia/osteoporosis___________________________________________________ _______________________________________________________________________________ 72. orthosis/prosthesis__________________________________________________________ _______________________________________________________________________________ 73. closed reduction, external fixation of a Fx/open reduction, internal fixation of a Fx _______________________________________________________________________________ 74. ankylosis/spondylosis _______________________________________________________ _______________________________________________________________________________ 180 Medical Terminology: The Language of Health Care 75. leiomyoma/leiomyosarcoma _________________________________________________ _______________________________________________________________________________ 76. lordosis/kyphosis ___________________________________________________________ _______________________________________________________________________________ 77. spondylolisthesis/spondylosyndesis___________________________________________ _______________________________________________________________________________ Match the following positions: 78. ________ erect a. lying down, especially in bed 79. ________ supine b. normal standing 80. ________ decubitus c. face down and flat 81. ________ prone d. horizontal recumbent (“on the spine”) Define the following abbreviations: 82. CT ________________________________________________________________________ 83. PT_________________________________________________________________________ 84. Tx_________________________________________________________________________ 85. ROM ______________________________________________________________________ 86. Fx _________________________________________________________________________ 87. EMG ______________________________________________________________________ For each of the following, circle the correct spelling of the term: 88. spondelosis spandalosis spondylosis 89. scholiosis scoliosis scoleosis 90. arthrodynia arthradynia arthrodenia 91. osteoalgia ostealgia osstealgia 92. sagital saggittal sagittal Chapter 6 • Musculoskeletal System 181 93. flaccid flacid flascid 94. sekquestrum sequestrom sequestrum 95. anklylosis ankylosis anklosis 96. chondral chrondral chondrel 97. dorsaflexion dorsiflexion dorsflexion 98. osteoparosis osteoporosis osteophorosis 99. rabdomyoma rrhabdomyoma rhabdomyoma Write in the missing words on the blank lines in the following illustrations of body planes. 100–107. 105. (cephalic) 102. 104. Lateral (ventral) (dorsal) 100. 106. (caudal) 101. plane 103. Coronal or plane 107. plane 182 Medical Terminology: The Language of Health Care Write in the missing words on the blank lines in the following illustrations of body movements. 108–118. 108. 109. 110. 111. 112. Additional movements of the feet Additional movements of the hands and arms 113. 114. 115. 116. Additional movements of the feet 117. 118. Chapter 6 • Musculoskeletal System 183 Write in the missing anatomical terms on the blank lines in the following illustrations. 119–143. 120. 119. Face Hyoid 1 122. 2 Manubrium 3 123. 4 124. 5 Ribs 6 7 125. 8 126. 9 10 Vertebral column 11 Iliac crest 12 127. 128. 129. 130. 131. 132. 133. 121. Pubic bone 134. 141. 142. 135. 136. 137. 138. 139. 143. 140. Anterior view Posterior view Color key: Appendicular skeleton Axial skeleton 184 Medical Terminology: The Language of Health Care Give the noun that was used to form the following adjectives: 144. orthotic __________________________________________________________________ 145. hypertrophic______________________________________________________________ 146. radial ____________________________________________________________________ 147. kyphotic__________________________________________________________________ 148. bursal ____________________________________________________________________ 149. dystrophic ________________________________________________________________ 150. necrotic __________________________________________________________________ 151. osteoporotic ______________________________________________________________ 152. lordotic___________________________________________________________________ 153. ulnar _____________________________________________________________________ 154. scoliotic __________________________________________________________________ 155. prosthetic ________________________________________________________________ Chapter 6 • Musculloskellettall Systtem 185 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 6 . 1 History and Physical Examination CC: “attacks” of right knee discomfort and instability HPI: This 19 y/o  presents with “attacks” of right knee pain and instability. Three years ago, while playing basketball, he turned sharply and felt his kneecap pop in and out. It was acutely swollen and painful and required manipulation to reduce it. He had a course of PT and did reasonably well for a few months until resuming athletic activ- ities. Since then, he has had recurrent episodes of the knee slipping in and out, all re- lated to twisting and turning while surfing or playing basketball. His primary com- plaint is the episodic discomfort and the inability to trust the knee. He is asymptomatic at this time. PMH: NKDA. Hx of right ankle Fx in 20xx. Meds: none. Operations none. SH: alcohol rarely used. FH: Father, age 49, Mother, age 43, both L&W. ROS: noncontributory PE: The patient is a cooperative male in NAD. VS: T 97.2° F., P 64, R 14, BP 118/66 HEENT: WNL. Neck: supple, no tenderness, full ROM, no adenopathy. Lungs, heart, abdomen: WNL. Back: no tenderness or deformity. Extremities: unremarkable except for involved knee. Knee ROM is 0–45° equally. There is no parapatellar tenderness. Neurologic: Negative. Radiographs show subluxation of the right knee. IMP: RECURRENT RIGHT KNEE PATELLAR INSTABILITY RECOMMENDATION: Patelloplasty is being discussed, and the risks and benefits of the procedure have been explained. The patient will return with his parents for further consultation before deciding whether to proceed with treatment. 1. Which describes the patient’s symptoms at the time of the initial injury? a. severe pain over a short course b. pain that comes and goes c. pain that progressively gets worse d. pain that develops slowly over time e. no pain 2. What treatment was provided 3 years ago? a. puncture for aspiration of a joint b. transplantation of a piece of bone from one site to another c. examination of a joint from within d. physical rehabilitation including exercise e. binding or fusing joint surfaces 186 Medical Terminology: The Language of Health Care 3. Which best describes the patient’s symptoms at the time of this visit? a. severe pain b. moderate pain c. progressive pain d. mild pain e. no pain 4. Describe the orthopedic condition noted in the past history: a. forward slipping of a vertebra b. broken bone c. arthritis d. bone pain e. dislocation 5. What does full ROM indicate? a. swelling b. spasm c. inflammation d. bruising e. mobility 6. What did the radiographs indicate? a. no radiographs were mentioned b. patellar instability c. partial dislocation d. inflammation e. joint stiffness 7. What treatment did the physican recommend? a. surgical reconstruction of the knee cap b. physical therapy c. surgical repair of bone d. excision of the patella e. examination and repair of a joint from within using an endoscope Chapter 6 • Musculoskeletal System 187 M E D I C A L R E C O R D 6 . 2 As Alice Toohey was playing with her young granddaughter, she stepped on a toy dump truck and fell down her porch steps, wrenching her ankle violently. Because of the sharp pain and immediate swelling, Ms. Toohey was taken immediately to the hos- pital. After being seen by the emergency room physician, she was admitted and sched- uled for surgery. Directions Read Medical Record 6.2 for Alice Toohey (page 189) and answer the following questions. This record is the operative report dictated by the surgeon, Dr. Ricardo Rodriguez, immediately after the operation and processed by a medical transcriptionist. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 6 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: malleolus ___________________________________________________________________ oblique _____________________________________________________________________ sterile_______________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe the preoperative diagnosis for Ms. Toohey. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Put the following operative steps in correct order by numbering them 1 to 10: ____ x-ray of the screws that were too long ____ incision on the outer side of the ankle ____ plate placed onto the fibula ____ sewing the incisions ____ x-ray of satisfactory screw position ____ towel clip positioned ____ removal of medial hematoma ____ removal of lateral hematoma ____ placement of a screw into the lower tibia ____ incision on the inner side of the right ankle 188 Medical Terminology: The Language of Health Care 4. In this operation, the surgeon redid one step after using a diagnostic procedure to check whether that step was as effective as possible. In your own words, explain what Dr. Rodriguez changed and why. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. Describe the fracture line. ____________________________________________________________________________ 6. When Dr. Rodriguez examined the ankle after making the first incision, he found a problem he could not and did not repair. In your own words, what had been destroyed in Ms. Toohey’s injury? ____________________________________________________________________________ ____________________________________________________________________________ 7. Which of the following actions did not occur in this operation? a. washing the wound with antibiotic b. taping the fracture line c. drilling holes in the bone d. stapling the skin closed 8. Describe Ms. Toohey’s condition when transferred to PAR after the operation. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 6 • Musculoskeletal System 189 Medical Record 6.2 190 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 6 . 3 Jay Dorn, a retired construction worker, has had intermittent back pain for the last 2 months. When he began also having shooting pains in his legs, he went to his doctor at Central Medical Center. After a physical examination, Mr. Dorn underwent a series of back x-rays. Directions Read Medical Record 6.3 for Jay Dorn (page 191) and answer the following questions. This record is the radiographic report dictated by Dr. Mary Volz, the radiographer, af- ter studying Mr. Dorn’s x-rays and later transcribed for the record. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 6 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: eburnation _________________________________________________________________ lipping _____________________________________________________________________ discogenic __________________________________________________________________ 2. What phrase in the report indicates that more than one x-ray was taken? ____________________________________________________________________________ Does the report state how many x-rays were taken? __________ no __________ yes If yes, how many? ________________________________ 3. In your own words, not using medical terminology, describe the three diagnoses Dr. Volz makes. a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 4. Not using any abbreviations, explain what test Dr. Volz says may be useful for Mr. Dorn to have next. ____________________________________________________________________________ 5. Which of the following is not mentioned in the report as a finding? a. lateral curvature of the spine b. forward slipping of a vertebra c. immobile condition of the spine d. inflammation of the bone marrow e. inflammation of both hips Chapter 6 • Musculoskeletal System 191 Medical Record 6.3 Chaptter 7 Cardiovascular System OBJECTIVES After completion of this chapter you will be able to Define common combining forms used in relation to the cardiovascular system Identify basic anatomical terms referring to the heart and blood vessels Trace the flow of blood through the heart Define blood pressure and related terms Describe the pathway of electrical conduction in the heart and define related terms Define common symptomatic terms referring to the cardiovascular system Identify common diagnostic terms related to the cardiovascular system List the common diagnostic tests and procedures related to the cardiovascular system Identify common operative terms referring to the cardiovascular system Identify common therapeutic terms including drug classifications related to the cardiovascular system Explain terms and abbreviations used in documenting medical records involving the cardiovascular system Combining Forms Combining Form Meaning Example angi/o vessel angiogram anjē-ō-gram vas/o vasospasm vāsō-spazm vascul/o vascular vasku-lar aort/o aorta aortic ā-ōrtik arteri/o artery arteriosclerosis ar-tērēōskler-ōsis ather/o fatty (lipid) paste atheroma ath-er-ōmaă 192 Chapter 7 • Cardiovascular System 193 Combining Form Meaning Example atri/o atrium atrioventricular atrē-ō-ven-trikyū-lăr cardi/o heart cardiology kar-dē-olō-jē coron/o circle or crown coronary kōro-nār-ē my/o muscle myocardial mı̄-ō-kardē-ăl pector/o chest pectoral pektŏ-ral steth/o stethoscope stethō-skōp sphygm/o pulse sphygmomanometer sfig-mō-mă-nomĕ-ter thrombo clot thrombocyte thrombō-sı̄t ven/o vein venous vēnŭs phleb/o phlebitis flĕ-bı̄tis varic/o swollen, twisted vein varicosis vār-i-kōsis ventricul/o ventricle (belly or pouch) ventricular ven-trikyū-lăr Cardiovascular System Overview The cardiovascular system consists of the heart and blood vessels that transport blood throughout the body. The heart is the muscular organ that pumps blood throughout the body (Fig. 7.1). Its hollow interior has four chambers: the right atrium and left atrium (upper cham- bers) and the right ventricle and left ventricle (lower chambers). A partition, called the septum, divides the heart into right and left portions. The atria are separated by the in- teratrial septum, and the ventricles are separated by the interventricular septum. The valves of the heart open and close with the heartbeat to maintain the one-way flow of blood through the heart. They include the tricuspid valve, the mitral (bicuspid) valve, the pulmonary semilunar valve, and the aortic valve. There are three layers of the heart: endocardium, myocardium, and epicardium. The endocardium is the membrane that

lines the interior cavities of the heart; the my- ocardium is the thick, muscular layer; and the epicardium is the outer membrane. Sur- rounding and enclosing the heart is a loose, protective sac called the pericardium. Blood transports essential elements within the body. It is circulated throughout the body via arteries, arterioles, capillaries, venules, and veins. (Blood is discussed sepa- rately in Chapter 8.) Blood flow through the heart is as follows. Deoxygenated (depleted of oxygen) blood returning from circulation in the body en- ters the heart through the superior vena cava and inferior vena cava into the right atrium. During atrial contraction, the tricuspid valve opens to allow blood to flow into the right ventricle. Contraction of the ventricle pushes blood through the pulmonary STRUCTURES OF THE HEART (arrows indicate path of blood flow) Superior vena cava Aortic arch Interatrial septum Aorta Pulmonary artery Pulmonary veins Pulmonary veins Left atrium Mitral valve Aortic valve Right atrium Pulmonary semilunar valve Left ventricle Tricuspid valve Interventricular septum Endocardium Right ventricle Myocardium Epicardium Inferior vena cava Pericardium BLOOD CIRCULATION ECHOCARDIOGRAM Normal, two - dimensional, apical four-chamber view Upper extremity Vein Artery Lung Lung Capillaries Lower extremity Figure 7.1 The heart and blood circulation. Chapter 7 • Cardiovascular System 195 semilunar valve into the pulmonary artery. The pulmonary artery carries the blood through two branches going to the lungs and on through the pulmonary circulation (a network of arteries, capillaries, air sacs, and veins in the lung), where it is oxygenated (supplied with oxygen) and gives off carbon dioxide waste. The oxygenated blood re- turns to the heart via the pulmonary veins into the left atrium. With atrial contraction, the mitral valve (also called bicuspid valve) opens to allow blood flow into the left ven- tricle. Contraction of the left ventricle pushes blood through the aortic valve into the aorta. Blood is then carried to all parts of the body through the systemic circulation (ar- teries, arterioles, capillaries, and veins) to provide transport for oxygen and nutrients. Note that the right side of the heart (right heart) handles deoxygenated blood and the left side of the heart (left heart) handles oxygenated blood. The heart is the first organ to receive oxygenated blood via the coronary circula- tion. Branching from the aorta, the right and left coronary arteries divide to distribute blood throughout the entire heart (Fig. 7.2). Anatomical Terms Term Meaning SEPTA AND LAYERS OF THE HEART atrium upper right and left chambers of the heart ātrē-ŭm endocardium membrane lining the cavities of the heart en-dō-kardē-ŭm epicardium membrane forming the outer layer of the heart ep-i-kardē-ŭm interatrial septum partition between right and left atrium in-ter-ā-trē-ăl septŭm interventricular septum partition between right and left ventricle in-ter-ven-trikyū-lăr septŭm myocardium heart muscle mı̄-ō-kardē-ūm pericardium protective sac enclosing the heart composed of two per-i-kardē-ūm layers with fluid between parietal pericardium outer layer (parietal  pertaining to wall) pā-rı̄ē-tāl pericardial cavity fluid-filled cavity between the pericardial layers pēr-ı̄-kardē-āl visceral pericardium layer closest to the heart (visceral  pertaining to viser-āl organ) MITRAL. Stems ventricle lower right and left chambers of the heart from mitre, the ventri-kāl Latin word referring to a kind of cap or VALVES OF THE HEART AND VEINS headband worn on the head and tied under the heart valves structures within the heart that open and close chin, and used to name the with the heartbeat to regulate the one-way flow of headdress of Christian blood bishops. In medicine, the aortic valve heart valve between the left ventricle and the aorta term mitral is applied to the ā-ōrtik bicuspid valve of the heart because its two parallel mitral or bicuspid valve heart valve between the left atrium and left cusps have a shape similar mı̄trăl or bı̄-kŭspid ventricle (cuspis  point) to a bishop’s mitre. ANTERIOR VIEW OF POSTERIOR VIEW OF CORONARY ARTERIES CORONARY ARTERIES Superior vena Arch of aorta Superior vena cava cava Pulmonary trunk Sinoatrial nodal Left coronary artery artery Circumflex branch Right Anterior pulmonary Right interventricular veins coronary artery artery Left marginal artery Diagonal artery Atrioventricular nodal artery Right marginal artery Posterior interventricular artery Anterior interventricular artery PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) Predilation angiogram revealing 99% PTCA procedure showing catheter Post-PTCA angiogram showing stenosis of the right coronary artery (RCA). placement and straddling of the balloon successful dilation. at the occluded site. Catheter and wire placement with balloon inflation. Figure 7.2. Coronary arteries and angiograms illustrating angioplasty. Chapter 7 • Cardiovascular System 197 Term Meaning pulmonary semilunar valve heart valve opening from the right ventricle to the pŭlmō-nār-ē sem-ē-lūnăr pulmonary artery (luna  moon) tricuspid valve valve between the right atrium and the right trı̄-kŭspid ventricle valves of the veins valves located at intervals within the lining of veins, especially in the legs, which constrict with muscle action to move the blood returning to the heart BLOOD VESSELS (FIG. 7.3) arteries vessels that carry blood from the heart to the ărtĕr-ēz arterioles (Fig. 7.4) aorta large artery that is the main trunk of the arterial ā-ōrtă system branching from the left ventricle Lungs Artery Vein Heart Valve Veennuulele Lymph node Arrtterriiolle Valve Lymph vessels Lymph capillaries Tissue cells Blood capillaries Deoxygenated blood Oxygenated blood Figure 7.3 Blood and lymph circulation. 198 Medical Terminology: The Language of Health Care ARTERIAL BLOOD CIRCULATION Arteries (carry blood from the heart) Tunica media Carotid artery Arch of aorta Tunica externa Pulmonary artery Brachial Endothelium artery Aorta Tunica Subendothelial layer intima Artery Internal elastic lamina Normal Doppler color flow study of internal carotid artery Femoral artery Abnormal Doppler color flow study showing occlusion of carotid artery Figure 7.4 Arteries. Chapter 7 • Cardiovascular System 199 Term Meaning arterioles small vessels that receive blood from the arteries ăr-tērē-ōlz capillaries tiny vessels that join arterioles and venules CAPILLARY. kapi-lār-ēz A term formed from the Latin venules small vessels that gather blood from the capillaries word capillus, a hair of the venyūlz into the veins head (from caput, meaning veins vessels that carry blood to the heart from the head, and pilus, a hair), vānz venules (Fig. 7.5) hence a very fine tube. Leonardo da Vinci was the CIRCULATION first to make observations on capillary phenomena and systemic circulation circulation of blood throughout the body through spoke of capillary veins. sis-tēmik arteries, arterioles, capillaries, and veins to deliver oxygen and nutrients to body tissues coronary circulation circulation of blood through the coronary blood kōro-nār-ē vessels to deliver oxygen and nutrients to the heart muscle tissue pulmonary circulation circulation of blood from the pulmonary artery pūlmō-nār-ē through the vessels in the lungs and back to the heart via the pulmonary vein, providing for the exchange of gases Blood Pressure Blood pressure is the force exerted by circulating blood on the walls of the arteries, veins, and heart chambers. This pressure is determined by the volume of blood, the space within the arteries and arterioles, and the force of heart contractions (Fig. 7.6). Blood pressure (BP) technique involves measuring pressure within the walls of an artery during the period of contraction of the heart, or systole, and during the period of relaxation of the heart, or diastole. When blood pressure is written, the systolic measurement is recorded first, followed by a slash, then the diastolic measurement (e.g., BP 120/80 means that the systolic reading is 120 and the diastolic reading is 80). Blood Pressure Terms Term Meaning diastole to expand; period in the cardiac cycle when blood dı̄-astō-lē enters the relaxed ventricles from the atria systole to contract; period in the cardiac cycle when the sistō-lē heart is in contraction and blood is ejected through the aorta and pulmonary artery normotension normal blood pressure nōr-mō-tenshŭn hypotension low blood pressure hı̄pō-tenshŭn hypertension high blood pressure hı̄per-tenshŭn 200 Medical Terminology: The Language of Health Care VENOUS CIRCULATION Veins (carry blood to the heart) Tunica Jugular vein externa Subclavian vein Tunica media Superior vena cava Cephalic Endothelium Inferior vein Subendothelial vena cava layer Tunica ternal elastic intima Vein In lamina FEMORAL THROMBUS Artery Vein Femoral vein Thrombus Color flow Doppler showing femoral vein thrombus Figure 7.5 Veins. Chapter 7 • Cardiovascular System 201 Figure 7.6 Blood pressure determination. Cardiac Conduction Movement of blood through the heart is made possible by cardiac conduction. The cardiac cycle is the repeated action of the heart during which an electrical impulse is conducted from the sinoatrial (SA) node (the pacemaker of the heart) to the atrioven- tricular (AV) node, to the bundle of His, to the left and right bundle branches, and to the Purkinje fibers, causing contraction of the heart and circulation of the blood (Fig. 7.7). Initiated by the SA node, each myocardial cell responds to stimulation conducted by electrical impulses, changing from a resting state (polarized) to a state of contrac- tion (depolarized) and then returning to a resting state by recharging (repolarizing); it is then ready again to begin the continuous cycle of contraction and relaxation of the myocardium that pumps blood through the heart. Cardiac Conduction Terms Term Meaning sinoatrial node (SA node) the pacemaker; highly specialized neurological sı̄nō-ātrē-ăl nōd tissue, embedded in the wall of the right atrium, responsible for initiating electrical conduction of the heartbeat, causing the atria to contract and firing conduction of impulses to the AV node atrioventricular node neurological tissue in the center of the heart that (AV node) receives and amplifies the conduction of impulses ātrē-ō-ven-trikyū-lăr from the SA node to the bundle of His bundle of His neurological fibers, extending from the AV node to bŭndl the right and left bundle branches, that fire the impulse from the AV node to the Purkinje fibers 202 Medical Terminology: The Language of Health Care Term Meaning Purkinje fibers (network) fibers in the ventricles that transmit impulses to pŭr-kinjē f ı̄berz the right and left ventricles, causing them to contract polarization resting; resting state of a myocardial cell pōlăr-i-zāshŭn depolarization change of a myocardial cell from a polarized dē-pō-lār-i-zāshŭn (resting) state to a state of contraction (de  not; polarization  resting) repolarization recharging of the myocardial cell from a contracted rē-pō-lăr-i-zāshŭn state back to a resting state (re  again; polarization  resting) normal sinus rhythm (NSR) regular rhythm of the heart cycle stimulated by the SA node (average rate of 60 to 100 beats/minute) (see Figs. 7.7 and 7.11) SA node AV node Left bundle Bundle of His Right bundle Purkinje fibers A SA AV node node Bundle of His Purkinje fibers Firing from SA node across atria Firing from AV node to bundle of His, Firing of Purkinje fibers showing (contraction of atria) to AV node down right and left bundle branches contraction of ventricles B Figure 7.7 Cardiac conduction. A. Anatomy. B. Path of conduction. Chapter 7 • Cardiovascular System 203 Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC TERMS (FIG. 7.8) arteriosclerosis thickening, loss of elasticity, and calcification ar-tērēōskler-ōsis (hardening) of the arterial walls atherosclerosis buildup of fatty substances within the walls of ather-ō-skler-ōsis arteries atheromatous plaque a swollen area within the lining of an artery caused ath-er-ōmă-tŭs plak by the buildup of fat (lipids) thrombus a stationary blood clot thrombŭs embolus a clot (e.g., air, fat, foreign object) carried in the embō-lŭs bloodstream that obstructs when it lodges (embolus  a stopper) stenosis condition of narrowing of a part ste-nō-sis constriction compression of a part kon-strikshŭn occlusion plugging; obstruction or a closing off ŏ-klūzhŭn ischemia to hold back blood; decreased blood flow to tissue is-kēmē-ă caused by constriction or occlusion of a blood vessel A Constriction Atheromatous Thrombus Embolus plaque B Ischemia Infarction Obstruction Occlusion Oxygenated Oxygen-deficient Oxygenated Dead tissue cells tissue cells tissue cells tissue cells Figure 7.8 A. Examples of conditions causing reduction of blood flow. B. Effects of reduction of blood flow. 204 Medical Terminology: The Language of Health Care Term Meaning perfusion deficit a lack of flow through a blood vessel caused by per-fyūzhŭn defi-sit narrowing, occlusion, etc. infarct to stuff; a localized area of necrosis (condition of infarkt tissue death) caused by ischemia as a result of occlusion of a blood vessel angina pectoris chest pain caused by a temporary loss of anji-nā pektō-ris oxygenated blood to heart muscle often caused by narrowing of the coronary arteries (angina  to choke) aneurysm a widening; bulging of the wall of the heart, the anyū-rizm aorta, or an artery caused

by congenital defect or acquired weakness (Fig. 7.9) saccular a sac-like bulge on one side săk-ū-lăr fusiform a spindle-shaped bulge fūzĭ-form dissecting a split or tear of the vessel wall dı̄-sĕkting claudication to limp; pain in a limb (especially the calf) while klaw-di-kāshŭn walking that subsides after rest; it is caused by inadequate blood supply diaphoresis profuse sweating dı̄-ă-fō-rēsis heart murmur an abnormal sound from the heart produced by hart mermer defects in the chambers or valves palpitation subjective experience of pounding, skipping, or pal-pi-tāshŭn racing heartbeats vegetation to grow; an abnormal growth of tissue around a vej-ĕ-tāshŭn valve, generally a result of an infection such as bacterial endocarditis (Fig. 7.10) Common types of aneurysms Saccular Fusiform Dissecting Normal artery Artery with aneurysm Figure 7.9 Types of aneurysms. Chapter 7 • Cardiovascular System 205 Figure 7.10 The mitral valve shows destructive vegetations, which have eroded through the free margins of the valve leaflets in a patient with bacterial endocarditis. DIAGNOSTIC TERMS arrhythmia any of several kinds of irregularity or loss of ă-rithmē-ă rhythm of the heartbeat (Fig. 7.11) dysrhythmia dis-rithmē-ă bradycardia slow heart rate (60 beats/minute) brad-ē-kardē-ă fibrillation chaotic, irregular contractions of the heart, as in fib-ri-lāshŭn atrial or ventricular fibrillation flutter extremely rapid but regular contractions of the flŭter heart, as in atrial or ventricular flutter (typically from 250 to 350 beats/minute) heart block an interference with the normal electrical hart blok conduction of the heart defined by the location of the block (e.g., AV block) premature ventricular a ventricular contraction preceding the normal contraction (PVC) impulse initiated by the SA node (pacemaker) prē-mă-tūr ven-trikyū-lăr kon-trakshūn tachycardia fast heart rate (100 beats/minute) takikardē-ă arteriosclerotic heart a degenerative condition of the arteries disease (ASHD) characterized by thickening of the inner lining, ar-tērē-ō-skler-otik loss of elasticity, and susceptibility to rupture— seen most often in the aged or smokers bacterial endocarditis a bacterial inflammation that affects the bak-tērē-ăl endō-kar-dı̄tis endocardium or the heart valves (see Fig. 7.10) cardiac tamponade compression of the heart produced by the kardē-ak tam-pŏ-nād accumulation of fluid in the pericardial sac as results from pericarditis or trauma, causing rupture of a blood vessel within the heart (tampon  a plug) Normal sinus rhythm (NSR) Bradycardia Fibrillation (ventricular) Flutter (atrial) Heart block Premature ventricular contraction (PVC) Tachycardia (sinus) Figure 7.11 Electrocardiogram tracings showing common types of arrhythmia. 206 Chapter 7 • Cardiovascular System 207 Term Meaning cardiomyopathy a general term for disease of the heart muscle kardē-ō-mı̄-opă-thē [e.g., alcoholic cardiomyopathy (damage to the heart muscle caused by excessive consumption of alcohol)] congenital anomaly of malformations of the heart present at birth the heart (anomaly  irregularity) kon-jeni-tăl ă-nomă-lē atrial septal defect (ASD) an opening in the septum separating the atria ātrē-ăl septăl dēfekt coarctation of the aorta narrowing of the descending portion of the aorta kō-ark-tāshŭn resulting in a limited flow of blood to the lower part of the body (Fig. 7.12) patent ductus arteriosus an abnormal opening between the pulmonary (PDA) artery and the aorta caused by the failure of the pātĕnt dŭktŭs ăr-tĕr-ē-ōsŭs fetal ductus arteriosus to close after birth (patent  open) (Fig. 7.13) tetralogy of Fallot an anomaly that consists of four defects: tet-ral-ō-jē făl-ō pulmonary stenosis, ventricular septal defect, malposition of the aorta, and right ventricular hypertrophy—causes blood to bypass the pulmonary circulation so that deoxygenated blood goes into the systemic circulation, resulting in cyanosis (tetra  four) ventricular septal defect an opening in the septum separating the (VSD) ventricles ven-trikyū-lăr septăl dēfekt congestive heart failure failure of the left ventricle to pump an adequate (CHF) amount of blood to meet the demands of the kon-jestiv body, resulting in a “bottleneck” of congestion in left ventricular failure the lungs that may extend to the veins, causing edema in lower portions of the body cor pulmonale a condition of enlargement of the right ventricle kōr pul-mō-nālē as a result of chronic disease within the lungs right ventricular failure that causes congestion within the pulmonary circulation and resistance of blood flow to the lungs (cor  heart) Descending aorta Figure 7.12. Coarctation of the aorta. 208 Medical Terminology: The Language of Health Care Arch of aorta Ductus arteriosus Left pulmonary artery Pulmonary trunk Figure 7.13. Patent ductus arteriosus. Term Meaning coronary artery disease (CAD) a condition affecting arteries of the heart that reduces the flow of blood and delivery of oxygen and nutrients to the myocardium—most often caused by atherosclerosis (Fig. 7.14) hypertension (HTN) persistently high blood pressure hı̄per-tenshŭn essential (primary) high blood pressure attributed to no single cause, hypertension but risks include smoking, obesity, increased salt ĕ-senshăl hı̄per-tenshŭn intake, hypercholesterolemia, and hereditary factors secondary hypertension high blood pressure caused by the effects of another disease (e.g., kidney disease) mitral valve prolapse (MVP) protrusion of one or both cusps of the mitral valve mı̄trăl back into the left atrium during ventricular contraction, resulting in incomplete closure and backflow of blood Anterior interventricular artery Plaque buildup in artery wall Figure 7.14 Coronary artery disease. Chapter 7 • Cardiovascular System 209 Term Meaning myocardial infarction (MI) heart attack; death of myocardial tissue (infarction) mı̄-ō-kardē-ăl in-farkshŭn owing to loss of blood flow (ischemia) as a result of an occlusion (plugging) of a coronary artery— usually caused by atherosclerosis; symptoms include pain in the chest or upper body (shoulders, neck, and jaw), shortness of breath, diaphoresis, and nausea (Fig. 7.15) myocarditis inflammation of the myocardium most often mı̄o-kar-dı̄tis caused by viral or bacterial infection pericarditis inflammation of the pericardium peri-kar-dı̄tis phlebitis inflammation of a vein flĕ-bı̄tis rheumatic heart disease damage to heart muscle and heart valves by rū-matik rheumatic fever (a streptococcal infection) thrombophlebitis inflammation of a vein associated with a clot thrombō-flĕ-bı̄tis formation AUSCULTATION. varicose veins abnormally swollen, twisted veins with defective The Latin root vărĭ -kōs valves, most often seen in the legs (Fig. 7.16) means to listen or hear with attention. Listening deep vein thrombosis (DVT) formation of a clot in a deep vein of the body, to the sound of throm-bōsis occurring most often in the femoral and iliac veins the breathing and of the (see Fig 7.5) beating of the heart is an ancient art that was current in Hippocrates’ time. It was Diagnostic Tests and Procedures accomplished by placing the ear directly on the chest Test or Procedure Explanation wall—direct or immediate auscultation. Indirect or auscultation a physical examination method of listening to mediate auscultation has aws-kŭl-tāshŭn sounds within the body with the aid of a been used in modern times stethoscope (e.g., auscultation of the chest for since the invention of the heart and lung sounds) (Fig. 7.17) stethoscope. Figure 7.15 Anterolateral myocardial infarction (darkened area), caused by occlusion of the anterior descending branch of the left coronary artery. 210 Medical Terminology: The Language of Health Care Valve Valve opened closed Valve closed Valve open Valve closed Defective valve in varicose vein causing pooling of blood A B Figure 7.16 Varicose veins. A. Function of valves in the venous system. B. C Contraction of skeletal muscle causes valves to open and close, preventing backflow of blood returning to the heart. C. Photo of patient with varicose veins. Figure 7.17. Auscultating heart sounds. Chapter 7 • Cardiovascular System 211 Test or Procedure Explanation bruit noise; an abnormal heart sound caused by brū-ē turbulence within gallop an abnormal heart sound that mimics the gait of a horse; related to abnormal ventricular contraction electrocardiogram an electrical picture of the heart represented by (ECG or EKG) positive and negative deflections on a graph ē-lek-trō-kardē-ō-gram labeled with the letters P, Q, R, S, and T, corresponding to events of the cardiac cycle (Fig. 7.18) stress electrocardiogram an ECG of the heart recorded during the induction of controlled physical exercise using a treadmill or ergometer (bicycle); useful in detecting conditions such as ischemia and infarction (Fig. 7.19) Holter ambulatory monitor a portable electrocardiograph worn by the patient hōlter ambyū-lă-tōr-ē that monitors electrical activity of the heart over 24 moni-ter hours—useful in detecting periodic abnormalities intracardiac invasive procedure involving placement of electrophysiological catheter-guided electrodes within the heart to study (EPS) evaluate and map the electrical conduction of intr ă-kardē-ak cardiac arrhythmias; intracardiac catheter ablation ē-lektrō-fiz-ē-ō-loji-kăl may be performed at the same time to treat the stŭdē arrhythmia R S-T P segment T U Q S QRS P-R complex interval Q-T interval A B Figure 7.18 A. Electrocardiographic pattern associated with electrical conduction of the heart. B. Resting electrocardiography. 212 Medical Terminology: The Language of Health Care Figure 7.19 Stress electrocardiography. Test or Procedure Explanation intracardiac catheter use of radiofrequency waves sent through a ablation catheter within the heart to treat arrhythmias by intră-kardē-ak kathēter selectively destroying myocardial tissue at sites ab-lāshŭn generating abnormal electrical pathways magnetic resonance magnetic resonance imaging of the heart and angiography (MRA) blood vessels for evaluation of pathology (see rezō-nans an-jē-ogră-fē Chapter 10, Fig. 10.18) nuclear medicine imaging radionuclide organ imaging of the heart after of the heart administration of radioactive isotopes to visualize nūklē-ar medi-sin imă-jing structures and analyze functions myocardial radionuclide a scan of the heart made after an intravenous perfusion scan injection of an isotope (e.g., thallium) that is mı̄-ō-kardē-ăl absorbed by myocardial cells in proportion to rādē-ō-nūklı̄d per-fyūzhŭn blood flow throughout the heart myocardial radionuclide a nuclear scan of the heart taken after the perfusion stress scan induction of controlled physical exercise via treadmill or bicycle or administration of a pharmaceutical agent that produces the effect of exercise stress in patients unable to ambulate positron emission use of nuclear isotopes and computed tomography tomography (PET) scan techniques to produce perfusion (blood flow) of the heart images and study the cellular metabolism of the pozi-tron ē -mishshŭn heart; can be taken at rest or with stress tō-mogră-fē Chapter 7 • Cardiovascular System 213 Test or Procedure Explanation radiology x-ray imaging angiography an x-ray of a blood vessel after injection of contrast an-jē-ogră-fē medium angiogram a record obtained by angiography anjē-ō-gram coronary angiogram an x-ray of the blood vessels of the heart kōro-nār-ē anjē-ō-gram (see Fig. 7.2) arteriogram an x-ray of a particular artery (e.g., coronary ar-tēre-ō-gram arteriogram, renal arteriogram) aortogram an x-ray of the aorta ā-ōrtō-gram venogram an x-ray of a vein vēnō-gram cardiac catheterization introduction of a flexible, narrow tube or catheter kardē-ak kathĕ-ter-ı̄-zāshŭn through a vein or artery into the heart to withdraw samples of blood, measure pressures within the heart chambers or vessels, and inject contrast media for fluoroscopic radiography and cine film (motion picture) imaging of the chambers of the heart and coronary arteries—very often includes interventional procedures such as angioplasty and atherectomy (see endovascular procedures listed under “Operative Terms”) (Fig. 7.20) left heart catheterization an x-ray of the left ventricular cavity and coronary arteries right heart catheterization measurement of oxygen saturation and pressure readings of the right side of the heart ventriculogram an x-ray visualizing the ventricles ven-trikū-lō-gram stroke volume (SV) measurement of the amount of blood ejected from a ventricle in one contraction cardiac output (CO) measurement of the amount of blood ejected from either ventricle of the heart per minute ejection fraction measurement of the volume percentage of left ē-jekshŭn frakshŭn ventricular contents ejected with each contraction sonography sonographic imaging echocardiography (ECHO) recording of sound waves through the heart to ekō-kar-dē-ogr ă-f ē evaluate structure and motion (see Figs. 7.1 and 7.21) stress echocardiogram an echocardiogram of the heart recorded during (stress ECHO) the induction of controlled physical exercise via treadmill or bicycle or administration of a pharmaceutical agent that produces the effect of exercise stress in patients unable to ambulate— useful in detecting conditions such as ischemia and infarction 214 Medical Terminology: The Language of Health Care A Femoral vein Femoral artery Antecubital vein Brachial artery Upper thigh insertion Arm insertion B C Figure 7.20 Cardiac catheterization. A. Possible insertion sites for cardiac catheterization. B. Cardiac catheterization catheters: left, 6 French JL4; middle, 6 French pigtail; right, 6 French JR4.C. Cardiac catheteri- zation laboratory. Chapter 7 • Cardiovascular System 215 Figure 7.21 Echocardiography. Test or Procedure Explanation transesophageal an echocardiographic image of the heart after echocardiogram (TEE) placement of an ultrasonic transducer at the end of trans-ē-sofă-jēăl an endoscope inside the esophagus Doppler sonography an ultrasound technique used to evaluate blood dōplēr sō-nogră-fē flow to determine the presence of a deep vein thrombosis (DVT) or carotid insufficiency, or flow through the heart, chambers,

valves, etc. (see Figs. 7.4 and 7.5) intravascular sonography ultrasound images made after a sonographic intra-vaskyū-lăr transducer is placed at the tip of a catheter within sŏ-nogră-fē a blood vessel—done to evaluate pathological conditions such as buildup of plaque Operative Terms Term Meaning coronary artery bypass grafting of a portion of a blood vessel retrieved graft (CABG) from another part of the body (such as a length of saphenous vein from the leg or mammary artery from the chest wall) to bypass an occluded coronary artery, restoring circulation to myocardial tissue (Fig. 7.22); the traditional method includes temporary arrest of the heart with circulation (bypass) of the patient’s blood through a heart-lung machine during the procedure—an alternative off-pump approach uses a stabilizer to perform the procedure on the beating heart anastomosis opening; joining of two blood vessels to allow flow ă-nastō-mōsis from one to the other endarterectomy incision and coring of the lining of an artery to end-ar-ter-ektō-mē clear a blockage caused by a clot or atherosclerotic plaque buildup (e.g., carotid endarterectomy) 216 Medical Terminology: The Language of Health Care A Aorta Internal mammary artery graft Saphenous vein grafts B Internal mammary artery graft Blocked artery Chest incision Saphenous vein Bypass graft 1. Bypass incisions 2. Bypass vessels 3. Bypass grafting An incision is made in the chest The long saphenous vein in the Grafting is performed under dividing the sternum to allow leg can be used to make several magnification using extremely access to the heart. bypasses, if needed. The internal fine sutures. Each graft is sewn mammary artery may also be used to the aorta, except for the as a graft. Both are “excess” blood internal mammary artery, which vessels the body does not need. already originates from a branch of the aorta. The other end is sewn to the artery below the blockage. Figure 7.22 Coronary artery bypass graft. A. Common sites for bypass grafts. B. Bypass process. Chapter 7 • Cardiovascular System 217 Term Meaning transmyocardial a laser technique used to open tiny channels in the revascularization (TMR) heart muscle to restore blood flow, thereby relieving angina in patients with advanced coronary artery disease; an option for patients not treatable with angioplasty or coronary artery bypass valve replacement surgery to replace a diseased heart valve with an artificial one types of artificial valves: tissue—most commonly made from animal tissue such as porcine (pig) or bovine (cow) mechanical—made from synthetic material (Fig. 7.23) valvuloplasty repair of a heart valve valvyū-lō-plas-tē endovascular surgery interventional procedures performed endoscopi- cally at the time of cardiac catheterization (Fig. 7.24) angioscopy use of a flexible fiberoptic angioscope accompanied (vascular endoscopy) by an irrigation system, a camera, a video recorder, an-jē-oskō-pē and a monitor that is guided through a specific blood vessel to visually assess a lesion and select the mode of therapy atherectomy excision of atheromatous plaque from within an ăth-er-ektō-mē artery utilizing a device housed in a flexible catheter that selectively cuts away or pulverizes tissue buildup (Fig. 7.24A) Figure 7.23 A. X-ray showing artificial replacement of mitral valve (Starr-Edwards). B. Starr-Edwards Silastic ball mechanical valve. 218 Medical Terminology: The Language of Health Care A Atheromatous Drive cable debris Nose cone (collection chamber) Diamond- Balloon coated burr Cutting blade Cutter Guide wire Guide wire Guide wire Transluminal Rotational catheter Directional catheter extraction catheter B Stent delivered Stent expanded Stent in place Figure 7.24 Examples of devices used in endovascular interventional procedures. A. Atherectomy devices. B. Intravascular stent. Term Meaning percutaneous transluminal a method of treating the narrowing of a coronary coronary angioplasty artery by inserting a specialized catheter with a (PTCA) balloon attachment, then inflating it to dilate and per-kyū-tānē-ŭs open the narrowed portion of the vessel and restore trăns-lūmĭ-năl kōro-nār-ē blood flow to the myocardium (see Fig. 7.2); most anjē-ō-plas-tē often includes placement of a stent intravascular stent implantation of a device used to reinforce the wall intra-vaskyū-lăr of a vessel and ensure its patency (openness)—most often used to treat a stenosis or a dissection (a split or tear in the wall of a vessel) or to reinforce patency of a vessel after angioplasty (see Fig. 7.24B) Therapeutic Terms Term Meaning defibrillation termination of ventricular fibrillation by delivery dē-fibri-lāshŭn of an electrical stimulus to the heart, most commonly by applying electrodes of the defibrillator externally to the chest wall but can be performed internally at the time of open heart surgery or via an implanted device (Fig. 7.25) defibrillator a device that delivers the electrical stimulus in dē-fibri-lāter defibrillation Chapter 7 • Cardiovascular System 219 Figure 7.25 A. External defibrillation. B. Internal defibrillation performed in the operating room. Term Meaning cardioversion termination of tachycardia either by kardē-ō-verzhŭn pharmaceutical means or by delivery of electrical energy implantable cardioverter an implanted, battery-operated device with rate- defibrillator (ICD) sensing leads that monitors cardiac impulses and kardē-ō-verter dē-fibri-lāter initiates an electrical stimulus as needed to stop ventricular fibrillation or tachycardia pacemaker a device used to treat slow heart rates (bradycardia) by electrically stimulating the heart to contract, most often implanted with lead wires and battery circuitry under the skin but can be temporarily placed externally with lead wires inserted into the heart via a vein (Fig. 7.26) thrombolytic therapy dissolution of thrombi using drugs [e.g., throm-bō-litik streptokinase, tissue plasminogen activator (TPA)] COMMON THERAPEUTIC DRUG CLASSIFICATIONS angiotensin-converting a drug that suppresses the conversion of enzyme (ACE) inhibitor angiotensin in the blood by the angiotensin- ănjē-ō-tĕnsin-kŏn-vĕrting converting enzyme; used in the treatment of ĕnzı̄m hypertension antianginal a drug that dilates coronary arteries, restoring antē-anji-năl oxygen to the tissues to relieve the pain of angina pectoris 220 Medical Terminology: The Language of Health Care Small incision Pacemaker Leads Pacemaker Right atrium Right ventricle A small incision is made in the upper The pacemaker leads are then guided A small “pocket” to house the pacemaker chest, below the clavicle, to access through the vein and into the heart. is created just under the skin at the a large vein nearby. After proper placement is determined, incision site. The leads are connected the leads are secured in position. to the pacemaker that is secured in A the “pocket.” Finally, the incision is closed with a few sutures. Figure 7.26 Pacemaker. A. Endocardial pacemaker. B B. Teleradiology/critical care workstation. Chest x-rays on screen show pacemaker placement. Term Meaning antiarrhythmic a drug that counteracts cardiac arrhythmia antē-ă-rithmik anticoagulant a drug that prevents clotting of the blood antē-kō-agyū-lant commonly used in treating thrombophlebitis and myocardial infarction antihypertensive a drug that lowers blood pressure antē-hı̄-per-tensiv beta-adrenergic blocking agents that inhibit responses to sympathetic agents adrenergic nerve activity causing a slowing of bātā ad-rĕ-nerjik bloking electrical conduction and heart rate and a beta blockers lowering of the pressure within the walls of the bātā blokers vessels; used to treat angina pectoris and hypertension Chapter 7 • Cardiovascular System 221 Term Meaning calcium channel blockers agents that inhibit the entry of calcium ions in kalsē-ŭm chanĕl blokers heart muscle cells causing a slowing of the heart rate, lessening the demand for oxygen and nutrients, and relaxing of the smooth muscle cells of the blood vessels to cause dilation; used to prevent or treat angina pectoris, some arrhythmias, and hypertension cardiotonic a drug that increases the force of myocardial kardē-ō-tonik contractions in the heart commonly used to treat congestive heart failure diuretic a drug that increases the secretion of urine dı̄-yū-retik commonly prescribed in treating hypertension hypolipidemic a drug that reduces serum fat and cholesterol hı̄-pō-lipi-dēmik statins agents that lower cholesterol in the blood by inhibiting the effect of HMG-CoA reductase, a liver enzyme responsible for producing cholesterol thrombolytic agents drugs used to dissolve thrombi (blood clots) (e.g., thrombō-litik streptokinase, tissue plasminogen activator [TPA or tPA]) vasoconstrictor a drug that causes narrowing of the blood vessels, vāsō-kon-strikter decreasing blood flow vasodilator a drug that causes dilation of the blood vessels, vāsō-dı̄-lāter increasing blood flow Summary of Chapter 7 Acronyms/Abbreviations ACE ....................angiotensin-converting enzyme MI........................myocardial infarction ASD ....................atrial septal defect MRA ..................magnetic resonance angiography ASHD ...............arteriosclerotic heart disease MVP...................mitral valve prolapse AV .......................atrioventricular NSR ...................normal sinus rhythm BP .......................blood pressure PDA....................patent ductus arteriosus CABG................coronary artery bypass graft PET ....................positron emission tomography CAD....................coronary artery disease PTCA .................percutaneous transluminal coronary CHF ...................congestive heart failure angioplasty CO .......................cardiac output PVC ....................premature ventricular contraction DVT ...................deep vein thrombosis SA ........................sinoatrial ECG, EKG.....electrocardiogram SV........................stroke volume ECHO ...............echocardiography TEE....................transesophageal echocardiogram EPS ....................electrophysiological study TMR ..................transmyocardial revascularization HTN...................hypertension tPA, TPA.........tissue plasminogen activator ICD .....................implantable cardioverter-defibrillator VSD....................ventricular septal defect 222 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the term. EXAMPLE endocardial _______ / _______ / _______ P R S endo/cardi/al P R S DEFINITION: within/heart/pertaining to 1. angiography __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 2. varicosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 3. pectoral __________________ / __________________ R S DEFINITION: _________________________________________________________________ 4. vasospasm __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. venous __________________ / __________________ R S DEFINITION: _________________________________________________________________ 6. aortocoronary __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 7. thrombophlebitis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 7 • Cardiovascular System 223 8. pericardiocentesis __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 9. vasculopathy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 10. atherogenesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 11. stethoscope __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. myocardium __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 13. aortoplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 14. venostomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 15. arteriostenosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 16. phlebotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 17. cardioaortic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 224 Medical Terminology: The Language of Health Care 18. ventriculogram __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. phlebitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 20. angioplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 21. endovascular __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 22. cardiotoxic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 23. arteriogram __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 24. atherectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 25. atherothrombosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Fill in the blanks with the appropriate medical terms. 26. __________________ anomalies  malformations of the heart present at birth 27. arterio __________________ osis  thickening, loss of elasticity, and calcification (hardening) of arterial walls 28. __________________  irregularity or loss of rhythm of the heartbeat 29. cardiomyo __________________  general term for disease of the heart muscle Chapter 7 • Cardiovascular System 225 30. __________________  joining of two blood vessels to allow flow from one to the other 31. ______________________  abnormal heart sound that mimics the gait of a horse 32. __________________ cardiogram  a recording of sound waves directed through the heart to evaluate structure and motion 33. cor __________________  a condition of enlargement of the right ventricle as a result of chronic disease within the lungs 34. coronary __________________  an x-ray of the blood vessels of the heart made with the introduction of a catheter and release of a contrast medium 35. __________________ ECG  electrocardiogram of the heart recorded during controlled physical exercise 36. intracardiac catheter __________________  treatment of arrhythmia by destroying myocardial tissue at sites generating abnormal electrical pathways For each of the following, circle the combining form that corresponds to the meaning given: 37. chest phleb/o sphygm/o pector/o 38. vein aort/o phleb/o varic/o 39. vessel angi/o arteri/o coron/o 40. heart ven/o coron/o cardi/o 41. fatty paste aor/o ather/o atri/o 42. circle cardi/o coron/o sphygm/o 43. pulse sphygm/o steth/o thromb/o 44. clot atri/o angi/o thromb/o 45. artery arteri/o angi/o aort/o 46. belly or pouch varic/o ventricul/o ven/o 226 Medical Terminology: The Language of Health Care Match the following terms with their meanings: 47. ________ atherosclerosis a. high blood pressure 48. ________ infarct b. bulging of a vessel 49. ________ hypotension c. stationary clot 50. ________ vegetation d. cramp in leg muscle 51. ________ embolus e. normal blood pressure 52. ________ occlusion f. hard, nonelastic condition 53. ________ hypertension g.

traveling clot that obstructs when it lodges 54. ________ thrombus h. buildup of fat 55. ________ constriction i. growth of tissue 56. ________ normotension j. a plugging 57. ________ angina k. loss of blood flow 58. ________ claudication l. compression 59. ________ ischemia m. cramp in heart muscle 60. ________ arteriosclerosis n. low blood pressure 61. ________ aneurysm o. scar left by necrosis Write the full medical term for the following abbreviations: 62. PVC _______________________________________________________________________ 63. PDA ______________________________________________________________________ 64. ASHD _____________________________________________________________________ 65. ICD _______________________________________________________________________ 66. CHF _______________________________________________________________________ 67. CAD _______________________________________________________________________ 68. HTN_______________________________________________________________________ 69. MVP_______________________________________________________________________ 70. MRA ______________________________________________________________________ 71. VSD _______________________________________________________________________ Write in the missing words on the blank lines in the following illustration of the heart. 72–80. Superior vena cava Aortic arch 72. Atrial Aorta Pulmonary artery Pulmonary veins 76. Left Mitral valve 77. Aortic 73. Right 78. Pulmonary valve 79. Left 74. Tricuspid 80. Ventricular 75. Right Endocardium Inferior vena cava Myocardium Epicardium Oxygenated blood Pericardium Deoxygenated blood Match the following abbreviations with their meanings: 81. ________ ECG a. balloon angioplasty 82. ________ tPA b. magnetic resonance of blood vessels 83. ________ MRA c. a clot in a vein 84. ________ PTCA d. heart bypass surgery 85. ________ MI e. electrical picture of heart 86. ________ DVT f. echocardiogram directed through the esophagus 87. ________ ASD g. left ventricular failure 88. ________ CABG h. thrombolytic drug 89. ________ TEE i. an abnormal opening in the atrial septum 90. ________ CHF j. heart attack 227 228 Medical Terminology: The Language of Health Care For each of the following, circle the correct spelling of the term: 91. ventricel ventrical ventricle 92. aorta aorto aorrta 93. thrombos thrombus thrommbus 94. myocardial mycardial myocardiol 95. hypatension hyptension hypotension 96. diastolie diastoly diastole 97. ischemia ishchemia ishemia 98. oclusion occlusion ocllusion 99. infart enfarct infarct 100. anuerysm aneurysm annurysm 101. atherosclerotic atherosclerrotic atherasclerotic 102. thromboflebitus thromboflebitis thrombophlebitis 103. anngiogram angiogram angeogram 104. defibrillation defibillation defibrilation 105. antarhythmic antiarrhythmic antiarhythmic Write the term that means the opposite of each given term: 106. vasoconstriction __________________________________________________________ 107. coagulant _________________________________________________________________ 108. hypotension ______________________________________________________________ 109. bradycardia _______________________________________________________________ 110. diastole __________________________________________________________________ Chapter 7 • Cardiovascular System 229 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 7 . 1 Progress Note S: This 54 y.o.  was admitted to CCU with onset of acute anterior chest pain radiating to the left shoulder and SOB; pt underwent a CABG  4 six months ago. O: BP 190/110, P 100, R 72, T 38ºC On PE, pt was in moderate to severe distress. An ECG showed sinus tachycardia, and a CXR revealed left ventricular hypertrophy. A: R/O MI P: Order blood enzyme measurement STAT echocardiogram CT scan of chest 1. What is the patient’s CC? 5. What did the electrical picture of the heart reveal? a. severe angina a. extremely rapid but regular contractions of the b. angina developing slowly over time heart c. enlargement of the heart b. slow heart rate d. fast heart rate c. chaotic, irregular contractions of the heart e. slow heart rate d. fast heart rate e. interference with normal electrical conduction 2. Describe the procedure that the patient under- of the heart known as a block went 6 months ago: a. surgery to dilate and open narrowed portions 6. What was the assessment? of coronary arteries a. patient may have had a heart attack b. replacement of occluded arteries with trans- b. patient may be suffering from right heart fail- planted portions of vein ure c. replacement of a diseased heart valve c. patient has congestive heart failure d. coring of the lining of an artery to remove a d. patient may have high blood pressure clot e. patient may have an enlarged heart e. heart transplant 7. What were the objective findings of the chest radi- 3. Where was the patient treated? ograph? a. outpatient medical office a. unknown b. outpatient emergency room b. increase in size of left ventricle c. inpatient intensive care c. vessel disease d. inpatient coronary care d. dead heart muscle e. outpatient cardiology department e. fast heart rate 4. What type of physician is most appropriate to 8. Identify the x-ray imaging procedure ordered in provide initial care and assessment of this pa- the plan: tient? a. sonogram of heart a. emergency room physician b. chest radiography b. internist c. blood pressure c. gerontologist d. computed tomography d. cardiovascular surgeon e. biochemistry panel e. cardiologist 230 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 7 . 2 Richard Stratten has had serious heart problems for more than 10 years. He has had two operations. During the past 6 months, he has developed increasing pain in the chest and is having more trouble breathing. His cardiologist, Dr. Charles Feingold, has now admitted him to Central Medical Center for further tests. Directions Read Medical Record 7.2 for Richard Stratten (pages 233–236) and answer the follow- ing questions. This record is the history and physical examination dictated by Dr. Feingold after his examination of Mr. Stratten. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 7 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: obtuse ______________________________________________________________________ dyspnea (dyspneic) __________________________________________________________ hiatal hernia ________________________________________________________________ basilar rales ________________________________________________________________ visceromegaly _______________________________________________________________ clubbing ____________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe why Mr. Stratten has been admitted to the hospital and what test he will be undergoing. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Name the diagnosis that underlies the nature of Mr. Stratten’s heart conditions. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Briefly describe this diagnosis using nonmedical language. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 7 • Cardiovascular System 231 4. Identify the surgical procedure noted in the history that was initially performed to treat Mr. Stratten’s heart disease. a. dilation of narrow occluded coronary arteries b. replacement of occluded arteries with transplanted portion of vein c. replacement of a diseased heart valve d. coring of the lining of an artery to remove a thrombus e. heart transplant 5. What were the patient’s symptoms 8 years later on May 15, 20xx? __________________________________________________________________________ Using nonmedical language, briefly describe the diagnosis made at that time. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. Describe the test that showed changes consistent with the diagnosis. ____________________________________________________________________________ ____________________________________________________________________________ 7. Spell out TPA, and identify the reason why the drug was given to Mr. Stratten. 8. Which of the following were findings of the radiographic tests performed after the May 15 hospitalization? (Mark all that are appropriate.) a. hemorrhage of insertion site of obtuse marginal artery graft b. thromboembolism in the left anterior descending artery c. occluded circumflex artery d. torn sutures of the circumflex artery graft e. stenosis of the left anterior descending artery graft f. total occlusion of the left internal mammary vein graft g. dilated right coronary artery graft 9. List the arteries that were grafted in both bypass operations. ____________________________________________________________________________ ____________________________________________________________________________ 10. Using nonmedical language, list the three symptoms Mr. Stratten is now experiencing. a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ 232 Medical Terminology: The Language of Health Care 11. Mr. Stratten is taking eight different medications. Translate the medication in- struction for these: Drug Name Dosage Frequency of Dose _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ 12. What family members have had a medical history of problems in the same body system? ____________________________________________________________________________ ____________________________________________________________________________ 13. In addition to Mr. Stratten’s heart problems, Dr. Feingold’s physical examination revealed abnormal findings in what other areas? a. head b. abdomen c. extremities d. all of the above e. none of the above 14. What does “probable end-stage cardiomyopathy” mean? What treatment seems possible to Dr. Feingold, even though he had not yet performed the diagnostic tests for which he hospitalized Mr. Stratten? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 7 • Cardiovascular System 233 Medical Record 7.2 234 Medical Terminology: The Language of Health Care Medical Record 7.2 Continued. Chapter 7 • Cardiovascular System 235 Medical Record 7.2 Continued. 236 Medical Terminology: The Language of Health Care Medical Record 7.2 Continued. Chapter 7 • Cardiovascular System 237 M E D I C A L R E C O R D 7 . 3 William Smith woke in the middle of the night with substernal chest heaviness that ra- diated to both arms. After getting no relief from taking aspirin and antacids, he went to the emergency room and was seen by Dr. Roland Galasso. The chest pain subsided only after administration of intravenous nitroglycerin. Dr. Galasso decided to admit Mr. Smith for further cardiac evaluation and treatment. A cardiac catheterization was performed the next day. Directions Read Medical Record 7.3 for William Smith (pages 239–240) and answer the following questions. This record is a report of the cardiac catheterization performed by Dr. Galasso and transcribed by a cardiology department transcriptionist. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 7 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record: ostium _____________________________________________________________________ hemodynamic _______________________________________________________________ mitral regurgitation _________________________________________________________ focal _______________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe the indications for performing the cardiac catheterization. ____________________________________________________________________________ 3. Put the following actions in correct order by numbering them 1 to 14: _____ pigtail catheter advanced to the left ventricle _____ hemostasis obtained by C-clamp pressure _____ right coronary arteriography performed _____ pigtail catheter exchanged for left coronary artery catheter _____ informed consent signed _____ arterial pressures recorded _____ right groin prepped and draped _____ left coronary arteriography performed _____ right femoral artery entered and Cordis sheath inserted _____ right coronary catheter and femoral artery sheath removed 238 Medical Terminology: The Language of Health Care _____ pigtail catheter inserted through sheath and guided to descending thoracic aorta _____ left coronary catheter exchanged for right coronary catheter _____ left ventriculography performed _____ heparin administered 4. Briefly describe the conclusions of the procedure in nonmedical language: a.___________________________________________________________________________ b.___________________________________________________________________________ 5. From the recommendations, describe the test that will be performed right away. __________________________________________________________________________ 6. Identify the possible complications likely to occur in the future. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Describe the procedure that is recommended should these complications occur. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Chapter 7 • Cardiovascular System 239 Medical Record 7.3 240 Medical Terminology: The Language of Health Care Medical Record 7.3 Continued. Chapter 8 Blood and Lymph Systems OBJECTIVES After completion of this chapter, you will be able to Define common term components used in relation to the blood and lymph systems Describe the basic functions of the blood and lymph systems Define the basic anatomical terms referring to blood and lymph Define common symptomatic and diagnostic terms referring to the blood and lymph systems List common diagnostic tests and procedures related to the blood and lymph systems Identify common operative terms referring to the blood and lymph systems Identify common therapeutic terms including drug classifications related to the blood and lymph systems Explain terms and abbreviations used in documenting medical records involving the blood or lymph systems Combining Forms Combining Form Meaning Example blast/o germ or bud erythroblastemia ĕ-rith´rō-blas-tē´ mē-ă -blast (also a suffix) megaloblast meg´ă-lō-blast chrom/o color chromic krō´ mik chromat/o hemochromatosis hē´ mō-krō-mă-tō´ sis chyl/o juice chylemia kı̄-lē´ mē-ă hem/o blood hemostat hē´ mō-stat hemat/o hematopoiesis hē´ mă-tō-poy-ē´ sis 241 242 Medical Terminology: The Language of Health Care Combining Form Meaning Example immun/o safe immunology im´yū-nol´ō-jē lymph/o clear fluid lymphogenous lim-foj´ĕ-nŭs morph/o form morphologic mōr-fō-loj´ik myel/o bone marrow (also spinal cord) myelogenous mı̄-ĕ-loj´ĕ-nŭs phag/o eat or swallow phagocytosis fag´ō-sı̄-tō´ sis plas/o formation aplastic ā-plas´tik reticul/o a net reticulocyte re-tik´yū-lō-sı̄t splen/o spleen splenomegaly splē-nō-meg´ă-lē thromb/o clot thrombocyte throm´bō-sı̄t thym/o thymus gland thymic thı̄´mik Blood System Overview The blood circulates through the blood vessels to transport oxygen, nutrients, and

hor- mones to body cells and to carry away wastes. The liquid portion of the blood is called plasma. The cellular components suspended in the plasma are the erythrocytes, leuko- cytes, and platelets. The portion of the plasma that remains after the clotting process is called serum (Fig. 8.1). Anatomical Terms Term Meaning TERMS RELATED TO BLOOD FLUID plasma liquid portion of the blood and lymph plaz´mah containing water, proteins, salts, nutrients, hormones, vitamins, and cellular components (leukocytes, erythrocytes, and platelets) SERUM. Serum serum liquid portion of the blood left after the clotting is Latin for sēr´ŭm process whey, the CELLULAR COMPONENTS OF THE BLOOD watery part of curdled milk, which looks similar to the erythrocyte red blood cell that transports oxygen and carbon watery part of clotted blood. ĕ-rith´rō-sı̄t dioxide within the bloodstream The term was first recorded in English in 1672. hemoglobin protein-iron compound contained in the erythrocyte hē´ mō-glō´ bin that has bonding capabilities for the transport of oxygen and carbon dioxide Unclotted Clotted Red blood cells Plasma Serum Cellular components Platelets White blood cells White blood cells (leukocytes) Granulocytes Neutrophil Basophil Eosinophil White blood cells (leukocytes) Red blood cells Platelets Agranulocytes (erythrocytes) (thrombocytes) Monocyte Lymphocyte Figure 8.1 Components of the blood. 243 244 Medical Terminology: The Language of Health Care Term Meaning leukocyte white blood cell that protects the body from invasion lu´kō-sı̄t of harmful substances granulocytes a group of leukocytes containing granules in their gran´yū-lō-sı̄ts cytoplasm neutrophil a granular leukocyte, named for the neutral stain of nū´ trō-fil its granules, that fights infection by swallowing bacteria (phagocytosis) (neutro  neither; phil  attraction for) polymorphonuclear another term for neutrophil, named for the many leukocyte (PMN) segments present in its nucleus (poly  many; pol-ē-mōr´fō-nū´ klē-ăr morpho  form; nucleus  kernel) band an immature neutrophil eosinophil a granular leukocyte, named for the rose-color ē-ō-sin´ō-fil stain of its granules, that increases with allergy and some infections [eos  dawn-colored (rosy); phil  attraction for] basophil a granular leukocyte, named for the dark stain of bā´sō-fil its granules, that brings anticoagulant substances to inflamed tissues (baso  base; phil  attraction for) agranulocytes a group of leukocytes without granules in their nuclei ă-gran´yū-lō-sı̄ts lymphocyte an agranulocytic leukocyte that is active in the lim´fō-sı̄t process of immunity—there are four categories of lymphocytes: T cells (thymus dependent) B cells (bone marrow derived) NK cells (natural killer) K-type cells monocyte an agranulocytic leukocyte that performs mon´ō-sı̄t phagocytosis to fight infection (mono  one) platelets thrombocytes; cell fragments in the blood essential plāt´lets for blood clotting (coagulation) Lymphatic System Overview The lymphatic system is made up of an intricate network of capillaries, vessels, valves, ducts, nodes, and organs. It protects the body by filtering microorganisms and foreign particles from the lymph and supporting the activities of the lympho- cytes in the immune response. It also serves to maintain the body’s internal fluid en- vironment by acting as an intermediary between the blood in the capillaries and tis- sue cells. In addition, it is responsible for carrying fats away from the digestive organs (Fig. 8.2). A B Chapter 8 • Blood and Lymph Systems 245 Upper right quadrant The remainder of Tonsils of body drains to the the body drains right lymphatic duct. to the thoracic duct. Cervical lymph nodes Right lymphatic duct Thymus Axillary lymph gland nodes Thoracic Spleen duct Pancreas Inguinal lymph nodes C Lymphatic Artery vessels Vein Lymph node Heart Valve Venule Arteriole Valve Lymph vessels Lymph capillaries Tissue cells Blood capillaries Figure 8.2 Lymphatic system. A. Lymph structures. B. Lymph drainage. C. Blood and lymph circulation. 245 246 Medical Terminology: The Language of Health Care Anatomical Terms Term Meaning LYMPH ORGANS thymus the primary gland of the lymphatic system, located thı̄´mŭs within the mediastinum; helps maintain the body’s immune response by producing T lymphocytes spleen the organ between the stomach and diaphragm that splēn filters out aging blood cells, removes cellular debris by performing phagocytosis, and provides the envi- ronment for the initiation of immune responses by lymphocytes LYMPH STRUCTURES lymph fluid originating in the organs and tissues of the body limf that is circulated through the lymph vessels lymph capillaries microscopic vessels that draw lymph from the tissues limf kap´i-lār-ēz to the lymph vessels lymph vessels vessels that receive lymph from the lymph capillaries limf ves´ĕlz and circulate it to the lymph nodes lacteals specialized lymph vessels in the small intestine that lak´tē-ălz absorb fat into the bloodstream (lacteus  milky) chyle a white or pale yellow substance of the lymph that kı̄l contains fatty substances absorbed by the lacteals lymph nodes many small oval structures that filter the lymph limf nōdz received from the lymph vessels—major locations include the cervical region, axillary region, and inguinal region lymph ducts collecting channels that carry lymph from the lymph limf dŭktz nodes to the veins right lymphatic duct receives lymph from the upper-right part of the body lim-fat´ik dŭkt thoracic duct receives lymph from the left side of the head, neck, thō-ras´ik dŭkt chest, abdomen, left arm, and lower extremities IMMUNITY antigen a substance that, when introduced into the body, an´ti-jen causes the formation of antibodies against it antibody a substance produced by the body that destroys or an´tē-bod-ē inactivates an antigen that has entered the body immunoglobulins (Ig) protein antibodies secreted by B lymphocytes that im´yu-nō-glob´yu-lins protect the body from invasion of foreign pathogens; the five major classes include IgA, IgD, IgE, IgG, and IgM Chapter 8 • Blood and Lymph Systems 247 Term Meaning immunity process of disease protection induced by exposure to an i-myū´ ni-tē antigen active immunity an immunity that protects the body against a future ak´tiv i-myū´ ni-tē infection, as the result of antibodies that develop naturally after contracting an infection or artificially after administration of a vaccine passive immunity an immunity resulting from antibodies that are conveyed pas´iv i-myū´ ni-tē naturally through the placenta to a fetus or artificially by injection of a serum containing antibodies Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC Related to Blood microcytosis the presence of small red blood cells (Fig. 8.3) mı̄´krō-sı̄-tō´ sis macrocytosis the presence of large red blood cells (see Fig. 8.4) mak´rō-sı̄-tō´ sis anisocytosis the presence of red blood cells of unequal size (an  an- ı̄´sō-sı̄-tō´ sis without; iso  equal) (see Fig. 8.4) poikilocytosis the presence of large, irregularly shaped red blood cells poy´ki-lō-sı̄-tō´ sis (poikil/o  irregular) (Fig. 8.4) reticulocytosis an increase of immature erythrocytes in the blood re-tik´yū-lō-sı̄-tō´ sis erythropenia an abnormally reduced number of red blood cells ĕ-rith-rō-pē´ nē-ă lymphocytopenia an abnormally reduced number of lymphocytes lim´fō-sı̄-tō-pē´ nē-ă neutropenia a decrease in the number of neutrophils nū´ trō-pē´ nē-ă pancytopenia an abnormally reduced number of all cellular pan´sı̄-tō-pē´ nē-ă components in the blood hemolysis breakdown of the red blood cell membrane hē-mol´i-sis Related to Lymph immunocompromised impaired immunological defenses caused by an im´yū-nō-kom´pro-m ı̄zd immunodeficiency disorder or therapy with immunosuppressive agents immunosuppression impaired ability to provide an immune response im´yū-nō-sŭ-presh´ŭn lymphadenopathy the presence of enlarged (diseased) lymph nodes lim-fad-ĕ-nop´ă-thē 248 Medical Terminology: The Language of Health Care Figure 8.3 A blood smear showing normal erythrocytes (A) compared with a Figure 8.4 Photomicrograph of a blood smear revealing microcytic-hypochromic erythrocytes in a patient with iron de- blood smear from a patient with perni- ficiency anemia (B). cious anemia reveals macrocytosis, anisocytosis, and poikilocytosis. Term Meaning splenomegaly enlargement of the spleen splē-nō-meg´ă-lē DIAGNOSTIC acquired a syndrome caused by the human immunodeficiency immunodeficiency virus (HIV) that renders immune cells ineffective, syndrome (AIDS) permitting opportunistic infections, malignancies, ă-kwı̄rd´ and neurological diseases to develop; it is i-myūn´o-dē-fish´en-sē transmitted sexually or through exposure to sin´drōm contaminated blood anemia a condition in which there is a reduction in the ă-nē´ mē-ă number of red blood cells, the amount of hemoglobin, or the volume of packed red cells in the blood, resulting in a diminished ability of the red blood cells to transport oxygen to the tissues; common types follow: aplastic anemia a normocytic-normochromic ā-plas´tik type of anemia characterized by the failure of bone marrow to produce red blood cells iron deficiency anemia a microcytic-hypochromic type i´ern dē-fish´en-sē of anemia characterized by a lack of iron, affecting production of hemoglobin and characterized by small red blood cells containing low amounts of hemoglobin (see Fig. 8.3) pernicious anemia a macrocytic-normochromic type per-nish´ŭs of anemia characterized by an inadequate supply of vitamin B12, causing red blood cells to become large, varied in shape, and reduced in number (see Fig. 8.4) autoimmune disease any disorder characterized by abnormal function of aw-tō-i-myun´ di-zēz´ the immune system that causes the body to produce antibodies against itself, resulting in tissue destruction or loss of function; rheumatoid arthritis and lupus are examples of autoimmune diseases Chapter 8 • Blood and Lymph Systems 249 Term Meaning erythroblastosis fetalis a disorder that results from the incompatibility of a ĕ-rith´rō-blas-tō´ sis fetus with an Rh-positive blood factor and a mother fē´ tă´ lis who is Rh negative, causing red blood cell destruction in the fetus; necessitates a blood transfusion to save the fetus Rh factor the presence, or lack, of antigens on the surface of red blood cells that may cause a reaction between the blood of the mother and fetus, resulting in fetal anemia Rh positive the presence of antigens Rh negative the absence of antigens hemochromatosis a hereditary disorder that results in an excessive hē´ mō-krō-mă-tō´ sis buildup of iron deposits in the body hemophilia a group of hereditary bleeding disorders in which hē-mō-fil´ē-ă there is a defect in clotting factors necessary for the coagulation of blood leukemia a chronic or acute malignant (cancerous) disease of lū-kē´ mē-ă the blood-forming organs, marked by abnormal leukocytes in the blood and bone marrow; classified according to the types of white cells affected (e.g., myelocytic, lymphocytic) myelodysplasia a disorder within the bone marrow characterized by mı̄´ĕ-lō-dis-plā́ zē-ă the proliferation of abnormal stem cells (cells that give rise to the different types of blood cells); usually develops into a specific type of leukemia lymphoma any neoplastic disorder of lymph tissue, usually lim-fō´ mă malignant, as in Hodgkin disease metastasis the process by which cancer cells are spread by blood mĕ-tas´tă-sis or lymph circulation to distant organs mononucleosis a condition caused by the Epstein-Barr virus mon´ō-nū-klē-ō´ sis characterized by an increase in mononuclear cells (monocytes and lymphocytes) in the blood, along with enlarged lymph nodes (lymphadenopathy), fatigue, and sore throat (pharyngitis) polycythemia an increase in the number of erythrocytes and pol´ē-sı̄-thē´ mē-ă hemoglobin in the blood septicemia a systemic disease caused by the infection of sep-ti-sē´ mē-ă microorganisms and their toxins in the circulating blood thrombocytopenia a bleeding disorder characterized by an abnormal throm´bō-sı̄-tō-pē´ nē-ă decrease in the number of platelets in the blood, which impairs the clotting process 250 Medical Terminology: The Language of Health Care Diagnostic Tests and Procedures Test or Procedure Explanation BLOOD STUDIES blood chemistry a test of the fluid portion of blood to measure the blŭd kem´is-trē presence of a chemical constituent (e.g., glucose, cholesterol) blood chemistry panels specialized batteries of automated blood chemistry tests performed on a single sample of blood; used as a general screen for disease or to target specific organs or conditions (e.g., metabolic panel, lipid panel, arthritis panel) basic metabolic panel battery of tests used as a general screen met-ă-bol´ik for disease: calcium, carbon dioxide (CO2), chloride, creatinine, glucose, potassium, sodium and blood urea nitrogen (BUN) comprehensive metabolic tests in addition to basic metabolic panel panel for expanded screening purposes: albumin, bilirubin, alkaline phosphatase, protein, ALT, and AST (Fig. 8.5) blood culture a test to determine if infection is present in the blŭd kŭl´chŭr bloodstream by isolating a specimen of blood in an environment that encourages the growth of microorganisms; the specimen is observed and the organisms that grow in the culture are identified CD4 cell count a measure of the number of CD4 cells (a subset of T lymphocytes) in the blood; used in monitoring the course of HIV and timing the treatment of AIDS; the normal adult range is 600–1,500 cells complete blood count (CBC) the most common laboratory blood test performed as a screen of general health or for diagnostic purposes; the following is a listing of the component tests included in a CBC (Fig. 8.6) (note: CBC results are usually reported with normal values so

that the clinician can interpret the results based on the instrumentation used by the laboratory; normal ranges also may vary depending on factors such as the region and climate) white blood count (WBC) a count of the number of white blood cells per cubic millimeter obtained by manual or automated laboratory methods red blood count (RBC) a count of the number of red blood cells per cubic millimeter obtained by manual or automated laboratory methods hemoglobin (HGB or Hgb) a test to determine the blood level of hemoglobin hē´ mō-glō´ bin (expressed in grams) hematocrit (HCT or Hct) a measurement of the percentage of packed hē´ mă-tō-krit red blood cells in a given volume of blood Chapter 8 • Blood and Lymph Systems 251 CENTRAL MEDICAL CENTER 211 Medical Center Drive • Central City, US 90000-1234 • PHONE: (012) 125-6784 • FAX: (012) 125-9999 11/02/20xx 14:27 NAME : TEST, PATIENT LOC: TEST DOB: 02/03/xx AGE: 38Y MR# : TEST-221 SEX: M ACCT# : H111111111 M63561 COLL: 11/02/20xx 13:24 REC: 11/02/20xx 13:25 COMPREHENSIVE METABOLIC PANEL Blood Urea Nitrogen *30 [5–25] mg/dL (BUN) Sodium 139 [135–153] mEq/L Potassium 4.2 [3.5–5.3] mEq/L Chloride 105 [101–111] mEq/L Carbon Dioxide (CO2) 27 [24–31] mmol/L Glucose, Random *148 [70–110] mg/dL Creatinine *1.5 [<1.5] mg/dL SGOT (AST) 18 [10–42] U/L SGPT (ALT) *8 [10–60] U/L Alkaline Phosphatase 58 [42–121] U/L Total Protein 6.5 [6.0–8.0] G/dL Albumin 3.7 [3.5–5.0] G/dL Amylase 33 [<129] U/L Bilirubin, Total 0.7 [<1.5] mg/dL Calcium, Total 9.7 [8.6–10.6] mg/dL TEST, PATIENT TEST-221 END OF REPORT PAGE 1 11/02/20xx 14:27 INTERIM REPORT COMPLETED Figure 8.5 Comprehensive metabolic panel report. Note: Normal ranges are in brackets [ ]. Test or Procedure Explanation blood indices calculations of RBC, HGB, and HCT results to determine in´di-sēz the average size, hemoglobin concentration, and content of red blood cells for classification of anemia mean corpuscular a calculation of the volume of individual cells in cubic (cell) volume (MCV) microns using HCT and RBC results: MCV  HCT/RBC kōr-pŭs´kyū-lăr mean corpuscular a calculation of the content in weight of hemoglobin in (cell) hemoglobin the average red blood cell using HGB and RBC results: (MCH) MCH  HGB/RBC kōr-pŭs´kyū-lăr hē´ mō-glō´ bin mean corpuscular a calculation of the average hemoglobin (cell) hemoglobin concentration in each red blood cell using HGB and HCT concentration (MCHC) results: MCHC  HGB/HCT hē´ mō-glō´ bin kon-sen-trā´shŭn 252 Medical Terminology: The Language of Health Care CENTRAL MEDICAL CENTER 211 Medical Center Drive • Central City, US 90000-1234 • PHONE: (012) 125-6784 • FAX: (012) 125-9999 11/02/20xx 14:27 NAME : TEST, PATIENT LOC: TEST DOB: 2/2/xx AGE: 27Y MR# : TEST-221 SEX: M ACCT# : H111111111 M63558 COLL: 11/2/20xx 13:23 REC: 11/2/20xx 13:24 HEMOGRAM CBC WBC *11.5 [4.5–10.5] K/UL RBC 5.84 [4.6–6.2] M/UL HGB 17.2 [14.0–18.0] G/DL HCT 50.8 [42.0–52.0] % MCV 87 [82–92] FL MCH 29.5 [27–31] PG MCHC 33.9 [32–36] G/DL PLT 202 [150–450] K/UL Auto Lymph % 15 [20–40] % Auto Mono % 2 [1–11] % Auto Neutro % 82 [50–75] % Auto Eos % 1 [0–6] % Auto Baso % 0 [0–2] % Auto Lymph # 1.7 [1.5–4.0] K/UL Auto Mono # 0.2 [0.2–0.9] K/UL Auto Neutro # 9.4 [1.0–7.0] K/UL Auto Eos # 0.1 [0–0.7] K/UL Auto Baso # 0.0 [0–0.2] K/UL TEST, PATIENT TEST-221 END OF R E P ORT PAGE 1 11/02/20xx 14:27 INTERIM REPORT INTERIM REPORT COMPLETE Figure 8.6 Complete blood count (CBC) report. Test or Procedure Explanation differential count a determination of the number of each type of white blood cell (leukocyte) seen on a stained blood smear; each type is counted and reported as a percentage of the total examined Type of Leukocyte Normal Range lymphocytes 25–33% monocytes 3–7% neutrophils 54–75% eosinophils 1–3% basophils 0–1% red cell morphology as part of identifying and counting the WBCs, the mōr-fol´ō-jē condition of the size and shape of the red blood cells in the background of the smeared slide is noted (e.g., anisocytosis, poikilocytosis) platelet count (PLT) a calculation of the number of thrombocytes in the plāt´let blood: normal range 150,000–450,000/cubic millimeters Chapter 8 • Blood and Lymph Systems 253 Test or Procedure Explanation erythrocyte a timed test to measure the rate at which red blood sedimentation rate (ESR) cells settle or fall through a given volume of plasma ĕ-rith´rō-sı̄t sed´i-men-tā´shŭn rāt partial thromboplastin a test to determine coagulation defects such as time (PTT) platelet disorders thromboplastin a substance present in tissues, platelets, and throm-bō-plas´tin leukocytes that is necessary for coagulation prothrombin time (PT) a test to measure the activity of prothrombin in the blood prothrombin a protein substance in the blood that is essential to the prō-throm´bin clotting process venipuncture an incision into or puncture of a vein to withdraw ven-i-pŭnk´chūr blood for testing phlebotomy flĕ-bot´ō-mē BONE AND LYMPH STUDIES bone marrow aspiration a needle aspiration of bone marrow tissue for bōn mar´ō as-pi-rā´shŭn pathological examination (Fig. 8.7) bone marrow biopsy a pathological examination of bone marrow tissue bōn mar´ō bı̄´op-sē lymphangiogram an x-ray image of a lymph node or vessel taken lim-fan´jē-ō-gram after injection of a contrast medium DIAGNOSTIC IMAGING computed tomography full-body x-ray CT images are used to detect (CT) tumors and cancers such as lymphoma positron emission radionuclide scans, especially of the whole body, tomography (PET) are useful in determining the recurrence of cancers or to measure response to therapy; commonly used in evaluating lymphoma Operative Terms Term Meaning bone marrow transplant the transplantation of healthy bone marrow from a bōn mar´ō tranz´plant compatible donor to a diseased recipient to stimulate blood cell production lymphadenectomy the removal of a lymph node lim-fad-ĕ-nek´tō-mē lymphadenotomy an incision into a lymph node lim-fad-ĕ-not´ă-mē lymph node dissection the removal of possible cancer-carrying lymph nodes limf nōd di-sek´shŭn for pathological examination 254 Medical Terminology: The Language of Health Care Figure 8.7 Bone marrow aspiration. Posterior view of the pelvic region showing common site. Term Meaning splenectomy the removal of the spleen splē-nek´tō-mē thymectomy the removal of the thymus gland thı̄-mek´tō-mē Therapeutic Terms Term Meaning blood transfusion the introduction of blood products into the circulation of a recipient whose blood volume is reduced or deficient in some manner autologous blood blood donated by, and stored for, a patient for aw-tol´ŏ-gŭs blud future personal use (e.g., upcoming surgery) homologous blood blood voluntarily donated by any person for hŏ-mol´ō-gŭs blud transfusion to a compatible recipient blood component therapy the transfusion of specific blood components such as packed red blood cells, platelets, and plasma crossmatching a method of matching a donor’s blood to the recipient by mixing a sample in a test tube to determine compatibility chemotherapy the treatment of malignancies, infections, and kem´ō-thēr´ă-pē other diseases with chemical agents that destroy selected cells or impair their ability to reproduce immunotherapy the use of biological agents to prevent or treat im´ū-nō-thār´ă-pē disease by stimulating the body’s own defense mechanisms; as seen in the treatment of AIDS, cancer, and allergy plasmapheresis the removal of plasma from the body with plaz´mă-fĕ -rē´ sis separation and extraction of specific elements (such as platelets) followed by reinfusion (apheresis  a withdrawal) Chapter 8 • Blood and Lymph Systems 255 Term Meaning Common Therapeutic Drug Classifications anticoagulant a drug that prevents clotting of the blood an´tē-kō-ag´yū-lant hemostatic a drug that stops the flow of blood within the vessels hē-mō-stat´ik vasoconstrictor a drug that causes a narrowing of blood vessels, vā´sō-kon-strik´ter decreasing blood flow vasodilator a drug that causes dilation of blood vessels, increasing vā´sō-dı̄´lā-ter blood flow Summary of Chapter 8 Acronyms/Abbreviations AIDS........................acquired immunodeficiency Ig................................immunoglobulin syndrome MCH........................mean corpuscular (cell) ALT ..........................alanine aminotransferase (enzyme) hemoglobin AST ..........................aspartate aminotransferase MCHC ....................mean corpuscular (cell) (enzyme) hemoglobin concentration BUN.........................blood urea nitrogen MCV ........................mean corpuscular (cell) volume CBC..........................complete blood count PET ..........................positron emission tomography CO2...........................carbon dioxide PLT ..........................platelet count CT..............................computed tomography PMN ........................polymorphonuclear leukocyte ESR..........................erythrocyte sedimentation rate PT..............................prothrombin time Fe...............................iron (ferrous) PTT ..........................partial thromboplastin time HCT or Hct ........hematocrit RBC .........................red blood cell or count HGB or Hgb......hemoglobin WBC ........................white blood cell or count 256 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE dyshematopoiesis _______ / _______ / _______ P CF S dys/hemato/poiesis P CF S DEFINITION: painful, difficult, or faulty/blood/formation 1. erythroblastosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 2. myelodysplasia __________________ / __________________ / __________________ / __________________ CF P R S DEFINITION: _________________________________________________________________ 3. hemocytometer __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 4. splenorrhagia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. lymphadenitis __________________ / __________________ / __________________ R R S DEFINITION: _________________________________________________________________ 6. immunotoxic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 7. reticulocytosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 8 • Blood and Lymph Systems 257 8. thymopathy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 9. leukocytic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 10. lymphangiogram __________________ / __________________ / __________________ R CF S DEFINITION: _________________________________________________________________ 11. splenomegaly __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. promyelocyte __________________ / __________________ / __________________ / __________________ P CF R S DEFINITION: _________________________________________________________________ 13. leukocytopenia __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 14. splenectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 15. chylopoiesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 16. lymphoma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 17. cytomorphology __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 258 Medical Terminology: The Language of Health Care 18. hemolysis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. anemia __________________ / __________________ P S DEFINITION: _________________________________________________________________ 20. metastasis __________________ / __________________ P S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 21. neutro____________  abnormal reduction of neutrophils 22. _____________ cyte  white blood cell 23. hemato______________  formation of blood 24. spleno_______________  enlargement of the spleen 25. ______________ penia  an abnormally reduced number of red blood cells 26. ______________ ic  pertaining to the thymus gland 27. ____ granulocytes  white cells without granules in their nuclei 28. eosino__________  a granular leukocyte named for its attraction to the rose- color stain of its granules 29. ____________ cyte  red blood cell 30. _________ cytopenia  reduced number of all cellular components in the blood For each of the following, circle the combining form that corresponds to the meaning given: 31. eat or swallow phas/o phag/o plas/o 32. clot thromb/o thym/o lymph/o 33. juice lymph/o hemat/o chyl/o 34. formation plas/o troph/o thromb/o 35. color hem/o chrom/o cyan/o 36. blood erythr/o hem/o lymph/o Chapter 8 • Blood and Lymph Systems 259 37. safe toxic/o reticul/o immun/o 38. germ or bud blast/o gen/o crin/o Fill in the blanks with the appropriate medical terms and abbreviations: 39. The procedure of counting the number of leukocytes in the blood is called a____________ ____________ ____________ and is abbreviated ____________. 40. The blood study that determines the amount of pigment present in RBCs is called a ________________ and is abbreviated ________________. 41. The blood study that determines packed red blood cell volume is called a ____________ and is abbreviated ____________. 42. The classification of WBCs is performed in a ________________ ________________. 43. The calculations provided in blood indices, MCV_________ _______________ _________________, MCH_________ _______________ _________________, and MCHC_________ ______________ _______________ _________________, are used to classify types of _______________________. 44. Venipuncture is also termed _______________________. 45. Hodgkin disease is a malignant type of __________________________. Write the full medical term for the following abbreviations: 46. PT ________________________________________________________________________ 47. ESR ______________________________________________________________________ 48. PTT _______________________________________________________________________ 49. CBC ______________________________________________________________________ 260 Medical Terminology: The Language of Health Care Match the following terms with their meanings: 50. ________ microcytosis a. large red blood cells 51. ________ poikilocytosis b. thrombocyte 52. ________ neutrophil c. WBC with rose-stained granules 53. ________ monocyte d. RBC 54. ________ eosinophil e. agranulocyte active in immunity 55. ________ lymphocyte f. WBC with dark-stained granules 56. ________ basophil g. WBC termed “one cell” 57. ________ platelet h. RBCs of unequal size 58. ________ erythrocyte i. WBC with granules 59. ________ granulocyte j. large, irregular RBCs 60. ________ anisocytosis k. polymorphonuclear WBC 61. ________ macrocytosis l. small red blood cells Write the correct medical term for each of the following: 62. impaired ability to provide an

immune response ______________________________ 63. test tube method of matching a donor’s blood to the recipient __________________ 64. syndrome caused by HIV ___________________________________________________ 65. condition characterized by an increase in mononuclear cells caused by the Epstein-Barr virus _________________________________________________________ 66. removal of plasma from the body, extraction of specific elements, then reinfusion ___________________________________________________________________________ Chapter 8 • Blood and Lymph Systems 261 Briefly describe the difference between the following terms: 67. plasma/serum ______________________________________________________________ _______________________________________________________________________________ 68. anemia/leukemia ___________________________________________________________ _______________________________________________________________________________ 69. autologous blood/homologous blood _________________________________________ _______________________________________________________________________________ 70. antibody/antigen ___________________________________________________________ _______________________________________________________________________________ 71. vasoconstrictor/vasodilator _________________________________________________ _______________________________________________________________________________ 72. anticoagulant/hemostatic ___________________________________________________ _______________________________________________________________________________ 73. polycythemia/hemochromatosis _____________________________________________ _______________________________________________________________________________ Write in the missing words on the lines in the following illustrations of the components of blood. 74–78. Unclotted Clotted 76. 78. 74. Cellular components 77. 75. 262 Medical Terminology: The Language of Health Care Write in the missing words on the lines in the following illustrations of the lymphatic system. 79–84. THE LYMPHATIC SYSTEM Tonsils 83. Cervical lymph 79. Right duct 80. gland Axillary lymph nodes 81. 84. duct Pancreas Inguinal lymph nodes 82. vessels Chapter 8 • Blood and Lymph Systems 263 For each of the following, circle the correct spelling of the term: 85. hematopoesis hematopoiesis hematoepoisis 86. platelets plattelets plateletts 87. anissocytosis aniscocytosis anisocytosis 88. polkulocytosis poikilocytosis poiekilocytosis 89. hemalysis hemoliesis hemolysis 90. lymphadenpathy lymphadenopathy lymphoadenopathy 91. myelodysplasia mylodysplaszia myelodysphazia 92. thrombocytopnea thrombocytopenia throbocytpenia 93. hematocrit hemacrit hematocrete 94. splenecktomy splenectomy spleenectomy 95. plasmapheresis plazmaphoresis plasmophoresis 96. vasodialator vasodilater vasodilator 97. venipuncture venapuncture venepuncture Give the noun that was used to form the following adjectives: 98. leukemic _________________________________________________________________ 99. immunosuppressive _______________________________________________________ 100. thymic ___________________________________________________________________ 101. hematopoietic ____________________________________________________________ 102. splenic ___________________________________________________________________ 103. septicemic _______________________________________________________________ 104. hemophilic _______________________________________________________________ 105. myelodysplastic __________________________________________________________ 264 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 8 . 1 Progress Note CC: fatigue S: This 43 y/o female c/o feeling rundown with lack of energy  1 mo. Pt denies fever, chills, nausea, vomiting, diarrhea, constipation and reports no weight loss. She has had very heavy menstrual periods lasting 5 days since DC of birth control pills 1 year ago. PMH: mononucleosis at age 14, NKDA. FH: father, age 68, died of MI Mother, age 74, has myelodysplasia; sister, age 45, L&W SH: married  8 yr, no children; ETOH—wine with dinner, denies smoking. O: VS: T 98.8ºF, P 81, R 15, BP 136/62. WDWN female in NAD. HEENT-WNL Neck: supple s̄ lymphadenopathy. Lungs: clear. Heart RRR s̄ murmur Abdomen: soft and tender s̄ organomegaly. Extremities: no edema. A: Etiology of fatigue and decreased energy unclear. Possible iron deficiency ane- mia in light of heavy menstrual periods. P: Blood studies to include comprehensive metabolic panel, CBC c̄ differential. RTO in 1 wk for lab results. 1. Which of the following is not mentioned in the b. macrocytic-normochromic type of anemia history? characterized by an inadequate supply of a. type of treatment the patient received for vitamin B12, causing red blood cells to mononucleosis become large, varied in shape, and reduced in number b. patient’s consumption of alcohol c. microcytic-hypochromic type of anemia chrac- c. how long the patient has been married terized by small red blood cells containing low d. health status of the patient’s sister amounts of hemoglobin because of lack of iron in the body 2. Describe the condition of the patient’s mother: d. normocytic-normochromic type of anemia a. she has leukemia characterized by the failure of bone marrow to b. she has a bleeding disorder characterized by an produce red blood cells abnormally decreased number of platelets in the blood 5. Identify the subjective information most signifi- c. she has a hereditary disorder characterized by cantly linked to the assessment: an excessive buildup of iron deposits in the body a. enlarged lymph glands d. she has a disorder within the bone marrow char- b. heavy menstrual periods acterized by a proliferation of abnormal stem c. fatigue cells, which usually develops into leukemia d. the patient quit taking birth control pills 3. Which of the following describes the findings of the physical examination? 6. Of the following tests, which test is part of the a. swollen lymph glands plan? b. normal examination a. test to determine coagulation defects such as platelet disorders c. fast heart rate b. test to diagnose an infection in the blood- d. heart murmur stream, by culturing a specimen of blood 4. What is the possible cause of the patient’s fatigue? c. needle aspiration of bone marrow tissue for a. viral condition characterized by an increase in pathological examination mononuclear cells (monocytes and lympho- d. expanded battery of automated blood chem- cytes) in the blood istry tests used as a general screen for disease Chapter 8 • Blood and Lymph Systems 265 M E D I C A L R E C O R D 8 . 2 Henry Lin went to his personal physician after an extended period of feeling weak and tired, and starting to lose weight. His doctor admitted him to Central Medical Center hospital for additional tests after conducting a physical examination and blood tests. He is now being treated as an outpatient by his internist, Dr. Bradley, and an oncolo- gist, Dr. Ellison, to whom he was referred for consultation and concurrent care. Directions Read Medical Record 8.2 for Mr. Lin (pages 267–268) and answer the following questions. The progress note is the oncology/hematology progress note dictated by Dr. Ellison, the oncologist treating Mr. Lin, at the time of a follow-up visit 2 weeks after Mr. Lin’s hospitalization. The second document is a hematology lab report, submitted before a second follow-up with Dr. Ellison 2 weeks later. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 8 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in the progress note you have not yet encountered in this text. Underline each where it appears in the record and define below: edema ______________________________________________________________________ scaphoid ___________________________________________________________________ anorexia ____________________________________________________________________ 2. In your own words, not using medical terminology, translate Mr. Lin’s diagnosis: ____________________________________________________________________________ 3. Name the diagnostic test that confirmed this diagnosis: ____________________________________________________________________________ 4. Write the medical term for Mr. Lin’s enlarged spleen: ____________________________________________________________________________ 5. Dr. Ellison’s March 31 record includes the results of two CBC component tests from the earlier March 23 lab report, as well as results from the same tests for March 31. The April 15 lab report also contains the CBC component tests. In the spaces below, write the name of the tests and their results at these three times. Do not use abbreviations. Be sure to include units of measure. Result Test March 23 March 31 April 15 ____________________ __________ __________ __________ ____________________ __________ __________ __________ 266 Medical Terminology: The Language of Health Care 6. What are the three elements Dr. Ellison includes in Mr. Lin’s treatment plan? a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ 7. Study the April 15 laboratory report carefully and complete the following table of selected test results. Write the name of the component that is abbreviated and an N if the result for Mr. Lin is within the normal range or an A (abnormal) if the re- sult is outside the normal range. a. WBC b. RBC c. HGB d. HCT e. MCV f. MCH g. MCHC h. PLT i. lymph j. mono k. neutro l. eos m. baso Chapter 8 • Blood and Lymph Systems 267 Medical Record 8.2 268 Medical Terminology: The Language of Health Care CENTRAL MEDICAL CENTER 211 Medical Center Drive • Central City, US 90000-1234 • PHONE: (012) 125-6784 • FAX: (012) 125-9999 04/15/20xx 14:27 NAME : Lin, Henry LOC: TEST DOB: 2/2/xx AGE: 69Y MR# : TEST-226 SEX: M ACCT# : 168946701 M63558 COLL: 04/15/20xx 13:23 REC: 04/15/20xx 13:25 HEMOGRAM CBC WBC 4.1 [4.5–10.5] K/UL RBC 2.93 [4.6–6.2] M/UL HGB 9.1 [14.0–18.0] G/DL HCT 25.3 [42.0–52.0] % MCV 86.2 [82–92] FL MCH 31.1 [27–31] PG MCHC 36.0 [32–36] G/DL PLT 90 [150–450] K/UL Auto Lymph % 8.3 [20–40] % Auto Mono % 32.6 [1–11] % Auto Neutro % 57.8 [50–75] % Auto Eos % 1.0 [0–6] % Auto Baso % 0.3 [0–2] % Auto Lymph # 0.3 [1.5–4.0] K/UL Auto Mono # 1.3 [0.2–0.9] K/UL Auto Neutro # 2.4 [1.0–7.0] K/UL Auto Eos # 0.0 [0–0.7] K/UL Auto Baso # 0.0 [0–0.2] K/UL TEST, PATIENT TEST-221 END OF REPORT PAGE 1 04/15/20xx 14:27 INTERIM REPORT INTERIM REPORT COMPLETE Medical Record 8.2 Continued. Chapter 89 Respiratory System OBJECTIVES After completion of this chapter, you will be able to Define common term components used in relation to the respiratory system Describe the basic functions of the respiratory system Define the basic anatomical terms referring to the respiratory system Define common symptomatic and diagnostic terms referring to the respiratory system List the common diagnostic tests and procedures related to the respiratory system Identify common operative terms referring to the respiratory system Identify common therapeutic terms including drug classifications related to the respiratory system Explain the terms and abbreviations used in documenting medical records involving the respiratory system Combining Forms Combining Form Meaning Example alveol/o alveolus (air sac) alveolar al-vē´ō-lăr bronch/o bronchus (airway) bronchoscope brong´kō-skōp bronchi/o bronchiocele brong´kē-ō-sēl bronchiol/o bronchiole (little airway) bronchiolitis brong-kē-ō-lı̄´tis capn/o carbon dioxide hypercapnia hı̄-per-kap´nē-ă carb/o hypocarbia hı̄-pō-kar´bē-ă laryng/o larynx (voice box) laryngospasm lă-ring´gō-spazm lob/o lobe (a portion) lobectomy lō-bek´tō-mē nas/o nose nasal nā´zăl rhin/o rhinorrhea rı̄-nō-rē´ ă 269 270 Medical Terminology: The Language of Health Care Combining Form Meaning Example or/o mouth oropharyngeal ōr-ō-fă-rin´jē-ăl ox/o oxygen hypoxemia hı̄-pok-sē´mē-ă palat/o palate palatoplasty pal´ă-tō-plas-tē pharyng/o pharynx (throat) pharyngitis far-in-jı̄´tis phren/o diaphragm (also mind) phrenospasm fren´ō-spazm pleur/o pleura pleurisy plūr´i-sē pneum/o air or lung pneumonia nū-mō´nē-ă pneumon/o pneumonectomy nū´mō-nek´tō-mē pulmon/o lung pulmonologist pŭl´mō-nol´ŏ-jist sinus/o sinus (cavity) sinusitis sı̄-nŭ-sı̄´tis spir/o breathing spirometry spı̄-rom´ĕ-trē thorac/o chest thoracotomy thōr-ă-kot´ō-mē pector/o pectoralgia pek-tō-ral´jē-ă steth/o stethoscope steth´ō-skōp tonsill/o tonsil (almond) tonsillitis ton´si-lı̄´tis trache/o trachea (windpipe) trachea trā´kē-ă uvul/o uvula uvulitis yu-vyu-lı̄´tis ADDITIONAL SUFFIX -pnea breathing dyspnea disp-nē´ ă Respiratory System Overview The respiratory system is composed of the organs and structures that function to exchange gases within the body. The exchange of gases, called respiration, occurs when oxygen from the air is inhaled into the lungs and passes into the blood and carbon dioxide diffuses from the blood into the lungs and is exhaled into the air. Respiration is also known as breathing or ventilation. Intake of air is called inspiration or inhalation, and outflow of air is called expiration or exhalation (Fig. 9.1). Chapter 9 • Respiratory System 271 RESPIRATORY SYSTEM Sinuses Frontal Frontal sinus sinus Sphenoid sinus Nasal cavity Ethmoidal Nasopharynx air cells Oral cavity Oropharynx Tonsils Nose Sphenoidal Laryngopharynx sinus Epiglottis Maxillary Esophagus sinus Trachea Tongue Larynx with vocal cords Superior view of larynx Rib Lung Lung Pleura Epiglottis Pleural cavity Vocal Right main cords bronchus Left main open Upper lobe of bronchus right lung Cartilage Upper lobe Middle lobe of left lung Lower lobe Carina Bronchioles Mediastinum Lower lobe Diaphragm Lining of airways Mucus Bronchiole with alveoli Bronchial cilia Bronchial lining cells Mucus-producing Pulmonary cells vein Mucous membranes Alveolus Lobes O2CO2 Pulmonary artery Figure 9.1. Respiratory tract. 272 Medical Terminology: The Language of Health Care Anatomical Terms Term Meaning nose structure that warms, moistens, and filters air as it enters nōz the respiratory tract and that houses the olfactory receptors for the sense of smell sinuses air-filled spaces in the skull that open into the nasal cavity sı̄´nŭs-ĕz palate partition between the oral and nasal cavities; divided into pal´ăt the hard and soft palate pharynx throat; passageway for food to the esophagus and air to far´ingks the larynx nasopharynx part of the pharynx directly behind the nasal passages nā´zō-far-ingks oropharynx central portion of the pharynx between the roof of the ŏr´ō-far-ingks mouth and the upper edge of the epiglottis laryngopharynx lower part of the pharynx just below the oropharynx lă-ring´gō-far-ingks opening into the larynx and the esophagus tonsils oval lymphatic tissues on each side of the pharynx that ton´silz filter air to protect the body from bacterial invasion— also called palatine tonsils adenoid lymphatic tissue on the back of the pharynx behind the ad´ĕ -noyd nose—also called pharyngeal tonsil uvula small projection hanging from the back middle

edge of yu´vyu-lă the soft palate, named for its grape-like shape (see Chapter 14, Fig. 14.2) larynx voice box; passageway for air moving from pharynx to lar´ingks trachea; contains vocal cords glottis opening between the vocal cords in the larynx glot´is epiglottis lid-like structure that covers the larynx during swallowing ep-i-glot´is to prevent food from entering the airway trachea windpipe; passageway for air from the larynx to the area tră´kē-ă of the carina where it splits into the right and left bronchus bronchial tree branched airways that lead from the trachea to the alveoli brong´kē-ăl right and left two primary airways branching from the area of the carina bronchus into the lungs brong´kŭs bronchioles progressively smaller tubular branches of the airways brong´kē-ōlz alveoli thin-walled microscopic air sacs that exchange gases al-vē´ ō-lı̄ Chapter 9 • Respiratory System 273 Term Meaning lungs two spongy organs, located in the thoracic cavity enclosed LUNG. Lung is lŭngz by the diaphragm and rib cage, responsible for an Anglo-Saxon respiration term derived from lungre, meaning lobes subdivisions of the lung, two on the left and three on the quickly or lightly. The lōbz right connection suggests that the lungs were named for their pleura membranes enclosing the lung (visceral pleura) and lining lightness and ability to float plūr´ă the thoracic cavity (parietal pleura) in water. The lungs were pleural cavity potential space between the visceral and parietal layers of also called “lights.” plūr´ăl kav´i-tē the pleura diaphragm muscular partition that separates the thoracic cavity from dı̄´ă-fram the abdominal cavity and aids in respiration by moving up and down mediastinum partition that separates the thorax into two compartments me´dē -as-tı̄´nŭm (that contain the right and left lungs) and encloses the heart, esophagus, trachea, and thymus gland mucous membranes thin sheets of tissue that line the respiratory passages and myū´kŭs mem´brānz secrete mucus, a viscid (sticky) fluid cilia hair-like processes from the surface of epithelial cells, sil´ē-ă such as those of the bronchi, that provide upward movement of mucus cell secretions parenchyma functional tissues of any organ such as the tissues of the pă-reng´ki-mă bronchioles, alveoli, ducts, and sacs that perform respiration Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC Breathing (Fig. 9.2) eupnea normal breathing yūp-nē´ ă bradypnea slow breathing brad-ip-nē´ ă tachypnea fast breathing tak-ip-nē´ ă hypopnea shallow breathing hı̄-pop´nē-ă hyperpnea deep breathing hi-perp-nē´ ă dyspnea difficulty breathing disp-nē´ ă apnea inability to breathe ap´nē-ă 274 Medical Terminology: The Language of Health Care Normal Bradypnea Tachypnea (decreased rate) (increased rate) Inspiration Expiration Time Volume of air Hypopnea Hyperpnea Cheyne-Stokes breathing (shallow depth) (increased depth) Figure 9.2 Examples of breathing patterns. Term Meaning orthopnea ability to breathe only in an upright position ōr-thop-nē´ ă Cheyne-Stokes pattern of breathing characterized by a gradual respiration increase of depth and sometimes rate to a res-pi-rā´ shŭn maximum level, followed by a decrease, resulting in apnea Lung Sounds crackles popping sounds heard on auscultation of the lung krak´ĕlz when air enters diseased airways and alveoli— rales occurs in disorders such as bronchiectasis or rahlz atelectasis wheezes high-pitched, musical sounds heard on hwēz´ez auscultation of the lung as air flows through a rhonchi narrowed airway—occurs in disorders such as rong´kı̄ asthma or emphysema stridor a high-pitched crowing sound that is a sign of str ı̄´dōr obstruction in the upper airway (trachea or larynx) General Symptomatic Terms caseous necrosis degeneration and death of tissue with a cheese- kā´ sē-ŭs nĕ-krō´sis like appearance (characteristic of tuberculosis) dysphonia hoarseness (phon/o  voice or sound) dis-fō´nē-ă epistaxis nosebleed (epi  upon; stazo  to drip) ep´i-stak´sis expectoration coughing up and spitting out of material from the ek-spek-tō-rā´ shŭn lungs sputum material expelled from the lungs by coughing spū´ tŭm hemoptysis coughing up and spitting out blood originating in hē-mop´ti-sis the lungs (ptysis  to spit) Chapter 9 • Respiratory System 275 Term Meaning hypercapnia excessive level of carbon dioxide in the blood hı̄-per-kap´nē-ă (capno  smoke; carbo  coal) hypercarbia hı̄-per-kar´bē-ă hyperventilation excessive movement of air in and out of the lungs hı̄´per-ven-ti-lā´ shŭn causing hypocapnia hypoventilation deficient movement of air in and out of the lungs hı̄´pō-ven-ti-lā´ shŭn causing hypercapnia hypoxemia deficient amount of oxygen in the blood hı̄-pok-sē´mē-ă hypoxia deficient amount of oxygen in tissue cells hı̄-pok´sē-ă obstructive condition blocking the flow of air moving out of lung disorder the lungs (Fig. 9.3C) lŭng dis-ōr´der restrictive lung disorder condition limiting the intake of air into the lungs (see Fig. 9.3B) pulmonary edema fluid filling of the spaces around the alveoli, even- pŭl´mō-nār-ē e-dē´mă tually flooding into the alveoli pulmonary infiltrate density on an x-ray representing solid material pŭl´mō-nār-ē in-fil´trāt within the air spaces of the lungs, usually indicating inflammatory changes (see Fig. 9.7) rhinorrhea thin, watery discharge from the nose r ı̄-nō-rē´ ă Loss of Alveolar elasticity duct Fibrotic tissue Air trapping Alveolus A Normal B Pneumoconiosis Bronchioles and alveolar ducts are Chronic inhalation of dust particles C Emphysema open, allowing air to reach alveoli results in the formation of fibrotic Alveoli lose their elasticity, making it and alveolar capillaries; alveoli and tissue surrounding the alveoli, limiting difficult to push air out of the lungs ducts are elastic, pushing air out of their ability to stretch and restricting and obstructing exhalation of air. the lungs during expiration. the intake of air. Figure 9.3 Comparison of normal alveoli (A) with alveoli in restrictive (B) and obstructive (C) lung disorders. 276 Medical Terminology: The Language of Health Care A B Cross section Cross section Mucus plugs Swelling Constriction Close-up of a bronchiole, showing spasm, edema, and mucus Figure 9.4 Constricted bronchial tubes in asthma. A. Normal. B. Asthma. Term Meaning DIAGNOSTIC asthma panting; obstructive pulmonary disease caused by az´mă a spasm of the bronchial tubes or by swelling of their mucous membrane, characterized by paroxysmal (sudden, periodic) attacks of wheezing, dyspnea, and cough (Fig. 9.4) atelectasis collapse of lung tissue (alveoli) (atele  at-ĕ-lek´tă-sis imperfect) bronchiectasis abnormal dilation of the bronchi with brong-kē-ek´tă-sis accumulation of mucus (Fig. 9.5) bronchitis inflammation of the bronchi brong-kı̄´tis bronchogenic carcinoma lung cancer brong-kō-jen´ik kar-si-nō´mă bronchospasm constriction of bronchi caused by spasm of the brong´kō-spazm peribronchial smooth muscle emphysema obstructive pulmonary disease characterized by em-fi-sē´mă overexpansion of the alveoli with air, with destructive changes in their walls resulting in loss of lung elasticity and gas exchange (emphysan  to inflate) (see Fig. 9.3C) chronic obstructive permanent, destructive pulmonary disorder that pulmonary disease (COPD) is a combination of chronic bronchitis and kron´ik pŭl´mō-nār-ē di-zēz´ emphysema cystic fibrosis inherited condition of exocrine gland malfunction sis´tik f ı̄-brō´ sis causing secretion of abnormally thick, viscous (sticky) mucus that obstructs passageways within the body, commonly affecting the lungs and digestive tract; mucus that obstructs the airways leads to infection, inflammation, and lung tissue damage laryngitis inflammation of the larynx lar-in-j ı̄ ´ tis Chapter 9 • Respiratory System 277 Normal Bronchiectasis Trachea Bronchi Trapped mucus Figure 9.5. Bronchiectasis. Term Meaning laryngotracheobronchitis inflammation of the upper airways with swelling (LTB) that creates a funnel-shaped elongation of tissue lăr-ing´gō-trā´kē-o-brong-kı̄´tis causing a distinct “seal bark” cough croup krūp laryngospasm spasm of laryngeal muscles causing constriction lă-ring´gō-spazm nasal polyposis presence of numerous polyps in the nose (a polyp nā´zăl pol´i-pō´ sis is a tumor on a stalk) pharyngitis inflammation of the pharynx far-in-j ı̄´tis pleural effusion accumulation of fluid within the pleural cavity plŭr´ăl e-fū´ zhŭn (Fig. 9.6) empyema accumulation of pus in the pleural cavity em-pı̄-ē´mă pyothorax pı̄-ō-thōr´aks hemothorax accumulation of blood in the pleural cavity hē-mō-thōr´aks pleuritis inflammation of the pleura plū-r ı̄´tis pleurisy plūr´i-sē 278 Medical Terminology: The Language of Health Care Normal Pleural effusion Pleural cavity Lung Pleura Pleural cavity Porous membrane Normal space occupied Pleural cavity allows fluid transport by the pleural cavity filling with fluid Figure 9.6 Pleural effusion. Term Meaning pneumoconiosis chronic restrictive pulmonary disease resulting nū´mō-kō-nē- ō´sis from prolonged inhalation of fine dusts such as coal, asbestos (asbestosis), or silicone (silicosis) (conio  dust) (see Fig. 9.3B) pneumonia inflammation in the lung caused by infection nū-mō´nē-ă from bacteria, viruses, fungi, or parasites, or resulting from aspiration of chemicals (Fig. 9.7) pneumocystis pneumonia pneumonia caused by the Pneumocystis carinii nū-mō-sis´tis nū-mō´nē-ă organism—a common opportunistic infection seen in those with positive human immunodeficiency virus pneumothorax air in the pleural cavity caused by a puncture of nū-mō-thōr´aks the lung or chest wall (Fig. 9.8) pneumohemothorax air and blood in the pleural cavity nū´mō-hē-mō-thōr´aks pneumonitis inflammation of the lung often caused by nū-mō-nı̄´tis hypersensitivity to chemicals or dusts pulmonary embolism (PE) occlusion in the pulmonary circulation, most pŭl´mō-nār-ē em´bō-lizm often caused by a blood clot (see Figs. 9.11 and 9.15) pulmonary tuberculosis (TB) disease caused by the presence of Mycobacterium pŭl´mō-nār-ē t ū-ber-kyū-lō´ sis tuberculosis in the lungs characterized by the formation of tubercles, inflammation, and necrotizing caseous lesions (caseous necrosis) (Fig. 9.9) sinusitis inflammation of the sinuses sı̄-nŭ-sı̄´tis Chapter 9 • Respiratory System 279 Figure 9.7 Chest x-ray showing pulmonary infiltrates in right upper lobe consistent with lobar pneumonia. Dense ma- terial (inflammatory exudate) absorbs radiation, whereas normal alveoli do not. Term Meaning sleep apnea periods of breathing cessation (10 seconds or slēp ap´nē-ă more) that occur during sleep, often causing snoring tonsillitis acute or chronic inflammation of the tonsils ton´si-lı̄´tis Normal Pneumothorax Air Inspiration Air entering through a wound in the chest causes a collapse of the lung; contents of the thoracic cavity shift to the opposite side, compressing the other lung. Figure 9.8 Simple pneumothorax. 280 Medical Terminology: The Language of Health Care Figure 9.9 Chest x-ray showing presence of tuberculosis in the left upper lobe (arrow). Term Meaning upper respiratory infection infectious disease of the upper respiratory tract (URI) involving the nasal passages, pharynx, and res´pi-ră-tōr-ē in-fek´shŭn bronchi Diagnostic Tests and Procedures Test or Procedure Explanation arterial blood gases (ABGs) analysis of arterial blood to determine the ar-tē´ rē-ăl adequacy of lung function in the exchange of gases pH a measure of blood acidity or alkalinity PaO2 partial pressure of oxygen measuring the amount of oxygen in the blood PaCO2 partial pressure of carbon dioxide measuring the amount of carbon dioxide in the blood endoscopy examination of a body cavity with a flexible en-dos´kŏ-pē endoscope to examine within for diagnostic or treatment purposes bronchoscopy use of a flexible endoscope, called a bronchoscope, brong-kos´kŏ-pē to examine the airways (Fig. 9.10) nasopharyngoscopy use of a flexible endoscope to examine the nasal nā´zō-fa-ring-gos´kŏ-pē passages and the pharynx (throat) to diagnose structural abnormalities such as obstructions, growths, and cancers Chapter 9 • Respiratory System 281 Bronchoscopy team performing procedure Area of carina Bronchoscopic views Carina Left main bronchus Right main bronchus Blood clot Blood clot occluding right main bronchus Mucus plug Mucus plug occluding right main bronchus Foreign body Embedded foreign body Right upper orifice Figure 9.10 Bronchoscopy procedure. 282 Medical Terminology: The Language of Health Care Figure 9.11 Posterior lung scan in a patient with an embolus in the right lung. Ventilation image (A) shows a normal pattern. Absence of blood flow to the right lung is apparent on perfusion scan (B). L, left; R, right. STETHOSCOPE. The Greek word stethos means chest and skopeo Test or Procedure Explanation means to view. The stetho- lung biopsy (Bx) removal of a small piece of lung tissue for scope was invented by René Laënnec in 1816. He is lŭng bı̄´op-sē pathological examination said to have first thought of lung scan two-part nuclear scan of the lungs to detect it when watching children lŭng skan abnormalities of perfusion (blood flow) or playing; some of them ventilation (respiration), commonly called a listening at one end of a V̇/Q̇ (ventilation/perfusion) scan (Fig. 9.11) beam of wood could hear a pin scratching at the other ventilation scan—made as the patient breathes end. He applied this radioactive material into the airways principle to auscultation of the chest, which was then perfusion scan—made after radioactive material is performed by placing the injected into the blood and circulates to the lungs ear directly on the patient’s chest. The first stethoscope magnetic resonance image nonionizing image of the lung to visualize lung was made of wood. (MRI) lesions mag-net´ic rez´ō-nans im´ij polysomnography (PSG) recording of various aspects of sleep (eye and pol´ē-som-nog´ră-fē muscle movements, respiration, brain wave patterns) for diagnosis of sleep disorders (somn/o  sleep) (see Chapter 10, Fig. 10.16) physical examination methods auscultation to listen; physical examination method of listening

aws-kŭl-tā´ shŭn to the sounds within the body with the aid of a stethoscope, such as auscultation of the chest for heart and lung sounds percussion physical examination method of tapping over the per-kŭsh´ŭn body to elicit vibrations and sounds to estimate the size, border, or fluid content of a cavity such as the chest pulmonary function testing direct and indirect measurements of lung volumes (PFT) and capacities pŭl´mō-nār-ē fŭngk´shŭn spirometry portion of pulmonary function testing that is a di- spı̄-rom´ĕ-trē rect measurement of lung volume and capacity (Fig. 9.12) Chapter 9 • Respiratory System 283 A B Bell Recorder FPO of Modern spirometer Air Lungs Breathing by the test subject causes the piston-like bell to rise and fall, H O Pen 2 moving the pen on the recording drum. Figure 9.12 A. Principle of spirometry. B. Modern spirometry. Test or Procedure Explanation tidal volume (TV or VT) amount of air exhaled after a normal inspiration tı̄´dăl vol´yŭm vital capacity (VC) amount of air exhaled after a maximal inspiration vı̄t´ăl kă-pas´i-tē peak flow (PF) measure of the fastest flow of exhaled air after a peak expiratory flow maximal inspiration (Fig. 9.13) rate (PEFR) ek-spı̄´ră-tō-rē flō rāt Figure 9.13. Routine peak flow monitoring by asthmatic adoles- cent female is performed to predict signs of an oncoming attack. 284 Medical Terminology: The Language of Health Care A B Figure 9.14 Pulse oximetry. A. Placement of a sensor on the patient’s finger. B. Oxygen saturation reading on a portable monitor. Test or Procedure Explanation pulse oximetry noninvasive method of estimating the percentage pŭls ok-sim´ĕ-trē of oxygen saturation in the blood using an oximeter with a specialized probe attached to the skin at a site of arterial pulsation, commonly the finger; used to monitor hypoxemia (Fig. 9.14) radiology x-ray imaging rā-dē-ol´ō-jē chest x-ray (CXR) x-ray image of the chest to visualize the lungs computed tomography (CT) computed x-ray imaging of the head is used to tō-mog´ră-fē visualize the structures of the nose and sinuses; CT of the thorax is used to detect lesions in the lung pulmonary angiography x-ray of the blood vessels of the lungs after pŭl´mō-nār-ē an-jē-og´ră-fē injection of contrast material (Fig. 9.15) Figure 9.15 Pulmonary angiogram: embolus obstructing pul- monary circulation (arrow). Chapter 9 • Respiratory System 285 Operative Terms Term Meaning adenoidectomy excision of the adenoids ad´ĕ-noy-dek´tō-mē lobectomy removal of a lobe of a lung lō-bek´tō-mē nasal polypectomy removal of a nasal polyp nā´zăl pol-i-pek´tō-mē pneumonectomy removal of an entire lung nū´mō-nek´tō-mē thoracentesis puncture for aspiration of the chest (Fig. 9.16) thōr´ă-sen-tē´ sis thoracoplasty repair of the chest involving fixation of the ribs thōr´ă-kō-plas-tē thoracoscopy endoscopic examination of the pleural cavity thōr-ă-kos´kŏ-pē using a thoracoscope thoracostomy creation of an opening in the chest usually for thōr-ă-kos´tō-mē insertion of a tube (see Fig. 9.16) thoracotomy incision into the chest thōr-ă-kot´ō-mē tonsillectomy excision of the palatine tonsils ton´si-lek´tō-mē tonsillectomy and adenoidectomy excision of the tonsils and adenoids (T & A) ad´ĕ-noy-dek´tō-mē tracheostomy creation of an opening in the trachea, most trā´kē-os´tō-mē often to insert a tube (Fig. 9.17) tracheotomy incision into the trachea (see Fig. 9.17) trā´kē-ot´ō-mē Thoracentesis Thoracostomy Surgical puncture with a needle Surgical puncture into the into the pleural space for pleural space and insertion of drainage of the pleural cavity thoracostomy tube for drainage of the pleural cavity Pleural effusion Figure 9.16 Common treatments of pleural effusion. 286 Medical Terminology: The Language of Health Care Tracheotomy Tracheostomy Incision of the trachea for exploration, Incision of the trachea and insertion Sagittal view, with tracheostomy for removal of a foreign body, or for of a tube to facilitate passage of air tube in place obtaining a biopsy specimen or removal of secretions Incision Placement of tracheostomy tube Tracheostomy tube Figure 9.17 Operative procedures related to the trachea. Therapeutic Terms Term Meaning cardiopulmonary resuscitation (CPR) method of artificial respiration and closed- kar´dē-ō-pŭl´mo-nār-ē rē-sŭs´i-tā´ shŭn chest massage used to restore breathing and cardiac output after cardiac arrest continuous positive airway pressure device that pumps a constant pressurized (CPAP) flow of air through the nasal passages, commonly used during sleep to prevent airway closure in sleep apnea (Fig. 9.18) endotracheal intubation passage of a tube into the trachea via the en´dō-trā´kē-ăl in-tū-bā´ shŭn nose or mouth to open the airway for delivering gas mixtures to the lungs (e.g., oxygen, anesthetics, or air) incentive spirometry common postoperative breathing therapy in-sen´tiv spı̄-rom´ĕ-trē using a specially designed spirometer to encourage the patient to inhale and repeatedly sustain an inspiratory volume to exercise the lungs and prevent pulmonary complications (Fig. 9.19) mechanical ventilation mechanical method performed by a mĕ-kan´i-kăl ven-ti-lā´ shŭn respiratory therapist to provide assisted breathing using a ventilator (Fig. 9.20) Figure 9.18 Patient wearing a CPAP mask. Figure 9.19 Incentive spirometer. Neonate Pediatric Adult Figure 9.20 Mechanical ventilation. 288 Medical Terminology: The Language of Health Care Term Meaning COMMON THERAPEUTIC DRUG CLASSIFICATIONS antibiotic drug that kills or inhibits the growth of microorganisms an´tē-b ı̄-ot´ik anticoagulant drug that dissolves, or prevents the formation of, thrombi an´tē-kō-ag´yū-lant or emboli in the blood vessels (e.g., heparin) antihistamine drug that neutralizes or inhibits the effects of histamine an-tē-his´tă-mēn histamine compound in the body that is released by injured cells in his´tă-mēn allergic reactions, inflammation, etc., causing constriction of bronchial smooth muscle, dilation of blood vessels, etc. bronchodilator drug that dilates the muscular walls of the bronchi brong-kō-dı̄-lā´ ter expectorant drug that breaks up mucus and promotes coughing ek-spek´tō-rănt Summary of Chapter 9 Acronyms/Abbreviations ABGs .............arterial blood gases PaO2 ..............partial pressure of oxygen Bx ....................biopsy PE ...................pulmonary embolism COPD............chronic obstructive pulmonary disease PEFR ............peak expiratory flow rate CPAP.............continuous positive airway pressure PF ....................peak flow CPR................cardiopulmonary resuscitation PFT ................pulmonary function testing CT....................computed tomography pH ...................potential of hydrogen CXR ...............chest x-ray PSG ................polysomnography HIV ................human immunodeficiency virus T & A ............tonsillectomy and adenoidectomy LTB ................laryngotracheobronchitis TB ...................tuberculosis MRI................magnetic resonance image TV or VT.....tidal volume O2 ....................oxygen URI.................upper respiratory infection PaCO2 ..........partial pressure of carbon dioxide VC ...................vital capacity Chapter 9 • Respiratory System 289 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE intranasal ______/ ____________/ __________ P R S intra/nas/al P R S DEFINITION: within/nose/pertaining to 1. pulmonology __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 2. thoracocentesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 3. nasosinusitis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 4. hypoxemia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 5. pleuritis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 6. hypercarbia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 290 Medical Terminology: The Language of Health Care 7. alveolar __________________ / __________________ R S DEFINITION: _________________________________________________________________ 8. tracheotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 9. oronasal __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 10. rhinorrhea __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 11. thoracostomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. tonsillectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 13. tracheobronchitis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 14. bronchospasm __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 15. laryngostenosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 16. spirogram __________________ / __________________ CF S DEFINITION: _________________________________________________________________ Chapter 9 • Respiratory System 291 17. lobectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 18. peripleural __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 19. stethoscope __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 20. pneumonic __________________ / __________________ R S DEFINITION: _________________________________________________________________ 21. nasopharyngoscopy __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 22. bronchiolectasis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 23. phrenoptosis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 24. pectoral __________________ / __________________ R S DEFINITION: _________________________________________________________________ 25. uvulopalatopharyngoplasty __________________ /__________________ / __________________ / __________________ CF CF CF S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 26. ______________coni______________  lung condition caused by prolonged dust inhalation 292 Medical Terminology: The Language of Health Care 27. bronchi______________  dilation of bronchus 28. ______________plasty  surgical repair of the chest 29. ______________itis  inflammation of the lung 30. ______________metry  process of measuring breathing 31. ______________ventilation  deficient movement of air in and out of the lungs 32. ______________pnea  normal breathing 33. ______________pnea  slow breathing 34. ______________pnea  difficulty breathing 35. ______________pnea  inability to breathe except in an upright position 36. ______________pnea  inability to breathe 37. ______________pnea  fast breathing For each of the following, circle the meaning that corresponds to the combining form given: 38. nose ren/o rhin/o nos/o 39. air or lung aden/o pneum/o thorac/o 40. throat thorac/o laryng/o pharyng/o 41. chest thorac/o pneum/o lapar/o 42. voice box laryng/o trache/o pharyng/o 43. breathing aer/o spir/o crin/o 44. diaphragm phren/o pleur/o pneumon/o 45. mouth ox/o or/o spir/o Write the correct medical term for each of the following: 46. air in the pleural space _______________________________________________________ 47. pus in the pleural space _______________________________________________________ 48. blood in the pleural space _______________________________________________________ 49. listening to sounds within the body _______________________________________________________ Chapter 9 • Respiratory System 293 50. endoscope used to examine the airways _______________________________________________________ 51. coughing up and spitting out material from the lungs _______________________________________________________ 52. inflammation of the pleura _______________________________________________________ 53. to elicit sounds or vibrations by tapping _______________________________________________________ 54. puncture for aspiration of the chest _______________________________________________________ 55. hoarseness _______________________________________________________ 56. inflammation of the voice box _______________________________________________________ 57. deficient amount of oxygen in tissue cells _______________________________________________________ 58. disease characterized by overexpansion of the alveoli with air _______________________________________________________ 59. nosebleed _______________________________________________________ 60. cancer originating in the bronchus _______________________________________________________ 61. inherited condition of exocrine gland malfunction that causes mucus to obstruct the airways _______________________________________________________ 62. collapse of lung tissue _______________________________________________________ 63. material expelled from the lungs by coughing _______________________________________________________ 64. high-pitched crowing sound that is a sign of obstruction in the upper airway _______________________________________________________ 65. blood clot in the lungs _______________________________________________________ 66. surgical creation of an opening in the trachea _______________________________________________________ 67. disease characterized by paroxysmal wheezing, dyspnea, and cough _______________________________________________________ 68. excessive movement of air in and out of the lungs _______________________________________________________ 294 Medical Terminology: The Language of Health Care 69. common lung infection seen in those with positive HIV _______________________________________________________ 70. disorder that is a combination of emphysema and chronic bronchitis _______________________________________________________ Write the full medical term for the following abbreviations: 71. PEFR ______________________________________________________________ 72. VC _________________________________________________________________ 73. TB _________________________________________________________________ 74. CPR ________________________________________________________________ 75. COPD ______________________________________________________________ 76. PaCO2 ______________________________________________________________ 77. URI _______________________________________________________________ 78. VT ________________________________________________________________ 79. PFT _______________________________________________________________ 80. PSG _______________________________________________________________ 81. CPAP ______________________________________________________________ Match the following: 82. ________ crackles a. naso 83. ________ wheezes b. hyperventilation 84. ________ pleurisy c. LTB 85. ________ pneumoconiosis d. thoraco 86. ________ empyema e. CPAP 87. ________ hemothorax f. asbestosis 88. ________ stetho g. pleuritis 89. ________ sleep apnea h. rhonchi 90. ________ hypocapnia i. pyothorax 91. ________ rhino j. hypoventilation 92. ________ hypercapnia k. rales 93. ________ croup l. thoracentesis Chapter 9 • Respiratory System 295 Write the standard abbreviations for the following: 94. chest x-ray ____________________ 95. analysis of blood to determine the adequacy of lung function in exchange of gases ______________________ 96. surgical removal of the tonsils and adenoids ______________________________ Write in the missing words on the blank lines in the following illustration of the respiratory tract. 97–104. Sinuses 102. Frontal Frontal sinus Sphenoid sinus Nasal cavity Ethmoidal 97. Naso air cells Oral cavity Oropharynx Tonsils Nose Sphenoidal Laryngopharynx sinus Epiglottis Maxillary Esophagus sinus 98. Tongue 103. with vocal cords Rib Lung Lung 99. Pleural cavity 104. Left main Right main bronchus 100. Upper of right lung Upper lobe Middle lobe of left lung Lower lobe Bronchioles Mediastinum Lower lobe 101. 296 Medical Terminology: The Language of Health Care For each of the following, circle the correct spelling of the term: 105. auskucation auscultation ascultation 106. tackypnea tachypenia tachypnea 107. eupnea eupenia eupneia 108. plurisy plurisey pleurisy 109. hemathorax hemothorax hematothorex 110. stethoscope stethescope stethascope 111. epitaxes epistaxes epistaxis 112. ronchi rhonchi rhonkhi 113. hemoptysis hemaptysis hemoptsis 114. rhinorhea rhinorrhea rinorhea 115. imphasema emphysema emphasema 116. atelectasis atalexisis attelexis 117. bronkodielater bronchodialator bronchodilator Give the noun that was used to form the following adjectives: 118. orthopneic ______________________________________________________________ 119. pleural __________________________________________________________________ 120. hypoxic _________________________________________________________________ 121. dyspneic ________________________________________________________________ 122. pharyngeal ______________________________________________________________ 123. apneic __________________________________________________________________ 124. tracheal _________________________________________________________________ 125. asthmatic _______________________________________________________________ Chapter

9 • Respiratory System 297 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 9 . 1 S: This is a 26 y.o.  c/o a nonproductive cough, dyspnea, and fever  2 d; pt does not smoke and has otherwise been in good health. O: T 101ºF, BP 100/64, R 25, 104 Tachypnea is accompanied by mild cyanosis, and inspiratory crackles are noted upon auscultation. WBC 31,000, Hct 37%, platelet count 109,000. CXR shows diffuse infiltrates at the bases of both lungs. An ABG taken while the patient was breathing room air showed a pH of 7.54, PaCo2, of 20, PaO2 of 74, sputum specimen contains 3 WBC but no bacteria. A: Pneumonia of unknown etiology P: IV erythromycin STAT admit to ICU deliver O2 by face mask and monitor for hypoxemia 1. What is the patient’s chief complaint? b. inflammation of the bronchi a. afebrile with a dry cough and difficulty breathing c. inflammation of the pleura b. febrile with a dry cough and difficulty breathing d. inflammation of the lungs due to sensitivity to c. cannot breathe, fever, and coughing up dust or chemicals material from the lungs e. inflammation of the lungs of unknown cause d. hoarse throat, dry cough, and fever e. febrile, coughing up sputum, and breathing fast 5. What is an ABG? a. analysis of blood to determine the adequacy of 2. What are the findings upon PE? lung function in the exchange of gases a. slow breathing, blue skin, and rhonchi heard in b. meausurement of lung volume and capacity the lungs as the patient exhales c. measure of the flow of air during inspiration b. fast breathing, blue skin, and musical sounds d. scan to detect breathing abnormalities heard in the lungs as the patient inhales e. image of the lungs used to visualize lung c. slow breathing, blue skin, and rales heard in lesions the lungs as the patient holds her breath d. fast heart, blue skin, and rales heard in the 6. Describe the condition for which the patient was lungs as the patient inhales monitored while undergoing oxygen therapy: e. fast breathing, blue skin, and popping sounds a. blockage of airflow out of the lungs heard in the lungs as the patient inhales b. excessive movement of air in and out of the lungs 3. What did the chest x-ray show? c. deficient amount of oxygen in the blood a. tuberculosis d. deficient amount of oxygen in the tissue cells b. asthma e. excessive level of carbon dioxide in the blood c. density representing solid material usually indicating inflammation 7. What is the Sig: on the erythromycin? d. fluid filling of spaces around the lungs a. not mentioned e. lung cancer b. inject into a vein immediately 4. What is the impression? c. take four immediately a. dilation of the bronchi with an accumulation of d. insert into the vagina immediately mucus e. inject into a muscle immediately 298 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 9 . 2 Angelica Torrance, a retired painter who for years has boasted to friends that she has the good health of a 30-year-old, suffered a broken ankle when she slipped off a foot- stool in her basement. The surgical repair of her fracture at Central Medical Center was routine, but soon after surgery Ms. Torrance developed other problems, and a pul- monologist was eventually called in for a consultation. Directions Read Medical Record 9.2 for Ms. Torrance (pages 300–302) and answer the following questions. This record is the history and physical examination report from Dr. Carl Brownley, the pulmonologist who consulted with Ms. Torrance’s doctors after she de- veloped breathing problems. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 9 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: morphine _________________________________________________________________ heparin ___________________________________________________________________ obese ____________________________________________________________________ 2. In your own words, not using medical terminology, describe what surgery Ms. Torrance had for her broken ankle: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. Describe in your own words the four symptoms that Ms. Torrance developed postsurgically: a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ d. _____________________________________________________________________ 4. Before Ms. Torrance’s acute “sense of suffocating,” she was being treated with what three pharmacological treatments? a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ 5. Immediately after her reported “sense of suffocating,” she was given what two treatments? a. _____________________________________________________________________ b. _____________________________________________________________________ Chapter 9 • Respiratory System 299 6. Put the following events that occurred in the hospital in correct order by numbering them 1 to 8: _____ postoperative pulmonary symptoms _____ transport to intensive care _____ sense of suffocation _____ episode of tachycardia _____ nuclear lung scan showing high probability of embolus _____ evaluation for complications in the lungs _____ open reduction, internal fixation _____ intravenous drugs first administered 7. In your own words, not using medical terminology, describe the two diagnostic imaging studies performed the morning of 10/24: a. _____________________________________________________________________ b. _____________________________________________________________________ 8. Name and describe the test that was performed to monitor Ms. Torrance’s heparin therapy: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9. Translate into lay language Dr. Brownley’s first four assessments from the examination: a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ d. _____________________________________________________________________ 10. Dr. Brownley’s recommendations include requests for certain tests to be run (or run again) and certain other actions to be taken while Ms. Torrance stays in the hospital. Without using abbreviations, list the tests to be performed and the actions to be taken: Tests: a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ d. _____________________________________________________________________ e. _____________________________________________________________________ f. _____________________________________________________________________ Actions: g. _____________________________________________________________________ h. _____________________________________________________________________ 300 Medical Terminology: The Language of Health Care Medical Record 9.2 Chapter 9 • Respiratory System 301 Medical Record 9.2 Continued. 302 Medical Terminology: The Language of Health Care Medical Record 9.2 Continued. Chapter 9 • Respiratory System 303 M E D I C A L R E C O R D 9 . 3 Richard Puma, a heavy smoker until recently, had been treated for pneumonia in the last month. Even though his condition had deteriorated in the last few days, he refused to be hospitalized. Today, May 18, having much trouble breathing, he came to Central Medical Center and was seen by Dr. Theresa Cunningham. Directions Read Medical Record 9.3 for Richard Puma (pages 306–309) and answer the following questions. This record includes the history, physical examination, and discharge sum- mary dictated by Dr. Cunningham and transcribed the next day. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 9 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in these records you have not yet encountered in this text. Underline each where it appears in the record and define below: hepatosplenomegaly ________________________________________________________ precordial ________________________________________________________________ fulminant _________________________________________________________________ respiratory acidosis _________________________________________________________ cardiac arrest _____________________________________________________________ 2. In your own words, not using medical terminology, describe Mr. Puma’s chief complaint to Dr. Cunningham: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 3. Following are various elements from the history of Mr. Puma’s present illness. Put them in correct chronological order by numbering them 1 to 7, starting with the event that occurred first: ___ productive cough with some show of blood ___ seen at the Bradford Emergiclinic ___ progressively worsening with marked SOB ___ diagnosis of pneumonia ___ refusal to be hospitalized ___ administration of Cipro began ___ administration of Cipro started a second time 304 Medical Terminology: The Language of Health Care 4. In your own words, not using medical terminology, describe how Mr. Puma looked in general at the time of examination: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. Although examination of the abdomen produced no negative findings, Dr. Cun- ningham’s auscultation of the lungs and heart was more significant. In your own words, what were her findings? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 6. Dr. Cunningham concluded her examination with a diagnosis and treatment plan. Although the cause of Mr. Puma’s condition is unclear, the diagnosis state- ment itself is definite. Describe it in your own words: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. In the history and physical examination, Dr. Cunningham’s treatment plan called for what immediate action? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. As noted in the discharge summary, Dr. Anderson was next to see Mr. Puma. In your own words, describe Dr. Anderson’s specialty: ________________________________________________________________________ 9. What diagnostic test was first to be performed on admission to the CCU? ________________________________________________________________________ 10. During the CCU examination, what happened to Mr. Puma? ________________________________________________________________________ How did Dr. Anderson respond? ________________________________________________________________________ Chapter 9 • Respiratory System 305 11. Put Dr. Cunningham’s final three diagnoses in your own words (do not include history or treatment information): a. _____________________________________________________________________ b. _____________________________________________________________________ c. _____________________________________________________________________ 306 Medical Terminology: The Language of Health Care The patient is a 62-year-old white male with a history of pneumonia diagnosed four weeks ago. He appeared to have a favorable response to a two-week course of Cipro; however, after being off the medication for two days, symptoms including hemoptysis and yellow sputum returned. He was restarted on half a dose of the antibiotic for five more days with some improvement. This was finished 11/2 weeks ago. Over the past 10 days, he has become progressively worse with a marked increase in shortness of breath and orthopnea. Two days ago, he was seen at the Bradford Emergiclinic because of the progressive nature of his shortness of breath. At that time, hospitalization was recommended, but the patient refused. 20xx Medical Record 9.3 Chapter 9 • Respiratory System 307 Medical Record 9.3 Continued. 308 Medical Terminology: The Language of Health Care Medical Record 9.3 Continued. Chapter 9 • Respiratory System 309 Medical Record 9.3 Continued. Chapter 10 Nervous System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the nervous system and psychiatry Describe the basic functions of the nervous system Define the basic anatomical terms referring to the nervous system Define common symptomatic and diagnostic terms related to the nervous system Define common diagnostic terms related to the nervous system List common diagnostic tests and procedures related to the nervous system Define common operative terms related to the nervous system Define common therapeutic terms including drug classifications related to the nervous system Define common symptomatic terms related to psychiatry Define common diagnostic terms related to psychiatry Define common therapeutic terms related to psychiatry Explain common terms and abbreviations used in documenting medical records involving the nervous system or field of psychiatry Combining Forms Combining Form Meaning Example arthr/o articulation dysarthria cerebell/o cerebellum (little brain) cerebellar ser-e-belar cerebr/o cerebrum (largest part of brain) cerebrospinal serĕ-brō-spı̄-năl crani/o skull cranium krānē-ŭm encephal/o entire brain encephalography en-sef-ă-logră-fĕ esthesi/o sensation hyperesthesia hı̄per-es-thēzē-ă gangli/o ganglion (knot) ganglioneuroma gangglē-ō-nū-rōmă 310 Chapter 10 • Nervous System 311 Combining Form Meaning Example gli/o glue glial glı̄ăl gnos/o knowing gnosia nōsēă hypn/o sleep hypnosis hip-nōsis somn/i somnipathy som-nipă-thē somn/o polysomnography polē-som-nogră-fē kinesi/o movement kinesiology ki-nē-sē-olō-jē lex/o word or phrase dyslexia dis-leksē-ă mening/o meninges (membrane) meningocele mĕ-ninggō-sēl meningi/o meningitis men-in-jı̄tis myel/o spinal cord or bone marrow myeloma mı̄-ĕ-lōmă narc/o stupor, sleep narcotic nar-kotik neur/o nerve neuralgia nū-raljē-ă phas/o speech dysphasia dis-fāzē-ă phob/o exaggerated fear or sensitivity phobia fōbē-ă phor/o carry or bear euphoria yu-fōrē-ă phren/o mind schizophrenia skiz-ō-frēnē-ă psych/o psychotic sı̄-kotik thym/o dysthymia dis-thı̄mē-ă schiz/o split schizoid skizoyd somat/o body psychosomatic sı̄kō-sō-matik spin/o spine (thorn) spinal spı̄năl spondyl/o vertebra spondylosyndesis spondi-lō-sin-dēsis vertebr/o vertebral verte-brăl 312 Medical Terminology: The Language of Health Care Combining Form Meaning Example stere/o three dimensional or solid stereotaxic sterē-ō-taksik tax/o order or coordination ataxic ă-taksik thalam/o thalamus (a room) thalamotomy thal-ă-motō-mē ton/o tone or tension tonic tonik top/o place topesthesia topes-thē-zē-ă ventricul/o ventricle (belly or pouch) ventriculostomy ven-trik-yū-lostō-mē ADDITIONAL PREFIX cata- down catatonic kat-ă-tonik ADDITIONAL SUFFIXES -asthenia weakness neurasthenia nūr-as-thēnē-ă -lepsy seizure narcolepsy narkō-lep-sē -mania condition of abnormal necromania impulse toward nek-rō-mānē-ă -paresis slight paralysis hemiparesis hemē-pa-rēsis -plegia paralysis paraplegia par-ă-plējē-ă Nervous System Overview The nervous system is an intricate communication network of structures that activates and controls

all functions of the body and receives all input from the environment. There are two major classes of cells that make up the nervous system: the neuron, the basic structure, and the neuroglia, the supporting cells (Fig. 10.1). Each neuron is made up of a soma (the body of the neuron), dendrites (the afferent branches of the soma), and an axon (the efferent branch of the soma), which are linked via terminals called synapses. At the synapse, chemicals known as neurotransmitters are released to effect changes that inhibit or excite cells. They function within the vast complex of impulse-carrying fibers called nerves. A ganglion is a collection of somas in the peripheral nervous system, and a nucleus is a collection of somas in the central nervous system. Four types of neuroglia perform essential functions in the nervous system: ependy- mal cells make the cerebrospinal fluid that circulates in and around the brain and spinal cord. The star-shaped astrocytes have the responsibility of passing nutrients from blood to neurons. Myelin, the lipid that surrounds nerve fibers and helps to con- duct neuronal impulses, is produced by the oligodendroglia. The small, branching microglia perform phagocytosis. The nervous system has three divisions: (a) central nervous system, (b) peripheral nervous system, and (c) autonomic nervous system. Chapter 10 • Nervous System 313 NEURON Soma Myelin sheath Dendrites Axon Synaptic terminals GLIAL CELLS Ependymal cells Oligodendrocytes Astrocytes Microglial cells (line brain ventricles) (wrap axons: myelination) (support capillaries) (engulf invading microorganisms and dead tissues) Axons Neurons (nerve fibers) Capillaries Figure 10.1 Basic components of the nervous system. Anatomical Terms Term Meaning central nervous system (CNS) brain and spinal cord brain portion of the central nervous system contained within the cranium cerebrum largest portion of the brain; it is divided into sĕr-ēbrum right and left halves known as cerebral hemispheres that are connected by a bridge of nerve fibers called the corpus callosum; lobes of the cerebrum are named after the skull bones they underlie (Fig. 10.2) frontal lobe anterior section of each cerebral hemisphere frŭntăl lōb responsible for voluntary muscle movement and personality parietal lobe portion posterior to the frontal lobe, responsible pă-rı̄ĕ-tăl lōb for sensations such as pain, temperature, and touch 314 Medical Terminology: The Language of Health Care A B Central sulcus Parietal lobe Motor area Somatosensory Speech area, Frontal lobe Expression Taste Body awareness Occipital Olfactory bulbs lobe Vision Temporal lobe Cerebellum Auditory Medulla oblongata Spinal cord Speech reception Figure 10.2 A. Lobes of the brain. B. Localized functions of the cerebrum. Term Meaning temporal lobe portion that lies below the frontal lobe, responsible tempŏ-răl lōb for hearing, taste, and smell occipital lobe portion posterior to the parietal and temporal ok-sipi-tăl lōb lobes, responsible for vision cerebral cortex outer layer of the cerebrum consisting of gray serĕ-brăl kōrteks matter, responsible for higher mental functions (cortex  bark) thalamus (diencephalon) two gray matter nuclei deep within the brain, thală-mŭs dı̄-en-sefă-lon responsible for relaying sensory information to the cortex gyri ring or circle; convolutions (mounds) of the jı̄rı̄ cerebral hemispheres sulci ditch; shallow grooves that separate gyri sŭlsı̄ fissures splitting crack; deep grooves in the brain fishŭrz cerebellum portion of the brain located below the occipital ser-ĕ-belŭm lobes of the cerebrum, responsible for control and coordination of skeletal muscles (Fig. 10.3) brainstem region of the brain that serves as a relay between brānstem the cerebrum, cerebellum, and spinal cord, responsible for breathing, heart rate, and body temperature; there are three levels: mesencephalon (midbrain), pons, and medulla oblongata ventricles series of interconnected cavities within the ventri-klz cerebral hemispheres and brainstem filled with cerebrospinal fluid (Fig. 10.4) Chapter 10 • Nervous System 315 THE BRAIN Corpus callosum Meninges Thalamus Pineal body Frontal sinus Hypothalamus Pituitary gland Sphenoid sinus Pons Medulla oblongata Cerebellum Spinal cord Midsagittal view of brain Cranium Venous sinus Dura mater Meninges Arachnoid Pia mater Subdural space Subarachnoid space Cerebrum Magnetic resonance imaging (MRI) of normal brain, midsagittal view Figure 10.3 Midsagittal view of the brain. 316 Medical Terminology: The Language of Health Care Lateral ventricles B Posterior horns of lateral ventricles A Magnetic resonance image, horizontal view A Interventricular foramen Third ventricle Inferior horn of lateral ventricle Cerebral aqueduct Fourth ventricle Magnetic resonance image, coronal view B Figure 10.4 Ventricles of the brain. Term Meaning cerebrospinal fluid (CSF) plasma-like clear fluid circulating in and around serĕ-brō-spı̄-năl flūid the brain and spinal cord spinal cord column of nervous tissue from the brainstem spı̄năl kōrd through the vertebrae, responsible for nerve conduction to and from the brain and the body meninges three membranes that cover the brain and mĕ-ninjēz spinal cord, consisting of the dura mater, pia mater, and arachnoid peripheral nervous system nerves that branch from the central nervous (PNS) system, including nerves of the brain (cranial nerves) and spinal cord (spinal nerves) (Fig. 10.5) cranial nerves 12 pairs of nerves arising from the brain krānē-ăl nervz Chapter 10 • Nervous System 317 THE PERIPHERAL NERVOUS SYSTEM Dorsal primary ramus Cervical Ventral primary ramus nerves Musculocutaneous nerve Median nerve Thoracic Radial nerve nerves Filum terminale Ulnar nerve Cauda Lumbar equina Deep branch of nerves radial nerve Sacral nerves Superficial branch of radial nerve Coccygeal nerve Femoral nerve Obturator nerve Saphenous nerve Sciatic nerve Common peroneal Common peroneal nerve nerve Tibial nerve Superficial peroneal nerve Superficial peroneal nerve Deep peroneal Deep peroneal nerve nerve Medial plantar Lateral plantar nerve nerve Anterior view Posterior view Figure 10.5 Peripheral nervous system. Term Meaning spinal nerves 31 pairs of nerves arising from the spinal cord sensory nerves nerves that conduct impulses from body parts sensŏ-rē nervz and carry sensory information to the brain—also called afferent nerves (ad  toward; ferre  carry) motor nerves nerves that conduct motor impulses from the brain to muscles and glands; also called efferent nerves (e  out; ferre  carry) 318 Medical Terminology: The Language of Health Care Term Meaning autonomic nervous system nerves that carry involuntary impulses to smooth (ANS) muscle, cardiac muscle, and various glands hypothalamus control center for the autonomic nervous system hı̄pō-thală-mŭs located below the thalamus (diencephalon) sympathetic nervous division of the ANS concerned primarily with system preparing the body in stressful or emergency sim-pă-thetik situations parasympathetic nervous division of the ANS that is most active in ordinary system conditions; it counterbalances the effects of the par-ă-sim-pă-thetik sympathetic system by restoring the body to a restful state after a stressful experience Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC aphasia condition without speech; impairment due to ă-fāzē-ă localized brain injury that affects understanding, retrieving, and formulating meaningful and sequential elements of language dysarthria condition of difficult articulation; group of related dis-arthrē-ă speech impairments that may affect the speed, range, direction, strength, and timing of motor movement as a result of paralysis, weakness, or incoordination of speech muscles (arthr/o  articulation) dysphasia difficulty speaking dis-fāzē-ă COMA. Coma is derived from a coma general term referring to levels of decreased Greek word kō mă consciousness with varying responsiveness; a meaning a deep sleep, a common method of assessment is the Glasgow coma state of unconsciousness scale (Fig. 10.6) from which one cannot be roused. In Greek mythology, delirium state of mental confusion due to disturbances in Comus was the guardian of dē-lirē-ŭm cerebral function—there are many causes, including banquets who indulged in fever, shock, or drug overdose (deliro  to draw the nightly orgies that resulted in furrow awry in plowing, i.e., to go off the rails) a state of profound insensibility caused by a dementia impairment of intellectual function characterized by drunken stupor. The dē-menshē-ă memory loss, disorientation, and confusion ingestion of a toxin such as (dementio  to be mad) alcohol is only one of many causes of coma. The words motor deficit loss or impairment of muscle function comic and comical share mō ter defi-sit the same origin with coma. sensory deficit loss or impairment of sensation sensŏ -rē defi-sit Chapter 10 • Nervous System 319 Glasgow Coma Scale A.M. P.M. A.M. Assessment Reaction Score 8 10 12 2 4 6 8 10 12 2 4 6 8 Eye Opening Spontaneously 4 X X X X X X Response To speech 3 X X To pain 2 X X X No response 1 Motor Response Obeys verbal command 6 X X X X X X Localizes pain 5 X X Flexion withdrawal 4 X X Flexion 3 X Extension 2 No response 1 Verbal Response Oriented x3 5 X X X X X X Conversation confused 4 X X Inappropriate speech 3 X Incomprehensible sounds 2 X X No response 1 Figure 10.6 Glasgow Coma Scale scoring for a child. A score of 3 to 8 denotes severe trauma; a score of 9 to 12 denotes moderate trauma; and a score of 13 to 15 denotes slight trauma. Notice the gradual improvement from coma in this example. Term Meaning neuralgia pain along the course of a nerve nū-raljē-ă paralysis temporary or permanent loss of motor control flaccid paralysis defective (flabby) or absent muscle control caused by flassid pă-rali-sis a nerve lesion spastic paralysis stiff and awkward muscle control caused by a central spastik pă-rali-sis nervous system disorder hemiparesis partial paralysis of the right or left half of the body hem-ē-pa-rēsis sciatica pain that follows the pathway of the sciatic nerve sı̄-ati-kă caused by compression or trauma of the nerve or its roots seizure sudden, transient disturbances in brain function sēzher resulting from abnormal firing of nerve impulses (may or may not be associated with convulsion) convulsion to pull together; type of seizure that causes a series of kon-vŭlshŭn sudden, involuntary contractions of muscles syncope fainting sinkŏ -pē tactile stimulation evoking a response by touching taktil 320 Medical Terminology: The Language of Health Care Term Meaning hyperesthesia increased sensitivity to stimulation such as touch or hı̄per-es-thēzē-ă pain paresthesia abnormal sensation of numbness and tingling par-es-thēzē-ă without objective cause DIAGNOSTIC agnosia any of many types of loss of neurological function ag-nōsē-ă associated with interpretation of sensory information astereognosis inability to judge the form of an object by touch ă-stērē-og-nōsis (e.g., a coin from a key) atopognosis inability to locate a sensation properly, such as to ă-top-og-nōsis locate a point touched on the body Alzheimer disease disease of structural changes in the brain resulting in an irreversible deterioration that progresses from forgetfulness and disorientation to loss of all intellectual functions, total disability, and death (see Fig. 10.19) amyotrophic lateral a condition of progressive deterioration of sclerosis (ALS) motor nerve cells resulting in total loss of voluntary ā-mı̄-ō-trōfik muscle control; symptoms advance from muscle weakness in the arms, legs, muscles of speech, swallowing, and breathing to total paralysis and death—also known as Lou Gehrig disease cerebral palsy (CP) condition of motor dysfunction caused by damage to serĕ-brăl pawlzē the cerebrum during development or injury at birth, characterized by partial paralysis and lack of muscle coordination (palsy  paralysis) cerebrovascular disease disorder resulting from a change within one or more blood vessels of the brain cerebral arteriosclerosis hardening of the arteries of the brain ar-tērē-ō-skler-ōsis cerebral atherosclerosis condition of lipid (fat) buildup within the blood ather-ō-skler-ōsis vessels of the brain (ather/o  fatty [lipid] paste) cerebral aneurysm dilation of a blood vessel in the brain anyū-rizm (aneurysm  dilation or widening) cerebral thrombosis presence of a stationary clot in a blood vessel of throm-bōsis the brain cerebral embolism obstruction of a blood vessel in the brain by an embō-lizm embolus transported through the circulation cerebrovascular damage to the brain caused by cerebrovascular accident (CVA) disease (e.g., occlusion of a blood vessel by an stroke embolus or thrombus or intracranial hemorrhage after rupture of an aneurysm) (Fig. 10.7) transient ischemic brief episode of loss of blood flow to the brain attack (TIA) usually caused by a partial occlusion that results in tranzē-ĕnt is-kēmik temporary neurological deficit (impairment)—often precedes a CVA (Fig. 10.8) Chapter 10 • Nervous System 321 Cerebral thrombosis Cerebral embolism Intracranial hemorrhage (thrombotic stroke) (embolic stroke) (hemorrhagic stroke) Thrombus Moving embolus gradually builds, creates damage blocking artery where it lodges Rupture or bleed of an artery Figure 10.7 Cerebrovascular accident. Frontal view Circle of Willis view from underneath the brain Anterior communicating artery Circle Anterior Middle of Willis cerebral artery cerebral artery Basilar artery Internal External carotid artery carotid Posterior artery communicating Posterior Internal artery cerebral artery carotid artery Carotid Superior

Basilar artery sinus cerebellar artery Vertebral artery Common carotid artery Innominate Subclavian artery Aorta Figure 10.8 Sites of transient ischemic attack: carotid and vertebrobasilar circulation. 322 Medical Terminology: The Language of Health Care Term Meaning CAROTID. carotid TIA ischemia of the anterior circulation of the brain Carotid stems ka-rotid from the Greek word meaning to stupefy or vertebrobasilar TIA ischemia of the posterior circulation of the brain throttle. The ancients used vertĕ-brō-basi-lăr the term to describe the encephalitis inflammation of the brain arteries in the neck because they believed that when they en-sef-ă-lı̄tis were pressed hard, one epilepsy disorder affecting the central nervous system became sleepy. epi-lepsē characterized by recurrent seizures EPILEPSY. tonic-clonic stiffening-jerking; a major motor seizure involving all Epilepsy comes tonik-klonik muscle groups—previously termed grand mal (big from a Greek bad) seizure word for seizure. Aristotle absence seizure involving a brief loss of consciousness used the word to mean a absens without motor involvement—previously termed petit convulsive seizure, a condition that came to be mal (little bad) seizure called epilepsy. It was partial seizure involving only limited areas of the brain with regarded in ancient times as localized symptoms an infliction from the gods, hence the Roman term, glioma tumor of glial cells graded by degree of malignancy morbus sacer (sacred glı̄-ōmă disease). Many other terms were applied to epilepsy, herniated disk protrusion of a degenerated or fragmented such as “disease of hernē-ā-ted intervertebral disk so that the nucleus pulposus Hercules” because sufferers protrudes, causing compression on the nerve root seemed to have superhuman (Fig. 10.9) strength. herpes zoster viral disease affecting the peripheral nerves, herpēz zoster characterized by painful blisters that spread over the skin following the affected nerves, usually unilaterally—also known as shingles (Fig. 10.10) Huntington disease (HD) hereditary disease of the central nervous system Huntington chorea characterized by bizarre involuntary body kōr-ēă movements and progressive dementia (choros  dance) Herniated disk Spinal Herniated disk cord presses on spinal Vertebra nerve, causing pain Spinal nerve Disk Disk Vertebra Superior view of vertebra Sagittal view of spine Figure 10.9 Herniated disk. Chapter 10 • Nervous System 323 Herpes affecting spine Figure 10.10 Herpes zoster: typical eruption site. Term Meaning hydrocephalus abnormal accumulation of cerebrospinal fluid in the hı̄-drō-sefă-lŭs ventricles of the brain as a result of developmental hydrocephaly anomalies, infection, injury, or tumor (Fig. 10.11; also see Fig. 10.13) meningioma benign tumor of the coverings of the brain mĕ-ninjē-ōmă (meninges) meningitis inflammation of the meninges men-in-jı̄tis migraine headache paroxysmal attacks of mostly unilateral headache mı̄grān often accompanied by disordered vision, nausea, and/or vomiting, lasting hours or days and caused by dilation of arteries multiple sclerosis (MS) disease of the central nervous system characterized sklĕ-rōsis by the demyelination (deterioration of the myelin sheath) of nerve fibers, with episodes of neurological dysfunction (exacerbation) followed by recovery (remission) (Fig. 10.12) myasthenia gravis autoimmune disorder that affects the neuromuscular mı̄-as-thēnē-ă gravăs junction, causing a progressive decrease in muscle strength with activity and a return of strength after a period of rest myelitis inflammation of the spinal cord mı̄-ĕ-lı̄tis 324 Medical Terminology: The Language of Health Care Figure 10.11 Sonogram of fetus with Figure 10.12 Magnetic resonance image of the brain. hydrocephalus. Arrows, plaque formation in a patient with multiple sclerosis. Term Meaning narcolepsy sleep disorder characterized by a sudden, narkō-lep-sē uncontrollable need to sleep, attacks of paralysis (cataplexy), and dreams intruding while awake (hypnagogic hallucinations) Parkinson disease condition of slowly progressive degeneration of an area of the brainstem (substantia nigra) resulting in a decrease of dopamine (a chemical neurotransmitter that is necessary for proper movement); characterized by tremor, rigidity of muscles, and slow movements (bradykinesia), usually occurring later in life plegia paralysis plējē-ă hemiplegia paralysis on one side of the body hem-ē-plējē-ă paraplegia paralysis from the waist down par-ă-plējē-ă quadriplegia paralysis of all four limbs kwahdri-plējē-ă poliomyelitis inflammation of the gray matter of the spinal cord polē-ō-miĕ-lı̄tis caused by a virus, often resulting in spinal and muscle deformity and paralysis (polio  gray) Chapter 10 • Nervous System 325 Figure 10.13 Spina bifida with myelomeningo- cele. The infant also has hydrocephaly. Term Meaning polyneuritis inflammation involving two or more nerves, often polē-nū-rı̄tis owing to a nutritional deficiency such as lack of thiamine reflex sympathetic condition of abnormal function of the sympathetic dystrophy (RSD) nervous system in response to pain perception, rēfleks sim-pă-thetik usually as the result of an injury to an extremity; distrō-fē symptoms include persistent burning pain, tissue edema, joint tenderness, changes in skin color and temperature, and abnormal sweating at the pain site—decreased mobility caused by pain can lead to muscle atrophy and loss of motor function sleep apnea periods of breathing cessation that occur during apnē-ă sleep, often causing snoring spina bifida congenital defect in the spinal column characterized spı̄nă bifă-dă by the absence of vertebral arches, often resulting in pouching of spinal membranes or tissue (Fig. 10.13) Diagnostic Tests and Procedures Test or Procedure Explanation electrodiagnostic procedures ē-lektrō-dı̄-ag-nōstik electroencephalogram record of the minute electrical impulses of the brain (EEG) used to identify neurological conditions that affect ē-lektrō-en-sefă-lō-gram brain function and level of consciousness (Fig. 10.14) evoked potentials record of minute electrical potentials (waves) that ē-vokt pō-tenshăls are extracted from ongoing EEG activity to diagnose auditory, visual, and sensory pathway disorders—also used to monitor the neurological function of patients during surgery (Fig. 10.15) 326 Medical Terminology: The Language of Health Care Electroencephalography (EEG) FP1 FP2 FZ F4 F7 F8 F3 C3 C4 (T3)T7 CZ T8 (T4) A1 A2 P3 PZ P4 (T5)P7 P8 (T6) 01 02 Position of electrodes Normal EEG wave forms shown on left and computer compilation of frequency bands (delta, theta, alpha, and beta) mapped on right Figure 10.14 Electroencephalography. SOMNUS. Somnus is a Test or Procedure Explanation Latin word for nerve conduction electrical shock of peripheral nerves to record time sleep that was derived from velocity (NCV) of conduction; used to diagnose various peripheral ancient mythology. Somnus nerv kon-dŭkshŭn nervous system diseases was the poetical god of sleep, the son of Nox polysomnography (PSG) recording of various aspects of sleep (e.g., eye and (night), who lived with his polē-som-nogră-fē muscle movements, respiration, EEG patterns) to brother Thanatos (death) in diagnose sleep disorders (Fig. 10.16) a palace at the western end of the world. Figure 10.15 Use of evoked potentials to monitor neurological function during surgery. Chapter 10 • Nervous System 327 Figure 10.16 Polysomnography. Figure 10.17 Magnetic resonance imaging unit. Test or Procedure Explanation lumbar puncture (LP) introduction of a specialized needle into the spine lŭmbar pŭnkchūr in the lumbar region for diagnostic or therapeutic purpose, such as to obtain cerebrospinal fluid for testing; also called spinal tap magnetic resonance nonionizing imaging technique using magnetic imaging (MRI) fields and radiofrequency waves to visualize mag-netic rezō-nans anatomical structures (especially soft tissue), such imă-jing as the tissues of the brain and spinal cord (Fig. 10.17; also see Figs. 10.3, 10.4, and 10.12) magnetic resonance use of magnetic resonance in imaging of the blood angiography (MRA) vessels—useful in detecting pathological conditions mag-netic rezō-nans such as atherosclerosis and thrombosis an-jē-ogră-fē intracranial MRA magnetic resonance image of the head to visualize intră-krānē-ăl the vessels of the circle of Willis (common site of cerebral aneurysm, stenosis, or occlusion) (Fig. 10.18A) extracranial MRA magnetic resonance image of the neck to visualize ekstră-krānē-ăl the carotid artery (Fig. 10.18B) nuclear medicine imaging radionuclide organ imaging SPECT brain scan scan combining nuclear medicine and computed (single photon emission tomography technology to produce images of the computed tomography) brain after administration of radioactive isotopes 328 Medical Terminology: The Language of Health Care A B Figure 10.18 A. Contrast-enhanced intracranial magnetic resonance angiography showing circulation of the circle of Willis. B. Contrast-enhanced extracranial magnetic resonance angiography showing carotid circulation. Test or Procedure Explanation positron emission technique combining nuclear medicine and tomography (PET) computed tomography technology to produce pozi-tron ē-mishŭn images of brain anatomy and corresponding tō-mogră-fē physiology—used to study stroke, Alzheimer disease, epilepsy, metabolic brain disorders, chemistry of nerve transmissions in the brain, etc.; it provides greater accuracy than SPECT but is used less often because of cost and limited availability of the radioisotopes (Fig. 10.19) Warm colors (red and yellow) indicate a higher rate of metabolism and brain activity in the normal brain when compared with the brain of the Alzheimer’s patient Area of scan PET scan of healthy brain PET scan of Alzheimer brain Figure 10.19 Positron emission tomography (PET) scans. Chapter 10 • Nervous System 329 A B Figure 10.20 Reflex testing. A. Normal plantar reflex. B. Babinski sign. Test or Procedure Explanation radiography x-ray imaging rādē-ogră-fē cerebral angiogram x-ray of blood vessels in the brain after intracarotid serĕ-brăl anjē-ō-gram injection of contrast medium computed tomography computed tomographic x-ray images of the head (of the head) used to visualize abnormalities within (e.g., brain tumors, malformations) myelogram x-ray of the spinal cord made after intraspinal injection of contrast medium reflex testing test performed to observe the body’s response to a stimulus (Fig. 10.20A) deep tendon involuntary muscle contraction after percussion at a reflexes (DTR) tendon (e.g., patella, Achilles) indicating function; positive findings are noted when there is either no reflex response or an exaggerated response to stimulus; numbers are often used to record responses: no response 1 diminished response 2 normal response 3 more brisk than average response 4 hyperactive response Babinski sign or reflex pathological response to stimulation of the plantar surface of the foot; a positive sign is indicated when the toes dorsiflex (curl upward) (Fig. 10.20B) transcranial sonogram image made by sending ultrasound beams through trans-krānē-ăl the skull to assess blood flow in intracranial vessels—used in diagnosis and management of stroke and head trauma (Fig. 10.21) 330 Medical Terminology: The Language of Health Care Figure 10.21 Transcranial sonography procedure. Operative Terms Term Meaning craniectomy excision of part of the skull to approach the brain krānē-ektō-mē craniotomy incision into the skull to approach the brain krā-nē-otō-mē diskectomy (discectomy) removal of a herniated disk often done dis-ektō-mē percutaneously (Fig. 10.22) laminectomy excision of one or more laminae of the vertebrae to lami-nektō-mē approach the spinal cord vertebral lamina flattened posterior portion of the vertebral arch (see Chapter 6, Figure 6.4) Vertebral disk Vertebral disk nucleus Spinal endoscope Disk herniation pushing on spinal nerve root Vertebra Spinal cord Spinal nerve Figure 10.22 Diskectomy (discectomy). Chapter 10 • Nervous System 331 A B Intervertebral disk Removal of disk (fusion of vertebrae) Spinal cord Figure 10.24 Spondylosyndesis. A. Spinal column. B. Spinal fusion. Figure 10.23 Microscope designed for neurological surgery. Term Meaning microsurgery utilization of a microscope to dissect minute mı̄-krō-serjer-ē structures during surgery (Fig. 10.23) neuroendovascular surgery diagnosis and treatment of disorders within nūrō-en-do-vaskyu-lăr cerebral blood vessels performed in a specialized serjer-ē angiographic laboratory by interventional neuroradiologists; common procedures include: • cerebral angioplasty and stent to restore blood flow through narrowed vessels such as the carotid artery, middle cerebral, and vertebrobasilar arteries • embolization (plugging) of intracranial aneurysms and other malformations neuroplasty surgical repair of a nerve nūrō-plas-tē spondylosyndesis spinal fusion (Fig. 10.24) spondi-lō-sin-dēsis 332 Medical Terminology: The Language of Health Care Therapeutic Terms Term Meaning chemotherapy treatment of malignancies, infections, and other kemō-thāră-pē diseases with chemical agents that destroy selected cells or impair their ability to reproduce radiation therapy treatment of neoplastic disease using ionizing rādē-āshŭn thāră-pē radiation to impede proliferation of malignant cells (Fig. 10.25) stereotactic (stereotaxic) radiation treatment to inactivate malignant lesions radiosurgery involving the focus of multiple, precise external sterē-ō-taktik radiation beams on a target with the aid of a (sterē-ō-taksik) stereotactic frame and imaging such as CT, MRI, or rādē-ō-serjer-ē angiography; used to treat inoperable brain tumors and other lesions stereotactic (stereotaxic) mechanical device used to localize a point in space frame targeting a precise site (Fig. 10.26) thrombolytic therapy dissolution of thrombi using drugs [e.g., tissue throm-bō-litik plasminogen activator (tPA)] used to treat acute ischemic stroke COMMON THERAPEUTIC DRUG CLASSIFICATIONS analgesic agent that relieves pain an-ăl-jēzik anticoagulant drug that prevents clotting of the blood; commonly antē-kō-agyū-lant used to prevent heart attack and ischemic stroke Figure 10.26 Stereotactic frame. Figure 10.25 Radiation therapy: linear accelerator. Chapter 10 • Nervous System 333 Term Meaning anticonvulsant agent that prevents or lessens convulsion antē-kon-vŭlsant hypnotic agent that induces sleep hip-notik sedative agent that has a calming effect sedă-tiv Psychiatric Terms Term Meaning SYMPTOMATIC TERMS affect emotional feeling or mood affekt flat

affect significantly dulled emotional tone or outward reaction apathy lack of interest or display of emotion apă-thē catatonia state of unresponsiveness to one’s outside kat-ă-tōnē-ă environment, usually including muscle rigidity, staring, and inability to communicate delusion persistent belief that has no basis in reality dē-loozhŭn grandiose delusion person’s false belief that he or she possesses great wealth, intelligence, or power persecutory delusion person’s false belief that someone is plotting against him or her with intent to harm dysphoria restless, dissatisfied mood dis-fōrē-ă euphoria exaggerated, unfounded feeling of well-being yu-fōrē-ă hallucination false perception of the senses for which there is no ha-loosi-nāshŭn reality, most commonly hearing or seeing things (alucinor  to wander in mind) ideation formation of thoughts or ideas [e.g., suicidal ı̄ -dē-āshŭn ideation (thoughts of suicide)] mania state of abnormal elation and increased activity mānē-ă neurosis psychological condition in which anxiety is noo-rōsis prominent psychosis mental condition characterized by distortion of sı̄-kōsis reality, resulting in the inability to communicate or function within one’s environment thought disorder thought that lacks clear processing or logical direction 334 Medical Terminology: The Language of Health Care Psychiatric Diagnostic Terms Term Meaning MOOD DISORDERS major depression disorder causing periodic disturbances in mood that major depressive illness affect concentration, sleep, activity, appetite, and clinical depression social behavior; characterized by feelings of major affective disorder worthlessness, fatigue, and loss of interest unipolar disorder dysthymia milder affective disorder characterized by a chronic dis-thı̄mē-ă depression persisting for at least 2 years manic depression affective disorder characterized by mood swings of bipolar disorder (BD) mania and depression (extreme up and down states) seasonal affective disorder affective disorder marked by episodes of depression (SAD) that most often occur during the fall and winter and remit in the spring ANXIETY DISORDERS generalized anxiety most common anxiety disorder, characterized by disorder (GAD) chronic, excessive, and uncontrollable worry about everyday problems that affects the ability to relax or concentrate but does not usually interfere with social interactions or employment; physical symptoms include muscle tension, trembling, twitching, fatigue, headaches, nausea, and insomnia—symptoms must exist for at least 6 months before a diagnosis can be made panic disorder (PD) disorder of sudden, recurrent attacks of intense feelings including physical symptoms that mimic a heart attack such as rapid heart rate, chest pain, shortness of breath, chills, sweating, and dizziness, with a general sense of loss of control or feeling that death is imminent; often progresses to agoraphobia Chapter 10 • Nervous System 335 Term Meaning phobia exaggerated fear of a specific object or fōbē-ă circumstance that causes anxiety and panic; named for the object or circumstance, such as agoraphobia (marketplace), claustrophobia (confinement), or acrophobia (high places) posttraumatic stress condition resulting from an extremely traumatic disorder (PTSD) experience, injury, or illness that leaves the sufferer with persistent thoughts and memories of the ordeal; may occur after a war, violent personal assault, physical or sexual abuse, serious accident, natural disaster, etc.; symptoms include feelings of fear, detachment, exaggerated startle response, restlessness, nightmares, and avoidance of anything or anyone who triggers the painful recollections obsessive-compulsive anxiety disorder featuring unwanted, senseless disorder (OCD) obsessions accompanied by repeated compulsions, which can interfere with all aspects of a person’s daily life (e.g., the thought that a door is not locked, with repetitive checking to make sure that it is locked; thoughts that one’s body has been contaminated, with repetitive washing) hypochondriasis preoccupation with thoughts of disease and concern hı̄pō-kon-drı̄ă-sis that one is suffering from a serious condition that persists despite medical reassurance to the contrary DISORDERS USUALLY DIAGNOSED IN CHILDHOOD autism developmental disability commonly appearing awtizm during the first 3 years of life, resulting from a neurological disorder affecting brain function, evidenced by difficulties with verbal and nonverbal communication, and an inability to relate to anything beyond oneself (auto  self) in social interactions; individuals with autism often exhibit body movements such as rocking, repetitive hand movements, and commonly become preoccupied with observing parts of small objects or moving parts or performing meaningless rituals dyslexia developmental disability characterized by a dis-leksē-ă difficulty understanding written or spoken words, sentences, or paragraphs, affecting reading, spelling, and self-expression attention-deficit/ dysfunction characterized by consistent hyperactivity disorder hyperactivity, distractibility, and lack of control (ADHD) over impulses, which interferes with the ability to function normally at school, home, or work; specific criteria must be met before a diagnosis is made mental retardation condition of subaverage intelligence characterized by an IQ of 70 or below, resulting in the inability to adapt to normal social activities 336 Medical Terminology: The Language of Health Care Term Meaning EATING DISORDERS anorexia nervosa severe disturbance in eating behavior caused by an-ō-reksē-ă nervōs-ă abnormal perceptions about one’s body weight, evidenced by an overwhelming fear of becoming fat that results in a refusal to eat and body weight well below normal bulimia nervosa eating disorder characterized by binge eating boo-limē-ă followed by efforts to limit digestion through induced vomiting, use of laxatives, or excessive exercise SUBSTANCE ABUSE DISORDERS substance abuse disorders mental disorders resulting from abuse of substances such as drugs, alcohol, or other toxins causing personal and social dysfunction; identified by the abused substance, such as alcohol abuse, amphetamine abuse, opioid (narcotic) abuse, or polysubstance abuse PSYCHOTIC DISORDERS schizophrenia disease of brain chemistry causing a distorted skizō-frēnē-ă cognitive and emotional perception of one’s environment characterized by a broad range of “positive” and “negative” symptoms positive symptoms include distortions of normal function (behaviors that are absent in normal people, e.g., disorganized thought, delusions, hallucinations, catatonic behavior) negative symptoms (normal reactions missing in persons with schizophrenia) including flat affect, apathy, and withdrawal from reality types: disorganized featuring disorganized speech, behavior, and flat or inappropriate affect catatonic featuring catatonia paranoid featuring delusions, most often persecutory or pară-noyd grandiose types schizoaffective disorder concurrent with major depression or manic skizō-ă-fektiv depression Psychiatric Therapeutic Terms Term Meaning electroconvulsive electrical shock applied to the brain to induce therapy (ECT) convulsions; used to treat severely depressed ē-lektrō-kon-vŭlsiv patients light therapy use of specialized illuminating light boxes and visors to treat seasonal affective disorder Chapter 10 • Nervous System 337 Term Meaning psychotherapy treatment of psychiatric disorders using verbal and sı̄kō-thāră-pē nonverbal interaction with patients, individually or in a group, employing specific actions and techniques behavioral therapy treatment to decrease or stop unwanted behavior bē-hāvver-ăl thāră-pē cognitive therapy treatment to change unwanted patterns of thinking kogni-tiv COMMON THERAPEUTIC DRUG CLASSIFICATIONS psychotropic drugs medications used to treat mental illnesses sı̄kō-trōpik (trop/o  a turning) antianxiety agents drugs used to reduce anxiety antē-ang-zı̄ĕ-tē anxiolytic agents angzē-ō-litik antidepressant agent that counteracts depression antē-dē-presănt neuroleptic agents drugs used to treat psychosis, especially noor-ō-leptik schizophrenia Summary of Chapter 10 Acronyms/Abbreviations ADHD ......attention-deficit/hyperactivity disorder MRI ...........magnetic resonance imaging ALS ............amyotrophic lateral sclerosis MS ..............multiple sclerosis ANS ...........autonomic nervous system NCV...........nerve conduction velocity BD ..............bipolar disorder OCD...........obsessive-compulsive disorder CNS ...........central nervous system PD...............panic disorder CP ...............cerebral palsy PET............positron emission tomography CSF ............cerebrospinal fluid PNS ...........peripheral nervous system CVA ...........cerebrovascular accident PSG............polysomnography DTR...........deep tendon reflexes PTSD ........posttraumatic stress disorder ECT ...........electroconvulsive therapy RSD ...........reflex sympathetic dystrophy EEG...........electroencephalogram SAD ...........seasonal affective disorder GAD...........generalized anxiety disorder SPECT .....single photon emission computed HD..............Huntington disease tomography LP ...............lumbar puncture TIA .............transient ischemic attack MRA..........magnetic resonance angiography 338 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE anencephaly _______ / _______ / _______ P R S an/encephal/y P R S DEFINITION: without/entire brain/condition or process of 1. ganglioma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 2. atopognosia __________________ / __________________ / __________________ / __________________ P CF R S DEFINITION: _________________________________________________________________ 3. catatonic __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 4. dystaxia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 5. bradykinesia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 6. meningocele __________________ / __________________ CF S DEFINITION: _________________________________________________________________ Chapter 10 • Nervous System 339 7. dysthymia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 8. polysomnogram __________________ / __________________ / __________________ P CF S DEFINITION: _________________________________________________________________ 9. spondylosyndesis __________________ / __________________ / __________________ CF P S DEFINITION: _________________________________________________________________ 10. hemiplegia __________________ / __________________ P S DEFINITION: _________________________________________________________________ 11. craniotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. thalamic __________________ / __________________ R S DEFINITION: _________________________________________________________________ 13. neuroglial __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 14. dyslexia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 15. somnipathy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 16. hydrocephalic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 340 Medical Terminology: The Language of Health Care 17. dysarthria __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 18. acrophobia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 19. hypnotic __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 20. euphoria __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 21. parasomnia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 22. narcolepsy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 23. stereotaxy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 24. hemiparesis __________________ / __________________ P S DEFINITION: _________________________________________________________________ 25. neurasthenia __________________ / __________________ R S DEFINITION: _________________________________________________________________ 26. myelopathy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 10 • Nervous System 341 27. intracranial __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 28. aphasia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 29. schizophrenia __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 30. cerebrospinal __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 31. electro___________________ gram  record of electrical brain impulses 32. ___________________ syndesis  spinal fusion 33. crani_____________  excision of part of the skull 34. cerebral _______________ sclerosis  fat buildup in blood vessels of the brain 35. hyper______________________  increased sensations 36. dys_________________  condition of difficulty speaking 37. __________ algesia  loss of sense of pain 38. a_________________ gnosis  inability to judge the form of an object by touch (e.g., to tell a coin from a key) For each of the following, circle the combining form that corresponds to the meaning given: 39. brain encephal/o crani/o neur/o 40. movement esthesi/o kinesi/o somat/o 41. speech lex/o gnos/o phor/o 42. body somn/o somat/o phren/o 43. spinal cord vertebr/o spondyl/o myel/o 342 Medical Terminology: The Language of Health Care 44. mind cerebr/o thym/o thalm/o 45. sensation esthesi/o neur/o kinesi/o 46. place top/o tax/o phor/o 47. sleep somat/o hypn/o esthesi/o 48. knowing phren/o phas/o gnos/o Write the correct medical term for each of the following: 49. inflammation of the meninges _______________________________________________ 50. excision of a herniated disk__________________________________________________ 51. slowly progressive degeneration of nerves in the brain characterized by tremor, rigidity of muscles, and slow movements _____________________________________ 52. pathological response to stimulation of the plantar surface of the foot indicated by dorsiflexion of the toes ___________________________________________________ 53. numbness and tingling ______________________________________________________ 54. state of unconsciousness ____________________________________________________ 55. congenital defect of the spinal column resulting in pouching of spinal membranes _______________________________________________________________ Match the following neurological terms with their abbreviations: 56. ________ amyotrophic lateral sclerosis a. PSG 57. ________ herpes zoster b. tonic-clonic 58. ________ spinal tap c. CVA 59. ________ faint d. Alzheimer disease 60. ________ grand mal e. Lou Gehrig disease 61. ________ petit mal f. flaccid 62. ________ cerebral thrombus g. absence 63. ________ flabby h. clot 64. ________ stroke i. LP 65. ________ dementia j. shingles 66. ________ sleep study k. syncope Chapter 10 • Nervous System 343 Write the full medical term for the following abbreviations: 67. CT ________________________________________________________________________ 68. MRI _______________________________________________________________________ 69. PET _______________________________________________________________________ 70. MS ________________________________________________________________________ 71. CNS _______________________________________________________________________ 72. CP ________________________________________________________________________ 73. TIA________________________________________________________________________ 74. EEG_______________________________________________________________________ 75. DTR _______________________________________________________________________ 76. CSF _______________________________________________________________________ 77. MRA ______________________________________________________________________ 78. CVA _______________________________________________________________________ 344 Medical Terminology: The Language of Health Care Write in the missing words on the blank lines in the following illustration of brain anatomy. 79–86. 82. Corpus Meninges 83. Pineal body Frontal sinus Hypothalamus Pituitary gland Sphenoid sinus 79. Medulla oblongata 80. 81. cord Midsagittal view of brain 84. Venous sinus Dura mater 85. Arachnoid Pia mater Subdural space Subarachnoid space 86. Chapter 10 • Nervous System 345 Match

the following psychiatric terms with their meanings: 87. ________ hallucination a. exaggerated, unfounded feeling of well-being 88. ________ persecutory delusion b. dull emotional tone or outward reaction 89. ________ catatonia c. false belief that one is very wealthy, intelligent, or powerful 90. ________ apathy d. false belief that one is being plotted against 91. ________ euphoria e. state of abnormal elation and increased activity 92. ________ mania f. lack of interest or display of emotion 93. ________ flat affect g. thoughts that lack clear process or logical direction 94. ________ dysphoria h. state of unresponsiveness in- cluding muscle rigidity, staring, and inability to communicate 95. ________ thought disorder i. restless, dissatisfied mood 96. ________ grandiose delusion j. hearing or seeing things Write the full medical term for the following abbreviations: 97. GAD______________________________________________________________________ 98. ADHD ____________________________________________________________________ 99. OCD _____________________________________________________________________ 100. ECT ______________________________________________________________________ 101. PD _______________________________________________________________________ 102. BD _______________________________________________________________________ 103. PTSD_____________________________________________________________________ Match the following psychiatric diagnoses: 104. ________ unipolar disorder a. hypochondriasis 105. ________ anxiety disorder b. anorexia nervosa 106. ________ bipolar disorder c. clinical depression 107. ________ psychosis d. dysthymia 108. ________ disorder identified in childhood e. schizophrenia 109. ________ eating disorder f. manic depression 110. ________ mild depression g. autism 346 Medical Terminology: The Language of Health Care Match the following psychiatric conditions with therapeutic terms: 111. ________ anxiety a. behavioral therapy 112. ________ schizophrenia b. light therapy 113. ________ seasonal affective disorder c. anxiolytic agent 114. ________ major affective disorder d. electroconvulsive therapy 115. ________ bulimia e. neuroleptic agent For each of the following, circle the correct spelling of the term: 116. Alsheimer Alzheimer Alshiemer 117. skitzoprenia skizophrenia schizophrenia 118. polysomnography polysonography polysolemography 119. parenoia paranoia paranoyea 120. atopagnosis atopegnosis atopognosis 121. demensha dementia dimentia 122. epilapsey epilepsey epilepsy 123. catonia catatonia catetonia 124. delushion dilusion delusion 125. hellucination hallucination hallucinashun 126. poliomyalitis poliomyelitis poleiomyalitis Give the noun that was used to form the following adjectives: 127. epileptic __________________________________________________________________ 128. euphoric__________________________________________________________________ 129. delusional ________________________________________________________________ 130. syncopal__________________________________________________________________ 131. autistic ___________________________________________________________________ 132. psychotic _________________________________________________________________ 133. cerebral __________________________________________________________________ 134. dysphasic _________________________________________________________________ 135. paranoid__________________________________________________________________ Chapter 10 • Nervous System 347 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 0 . 1 Progress Note OP H&P Neurological Services CC: numbness and tingling in feet and hands HPI: This 44 y.o. right-handed female c/o numbness in her feet for the past two weeks with “pockets” of numbness in the abdomen. Her legs feel heavy and numb. Her hands started tingling a week ago and she is feeling very nervous. She has had similar episodes over the past 3 years, lasting about a week at a time, often after stressful events, or during hot weather. PMH: Operations: none. No serious illnesses/accidents FH: Father, age 71, L&W; Mother, age 66, is bipolar; Her only sibling, a sister, age 28, has cerebral palsy. SH: Denies smoking or use of street drugs, but drinks socially OH: certified public accountant. Marital Status: single ROS: noncontributory. VS: T 98.2° F., P 82, R 16, BP 110/68, Ht 52, Wt 138# PE: HEENT: WNL. Neck: negative. Heart/Lungs: normal. Cranial nerves intact. Reflexes: DTR’s are increased, greater on the left than the right without spasticity. Toes upgoing bilaterally. There is numbness to tactile pin stimulation over both extremities. She has no finger-to-nose ataxia. Her gait is steady. A: R/O MS P: Schedule MRI of the brain with and without gaolinium (contrast) RTO for re- port and further evaluation  1 wk 1. Which medical term best describes the patient’s 3. Describe the sister’s condition: symptoms: a. disorder affecting the central nervous system a. hyperesthesia characterized by seizures b. paresthesia b. hereditary disease of the central nervous c. ataxia system characterized by bizarre involuntary body movements and progressive dementia d. hemiparesis c. abnormal accumulation of cerebrospinal fluid e. neuralgia in the ventricles of the brain as a result of developmental abnormality 2. What is noted in the history about the patient’s mother? d. condition of motor dysfunction caused by dam- age to the cerebrum during development or a. she is alive and well injury at birth b. she suffers from depression e. slowly progressive degeneration of nerves in the c. she has mood swings of mania and depression brain characterized by tremor, rigidity, and d. she suffers from generalized anxiety slow movements e. she is a hypochondriac 348 Medical Terminology: The Language of Health Care 4. Which medical term describes the positive finding 6. Describe the test noted in the plan: of the “toes upgoing” bilaterally? a. x-ray a. Babinski sign b. nuclear image b. neuralgia c. ultrasound scan c. hemiparesis d. tomographic radiograph d. spastic paralysis e. scan produced by magnetic fields and radiofre- e. flaccid paralysis quency waves 5. What is the doctor’s impression? a. the patient has multiple sclerosis b. the patient does not have multiple sclerosis c. the patient may have multiple sclerosis d. the patient may have hardening of the arteries in the brain e. the patient does not have hardening of the arteries in the brain Chapter 10 • Nervous System 349 M E D I C A L R E C O R D 1 0 . 2 Mary Clarke came into the living room where her father, Bob Clarke, had been watch- ing television and found him slumped back in his chair, apparently asleep. When she could not wake him, she realized he was unconscious and called 911. The ambulance rushed him to the Central Medical Center emergency room, where he was seen by Dr. Gregory Kincaid. Directions Read Medical Record 10.2 for Mr. Clarke (pages 351–353) and answer the following questions. This record is the history and physical examination report dictated by Dr. Kincaid after his examination and initial treatment of Mr. Clarke. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 0 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not encountered in this text so far. Underline each where it appears in the record and define below: abrasion ____________________________________________________________________ foci of atrophy_______________________________________________________________ ambulate____________________________________________________________________ cataract _____________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe Mr. Clarke’s condition from the time he was found at home: ____________________________________________________________________________ Describe his condition after he arrived at the ER: ____________________________________________________________________________ 3. Which of the following was not an emergency treatment provided for Mr. Clarke? a. administration of Valium b. assessment of respiratory rate c. CPR d. assistance with breathing 4. Define “postictal”: ____________________________________________________________ 5. Mr. Clarke has a past medical history of several different illnesses. On the follow- ing list, check all health problems Mr. Clarke has experienced: _____ skin bruising _____ heart attacks _____ excessive thyroid secretion 350 Medical Terminology: The Language of Health Care _____ COPD _____ skin scrapes _____ headaches _____ nausea and vomiting _____ atrial fibrillation _____ pulmonary embolus 6. From the list of medications Mr. Clarke is taking, one includes an abbreviation that has been deemed error prone. Identify the abbreviation, potential problem, and preferred wording. Abbreviation Potential Problem Preferred Wording ____________ _________________ _________________ 7. In your own words, describe the surgery Mr. Clarke had in the past: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. In lay language, what nervous system disorder did a family member experience? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 9. Dr. Kincaid’s diagnosis identifies three possible conditions that may have led to Mr. Clarke’s seizure. Put each in your own words: a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ 10. What three actions will now occur in the ICU? a.___________________________________________________________________________ b.___________________________________________________________________________ c.___________________________________________________________________________ Chapter 10 • Nervous System 351 Medical Record 10.2 352 Medical Terminology: The Language of Health Care Medical Record 10.2 Continued. Chapter 10 • Nervous System 353 Medical Record 10.2 Continued. 354 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 1 0 . 3 Anne Cross had been fairly healthy until she had a stroke about 2 months ago. She was treated by Dr. Paul Jiang, her personal physician, at that time and was discharged from the hospital on medication. At the request of Ms. Cross, Dr. Jiang called for a consul- tation from a neurologist, Dr. Melvin Classen. Directions Read Medical Record 10.3 for Ms. Cross (pages 356–357) and answer the following questions. This record is a consultation report written by Dr. Classen as a letter back to Ms. Cross’s physician, Dr. Jiang, after his consultation. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 0 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered. Under- line each where it appears in the record and define below: homonymous hemianopsia ___________________________________________________ finger-nose test ______________________________________________________________ apraxia _____________________________________________________________________ clonus ______________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe Ms. Cross’s symptoms in April before she was admitted to the hospital: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Write the missing parts in this table summarizing the diagnostic tests performed in April: Test Definition of Test Findings CT _________________________ ______________________ _________________ sound waves through heart ______________________ carotid ultrasound _________________________ ______________________ _________________ _________________________ slowed electrical pulses on right side 4. What family member had a problem perhaps similar to Ms. Cross’s? ____________________________________________________________________________ Chapter 10 • Nervous System 355 5. For each of the following medications given to Ms. Cross, translate the dosage instructions: Persantine __________________________________________________________________ aspirin ______________________________________________________________________ Proventil ____________________________________________________________________ Procardia ___________________________________________________________________ 6. Dr. Classen recommends two diagnostic studies. Describe both in your own words: a.___________________________________________________________________________ b.___________________________________________________________________________ In one sentence, describe Dr. Classen’s rationale for recommending the combina- tion of these two tests: ____________________________________________________________________________ ____________________________________________________________________________ 7. Name the preventive surgical procedure Dr. Classen suggests that may be appro- priate if changes are found in the carotid blood vessels: ____________________________________________________________________________ Describe that procedure in your own words: ____________________________________________________________________________ ____________________________________________________________________________ 356 Medical Terminology: The Language of Health Care Medical Record 10.3 Chapter 10 • Nervous System 357 Medical Record 10.3 Continued. Chapter 11 Endocrine System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the endocrine system Describe the basic functions of the endocrine system Define the basic anatomical terms referring to the endocrine system Define common symptomatic and diagnostic terms referring to the endocrine system List the common diagnostic tests and procedures related to the endocrine system Identify common operative terms referring to the endocrine system Identify common therapeutic terms including drug classifications related to the endocrine system Explain the terms and abbreviations used in documenting medical records involving the endocrine system Combining Forms Combining Form Meaning Example aden/o gland adenoma ad-ĕ-nōmă adren/o adrenal gland adrenotrophic ă-drē-nō-trōfik adrenal/o adrenalopathy ă-drē-nă-lopă-thē andr/o male androgenous an-drojĕ-nŭs crin/o to secrete endocrine endō-krin dips/o thirst polydipsia pol-ē-dipsē-ă gluc/o sugar glucogenic glū-kō-jenik glucos/o glucose glookōs glyc/o hyperglycemia hiper-glı̄ -sēmē-ă glycos/o glycosuria glı̄ -kō-sūrē-ă 358 Chapter 11 • Endocrine System 359 Combining Form Meaning Example THYMUS. Derived from the hormon/o hormone (an urging on) hormonal Greek word for hōr-mōnăl an offer or sacrifice, the thyme plant was burnt on ket/o ketone bodies ketogenic altars because of its sweet kē-tō-jenik smell. The term was applied keton/o ketonuria to the thymus gland because of its likeness to a bunch of kē-tō-nūrē-ă thyme. pancreat/o pancreas pancreatitis THYROID. pankrē-ă-tı̄ tis Thyroid is from a thym/o thymus gland thymoma Greek word thı̄ -mōmă referring to a large oblong shield carried by soldiers. It thyr/o thyroid gland (shield) thyrotoxic had a deep notch at the top thı̄ -rō-toksik for the chin. The thyroid gland and the thyroid thyroid/o thyroiditis cartilage in the neck were thı̄ -roy-dı̄tis named for this shield because of their similar appearance. Endocrine System Overview The endocrine system is a network of ductless glands and other structures that affect the function of targeted organs by the secreting hormones. Figure 11.1 shows the loca- tions of the endocrine glands. The hormones secreted by these glands and their func- tions are described under “Anatomical Terms” and in Figure 11.2. Anatomical Terms Gland or Hormone Location or Function adrenal glands located next to each kidney, the adrenal cortex ă-drēnăl secretes steroid hormones and the adrenal suprarenal

glands medulla secretes epinephrine and norepinephrine sūpră-rēnăl steroid hormones regulate carbohydrate metabolism and salt and stēroyd water balance; some effect on sexual glucocorticoids characteristics glū-kō-kōrti-koydz mineral corticosteroids miner-ăl kōrti-kō-stēroydz androgens andrō-jenz epinephrine affect sympathetic nervous system in stress epi-nefrin response norepinephrine nōrep-i-nefrin ovaries located one on each side of the uterus in the ōvă-rēz female pelvis, functioning to secrete estrogen and progesterone 360 Medical Terminology: The Language of Health Care Pineal body (Hypothalamus–CNS controller of endocrine system) Pituitary gland Parathyroid glands Thyroid gland Thymus gland (Trachea) (Heart) (Lungs) Adrenal glands Islets of Langerhans of the pancreas Ovaries in (Kidneys) female (Uterus) (Labels in parentheses indicate Testes organs shown for orientation only. These are not endocrine system organs.) Figure 11.1 Endocrine system. Chapter 11 • Endocrine System 361 Endocrine gland Secretions Function * Anterior pituitary Thyroid-stimulating hormone (TSH) Stimulates secretion from thyroid gland (adenohypophysis) Adrenocorticotropic hormone (ACTH) Stimulates secretion from adrenal cortex Follicle-stimulating hormone (FSH) Initiates growth of ovarian follicle; stimulates secretion of estrogen in females and sperm production in males Luteinizing hormone (LH) Causes ovulation; stimulates secretion of progesterone by corpus luteum; causes secretion of testosterone in testes Melanocyte-stimulating hormone (MSH) Affects skin pigmentation Growth hormone (GH) Influences growth Prolactin (lactogenic hormone) Stimulates breast development and milk production during pregnancy * Posterior pituitary Antidiuretic hormone (ADH) Influences the absorption of water by (neurohypophysis) kidney tubules Oxytocin Influences uterine contraction Pineal body Melatonin Exact function unknown, affects onset of puberty Serotonin Serves as a precursor to melatonin Thyroid gland Triiodothyronine (T3), thyroxine (T4) Regulate metabolism Calcitonin Regulates calcium and phosphorus metabolism Parathyroid glands Parathyroid hormone (PTH) Regulates calcium and phosphorus metabolism Pancreas Insulin, glucagon Regulates carbohydrate/sugar metabolism (islets of Langerhans) Thymus gland Thymosin Regulates immune response Adrenal glands Steroid hormones: Regulate carbohydrate metabolism and salt (suprarenal glands) glucocorticoids, mineral corticosteroids, and water balance; some effect on sexual androgens characteristics Epinephrine, norepinephrine Affect sympathetic nervous system in stress response Ovaries Estrogen, progesterone Responsible for the development of female secondary sex characteristics and for the regulation of reproduction Testes Testosterone Affects masculinization and reproduction * Release of hormones in pituitary is controlled by hypothalamus Figure 11.2 Functions of the endocrine glands. 362 Medical Terminology: The Language of Health Care Gland or Hormone Location or Function estrogen responsible for the development of female estrō-jen secondary sex characteristics and the regulation progesterone of reproduction prō-jester-ōn pancreas located behind the stomach in front of the first (islets of Langerhans) and second lumbar vertebrae, functioning to pankrē-as secrete insulin and glucagon insulin regulate carbohydrate/sugar metabolism insŭ-lin glucagon glūkă-gon parathyroid glands located on the posterior aspect of the thyroid par-ă-thı̄ royd gland in the neck, functioning to secrete parathyroid hormone (PTH) parathyroid regulates calcium and phosphorus metabolism hormone (PTH) pineal gland located in the center of the brain, functioning to pinē-ăl secrete melatonin and serotonin melatonin exact function unknown; affects onset of puberty mel-ă-tōnin serotonin a neurotransmitter that serves as the precursor to melatonin pituitary gland located at the base of the brain, the anterior pi-tūi-tār-ē pituitary secretes thyroid-stimulating hormone, hypophysis adrenocorticotropic hormone, follicle-stimulating hı̄ -pofi-sis hormone, luteinizing hormone, melanocyte- stimulating hormone, growth hormone, and prolactin; the posterior pituitary releases antidiuretic hormone and oxytocin anterior pituitary (adenohypophysis) adĕ-nō-hı̄ -pofi-sis thyroid-stimulating stimulates secretion from thyroid gland hormone (TSH) adrenocorticotropic stimulates secretion from adrenal cortex hormone (ACTH) ă-drēnō-kōrti-kō-trōfik follicle-stimulating initiates growth of ovarian follicle; stimulates hormone (FSH) secretion of estrogen in females and sperm foli-kl production in males luteinizing hormone (LH) causes ovulation; stimulates secretion of lūtē-ı̄ -nı̄z-ing progesterone by corpus luteum; causes secretion of testosterone in testes Chapter 11 • Endocrine System 363 Gland or Hormone Location or Function melanocyte-stimulating affects skin pigmentation hormone (MSH) melă-nō-sı̄ t growth hormone (GH) influences growth prolactin stimulates breast development and milk (lactogenic hormone) production during pregnancy prō-laktin posterior pituitary (neurohypophysis) nūrō-hı̄ -pofi-sis antidiuretic influences the absorption of water by kidney hormone (ADH) tubules antē-dı̄ -yū-retik oxytocin influences uterine contraction ok-sē-tōsin testes located one on each side within the scrotum in testēz the male, functioning to secrete testosterone testosterone affects masculinization and reproduction tes-tostĕ-rōn thymus gland located in the mediastinal cavity anterior to and thı̄ mŭs above the heart, functioning to secrete thymosin thymosin regulates immune response thı̄ mō-sin thyroid gland located in front of the neck, functioning to secrete triiodothyronine (T3), thyroxine (T4), and calcitonin triiodothyronine (T3) known as the thyroid hormones; regulate trı̄ -ı̄ ō-dō-thı̄ rō-nēn metabolism thyroxine (T4) thı̄ -roksēn calcitonin regulates calcium and phosphorus metabolism kal-si-tōnin Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC exophthalmos protrusion of one or both eyeballs, often because ek-sof-thalmos of thyroid dysfunction or a tumor behind the exophthalmus eyeball (see Fig. 11.6B) 364 Medical Terminology: The Language of Health Care Term Meaning glucosuria glucose (sugar) in the urine glū-kō-sūrē-ă glycosuria glı̄ -kō-sūrē-ă hirsutism shaggy; an excessive growth of hair especially in hersū-tizm unusual places (e.g., a woman with a beard) hypercalcemia an abnormally high level of calcium in the blood hı̄ per-kal-sēmē-ă hypocalcemia an abnormally low level of calcium in the blood hipō-kal-sēmē-ă hyperglycemia high blood sugar hı̄ per-glı̄ -sēmē-ă hypoglycemia low blood sugar hı̄ pō-glı̄ -sēmē-ă hyperkalemia an abnormally high level of potassium in the blood hı̄ per-kă-lēmē-ă (kalium  potassium) hypokalemia deficient level of potassium in the blood hı̄ pō-ka-lēmē-ă hypernatremia excessive level of sodium ions in the blood hı̄ per-nă-trēmē-ă (natro  sodium) hyponatremia low level of sodium ions in the blood hı̄ pō-nă-trēmē-ă hypersecretion abnormally increased secretion hı̄ per-se-krēshŭn hyposecretion decreased secretion hı̄ pō-se-krēshŭn ketosis presence of an abnormal amount of ketone bodies kē-tōsis (acetone, beta-hydroxybutyric acid, and ketoacidosis acetoacetic acid) in the blood and urine indicating kē-tō-as-i-dōsis an abnormal utilization of carbohydrates as seen diabetic ketoacidosis (DKA) in uncontrolled diabetes and starvation (keto  alter) metabolism all chemical processes in the body that result in mĕ-tabō-lizm growth, generation of energy, elimination of waste, and other body functions polydipsia excessive thirst pol-ē-dipsē-ă polyuria excessive urination pol-ē-yūrē-ă Chapter 11 • Endocrine System 365 Term Meaning DIAGNOSTIC Adrenal Glands Cushing syndrome collection of signs and symptoms caused by an excessive level of cortisol hormone from any cause, such as a result of excessive production by the adrenal gland (often caused by a tumor), or more commonly as a side effect of treatment with glucocorticoid (steroid) hormones such as prednisone for asthma, rheumatoid arthritis, lupus or other inflammatory diseases; symptoms include upper body obesity, facial puffiness (moon-shaped appearance), hyperglycemia, weakness, thin and easily bruised skin with stria (stretch marks), hypertension, and osteoporosis (Fig. 11.3) adrenal virilism excessive output of the adrenal secretion of ă-drēnăl viri-lizm androgen (male sex hormone) in adult women owing to tumor or hyperplasia; evidenced by amenorrhea (absence of menstruation), acne, hirsutism, and deepening of the voice (virilis  masculine) Pancreas (pankrē-as) diabetes mellitus (DM) metabolic disorder caused by an abnormal di-ă-bētēz meli-tŭs utilization of insulin secreted by the pancreas; evidenced by hyperglycemia and glucosuria (diabetes  passing through; mellitus  sugar) insulin hormone secreted by the beta cells of the islets of insŭ-lin Langerhans of the pancreas responsible for regulating the metabolism of glucose (insulin  island) type 1 diabetes mellitus diabetes in which there is no beta cell production of insulin—the patient is dependent on insulin for survival Figure 11.3 Cushing syndrome. 366 Medical Terminology: The Language of Health Care Term Meaning type 2 diabetes mellitus diabetes in which the body produces insulin, but not enough, or there is insulin resistance (a defective use of the insulin that is produced)— the patient usually is not dependent on insulin for survival hyperinsulinism condition resulting from an excessive amount of hı̄ per-insū-lin-izm insulin in the blood that draws sugar out of the bloodstream, resulting in hypoglycemia, fainting, and convulsions; often caused by an overdose of insulin or by a tumor of the pancreas pancreatitis inflammation of the pancreas pankrē-ă-tı̄ tis Parathyroid Glands (par-ă-thı̄ royd) hyperparathyroidism hypersecretion of the parathyroid glands, usually hı̄ per-par-ă-thı̄ royd-izm caused by a tumor hypoparathyroidism hyposecretion of the parathyroid glands hipō-par-ă-thı̄ royd-izm Pituitary Gland considered the master gland because it secretes (Hypophysis) hormones that regulate the function of other glands, such as the thyroid gland, adrenal glands, ovaries, and testicles acromegaly disease characterized by enlarged features, ak-rō-megă-lē especially the face and hands, caused by hypersecretion of the pituitary hormone after puberty, when normal bone growth has stopped; most often caused by a pituitary tumor (Fig. 11.4) Figure 11.4 Enlarged hands and facial features in a pa- tient with acromegaly. Figure 11.5 Normal male (extreme right) and three types of dwarfism. (1) On the extreme left is a child who has failed to grow because of the congenital absence of the thyroid gland (cretinism). (2) The next two dwarfs have normal proportions but are half normal size (pituitary dwarfism). The next two dwarfs on the right show disproportionately short extremities but normal-size trunk and head (disproportionate dwarfism). Chapter 11 • Endocrine System 367 Term Meaning diabetes insipidus condition of abnormal increase in urine output di-ă-bētēz in-sipid-ŭs most commonly caused by inadequate secretion of pituitary antidiuretic hormone (vasopressin); symptoms include polyuria and polydipsia; urine appears colorless due to the inability of the kidneys to concentrate urine (insipid  without taste) pituitary dwarfism condition of congenital hyposecretion of growth dwōrfizm hormone slowing growth and causing a short yet proportionate stature (not affecting intelligence)— often treated during childhood with growth hormone (Fig. 11.5) [note: there are many other forms of dwarfism, a condition of being markedly undersized; disproportionate types (short limb or short trunk) are most often caused by gene defects (see Fig. 11.5)] pituitary gigantism condition of hypersecretion of growth hormone jı̄ gan-tizm during childhood bone development that leads to an abnormal overgrowth of bone, especially of the long bones; most often caused by a pituitary tumor Thyroid Gland goiter enlargement of the thyroid gland caused by goyter thyroid dysfunction, tumor, lack of iodine in the diet, or inflammation (goiter  throat) (Fig. 11.6A) hyperthyroidism condition of hypersecretion of the thyroid gland hı̄ -per-thı̄ royd-izm characterized by exophthalmia, tachycardia, goiter, and tumor (see Fig. 11.6 and Fig. 11.7A) Graves disease grāvz di-zēz thyrotoxicosis thı̄ rō-tok-si-kōsis Figure 11.6 Hyperthyroidism. A. Patient with goiter. B. Patient with exophthalmos. 368 Medical Terminology: The Language of Health Care A B Fine, silky hair with hair loss Perspiration Dry, brittle hair with hair loss Decreased perspiration Exophthalmos Edema of face and eyelids Bradycardia Diffuse toxic goiter Tachycardia Thick, heavy tongue with slow speech and coarse voice Weight gain Skin: warm, moist, velvety Weight loss Skin: pale, cold, dry, scaling, doughy feeling Increased appetite Amenorrhea Lethargic, poor memory, slow, expressionless Restless, nervous, insomnia, and irritable Fine tremor Brisk deep tendon reflexes Menorrhagia Figure 11.7 A. Hyperthyroidism. B. Hypothyroidism. Term Meaning hypothyroidism condition of hyposecretion of the thyroid gland hı̄ pō-thı̄ royd-izm causing low thyroid levels in the blood that result in sluggishness, slow pulse, and often obesity (Fig. 11.7B) myxedema advanced hypothyroidism in adults characterized mik-se-dēmă by sluggishness, slow pulse, puffiness in the hands and face, and dry skin (myx  mucous) cretinism condition of congenital hypothyroidism in children krētin-izm that results in a lack of mental development and dwarfed physical stature; the thyroid gland is either congenitally absent or imperfectly developed (see Fig. 11.5) Chapter 11 • Endocrine System 369 Diagnostic Tests and Procedures Test or Procedure Explanation LABORATORY TESTING blood sugar (BS) measurement of the level of sugar (glucose) in the blood glucose blood fasting blood sugar (FBS) measurement of blood sugar level after a fast of 12 hours postprandial blood measurement of blood sugar level after a meal, sugar (PPBS) commonly after 2 hours glucose tolerance test (GTT) measurement of the body’s ability to metabolize carbohydrates by administering a prescribed amount of glucose after a fasting period, then measuring blood and urine for glucose levels every hour thereafter—usually for 4 to 6 hours glycohemoglobin molecule (fraction) in hemoglobin that rises in glı̄ -kō-hē-mō-glōbin the blood as a result of an increased level of blood sugar; it is a common blood test used in diagnosing and treating diabetes, also known as glycosylated hemoglobin (HbA1c) electrolytes measurement of the level of specific ions ē-lektro-lı̄ tz (sodium, potassium, CO2, and chloride) in the blood; electrolyte balance is essential for normal metabolism thyroid function study measurement of thyroid hormone levels in blood plasma to determine efficiency of glandular secretions, including T3, T4, and TSH urine sugar and ketone chemical tests to determine the presence of

sugar studies or ketone bodies in the urine; used as a screen for kētōn diabetes (note: to void means to urinate) IMAGING PROCEDURES computed tomography (CT) CT of the head is used to obtain a transverse view of the pituitary gland magnetic resonance imaging nonionizing images of magnetic resonance are (MRI) useful in identifying abnormalities of pituitary, pancreas, adrenal, and thyroid glands sonography sonographic images are used to identify endocrine pathology, such as with thyroid ultrasound thyroid uptake and image nuclear image involving scan of the thyroid to visualize the radioactive accumulation of previously ingested isotopes to detect thyroid nodules or tumors (Fig. 11.8) 370 Medical Terminology: The Language of Health Care Figure 11.8 Thyroid uptake and image detecting presence of multiple nodules (ar- rows). Operative Terms Term Meaning adrenalectomy excision of adrenal gland ă-drē-năl-ektō-mē hypophysectomy excision of pituitary gland hı̄ pof-i-sektō-mē pancreatectomy excision of pancreas pankrē-ă-tektō-mē parathyroidectomy excision of parathyroid gland pară-thı̄ -roy-dektō-mē thymectomy excision of thymus gland thı̄ -mektō-mē thyroidectomy excision of thyroid gland thı̄ -roy-dektō-mē Therapeutic Terms Term Meaning continuous subcutaneous use of an insulin-delivery device worn on the body insulin infusion (CSII) (usually the abdomen) that subcutaneously infuses insulin pump therapy doses of insulin programmed according to the individual needs of the diabetic patient (Fig. 11.9) radioiodine therapy use of radioactive iodine to treat disease, such as rādē-ō-ı̄ ō-din to eradicate thyroid tumor cells Chapter 11 • Endocrine System 371 Figure 11.9 Abdominal placement of insulin pump (continuous subcutaneous insulin infusion). Term Meaning COMMON THERAPEUTIC DRUG CLASSIFICATIONS antihypoglycemic drug that raises blood glucose antē-hı̄ pō-glı̄ -sēmik antithyroid drug agent that blocks the production of thyroid hormones; used to treat hyperthyroidism hormone replacement drug that replaces a hormone deficiency hōrmōn (e.g., estrogen, testosterone, thyroid) hypoglycemic drug that lowers blood glucose (e.g., insulin) antihyperglycemic hı̄ pō-glı̄ -sēmik antē-hı̄ per-glı̄ -sēmik Summary of Chapter 11 Acronyms/Abbreviations ACTH . . . . .adrenocorticotropic hormone GH . . . . . . . .growth hormone ADH . . . . . .antidiuretic hormone GTT . . . . . . .glucose tolerance test BS . . . . . . . . .blood sugar LH . . . . . . . .luteinizing hormone CO2 . . . . . . .carbon dioxide MRI . . . . . . .magnetic resonance imaging CSII . . . . . . .continuous subcutaneous insulin MSH . . . . . .melanocyte-stimulating hormone infusion PPBS . . . . .postprandial blood sugar CT . . . . . . . . .computed tomography PTH . . . . . . .parathyroid hormone DKA . . . . . . .diabetic ketoacidosis T3 . . . . . . . . .triiodothyronine DM . . . . . . . .diabetes mellitus T4 . . . . . . . . .thyroxine FBS . . . . . . .fasting blood sugar TSH . . . . . . .thyroid-stimulating hormone FSH . . . . . . .follicle-stimulating hormone 372 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE parathyroid _______ / _______ / _______ P R S para/thyr/oid P R S DEFINITION: alongside of/thyroid gland/resembling 1. adenitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 2. euglycemia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 3. thyrotoxicosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 4. polydipsia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 5. hormonal __________________ / __________________ R S DEFINITION: _________________________________________________________________ 6. ketosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 7. polyuria __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ Chapter 11 • Endocrine System 373 8. endocrine __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 9. thyroptosis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 10. thymoma __________________ / __________________ R S DEFINITION: _________________________________________________________________ 11. acromegaly __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. android __________________ / __________________ R S DEFINITION: _________________________________________________________________ 13. adrenotrophic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 14. pancreatogenic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 15. glycosuria __________________ / __________________ / __________________ R R S DEFINITION: _________________________________________________________________ 16. dipsogenic __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 374 Medical Terminology: The Language of Health Care Complete the medical term by writing the missing part: 17. _______________secretion  abnormally increased secretion 18. _______________glycemia  low blood sugar 19. _______________ syndrome  condition resulting from hypersecretion of the adrenal cortex causing obesity, hyperglycemia, and weakness 20. _______________secretion  decreased secretion 21. _______________glycemia  high blood sugar 22. _______________graphy  ultrasound imaging For each of the following, circle the meaning that corresponds to the combining form given: 23. adren/o male extremity adrenal gland 24. thyr/o nourishment shield chest 25. crin/o blue cell secrete 26. gluc/o stomach sugar pancreas 27. dips/o thirst ketones secrete 28. thym/o shield hormone thymus gland 29. hormon/o development urging on ketones 30. aden/o male extremity gland Write the correct medical term for each of the following: 31. another name for Graves disease ____________________________________________ 32. protrusion of one or both eyeballs ___________________________________________ 33. disease characterized by enlarged features caused by hypersecretion of the pituitary hormone after puberty ______________________________________________ 34. enlargement of the thyroid gland ____________________________________________ 35. condition of congenital hyposecretion of growth hormone _____________________ 36. nuclear image of the thyroid ________________________________________________ Chapter 11 • Endocrine System 375 Match the following: 37. ________ cretinism a. gigantism 38. ________ polydipsia b. inadequate antidiuretic hormone 39. ________ hyperthyroidism c. excessive sodium 40. ________ pituitary gland d. depends on insulin 41. ________ thyromegaly e. congenital hypothyroidism 42. ________ myxedema f. hypophysis 43. ________ hypokalemia g. not usually insulin dependent 44. ________ type 2 diabetes h. excessive thirst 45. ________ pituitary hypersecretion i. goiter 46. ________ adrenal virilism j. low potassium 47. ________ hypernatremia k. advanced adult hypothyroidism 48. ________ type 1 diabetes l. thyrotoxicosis 49. ________ diabetes insipidus m. hirsutism Write the full medical term for the following abbreviations: 50. BS ________________________________________________________________________ 51. HRT ______________________________________________________________________ 52. FBS _______________________________________________________________________ 53. DM _______________________________________________________________________ 54. PPBS _____________________________________________________________________ 55. GTT ______________________________________________________________________ 56. DKA ______________________________________________________________________ 376 Medical Terminology: The Language of Health Care Write in the missing words on the blank lines in the following illustration of the endocrine glands. 57–62. THE ENDOCRINE SYSTEM Pineal body (Hypothalamus–CNS controller of endocrine system) 60. gland 57. thyroid glands 61. gland 58. gland (Trachea) (Heart) 59. glands (Lungs) 62. Islets of Langerhans of the Ovaries in (Kidneys) female (Uterus) (Labels in parentheses indicate Testes organs shown for orientation only. These are not endocrine system organs.) Chapter 11 • Endocrine System 377 For each of the following, circle the correct spelling of the term: 63. hirsutism hirsuitism hirsitism 64. exopthalmos exopthamamos exophthalmos 65. myexedema myxedema myxadema 66. goiter goyter goitir 67. androgenius androgenous andreogenous 68. virillism virilism viralism 69. epinephrine epinefrine epineprine 70. hypoglicemic hypoglicemic hypoglycemic Give the noun that was used to form the following adjectives: 71. _______ acromegalic 72. _______ exophthalmic 73. _______ metabolic 74. _______ diabetic 75. _______ hypoglycemic 378 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 1 . 1 S: This is a 27 y.o.  c̄ a known Hx of diabetes seen in the ER with nausea and vom- iting for the past three hours. She has skipped two doses of her insulin because BS levels monitored at home have been low. She is now experiencing a cephalalgia similar to what she has had in the past before coma. O: T 35.5º C, P 90, R 20, BP 126/68 Lab blood studies: sodium 130, potassium 4.1, CO2 9, chloride 102, glucose 296 A: Diabetic ketoacidosis P: Admit to ICU: give 10 units insulin IV; measure BS 1º p̄ insulin given, then q 4 h; check urine for sugar and ketosis q void; repeat electrolytes in a.m. 1. What is the CC? 5. Why were the blood electrolyte studies performed? a. nausea, vomiting, and headache a. to examine the electrical impulses of the brain b. nausea, vomiting, and dizziness b. to measure the level of ions in the blood in c. nausea, vomiting, and high blood pressure evaluation of metabolism d. nausea, vomiting, and ringing in the ears c. to measure hormone levels and determine glandular efficiency e. nausea, vomiting, and unconsciousness d. to visualize the accumulation of radioactive 2. What is the diagnosis? isotopes to eliminate the presence of tumor a. hyperglycemia e. to measure the level of glucose in the blood b. hypoglycemia 6. How should the insulin be administered? c. type 1 DM with presence of ketone bodies in a. within the skin the blood b. absorption through unbroken skin d. type 2 DM without the presence of ketone bodies in the blood c. within the muscle e. combination of hyperglycemia and glucosuria d. within the vein e. under the skin 3. As an inpatient, where was treatment provided? 7. How often should the blood glucose be measured? a. neuropsychiatric facility a. one hour after insulin administration, then b. coronary care facility every four hours c. emergency room b. once each morning d. recovery room c. each time the patient urinates e. critical care facility d. one hour before insulin administration, then four times a day 4. Which of the following are electrolytes? 1. sodium e. one hour before insulin administration, then 2. potassium 3. chloride 4. glucose every four hours thereafter a. only 1, 2, and 3 are correct b. only 1 and 3 are correct c. only 2 and 4 are correct d. only 4 is correct e. all are correct Chapter 11 • Endocrine System 379 M E D I C A L R E C O R D 1 1 . 2 Tara Nguyen had a long history of hyperthyroidism that was managed by pharmaco- logical treatment for more than 5 years. She was often unhappy with how she felt, how- ever, and decided on her own to stop taking the drug. Two months ago, the symptoms of hyperthyroidism recurred, and she sought medical attention. Directions Read Medical Record 11.2 for Ms. Nguyen (page 380) and answer the following ques- tions. This record is the report by Dr. Rincon, who analyzed Ms. Nguyen’s thyroid uptake and imaging study. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 1 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: propylthiouracil (PTU) _______________________________________________________ uptake ______________________________________________________________________ baseline (nonmedical term) ___________________________________________________ 2. In your own words, not using medical terminology, briefly describe what seems to have been missing in Ms. Nguyen’s past medical management: ____________________________________________________________________________ ____________________________________________________________________________ 3. In nonmedical terms, explain how the sodium iodide was administered: ____________________________________________________________________________ 4. In your own words, not using medical terminology, briefly describe Dr. Rincon’s diagnosis: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. What additional test did Dr. Rincon order on his own authority? a. thyroid function study b. fasting blood sugar c. thyroid MRI d. thyroid ultrasound 6. Which of the following tests is recommended to be performed in 6 months? a. thyroid function study b. fasting blood sugar c. thyroid MRI d. thyroid ultrasound 380 Medical Terminology: The Language of Health Care Medical Record 11.2 Chapter 11 • Endocrine System 381 M E D I C A L R E C O R D 1 1 . 3 Jane Dano, an 11-year-old girl, started experiencing a constant thirst accompanied by frequent urination. Gradually, she lost weight. At the suggestion of Dr. Freeman, her family doctor, she was admitted to Central Medical Center for tests. Shortly after ad- mission, her care was referred to Dr. Gallegos. Directions Read Medical Record 11.3 regarding Jane Dano (pages 383–385) and answer the fol- lowing questions. These records represent the physician’s orders from Dr. Gallegos, who assumed the care of Jane at the time of her admission, and his clinical summary dictated at the time of her

discharge. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 1 . 3 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the records and define below: void ________________________________________________________________________ urinalysis ___________________________________________________________________ nocturia ____________________________________________________________________ dietitian_____________________________________________________________________ Kussmaul respiration ________________________________________________________ 2. In your own words, not using medical terminology, briefly describe Jane’s condi- tion as identified by the admitting and final diagnosis: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Dr. Gallegos requested that the unit nurses take Jane’s blood pressure every ___ hours. 4. Explain in lay language Dr. Gallegos’ instructions to the nurses for Jane’s fluid intake: ____________________________________________________________________________ ____________________________________________________________________________ 5. Every nurse helping care for Jane needs to know to check her urine for acetone and sugar at what times? ____________________________________________________________________________ 382 Medical Terminology: The Language of Health Care 6. Part of Jane’s care involves teaching her and others how to manage her diabetes when she returns home after discharge. The nurses and dietician provided this education to which of the following people (check all that apply): _____ Jane’s stepmother _____ Jane’s father _____ Jane’s teachers _____ Jane’s older brother _____ a neighbor _____ Dr. Gallegos _____ the twins 7. Explain in lay language the two symptoms Jane had for 2 months before being admitted: ___________________________________________________________________________ What two additional symptoms occurred in the last 3 weeks? ___________________________________________________________________________ ___________________________________________________________________________ 8. At the time of discharge, Jane weighed: a. 40 lb b. 148 lb c. 89 lb d. 148 kg 9. Which of the following diagnostic tests will Jane and her family be performing at home? a. blood glucose monitoring b. vital signs c. body weight d. insulin injections 10. If you were Jane’s parent, what guidance would you give about how active she can be at school? (Put in terms an 11-year-old can understand.) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Chapter 11 • Endocrine System 383 Medical Record 11.3 384 Medical Terminology: The Language of Health Care Medical Record 11.3 Continued. Chapter 11 • Endocrine System 385 Medical Record 11.3 Continued. Chapter 12 Eye OBJECTIVES After completion of this chapter you will be able to Define the common term components used in relation to the eye Locate and name the major structures of the eye and list their functions Define common symptomatic and diagnostic terms referring to the eye List the common diagnostic tests and procedures related to the eye Identify common operative terms referring to the eye Identify common therapeutic terms including drug classifications related to the eye Explain the terms and abbreviations used in documenting medical records involving the eye Combining Forms Combining Form Meaning Example aque/o water aqueous akwē-ŭs blephar/o eyelid blepharospasm blefă-rō-spazm conjunctiv/o conjunctiva (to join together) conjunctival kon-jŭnk-tı̄ văl corne/o cornea corneal kōrnē-ăl kerat/o keratoplasty keră-tō-plas-tē cycl/o ciliary body (circle) cycloplegia sı̄ -klō-plējē-ă ir/o iris (colored circle) iritis irid/o ı̄ -rı̄ tis iridectomy iri-dektō-mē lacrim/o tear lacrimal lakri-măl dacry/o dacryocyst dakrē-ō-sist 386 Chapter 12 • Eye 387 Combining Form Meaning Example ocul/o eye ocular okyū-lăr ophthalm/o ophthalmology of-thal-molō-jē opt/o optometry op-tomĕ-trē phac/o lens (lentil) phacolysis fă-koli-sis phak/o phakoma fa-kōmă phot/o light photophobia fō-tō-fōbē-ă presby/o old age presbyopia prez-bē-ōpē-ă retin/o retina retinopathy ret-i-nopă-thē scler/o sclera (hard) scleritis sklĕ-rı̄ tis vitre/o glassy vitreous vitrē-ŭs ADDITIONAL SUFFIX -opia condition of vision hyperopia hı̄ -per-ōpē-ă Eye Overview The eye is the organ of sight that through pairing provides three-dimensional vision (Fig. 12.1). Each eye is located in a bony orbit (cavity) of the skull and is covered by the protective fold of the eyelid. The sclera, the white of the eye, and the cornea, the transparent anterior coating, are part of the outer fibrous tunic (layer) that refracts (bends) light that enters the eye. The choroid, a vascular layer located just beneath the sclera, contains blood vessels that nourish the outer portion of the retina. The iris contains blood vessels, pigment cells, and muscle fibers. Muscles of the iris regulate the amount of light that enters through the central opening known as the pupil. Melanin, the pigment present in the epithelial cells that cover the iris, gives color to the eyes. The ciliary body is a ring of muscle located behind the peripheral iris that controls the power of the lens. The elas- tic, transparent lens, located behind the pupil, focuses light rays on the retina in the in- ner, posterior part of the eye. Aqueous humor, produced by the surface epithelium of the ciliary body, provides nutrition to the avascular lens and cornea. Vitreous is the jelly-like material that occupies the space between the lens and retina. The retina is the nerve tissue layer that contains cells for visual reception. The vi- sual receptor neurons of the retina are the rods and cones. Rods are responsible for vi- sion in dim light, and cones are responsible for vision in bright light. The macula lutea is the central region of the retina. It has a yellowish color caused by its pigment. At the center of the macula, a tiny, pinpoint depression known as the fovea centralis is the site of sharpest, central vision. The optic disk is the area in the retina where nerve fibers form the optic nerve for transmission to the optic tracts in the brain. 388 Medical Terminology: The Language of Health Care Eyelid (palpebra) Canal of Schlemm Retina Meibomian glands Choroid Glands of Vitreous chamber Zeis Lashes Pupil Cornea Fovea Lens capsule centralis Lens Ciliary processes Anterior Optic nerve chamber Ciliary body and Blood supply Posterior ciliary muscle to retina chamber Iris Conjunctiva Sclera Optic disk Figure 12.1 Anatomy of the eye (sagittal view). The conjunctiva provides a lining for the eye and eyelid. The lacrimal gland, located in the orbit above each eye, secretes tears that lubricate and protect the eye. Tears con- stantly flow across the eye and downward to the lacrimal ducts, to the lacrimal sac, and then into the nasolacrimal duct that drains into the nose. The meibomian glands are sebaceous glands located within the rim of the eyelid that secrete sebum to keep the lids from sticking together, and the glands of Zeis are sebaceous glands surrounding the hair follicles of the eyelashes. Anatomical Terms Term Meaning anterior chamber fluid-filled space between the cornea and iris aqueous humor watery liquid secreted at the ciliary body that fills akwē-ŭs hyūmer the anterior and posterior chambers of the eye and provides nourishment for the cornea, iris, and lens (humor  fluid) canal of Schlemm duct in the anterior chamber that carries filtered aqueous humor to the veins and bloodstream choroid vascular layer beneath the sclera that provides kōroyd nourishment to the outer portion of the retina ciliary body ring of muscle behind the peripheral iris that silē-ar-ē controls the power of the lens ciliary muscle smooth muscle portion of the ciliary body, which contracts to assist in near-vision capability ciliary processes epithelial tissue folds on the inner surface of the ciliary body that secrete aqueous humor conjunctiva joining together; mucous membrane that lines the kon-jŭnk-tı̄ vă eyelids and outer surface of the eyeball Chapter 12 • Eye 389 Term Meaning cornea transparent, anterior part of the eyeball covering kōrnē-ă the iris, pupil, and anterior chamber that functions to refract (bend) light to focus a visual image eyelid (palpebra) movable protective fold that opens and closes, pal-pēbră covering the eye fovea centralis pinpoint depression in the center of the macula fōvē-ă sen-trālis lutea that is the site of sharpest vision (fovea  pit) fundus (base) interior surface of the eyeball including the retina, fŭndŭs optic disk, macula, and posterior pole (curvature at the back of the eye) glands of Zeis oil glands surrounding the eyelashes meibomian glands oil glands located along the rim of the eyelids mı̄ -bōmē-an iris colored circle; colored part of the eye located ı̄ ris behind the cornea that contracts and dilates to regulate light passing through the pupil lacrimal gland gland located in the upper outer region above the lakri-măl eyeball that secretes tears (Fig. 12.2) lacrimal ducts tubes that carry tears to the lacrimal sac lacrimal sac structure that collects tears before emptying into the nasolacrimal duct lens transparent structure behind the pupil that bends and focuses light rays on the retina lens capsule capsule that encloses the lens macula lutea (macula) central region of the retina responsible for central makyū-lă vision; yellow pigment provides its color (lutea  yellow) (see Fig. 12.13B) Puncta Lacrimal ducts Lacrimal gland Lacrimal sac Meibomian glands Nasolacrimal duct Figure 12.2 Lacrimal apparatus. 390 Medical Terminology: The Language of Health Care Term Meaning nasolacrimal duct passageway for tears from the lacrimal sac into the nā-zō-lakri-măl nose optic disk exit site of retinal nerve fibers, as well as the optik entrance point for retinal arteries and the exit point for retinal veins (see Fig. 12.13B) optic nerve nerve responsible for carrying impulses for the sense of sight from the retina to the brain posterior chamber space between the back of the iris and the front of the vitreous filled with aqueous fluid PUPIL. The Latin pupil black circular opening in the center of the iris word, pupilla, pyūpı̄ l through which light passes as it enters the eye the pupil of the eye, is derived from pupa, retina innermost layer that perceives and transmits light meaning a doll or little girl. reti-nă to the optic nerve (see Fig. 12.13B) The name is said to have been given to the pupil of cones cone-shaped cells within the retina that are color the eye because a tiny sensitive and respond to bright light image of the beholder may be seen reflected in it. rods rod-shaped cells within the retina that respond to dim light sclera tough, fibrous, white outer coat extending from sklēră the cornea to the optic nerve trabecular meshwork mesh-like structure in the anterior chamber that tră-bekyū-lăr filters the aqueous humor as it flows into the canal of Schlemm vitreous jelly-like mass filling the inner chamber between vitrē-ŭs the lens and retina that gives bulk to the eye Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC asthenopia eyestrain (asthenia  weak condition) as-thĕ-nōpē-ă blepharospasm involuntary contraction of the muscles blefă-rō-spazm surrounding the eye, causing uncontrolled blinking and lid squeezing diplopia double vision di-plōpē-ă exophthalmos abnormal protrusion of one or both eyeballs ek-sof-thalmos exophthalmus lacrimation secretion of tears lak-ri-māshŭn nystagmus involuntary, rapid oscillating movement of the nis-tagmŭs eyeball (nystagmos  a nodding) photophobia extreme sensitivity to, and discomfort from, light fō-tō-fōbē-ă Chapter 12 • Eye 391 Term Meaning scotoma blind spot in vision (skotos  darkness) skō-tōmă DIAGNOSTIC refractive errors defects in the bending of light as it enters the eye, rē-fraktiv causing an improper focus on the retina astigmatism distorted vision caused by an oblong or cylindrical ă-stigmă-tizm curvature of the lens or cornea that prevents light rays from coming to a single focus on the retina (stigma  point) hyperopia farsightedness; difficulty seeing close objects when hı̄ -per-ōpē-ă light rays extend beyond the proper focus on the retina (Fig. 12.3A and B) myopia nearsightedness; difficulty seeing distant objects mı̄ -ōpē-ă when light rays fall short of the proper focus on the retina (Fig. 12.3A and C) presbyopia impaired vision owing to old-age loss of prez-bē-ōpē-ă accommodation accommodation ability of the eye to adjust focus on near objects ă-komŏ-dāshŭn amblyopia decreased vision in early life due to a functional am-blē-ōpē-ă defect that can occur as a result of strabismus, refractive errors (when one eye is more near- sighted, farsighted, or astigmatic than the other), or trauma; usually occurs in one eye, also known as lazy eye (ambly/o  dim) aphakia absence of the lens, usually after cataract ă-fākē-ă extraction blepharitis inflammation of the eyelid blefă-rı̄ tis blepharochalasis baggy eyelid; overabundance and loss of elasticity blefă-rō-kală-sis of skin on the upper eyelid, causing a fold of skin dermatochalasis to hang down over the edge of the eyelid when the dermă-tō-kală-sis eyes are open (chalasis  a slackening) blepharoptosis drooping of the eyelid usually caused by paralysis blefă-roptō-sis ptosis Normal vision Hyperopia Myopia A B C Figure 12.3 A. Proper focus of light rays on the retina. B. Light rays extend beyond proper focus in hyperopia. C. Light rays fall short of proper

focus in myopia. 392 Medical Terminology: The Language of Health Care Term Meaning chalazion chronic nodular inflammation of a meibomian ka-lāzē-on (shă-lāzē-on) gland, usually the result of a blocked duct; commonly presents as a swelling on the upper or lower eyelid (chalaza  hailstone) (Fig. 12.4) CATARACT. This cataract opaque clouding of the lens causing decreased Greek word meaning kată-rakt vision (Figs. 12.5 and 12.6B) waterfall, or something that conjunctivitis pinkeye; inflammation of the conjunctiva rushes down to form an kon-jŭnk-ti-vı̄ tis obstruction, like a portcullis, was probably related to the dacryoadenitis inflammation of the lacrimal gland obstruction of vision that is dakrē-ō-ad-ĕ-nı̄ tis symptomatic of a cataract. It was an ancient belief that dacryocystitis inflammation of the tear sac (cyst/o  sac) the interference with vision dakrē-ōsis-tı̄ tis occurred between the lens diabetic retinopathy disease of the retina in diabetics characterized by and the iris (like a veil). dı̄ -ă-betik ret-i-nopă-thē capillary leakage, bleeding, and new vessel formation (neovascularization), leading to scarring and loss of vision (Figs. 12.6C and 12.13C) ectropion outward turning of the rim of the eyelid (trop/o  ek-trōpē-on turning) (Fig. 12.7A) entropion inward turning of the rim of the eyelid (Fig. 12.7B) en-trōpē-on epiphora abnormal overflow of tears caused by blockage of ē-pifō-ră the lacrimal duct (epi  upon; phor/o  to carry or bear) glaucoma group of diseases of the eye characterized by glaw-kōmă increased intraocular pressure that results in damage to the optic nerve, producing defects in vision (Fig. 12.6D) hordeolum sty; an acute infection of a sebaceous gland of the hōr-dēō-lŭm eyelid (hordeum  barley) (Fig. 12.8) iritis inflammation of the iris ı̄ -rı̄ tis keratitis inflammation of the cornea ker-ă-tı̄ tis Figure 12.4 Chalazion. Chapter 12 • Eye 393 Normal focus of light rays on the retina Light rays diffused by a cataract Iris Retina Clouded lens (cataract) Cornea Pupil A Clear lens (normal) Normal daytime vision Simulation of daytime cataract vision B1 B2 Normal nighttime vision Simulation of nighttime cataract vision Figure 12.5 Cataract. A. Normal light focus compared with light focus interference caused by a cataract. B. Simu- lation of cataract vision. 394 Medical Terminology: The Language of Health Care A Normal vision B Cataract (hazy vision) C Diabetic retinopathy (retinal damage leads to blind spots) D Glaucoma (loss of peripheral vision) E Macular degeneration (loss of central vision) Figure 12.6 Simulations of vision loss. Term Meaning macular degeneration breakdown or thinning of the tissues in the makyū-lăr dē-jen-er-āshŭn macula, resulting in partial or complete loss of central vision (see Fig. 12.6E) pseudophakia eye in which the natural lens is replaced with an sū-dō-fakē-ă artificial lens implant (pseudo  false) pterygium fibrous growth of conjunctival tissue that extends tĕ-rijēŭm onto the cornea (Fig. 12.9) retinal detachment separation of the retina from the underlying ret-i-nal epithelium, disrupting vision and resulting in blindness if not repaired surgically (Fig. 12.13D) retinitis inflammation of the retina ret-i-nı̄ tis Chapter 12 • Eye 395 A B Figure 12.7 Eyelid abnormalities. A. Severe bilateral lower lid ectropion. B. Lower lid entropion causing the lashes to rub on the cornea. Term Meaning strabismus crossed eyes; a condition of eye misalignment STRABISMUS. stra-bizmŭs caused by intraocular muscle imbalance Strabo, a (strabismus  a squinting; hetero  other) geographer and (Fig. 12.10) prominent figure in Alexandria during the heterotropia Roman period, suffered from heter-ō-trōpē-ă a peculiar and noticeable squint. Any man with the esotropia right or left eye deviates inward toward the nose same type of squint was es-ō-trōpē-ă (eso  inward; tropo  turning) called Strabo, which led to exotropia right or left eye deviates outward away from the the word strabismus. ek-sō-trōpē-ă nose (exo  out; tropo  turning) scleritis inflammation of the sclera sklĕ-rı̄ tis trichiasis misdirected eyelashes that rub on the conjunctiva trı̄ -kı̄ ă-sis or cornea Figure 12.8 Upper lid hordeolum. Figure 12.9 Pterygium caused by ultraviolet exposure and drying. 396 Medical Terminology: The Language of Health Care Esotropia Exotropia Figure 12.10 Strabismus. Diagnostic Tests and Procedures Test or Procedure Explanation distance visual acuity measure of the ability to see the details and shape of identifiable objects from a specified distance (usually 20 feet), typically using a Snellen chart (Fig. 12.11) fluorescein angiography visualization and photography of retinal and flūr-esē-in an-jē-ogră-fē choroidal vessels made as fluorescein dye, which is injected into a vein, circulates through the eye (Fig. 12.12) ophthalmoscopy use of an ophthalmoscope to view the interior of of-thal-moskō-pē the eye (Fig. 12.13) refraction measurement of refractive errors using a rē-frak´shŭn phoropter to determine best corrected vision and prescription for eye glasses or contact lenses phoropter instrument that holds corrective lenses in front fŏ-rop´ter of the eye to determine optical correction Figure 12.11 Snellen eye chart for testing distance visual acuity. Chapter 12 • Eye 397 A B Figure 12.12 Fluorescein angiography photo- graphs. A. Right eye before injection of fluorescein. B. Maximal levels of fluorescein circulating through the retinal blood vessels 30 seconds after injection. C C. Elimination after 5 minutes. Macula Optic disk Vein Artery D Figure 12.13 A. Doctor performing ophthalmoscopy using an ophthalmoscope. B. Normal retina. C. Aneurysms seen in diabetic retinopathy. D. Retinal detachment. 398 Medical Terminology: The Language of Health Care Figure 12.14 Slit-lamp biomicroscope. Test or Procedure Explanation slit-lamp biomicroscopy use of a tabletop microscope to examine the biō-mi-kroskŏ-pē eye, especially the cornea, lens, fluids, and membranes (Fig. 12.14) sonography use of high-frequency sound waves to detect sŏ-nogră-fē pathology within the eye such as foreign bodies or a detached retina tonometry use of a tonometer to measure intraocular tō-nomĕ-trē pressure, which is elevated in glaucoma (Fig. 12.15) Operative Terms Term Meaning blepharoplasty surgical repair of an eyelid blefă-ro-plast-tē cataract extraction excision of a cloudy lens from the eye kată-rakt ek-strakshŭn cryoretinopexy use of intense cold to seal a hole or tear in the krı̄ -ō-reti-nō-pek-se retina; used to treat retinal detachment cryopexy dacryocystectomy excision of a lacrimal sac dakrē-ō-sis-tektō-mē Chapter 12 • Eye 399 Figure 12.15. Tonometer/tonometry. Term Meaning enucleation excision of an eyeball ē-nū-klē-āshŭn iridectomy excision of a portion of iris tissue iri-dektō-mē iridotomy incision into the iris (usually with a laser) to allow ir-i-dotō-mē for drainage of aqueous humor from the posterior to anterior chamber; used to treat a type of glaucoma keratoplasty corneal transplant; replacement of a diseased or keră-tō-plas-tē scarred cornea with a healthy one from a matched donor laser surgery use of a laser to make incisions or destroy tissues (e.g., to create fluid passages, to obliterate tumors or aneurysms) (Fig. 12.16) laser-assisted in situ technique using the excimer laser to reshape the keratomileusis (LASIK) surface of the cornea to correct refractive errors in sı̄ tū keră-tō-mil-oosis such as myopia, hyperopia, and astigmatism (smileusis  carving) 400 Medical Terminology: The Language of Health Care Figure 12.16. Simulation of laser application. Term Meaning intraocular lens (IOL) implantation of an artificial lens to replace a implant defective natural lens (e.g., after cataract intră-okyū-lăr extraction) (Fig. 12.17) phacoemulsification use of ultrasound to shatter and break up a fakō-ē-mŭl-si-fi-kāshŭn cataract with aspiration and removal scleral buckling surgery to treat retinal detachment by placing a sklĕrăl bŭkling band of silicone around the sclera to cinch it to- ward the middle of the eye and relieve pull on the retina—often combined with other techniques to seal retinal tears such as cryoretinopexy trabeculectomy removal of a portion of the trabecular meshwork tră-bekyū-lektō-mē to increase the flow of aqueous humor from the eye; used in treatment of acute glaucoma or glaucoma not treatable with medication Chapter 12 • Eye 401 Figure 12.17. Size comparison of an intraocular lens to a dime. Therapeutic Terms Term Meaning contact lens small plastic curved disk with optical correction that fits over the cornea; used to correct refractive errors eye instillation introduction of a medicated solution in the eye eye irrigation washing of the eye with water or other fluid (e.g., saline) 402 Medical Terminology: The Language of Health Care COMMON THERAPEUTIC DRUG CLASSIFICATIONS antibiotic ophthalmic solution antimicrobial agent in solution, used to treat antē-bı̄ -otik of-thalmik bacterial infections (e.g., conjunctivitis, corneal ulcers) cycloplegic agent that paralyzes the ciliary muscle and powers sı̄ -klō-plējik of accommodation; commonly used in pediatric eye examinations mydriatic (dilation of pupil) agent that causes dilation of the pupil (e.g., for mi-drē-atik certain eye examinations) miotic agent that causes the pupil to contract (mio  less) mı̄ -otik Summary of Chapter 12 Acronyms/Abbreviations IOL ..............intraocular lens LASIK .......laser-assisted in situ keratomileusis Chapter 12 • Eye 403 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE epikeratophakia _______ / _______ / _______ / _______ P CF R S epi/kerato/phak/ia P CF R S DEFINITION: upon/cornea/lens/condition of 1. blepharoptosis _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 2. iridotomy _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 3. ophthalmology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 4. vitrectomy _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 5. dacryolithiasis _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ 6. lacrimal _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 404 Medical Terminology: The Language of Health Care 7. photophobia _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ 8. keratoplasty _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 9. aqueous _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 10. iritis _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 11. corneal _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 12. phacolysis _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 13. retinopathy _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ 14. ocular _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 15. conjunctivitis _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ Chapter 12 • Eye 405 16. presbyopia _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 17. optometry _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 18. aphakia _____________________ / _____________________ / _____________________ P R S DEFINITION: _________________________________________________________________ 19. hyperopia _____________________ / _____________________ P S DEFINITION: _________________________________________________________________ 20. scleromalacia _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ Complete the following medical term by writing the missing part: 21. _______________phakia  absence of the lens of the eye 22. _______________ophthalmos  protrusion of the eyeball 23. ____________________chalasis  baggy eyelids 24. _______________ buckling  surgical placement of a band of silicone around the sclera to cinch it toward the middle of the eye 25. blepharo___________  involuntary contraction of the muscles surrounding the eye For each of the following, circle the combining form that corresponds to the meaning given: 26. eye or/o opt/o ot/o 27. old age presby/o scler/o phas/o 28. glassy aque/o vitre/o hydr/o 29. light phon/o phot/o opt/o 406 Medical Terminology: The Language of Health Care 30. hard or sclera corne/o vitre/o scler/o 31. lens (lentil) phac/o scler/o conjunctiv/o 32. colored circle chrom/o irid/o corne/o 33. tear dacry/o hydr/o aque/o 34. eyelid ocul/o ophthalm/o blephar/o 35. water aque/o hidr/o vitre/o Write the correct medical term for each of the following: 36. pinkeye ___________________________________________________________________ 37. inflammation of the eyelid __________________________________________________ 38. eyestrain __________________________________________________________________ 39. an agent that causes dilation of the pupil _____________________________________ 40. a sty; acute infection of a meibomian gland of the eyelid ______________________ 41. clouding of the lens causing decreased vision _________________________________ 42. breakdown or thinning of the tissues in the macula, resulting in partial or com- plete loss of central vision __________________________________________________ Match the surgical procedures with diagnoses: 43. ________ keratoplasty a. myopia 44. ________ phacoemulsification b. retinal detachment 45. ________ LASIK c. cataract 46. ________ trabeculectomy d. dermatochalasis 47. ________ blepharoplasty e. scarred cornea 48. ________ cryoretinopexy f. acute glaucoma Briefly define the following medical terms: 49. entropion _________________________________________________________________ 50. tonometer _________________________________________________________________ 51. ectropion _________________________________________________________________ 52. nystagmus ________________________________________________________________ Chapter 12 • Eye 407 Match the following: 53. ________ myopia a. old-age loss of accommodation 54. ________ strabismus b. lazy eye 55. ________ presbyopia c. pink eye 56. ________ astigmatism d. double vision 57. ________ hyperopia e. distorted vision 58. ________ amblyopia f. nearsightedness 59. ________ scotoma g. sty 60. ________ diplopia h. crossed eyes 61. ________ conjunctivitis i. farsightedness 62. ________ hordeolum j. blind spot in vision Write in the missing words on the blank lines in the following illustration of the eye’s anatomy. 63–70. 63. (palpebra) Canal of Schlemm 69. Meibomian glands Choroid Glands of 67. Zeis chamber Lashes Pupil 64. Fovea Lens capsule

centralis 65. Ciliary processes Anterior 70. chamber 68. Ciliary body and nerve Posterior chamber muscle Blood supply Iris to retina Conjunctiva 66. Optic disk For each of the following, circle the correct spelling of the term: 71. asthenopia assthinopia asthinopia 72. terigium pterygium pteregium 408 Medical Terminology: The Language of Health Care 73. horadeolum hordeolum hordeaolum 74. nistagmis nystagmis nystagmus 75. chalazion shalazion calazion 76. mydriatic midriatic myadriatic 77. skotoma scotoma schotoma 78. epiphora epifora epifhora 79. dakryeocyst dacryocyst dacreyocyst 80. opthalmoscope ofthalmoscope ophthalmoscope Give the noun that was used to form the following adjectives: 81. conjunctival _______________ 82. myopic _______________ 83. scleral _______________ 84. macular _______________ 85. exophthalmic _______________ Chapter 12 • Eye 409 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 2 . 1 S: This 51 y/o  c/o a growth in the corner of her right eye that is dry and irritated. She has had the feeling that there was “something in the eye” for about four months before actually noticing the growth three weeks ago. She wears contacts to correct farsightedness, but has recently switched to eyeglasses because of the discomfort. She is active physically and loves tennis and water sports, but does not frequently wear sunglasses. O: Inspection of the right eye reveals an inflamed, raised, whitish, triangular wedge of fibrovascular tissue, whose base lies within the interpalpebral conjunctiva and whose apex encroaches the cornea. A photo documentation is made and in- cluded in the chart. A: INFLAMED PTERYGIUM, RIGHT EYE P: 1) The patient is advised that the pterygium is not dangerous, but further growth could interfere with vision and warrant surgical excision. She was counseled on the importance of wearing UV blocking sunglasses and advised to avoid smoky or dusty areas as much as possible. 2) RX: fluorometholone, 0.1% suspension, 1 gt q 4h OD during the day for in- flammation; OTC artificial tears solution, prn dryness/irritation 3) RTO in 3 months for slit lamp evaluation, or sooner if symptoms persist. 1. Describe the refractive error noted in the subjec- c. use of a tabletop microscope to examine the tive information: eye, especially the cornea a. eyestrain d. implantation of an artificial lens b. inflammation of the cornea e. use of a tonometer to measure intraocular c. difficulty seeing distant objects pressure d. difficulty seeing close objects 4. How should the fluorometholone be adminis- e. blind spot in vision tered? a. one drop every 4 hours 2. Which action on the part of the patient likely contributed to the condition? b. four drops in the eye every morning a. wearing contact lenses c. one drop every day for 4 days b. removing contact lenses d. as needed during the day c. playing tennis e. one drop every other day for 4 days d. not routinely wearing sunglasses 5. When should the patient instill the artificial e. strenuous physical activity tears? a. every day 3. Which ophthalmological procedure is included in the plan? b. every night a. use of a laser to reshape the surface of the c. during the day cornea d. only as needed b. use of an ophthalmoscope to view the interior e. when feeling the need to cry of the eye 410 Medical Terminology: The Language of Health Care 6. What caused the pterygium? 7. What was the patient told about the pterygium? a. misdirected eyelashes that rub on the conjunc- a. it is cancerous tiva or cornea b. it is not cancerous b. intraocular muscle imbalance c. it must be removed c. separation of the retina from the underlying d. both a and c epithelium d. abnormal overflow of tears e. ultraviolet exposure and drying Chapter 12 • Eye 411 M E D I C A L R E C O R D 1 2 . 2 Not long ago, Cassandre Aquero had cataract surgery for her left eye, and she is now losing vision in her right eye because of another cataract. She is consulting an oph- thalmologist, Dr. Oanh Tran, about surgery on the right eye. Directions Read Medical Record 12.2 for Ms. Aquero (pages 413–414) and answer the following questions. This record is the history and physical examination written by Dr. Tran in planning for Ms. Aquero’s surgery. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 2 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: appendectomy ______________________________________________________________ irides ______________________________________________________________________ 2. In your own words, briefly describe Ms. Aquero’s current complaint and diagnosis noted under “History of Present Illness”: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Describe in lay language the two medical conditions Ms. Aquero has in addition to her current problem and past surgeries: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. Which of the following findings on physical examination is related to her general medical condition in addition to her eye problems? a. rales on auscultation b. disoriented consciousness c. BP 180/100 d. weight 135 lb 412 Medical Terminology: The Language of Health Care 5. The planned operation involves several risks that the patient has accepted in the hopes of regaining good eyesight. Which of the following was not mentioned by Dr. Tran as a risk? a. hypertensive crisis b. retinal detachment c. edema of the macula d. bleeding 6. The preoperative nursing staff will ensure that Ms. Aquero receives five medica- tions before surgery. Translate the instructions for these: a. __________________________________________________________________________ b. __________________________________________________________________________ c. __________________________________________________________________________ d. __________________________________________________________________________ e. __________________________________________________________________________ 7. In your own words, not using medical terminology, briefly describe what will oc- cur in the surgery: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 12 • Eye 413 Medical Record 12.2 414 Medical Terminology: The Language of Health Care Medical Record 12.2 Continued. Chapter 13 Ear OBJECTIVES After completion of this chapter you will be able to Define the common term components used in relation to the ear Locate and name the major structures of the ear and list their functions Define common symptomatic and diagnostic terms referring to the ear List the common diagnostic tests and procedures related to the ear Identify common operative terms referring to the ear Identify common therapeutic terms including drug classifications related to the ear Explain the terms and abbreviations used in documenting medical records involving the ear Combining Forms Combining Form Meaning Example acous/o hearing acoustic ă-kŭstik audi/o audiometry aw-dē-omĕ-trē aer/o air or gas aerotitis ār-ō-tı̄ tis aur/i ear auricle awri-kl ot/o otology ō-tolŏ-jē cerumin/o wax ceruminosis se-rū-mi-nōsis salping/o eustachian tube or uterine tube salpingoscope sal-pinggō-skōp tympan/o eardrum tympanic tim-panik myring/o myringotomy mir-ing-gotō-mē ADDITIONAL SUFFIX -acusis hearing condition presbyacusis prezbē-ă-kūsis 415 416 Medical Terminology: The Language of Health Care TYMPANUM. Overview of the Ear Tympanum is the Latin word for The sense of hearing occurs through the mechanical action of the ear and its three tambourine or kettledrum, percussion instruments that divisions: outer ear, middle ear, and inner ear (Fig. 13.1). are struck or beaten. Use of Sounds are gathered by the projections of the external ear called the pinna, or the term for eardrum was auricle, and then dispersed through the external auditory meatus (canal) to the tym- first introduced in 1255 and panum, or eardrum, of the middle ear. Glands located throughout the external canal was adopted by the famous secrete a protective, waxy substance called cerumen. anatomist, Gabrielle The tympanum transmits sound vibrations through the auditory ossicles— Fallopius, because of the malleus, incus, and stapes—to the oval window. Vibrations are increased as they are likeness of the eardrum to a distributed from the tympanum to the malleus, incus, and stapes. When the stapes, tambourine. held by a ligament called the oval window, vibrates, it stimulates the motion of the au- OSSICLE. ditory fluids in the inner ear. Ossicle means a Within the middle ear, the eustachian tube or auditory tube provides a passageway little bone; it is a to the throat, allowing air to pass to and from the outside of the body. This process is diminutive of the Latin important for maintaining equal air pressure. ossiculum, meaning bone. Located within the temporal bone of the skull, the inner ear receives sound vibra- Specifically, ossicle means one of the small bones in the tions passed from the oval window to the cochlea, the outer structure of the inner ear, middle ear. The first authentic which is part of the intricate intercommunicating tubes and chambers known as the records indicate that the labyrinth. Vibrations are passed through perilymph, a fluid within an area of the malleus and the incus were cochlea called the scala vestibuli, to the cochlear duct, which is filled with a fluid called the first two to be discovered endolymph. Finally, the vibrations are passed through the organ of Corti, where hairs in 1514. The stapes was along its lining stimulate surrounding nerve fibers, generating impulses that then discovered around 1546. travel to the brain for processing of hearing. THE EAR Auricle Malleus Ossicles (bones Incus of middle ear) Stapes Cochlea Facial nerve Vestibulocochlear nerve Oval window Round window Tympanic cavity Tympanic membrane External auditory Endolymph canal Eustachian tube Perilymph Utricle (auditory tube) Saccule Pharynx Osseous labyrinth Cochlear duct Perilymph Cochlea Membranous labyrinth Semicircular canals Ampulla Oval window Labyrinth and Cochlea Vestibule Organ of Corti Figure 13.1. Anatomy of the ear. Chapter 13 • Ear 417 In addition to hearing, the labyrinth is responsible for the equilibrium within the body. Within the labyrinth, the semicircular canals are connected to the cochlea by a cavity called the vestibule. Within the vestibule are structures known as the utricle and saccule. Hair cells and surrounding nerve fibers within the canals that connect with the utricle respond to and are moved by endolymph to stimulate nerve conduction when changes in movement occur. Anatomical Terms Term Meaning external ear pinna auricle (little ear); projected part of the external pină ear (pinna  feather) external auditory meatus external passage for sounds collected from the (canal) pinna to the tympanum (meat/o  opening) cerumen waxy substance secreted by glands located sĕ-rūmen throughout the external canal middle ear tympanic membrane (TM) eardrum; drum-like structure that receives sound tim-panik membrān collected in the external auditory meatus (canal) and amplifies it through the middle ear (see Fig. 13.3B) malleus hammer; first of the three auditory ossicles of malē-ŭs the middle ear incus anvil; middle of the three auditory ossicles of the ingkŭs middle ear stapes stirrup; last of the three auditory ossicles of the stāpēz middle ear eustachian tube tube connecting the middle ear to the pharynx yū-stāshŭn (throat) auditory tube mastoid process projection of the temporal bone located behind mastoyd the ear containing air cells that connect to the middle ear (masto  breast) oval window membrane that covers the opening between the middle ear and inner ear inner ear structures and liquids that relay sound waves to the auditory nerve fibers on a path to the brain for interpretation of sound labyrinth maze; inner ear consisting of bony and labi-rinth membranous labyrinths cochlea coiled tubular structure of the inner ear that koklē-ă contains the organ of Corti (cochlea  snail) perilymph fluid that fills the bony labyrinth of the ear peri-limf endolymph fluid within the cochlear duct of the inner ear endō-limf (labyrinth) 418 Medical Terminology: The Language of Health Care Term Meaning organ of Corti organ located in the cochlea that contains receptors (hair cells) that receive vibrations and generate nerve impulses for hearing vestibule middle part of the inner ear in front of the vesti-būl semicircular canals and behind the cochlea that contains the utricle and saccule utricle larger of two sacs within the membranous ūtri-kl labyrinth of the vestibule in the inner ear (uter  leather bag) saccule smaller of two sacs within the membranous sakyūl labyrinth of the vestibule in the inner ear (sacculus  small bag) semicircular canals three canals within the inner ear that contain semē-sirkyū-lăr kă-nalz specialized receptor cells that generate nerve impulses with body movement Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC otalgia earache ō-taljē-ă otodynia ō-tō-dinē-ă otorrhagia bleeding from the ear ō-tō-rājē-ă otorrhea purulent drainage from the ear ō-tō-rēă

tinnitus a jingling; ringing or buzzing in the ear ti-nı̄tŭs vertigo a turning round; dizziness verti-gō DIAGNOSTIC External Ear otitis externa inflammation of the external auditory meatus ō-tı̄tis eks-ternă (canal) (Fig. 13.2B) cerumen impaction excessive buildup of wax in the ear sĕ-rūmen im-pakshŭn Middle Ear myringitis inflammation of the eardrum mir-in-jı̄ tis tympanitis tim-pă-nı̄ tis Chapter 13 • Ear 419 A B Figure 13.2. A. Otoscopic examination of the external auditory meatus (canal). B. Otitis externa. Term Meaning otitis media inflammation of the middle ear (Fig. 13.3C) ō-tı̄ tis mēdē-ă aerotitis media inflammation of the middle ear from changes in ār-ō-t ı̄ tis mēdē-ă atmospheric pressure; often occurs in frequent air travel otosclerosis hardening of the bony tissue in the ear ōtō-sklē-rōsis mastoiditis inflammation of the mastoid process; most commonly mas-toy-dı̄ tis seen as a result of the spread of inflammation and infection in otitis media eustachian obstruction blockage of the eustachian tube usually as a result of yū-stāshŭn ob-strŭkshŭn infection, as in otitis media Inner Ear acoustic neuroma benign tumor on the auditory nerve (8th cranial ă-kŭstik noo-romă nerve) that causes vertigo, tinnitus, and hearing loss aplasia condition of absence or malformation of inner ear ă-plāzē-ă structures during embryonic development, resulting in hearing loss labyrinthitis inflammation of the labyrinth labı̆ -rin-thı̄ tis Ménière disease disorder of the inner ear due to an excessive buildup mĕn-yerz of endolymphatic fluid causing episodes of vertigo, tinnitus, nausea, vomiting, and hearing loss; one or both ears can be affected, and attacks vary in frequency and intensity 420 Medical Terminology: The Language of Health Care Figure 13.3. A. Doctor performing pneumatic otoscopy. B. Normal tympanic membrane. C. Otitis media. Term Meaning General deafness general term for partial or complete hearing loss defnes conductive hearing loss hearing impairment caused by interference with kon-dŭktiv sound or vibratory energy in the external canal, middle ear, or ossicles sensorineural hearing loss hearing impairment caused by lesions or dysfunction sensōr-i-nūrăl of the cochlea or auditory nerve mixed hearing loss combination of sensorineural and conductive hearing loss presbyacusis hearing impairment in old age prezbē-ă-kūsis presbycusis prez-bē-kūsis Chapter 13 • Ear 421 Diagnostic Tests and Procedures Test or Procedure Explanation audiometry process of measuring hearing (Fig. 13.4) aw-dē-omĕ-trē audiometer instrument to measure hearing aw-dē-omĕ-ter audiogram record of hearing measurement awdē-ō-gram audiologist person who specializes in the study of hearing aw-dē-olō-jist impairments auditory acuity physical assessment of hearing; useful in testing differentiating between conductive and awdi-tōr-ē ă-kyūi-tē sensorineural hearing loss (Fig. 13.5) tuning fork two-pronged, fork-like instrument that vibrates when struck: used to test for hearing, especially bone conduction Figure 13.4. Audiometry: hearing screening. 422 Medical Terminology: The Language of Health Care Bone conduction Air conduction A B Figure 13.5. Tuning fork testing. A. Weber test. B. Rinne test. Test or Procedure Explanation brainstem auditory evoked electrodiagnostic testing using computerized potentials (BAEP) equipment to measure involuntary responses to sound within the auditory nervous system— commonly used to assess hearing in newborns (Fig. 13.6) otoscopy use of an otoscope to examine the external auditory ō-toskŏ -pē meatus (canal) and tympanic membrane (Figs. 13.2A and Fig. 13.7) Figure 13.6. Brainstem auditory evoked potentials (BAEP) testing of a newborn. Chapter 13 • Ear 423 Test or Procedure Explanation pneumatic otoscopy otoscopic observation of the tympanic membrane as noo-matik ō-toskŏ-pē air is released into the external auditory meatus (canal); immobility indicates the presence of middle ear effusion (fluid buildup) as occurs as a result of otitis media (see Fig. 13.3A) tympanometry measurement of the compliance and mobility timpă-nomĕ-trē (conductibility) of the tympanic membrane and ossicles of the middle ear by monitoring the response after exposure to external airflow pressures Operative Terms Term Meaning microsurgery surgery with the use of a microscope; used in mı̄ -krō-serjer-ē procedures involving delicate tissue such as the ear myringotomy incision into the eardrum, most often for insertion mir-ing-gotŏ-mē of a small metal or plastic tube [e.g., polyethylene tympanostomy (PE) tube], to keep the meatus (canal) open, timpăn-ostō-mē avoiding fluid buildup (effusion) as that which occurs as a result of otitis media (Fig. 13.8) otoplasty surgical repair of the external ear ōtō-plas-tē stapedectomy excision of the stapes to correct otosclerosis stā-pĕ-dektō-mē tympanoplasty vein graft of a scarred tympanic membrane to timpă-nō-plas-tē improve sound conduction Figure 13.8. View through otoscope shows Figure 13.7. Otoscope. placement of tympanostomy tube. 424 Medical Terminology: The Language of Health Care Therapeutic Terms Term Meaning auditory prosthesis any internal or external device that improves or prosthē-sis substitutes for natural hearing hearing aid external amplifying device designed to improve hearing by more effective collection of sound into the ear cochlear implant electronic device implanted in the cochlea that provides koklē-ă r sound perception to patients with severe or profound sensorineural (nerve) hearing loss in both ears (Fig. 13.9) ear lavage irrigation of the external ear canal, commonly lă -vahzh done to remove excessive buildup of cerumen ear instillation introduction of a medicated solution into the in-sti-lāshŭn external canal COMMON THERAPEUTIC DRUG CLASSIFICATIONS antibiotic drug that inhibits the growth of or destroys antē-bı̄ -otik microorganisms; used to treat diseases caused by bacteria (e.g., otitis media) antihistamine drug that blocks the effects of histamine an-tē-histă-mēn histamine regulating body substance released in excess during histă -mēn allergic reactions that cause swelling and inflammation of tissues; seen in hay fever, urticaria (hives), etc. anti-inflammatory drug that reduces inflammation antē-in-flamă-tō-rē decongestant drug that reduces congestion and swelling of dē-kon-jestant membranes, such as those of the nose and eustachian tube after infection Chapter 13 • Ear 425 Figure 13.9. A and B. Operation of a cochlear im- plant. (1) Directional microphone. (2) Sound is carried from the microphone by a cord to the speech processor worn on the belt or pocket. (3) The speech processor fil- ters, analyzes, and digitizes the sound into coded signals and sends it (4) to the transmitting coil (5). The coil sends the coded signals as FM radio signals to the cochlear im- plant inserted under the skin. The cochlear implant (6) de- livers the electrical energy to the array of electrodes sur- gically inserted into the cochlea (7). The electrodes stimulate the remaining auditory nerve fibers (8), and sound information is sent to the brain for interpretation. Summary of Chapter 13 Acronyms/Abbreviations BAEP .......brainstem auditory evoked potentials TM .............tympanic membrane PE...............polyethylene 426 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE macrotia _______ / _______ / _______ P R S macr/ot/ia P R S DEFINITION: large or long/ear/condition of 1. acoustic _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 2. otorrhea _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 3. myringoplasty _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 4. aerotitis _____________________ / _____________________ / _____________________ R R S DEFINITION: _________________________________________________________________ 5. ototoxic _____________________ / _____________________ / _____________________ CF R S DEFINITION: _________________________________________________________________ 6. ceruminolysis _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 7. salpingoscope _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ Chapter 13 • Ear 427 8. hyperacusis _____________________ / _____________________ P S DEFINITION: _________________________________________________________________ 9. audiometry _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 10. tympanocentesis _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 11. otodynia _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 12. auricle _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 13. myringotomy _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ 14. ceruminosis _____________________ / _____________________ R S DEFINITION: _________________________________________________________________ 15. audiology _____________________ / _____________________ CF S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part: 16. oto_____________________osis  condition of hardening of the bony tissue of the ear 17. _____________________scope  instrument used to view the ear canal and tympanum 18. _____________________ disease  disorder of the inner ear due to an excessive buildup of endolymphatic fluid 19. _____________________neuroma  tumor of the auditory nerve affecting hearing 428 Medical Terminology: The Language of Health Care For each of the following, circle the combining form that corresponds to the meaning given: 20. eardrum salping/o ot/o myring/o 21. hearing ot/o audi/o angi/o 22. wax cerumin/o crin/o scler/o 23. eustachian tube tympan/o myring/o salping/o 24. ear rhin/o ot/o or/o 25. air acr/o aur/i aer/o Match the following: 26. ________ conductive hearing loss a. presbyacusis 27. ________ one who studies hearing impairments b. aplasia 28. ________ bleeding from the ear c. otalgia 29. ________ partial or complete hearing loss d. cochlear implant 30. ________ sensorineural hearing loss e. otorrhea 31. ________ hearing impairment of old age f. nerve conduction 32. ________ discharge from the ear g. otorrhagia 33. ________ auditory prosthetic h. deafness 34. ________ earache i. audiologist 35. ________ absence of inner ear structures j. bone conduction Write the correct medical term for each of the following: 36. ___________________________________  inflammation of labyrinth 37. ___________________________________  dizziness 38. ___________________________________  ringing in the ear 39. ___________________________________  excision of stapes to correct otosclerosis 40. ___________________________________  excessive buildup of earwax 41. ___________________________________  the study of hearing 42. The introduction of a medicated solution into the external canal is called ear instillation. Irrigation of the external ear canal is called ear ______________. Chapter 13 • Ear 429 Write in the missing words on the blank lines in the following illustration of the ear. 43–50. 43. 46. Ossicles (bones 47. of middle ear) 48. 49. Facial nerve Vestibulocochlear nerve Oval window Round window Tympanic cavity 50. membrane External auditory canal 44. tube (auditory tube) 45. For each of the following, circle the correct spelling of the term: 51. aerotitus aerotitis airotitis 52. cerumen ceramen ceruman 53. myrimogotomy mirongotomy myringotomy 54. presbyecusis presbyacusis presbeacusis 55. vertigo vertago verttigo 56. antihestamine antihistamine antehistamine 57. tinnitis tinitus tinnitus 58. stapedectomy stapesectomy stapedecktomy 59. defness deafnass deafness 60. eustation eustachian euhstation 430 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 3 . 1 Progress Note S: This 21 y.o white male c/o a clogged R ear c̄ increasing tinnitus. He has had a slight pharyngitis and nasal congestion 7 d. O: On PE there was moist infectious debris in the R ear that was suctioned clear. The R tympanum was dull and thickened. The L external ear was clear and the tympanic membrane intact. A: Otitis media R ear P: (1) Keep ears dry; (2) Rx Pen VK 250 mg #24 ·T q.i.d. p.c. and h.s.; (3) RTO in 10 d for followup (f/u) 1. Summarize the subjective information: a. patient complains of clogged, ringing ears; sore throat; and stuffy nose b. patient has a clogged right ear, sore throat, stuffy nose, and dizziness c. patient’s right eardrum is thick and dull and clogged with infectious matter, causing dizziness d. patient complains of a sore throat, stuffy nose, and a clogged right ear that is buzzing e. patient has a sore throat, stuffy nose, and purulent drainage from the right ear 2. What was the assessment? a. clogged right ear, sore throat, and stuffy nose b. inflammation of the right middle ear c. inflammation of the right external ear canal d. blockage of the eustachian tube e. inflammation of the right eardrum 3. When should the patient take the prescribed medication? a. twice in 24 hours b. before meals c. at bedtime d. four times a day e. every 4 hours 4. Which is true of the plan? a. patient should return to the office immediately if a fever develops b. patient is given ear drops and advised not to get the ears wet for 10 days c. doctor wants to examine the patient again in 10 days d. patient is given an antibiotic and advised to increase fluid intake e. if not better in 10 days, the patient will be referred to an otolaryngologist Chapter 13 • Ear 431 M E D I C A L R E C O R D 1 3 . 2 Hank Ball, a preschooler, has had recurrent ear infections for 1 year that his doctor has not been able to treat successfully with antibiotics and other drugs. His preschool teacher also identified nasal speech patterns that his doctor later confirmed were related to his medical problems. After Hank saw several doctors who recommended surgery, his parents have admitted him to Central Medical

Center. Directions Read Medical Record 13.2 for Hank Ball (pages 434–436) and answer the following questions. These records are the history and physical examination before surgery and the subsequent operative report, both dictated by Dr. Baird, the surgeon. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 3 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: hepatosplenomegaly ________________________________________________________ turbinates __________________________________________________________________ extubation _________________________________________________________________ 2. In the left column, list the patient’s medical problems noted in the HPI; in the right column, write the diagnosis that pertains to each. Medical Problem Diagnosis a. ______________________________ ______________________________ ______________________________ ______________________________ b. ______________________________ ______________________________ ______________________________ ______________________________ 3. In your own words, explain how Hank’s social history is related to his medical history: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. Under the “Review of Systems,” were any additional medical symptoms or problems identified? If so, list below. ____________________________________________________________________________ ____________________________________________________________________________ 432 Medical Terminology: The Language of Health Care 5. What does it mean that at the time of the examination Hank was afebrile? ____________________________________________________________________________ 6. Carefully read the physical examination. Mark the body areas/systems in which Dr. Baird found any abnormalities: __________ general __________ HEENT __________ chest __________ back __________ rectal/genitalia __________ extremities 7. List the surgical procedures identified under “Plan,” and briefly describe them in your own words, not using medical terminology: a. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ b. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ c. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 8. In your own words, not using medical terminology, briefly describe oral intubation. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 13 • Ear 433 9. Put the following operative actions in correct order by numbering them 1 to 11: __________ removal of adenoids __________ incision in right eardrum __________ PE tube placement in right tympanum __________ repositioning in Rose’s position __________ incision in left eardrum __________ aspiration of right middle ear __________ extubation __________ removal of wax in right ear __________ nasopharynx examination __________ polyethylene tube placement in left tympanum __________ intubation 10. In your own words, not using medical terminology, briefly describe the condition of Hank’s adenoids before adenoidectomy: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 434 Medical Terminology: The Language of Health Care Medical Record 13.2 Chapter 13 • Ear 435 Medical Record 13.2 Continued. 436 Medical Terminology: The Language of Health Care Medical Record 13.2 Continued. Chapter 14 Gastrointestinal System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the gastrointestinal system Describe the basic functions of the gastrointestinal system Define the basic anatomical terms referring to the gastrointestinal system and accessory organs Identify the anatomical and clinical divisions of the abdomen Define common symptomatic and diagnostic terms referring to the gastrointestinal system List the common diagnostic tests and procedures related to the gastrointestinal system Identify common operative terms referring to the gastrointestinal system Identify common therapeutic terms including drug classifications related to the gastrointestinal system Explain the terms and abbreviations used in documenting medical records involving the gastrointestinal system Combining Forms Combining Form Meaning Example abdomin/o abdomen abdominocentesis ab-domi-nō-sen-tēsis celi/o celiac sēlē-ak lapar/o laparoscopy lap-ă-roskŏ-pē an/o anus anal ānăl appendic/o appendix appendical ă-pendi-kăl bil/i bile biligenic bil-i-jenik chol/e cholelithiasis kōlē-li-thı̄ă-sis 437 438 Medical Terminology: The Language of Health Care Combining Form Meaning Example bucc/o cheek buccal bŭkăl cheil/o lip cheiloplasty kı̄lō-plas-tē col/o colon colitis kō-lı̄tis colon/o colonoscopy kō-lon-oskŏ-pē cyst/o bladder or sac cholecystectomy kōlē-sis-tektō-mē dent/i teeth dental dentăl doch/o duct choledochotomy kō-led-ō-kotō-mē duoden/o duodenum duodenal dūō-dēnăl enter/o small intestine enterocele enter-ō-sēl esophag/o esophagus esophageal ē-sofă-jēăl gastr/o stomach gastritis gas-trı̄tis gingiv/o gum gingivitis jin-ji-vı̄tis gloss/o tongue glossitis glo-sı̄tis lingu/o lingual linggwăl hepat/o liver hepatomegaly hepă-tō-megă-lē hepatic/o hepaticotomy he-pat-i-kotō-mē herni/o hernia herniorrhaphy hernē-ōră-fē ile/o ileum ileostomy ilē-ostō-mē inguin/o groin inguinal inggwi-năl jejun/o jejunum (empty) jejunitis je-jū-nı̄tis lith/o stone lithiasis li-thı̄ă-sis Chapter 14 • Gastrointestinal System 439 Combining Form Meaning Example or/o mouth oral orăl stomat/o stomatosis stō-mă-tōsis pancreat/o pancreas pancreatitis pankrē-ă-tı̄tis peritone/o peritoneum peritoneoscopy peri-tō-nē-oskŏ-pē phag/o eat or swallow aphagia ă-fājē-ă proct/o anus and rectum proctologic prok-tō-lojik pylor/o pylorus (gatekeeper) pyloric pı̄-lōrik rect/o rectum rectal rektăl sial/o saliva sialolithiasis sı̄ă-lō-li-thı̄ă-sis sigmoid/o sigmoid colon (resembles s) sigmoidoscopy sigmoy-doskŏ-pē steat/o fat steatolysis stē-ă-toli-sis ADDITIONAL SUFFIX -emesis vomiting hematemesis hē-mă-temĕ-sis Gastrointestinal System Overview The gastrointestinal (GI) system processes and transports nutrients and various wastes. The organs form a tube or tract, known as the alimentary canal, extending from the mouth to the anus. The alimentary canal is composed of the mouth, pharynx, esophagus, stomach, and intestines (Fig. 14.1). The gastrointestinal system has three functions: digestion, absorption, and excre- tion. Digestion is the process by which food is broken down by chewing and swallow- ing and is then mixed with digestive juices in the stomach to convert some of the food into absorbable molecules. Absorption is the passage of digested food molecules through the walls of the intestines into the bloodstream to be carried to the body cells. Excretion is the elimination of materials that are not absorbed (waste products) by transporting them outside the body. The accessory organs that aid in the digestion and absorption of food are the teeth, salivary glands, liver, gallbladder, and pancreas. Stomach Cardiac sphincter Esophagus Liver Fundus Gallbladder Tongue Small Esophagus intestine (duodenum, Lesser curvature Body jejunum, Lesser omentum ileum) Stomach Pancreas Duodenum Pyloric sphincter Pylorus Rugae Greater Greater omentum curvature Duodenum, gallbladder, pancreas, and liver Large intestine Rectum Anus Liver Gallbladder Hepatic duct Cystic duct Common bile duct Duodenum Duodenal papilla Pancreas Pancreatic duct Sphincter (of Oddi) Large intestine Duodenal ampulla Transverse colon Descending colon Ascending colon Ileocecal valve Ileum Cecum Appendix Sigmoid colon Rectum Anal canal Anus Figure 14.1 Gastrointestinal system. Chapter 14 • Gastrointestinal System 441 Anterior view Gums Incisors Soft palate Canine Premolars Uvula Palatoglossal arch Molars Palatine tonsil Dorsum of tongue Premolars Canine Incisors Figure 14.2 Oral cavity. Anatomical Terms Term Meaning oral cavity cavity that receives food for digestion (Fig. 14.2) mouth salivary glands three pairs of exocrine glands in the mouth that secrete saliva: sali-vār-ē parotid, submandibular (submaxillary), and sublingual cheeks lateral walls of the mouth lips fleshy structures surrounding the mouth palate structure that forms the roof of the mouth; it is divided into palăt the hard and soft palate uvula small projection hanging from the back middle edge of the yūvyū-lă soft palate tongue muscular structure of the floor of the mouth covered by mucous membrane and held down by a band-like membrane known as the frenulum gums tissue covering the processes of the jaws teeth hard bony projections in the jaws that serve to masticate (chew) food 442 Medical Terminology: The Language of Health Care Term Meaning pharynx throat; passageway for food traveling to the esophagus faringks and air traveling to the larynx esophagus muscular tube that moves food from the pharynx to ē-sofă-gŭs the stomach stomach sac-like organ that chemically mixes and prepares food stŭmŭk received from the esophagus cardiac sphincter opening from the esophagus to the stomach kardē-ak sfingkter (sphincter  band) pyloric sphincter opening of the stomach into the duodenum pı̄-lōrik sfingkter small intestine tubular structure that digests food received from the DUODENUM. The Latin word in-testin stomach for 12 is the duodenum first portion of the small intestine origin of the name for the dū-ō-dēnŭm first part of the small intestine because the length of the jejunum second portion of the small intestine structure was estimated to jĕ-jūnŭm be 12 fingerbreadths. ileum third portion of the small intestine JEJUNUM. The ilē-ŭm Latin word large intestine larger tubular structure that receives the liquid waste meaning empty products of digestion, reabsorbs water and minerals, or hungry was used for the and forms and stores feces for defecation portion of the small intestine that follows the duodenum cecum first part of the large intestine because the ancients noted sekŭm it was always empty after death. vermiform appendix worm-like projection of lymphatic tissue hanging off vermi-fōrm ă-pendiks the cecum with no digestive function—may serve to resist infection (vermi  worm) colon portions of the large intestine extending from the kōlon cecum to the rectum; identified by direction or shape ascending colon portion that extends upward from the cecum as-sending transverse colon portion that extends across from the ascending colon trans-vers descending colon portion that extends down from the transverse colon dē-sending sigmoid colon portion (resembling an s) that terminates at the rectum sigmoyd rectum distal (end) portion of the large intestine rektŭm rectal ampulla dilated portion of the rectum just above the anal canal rektăl am-pūllă anus opening of the rectum to the outside of the body ānŭs feces refuse; solid waste formed in the large intestine fēsēz Chapter 14 • Gastrointestinal System 443 Term Meaning defecation evacuation of feces from the rectum def-ĕ-kāshŭn peritoneum membrane surrounding the entire abdominal cavity peri-tō-neŭm consisting of the parietal layer (lining the abdominal wall) and visceral layer (covering each organ in the abdomen) peritoneal cavity space between the parietal and visceral peritoneum per-i-tō-nēăl omentum a covering; an extension of the peritoneum attached to the ō-mentŭm stomach and connecting it with other abdominal organs liver organ in the upper right quadrant that produces bile, which is secreted into the duodenum during digestion PANCREAS. The Greek word for gallbladder receptacle that stores and concentrates the bile produced sweetbread is gawlblad-er in the liver formed by the combination of -creas, meaning flesh, pancreas gland that secretes pancreatic juice into the duodenum, and pan-, meaning all. The pankrē-as where it mixes with bile to digest food organ was so named biliary ducts ducts that convey bile, including hepatic, cystic, and because of its meaty or bilē-ār-ē common bile ducts fleshy character. Aristotle used the term. Anatomical and Clinical Divisions of the Abdomen Anatomical and clinical divisions of the abdomen provide specific or general reference for descriptive purposes. There are nine specific anatomical divisions and four general clinical divisions (Figs. 14.3–14.5). All references are based on the patient’s right or left. Right Left hypochondriac hypochondriac region region Epigastric region Umbilical region Right lumbar Left lumbar region region Hypogastric region Right inguinal Left inguinal region region Figure 14.3 Anatomical divisions of the abdomen. 444 Medical Terminology: The Language of Health Care Right upper Left upper quadrant (RUQ) quadrant (LUQ) Right lower Left lower quadrant (RLQ) quadrant (LLQ) Figure 14.4 Clinical divisions of the abdomen. HYPOCHONDRIAC. This Greek word meaning below the Anatomical Divisions cartilage was used to refer to regions below the cartilages of Region Location the ribs. In these hypochondriac regions, hypochondriac regions upper lateral regions beneath the ribs various sensations of a hı̄-pō-kondrē-ak distressing nature were epigastric region upper middle region below the sternum sometimes experienced without apparent organic ep-i-gastrik disease. People with such lumbar regions middle lateral regions complaints were called lŭmbar hypochondriacs. Today, hypochondria refers to one who has an abnormal concern for one’s health with the false Right upper quadrant pain Left upper quadrant pain belief that he or she is suffering Gallbladder and Gastritis from disease. biliary tract Pancreatitis Cholecystitis Splenomegaly Hepatitis Renal pain Peptic ulcer Myocardial ischemia Renal pain Pneumonia Pneumonia Right lower quadrant pain Left lower quadrant pain Appendicitis Diverticulitis Intestinal obstruction Intestinal obstruction Diverticulitis Ectopic pregnancy Ectopic pregnancy Ovarian cyst Ovarian cyst Salpingitis Salpingitis Endometriosis Endometriosis Ureteral calculi Ureteral calculi Renal pain Renal pain Figure 14.5 Common sites of abdominal pain characteristic of various conditions. Chapter 14 • Gastrointestinal System 445 Region Location umbilical region region of the navel ŭm-bili-kăl inguinal regions lower lateral groin regions inggwi-năl hypogastric region region below the navel hı̄-pō-gastrik Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC anorexia loss of appetite (orexia  appetite) an-ō-reksē-ă aphagia inability to swallow ă-fājē-ă ASCITES. A Greek word for ascites accumulation of fluid in the peritoneal cavity (ascos  bag) pouch or sac ă-sı̄tēz (Fig. 14.6) referring to the appearance buccal in the cheek of the abdomen with the bŭkăl collection of fluid in the peritoneal cavity. Figure 14.6 Side view of a patient showing massive ascites and distention of abdomen. 446 Medical Terminology: The Language of Health Care Term Meaning constipation infrequent or incomplete bowel movements kon-sti-pāshŭn characterized by hardened, dry stool that is difficult to pass (constipo  to press together) diarrhea frequent loose

or liquid stools dı̄-ă-rēă dyspepsia indigestion (peptein  to digest) dis-pepsē-ă dysphagia difficulty in swallowing dis-fājē-ă eructation belch ē-rūk-tāshŭn flatulence gas in the stomach or intestines (flatus  a blowing) flatyū-lens halitosis bad breath (halitus  breath) hal-i-tōsis hematochezia red blood in the stool (chezo  defecate) ICTERUS. Icterus hēmă-tō-kēzē-ă is a Greek word hematemesis vomiting blood for jaundice hē-mă-temĕ-sis meaning yellow bird. The yellow color associated with hepatomegaly enlargement of the liver the condition was thought hepă-tō-megă-lē similar to the color of this bird. It was said that if a hyperbilirubinemia excessive level of bilirubin (bile pigment) in the blood person suffering from hı̄per-bili-rū-bi-nēmē-ă jaundice looks at the bird, the bird dies and the patient icterus yellow discoloration of the skin, sclera (white of the recovers. ikter-ŭs eye), and other tissues caused by excessive bilirubin jaundice in the blood (jaundice  yellow) (Fig. 14.7) NAUSEA. jawndis Nausea is melena dark-colored, tarry stool caused by old blood derived from a me-lēnă Greek word for ship referring to “ship sickness.” nausea sick in the stomach Hippocrates used the term nawzē-ă for seasickness; later, it became generally applied steatorrhea feces containing fat to the sick and uneasy steă-tō-rēă feeling that precedes vomiting. Figure 14.7 The yellow color of jaundice (icterus) is easily seen in the sclera of this patient and also in the skin as contrasted with the examiner’s hand. Chapter 14 • Gastrointestinal System 447 Term Meaning sublingual under the tongue sŭb-linggwăl hypoglossal hı̄-pō-glosăl DIAGNOSTIC stomatitis inflammation of the mouth stō-mă-tı̄tis sialoadenitis inflammation of a salivary gland siă-lō-ad-ĕ-nı̄tis parotitis (parotiditis) inflammation of the parotid gland; also par-ō-tı̄tis called mumps cheilitis inflammation of the lip kı̄-lı̄tis glossitis inflammation of the tongue glo-sı̄tis ankyloglossia tongue-tie; a defect of the tongue angki-lō-glosē-ă characterized by a short, thick frenulum (ankyl/o  crooked or stiff) gingivitis inflammation of the gums jin-ji-vı̄tis esophageal varices swollen, twisted veins in the esophagus ē-sofă-jēăl especially susceptible to ulceration and hemorrhage (see Fig. 14.15) esophagitis inflammation of the esophagus ē-sof-ă-jı̄tis gastritis inflammation of the stomach gas-trı̄tis (see Fig. 14.15) gastroesophageal reflux disease (GERD) backflow of stomach contents into the gastrō-ē-sofă-jēăl rēflŭks di-zēz esophagus, often as a result of abnormal function of the lower esophageal sphincter; causes burning pain in the esophagus pyloric stenosis narrowed condition of the pylorus pı̄-lōrik ste-nōsis peptic ulcer disease (PUD) a sore on the mucous membrane of the peptik ŭlser di-zēz stomach, duodenum, or any other part of the gastrointestinal system exposed to gastric juices; commonly caused by infection with Helicobacter pylori bacteria (pept/o  to digest) (Fig. 14.8) gastric ulcer ulcer located in the stomach gastrik duodenal ulcer ulcer located in the duodenum dūō-dēnăl 448 Medical Terminology: The Language of Health Care Excessive amounts of acid and pepsin are released into the stomach Gastric juices (acidic) Ulcer Duodenal Gastric Excess secretions ulcer ulcer overwhelm resistance of stomach lining and eventually break it down, forming an ulceration Figure 14.8 Peptic ulcer disease. Term Meaning gastroenteritis inflammation of the stomach and small intestine gastrō-en-ter-ı̄tis enteritis inflammation of the small intestine en-ter-ı̄tis ileitis inflammation of the lower portion of the small intestine il-ē-ı̄tis colitis inflammation of the colon (large intestine) kō-lı̄tis ulcerative colitis chronic inflammation of the colon along with ulcerations ŭlser-ă-tiv diverticulum a by-way; an abnormal side pocket in the gastrointestinal dı̄-ver-tikyū-lŭm tract usually related to a lack of dietary fiber diverticulosis presence of diverticula in the gastrointestinal tract, dı̄ver-tik-yū-lōsis especially in the bowel (Fig. 14.9; also see Fig. 14.15) diverticulitis inflammation of diverticula dı̄ver-tik-yū-lı̄tis dysentery inflammation of the intestine characterized by frequent, disen-tār-ē bloody stools, most often caused by bacteria or protozoa (e.g., amebic dysentery) Chapter 14 • Gastrointestinal System 449 Opening of diverticulum Diverticula Large intestine Figure 14.9 Diverticulosis. Term Meaning appendicitis inflammation of the appendix ă-pen-di-sı̄tis hernia protrusion of a part from its normal location hernē-ă hiatal hernia protrusion of part of the stomach upward through the hı̄-ātăl hiatal opening in the diaphragm (Fig. 14.10) inguinal hernia protrusion of a loop of the intestine through layers of the inggwi-năl abdominal wall in the inguinal region (see Fig. 14.10) incarcerated hernia hernia that is swollen and fixed within a sac, causing in-karser-ā-ted an obstruction strangulated hernia hernia that is constricted, cut off from circulation, and stranggyū-lā-ted likely to become gangrenous umbilical hernia protrusion of the intestine through a weakness in the ŭm-bili-kăl abdominal wall around the umbilicus (navel) intussusception prolapse of one part of the intestine into the lumen of the intŭs-sŭ-sepshŭn adjoining part (intus  within; suscipiens  to take up) (Fig. 14.11) volvulus twisting of the bowel on itself, causing obstruction volvū-lŭs (volvo  to roll) (Fig. 14.12) polyposis multiple polyps in the intestine and rectum with a high poli-pōsis malignancy potential (see Fig. 14.15) polyp tumor on a stalk polip proctitis inflammation of the rectum and anus prok-tı̄tis anal fistula abnormal tube-like passageway from the anus that may ānăl fistyū-lă connect with the rectum (fistula  pipe) (Fig. 14.13) 450 Medical Terminology: The Language of Health Care Hiatal hernia Herniation of the stomach through Diaphragm the hiatal opening Diaphragm Stomach Inguinal hernia Direct inguinal hernia Figure 14.10 Common hernias. Cross section of intussusception of small intestine Small Large intestine intestine Figure 14.11 Intussusception. Chapter 14 • Gastrointestinal System 451 Large intestine Small intestine Twisted portion of small intestine Small intestine is twisted upon itself Figure 14.12 Volvulus. Term Meaning hemorrhoid swollen, twisted vein (varicosity) in the anal region hemŏ -royd (haimorrhois  a vein likely to bleed) peritonitis inflammation of the peritoneum peri-tō -nı̄tis hepatitis inflammation of the liver hep-ă-tı̄tis hepatitis A infectious inflammation of the liver caused by the hepatitis A virus (HAV), usually transmitted orally through fecal contamination of food or water hepatitis B infectious inflammation of the liver caused by the hepatitis B virus (HBV) that is transmitted sexually or by exposure to contaminated blood or body fluids hepatitis C inflammation of the liver caused by the hepatitis C virus (HCV) transmitted by exposure to infected blood (rarely contracted sexually) CIRRHOSIS. A cirrhosis chronic disease characterized by degeneration of liver tissue, most Greek word sir-rō sis often caused by alcoholism or a nutritional deficiency referring to a (cirrho  yellow) yellow condition, cirrhosis was first applied to the cholangitis inflammation of the bile ducts fibrosis of the liver in kō -lan-jı̄tis alcoholics because the cholecystitis inflammation of the gallbladder granular deposits in the organ looked yellow. kō lē-sis-tı̄tis Opening Anal fistula Anus Anal fistula Figure 14.13 Anal fistula. 452 Medical Terminology: The Language of Health Care Term Meaning cholelithiasis presence of stones in the gallbladder or bile kō lē-li-thı̄ă-sis ducts (Fig. 14.14; also see Fig. 14.21B) choledocholithiasis presence of stones in the common bile duct kō -ledō -kō -lith-ı̄ă-sis (see Figs. 14.14 and 14.15) pancreatitis inflammation of the pancreas pankrē-ă-tı̄tis Diagnostic Tests and Procedures Test or Procedure Explanation endoscopy examination within a body cavity with a en-doskŏ -pē flexible endoscope for diagnosis or treatment; used in the gastrointestinal tract to detect abnormalities and perform procedures such as biopsies, excision of lesions, dilations of narrowed areas, and removal of swallowed objects (Fig. 14.15) esophagoscopy examination of the esophagus with an ē-sof-ă-goskŏ -pē esophagoscope gastroscopy examination of the stomach with a gas-troskŏ -pē gastroscope upper gastrointestinal endoscopy examination of the lining of the esophagus, gastrō -in-testin-ăl stomach, and duodenum with a flexible endoscope; also known as esophagogastroduodenoscopy (EGD) or panendoscopy (see Fig. 14.15) endoscopic retrograde endoscopic procedure including x-ray cholangiopancreatography (ERCP) fluoroscopy to examine the ducts of the en-doskŏpik retrō -grād liver, gallbladder, and pancreas (biliary kō -lanjē-ō -pan-krē-ă-togră-fē ducts) Intrahepatic Liver Stomach Common hepatic duct Gallbladder Cystic duct Common bile duct Ampulla Pancreas Figure 14.14 Sites of gallstones. The endoscope, an instrument for viewing and photographing Fiberoptics in the endoscope conduct bright, cool internal cavities of the body, is used for evaluating pathological light along a curved path, allowing illumination of conditions and performing minimally invasive corrective procedures. tissues and structures within the body. A color video Endoscope camera converts the optical images into electrical signals, which are displayed on a monitor. The pictures below were taken endoscopically. Tongue Esophageal Esophagus varices Stomach Duodenum Gastritis Gallbladder and common bile duct Jejunum Common bile duct stone extraction Gastrointestinal tract can be thought of as a long tube, folded to fit in the body; unfolded, it reveals its parts in a clear sequence. Ileum Diverticulosis Cecum and appendix Colon polypectomy Colon For endoscopic views of the lower portions of the digestive system, colon, and rectum, an endoscope is inserted through the anus. Rectum Anus Figure 14.15 Endoscopy of gastrointestinal system. Small intestine not drawn to scale; average length in adult is about 20 feet 454 Medical Terminology: The Language of Health Care Test or Procedure Explanation laparoscopy examination of the abdominal cavity with a lap-ă-roskŏ -pē laparoscope—often including interventional surgical procedures (Fig. 14.16) peritoneoscopy examination of the peritoneal cavity with a peri-tō -nē-oskŏ -pē peritoneoscope; often performed to examine the liver and obtain a biopsy specimen capsule endoscopy examination of the small intestine made by a tiny kapsool video camera placed in a capsule and swallowed; images are transmitted to a waist-belt recorder and downloaded onto a computer for assessment of possible abnormalities; traditional endoscopy cannot completely access the small intestine because of its length and complexity colonoscopy examination of the colon using a flexible colonoscope kō -lon-oskŏ -pē (see Fig. 14.15) sigmoidoscopy examination of the sigmoid colon with a rigid or sigmoy-doskŏ -pē flexible sigmoidoscope proctoscopy examination of the rectum and anus with a prok-toskŏ -pē proctoscope DIAGNOSTIC IMAGING magnetic resonance nonionizing imaging technique for visualizing the image of the abdomen abdominal cavity to identify disease or deformity in the gastrointestinal tract nuclear medicine radionuclide organ imaging liver scan scan of the liver made after injection of radioactive tracers into the bloodstream; used to detect tumors and functional abnormalities Laparoscope Liver Laparoscopic sleeve Gallbladder Uterus Spleen Bladder Stomach Large intestine Small intestine Fallopian tube Spleen Ovary Kidney Large Diaphragm Adrenal intestine Appendix gland Figure 14.16 Laparoscopy. Chapter 14 • Gastrointestinal System 455 Figure 14.17 Plain radiograph (without contrast) showing two impacted for- eign bodies in a child, aged 2 1/2 years. This child has ingested a safety pin and an ornamental pin. Endoscopic removal was required. Test or Procedure Explanation radiography x-ray imaging (Fig. 14.17) rādē-ogră-fē upper GI series x-ray of the esophagus, stomach, and duodenum after the patient has swallowed a contrast medium (barium is most commonly used) (Fig. 14.18) barium swallow x-ray of the esophagus only; often used to locate barē-ŭm swallowed objects fluoroscopy x-ray using a fluorescent screen to visualize structures flūr-oskŏ -pe in motion (such as during a barium swallow) small bowel series x-ray exam of the small intestine—generally done in conjunction with an upper GI series lower GI series x-ray of the colon after administration of an enema barium enema containing a contrast medium (Fig. 14.19) enĕ-mă cholangiogram x-ray of the bile ducts; often performed during surgery kō-lanjē-ō-gram cholecystogram x-ray of the gallbladder taken after oral ingestion of iodine kō -lē-sistō -gram 456 Medical Terminology: The Language of Health Care Figure 14.19 Barium enema radiograph of the colon showing a ruptured diverticulum. Its elongated appearance is similar to that of a deflated balloon. Figure 14.18 Upper gastrointestinal radiograph showing a hiatal hernia. Test or Procedure Explanation computed tomography cross-sectional x-ray of the abdomen used to identify (CT) of abdomen a condition or anomaly within the gastrointestinal tō -mogră-fē tract (e.g., tumor, injury) (Fig. 14.20) CT colonography computed tomographic image of the colon performed as an alternative to traditional invasive colonoscopy; also known as virtual colonoscopy sonography ultrasound imaging sŏ -nogră-fē abdominal sonogram ultrasound image of the abdomen to detect disease sonō -gram or deformity in organs and vascular structures (e.g., liver, pancreas, gallbladder, spleen, aorta) (Fig. 14.21) endoscopic sonography endoscopic procedure using a sonographic endō-skŏpik transducer within an endoscope to examine a body cavity and make sonographic images of structures and tissues Chapter 14 • Gastrointestinal System 457 Figure 14.20 A. CT scan of a patient involved in a motor vehicle accident demonstrates a jagged laceration (arrows) extending from the posterior to inferior vena cava (V ) through the right lobe of the liver (L). S, spleen. B. CT scanner. Test or Procedure Explanation LABORATORY STUDIES biopsy (Bx) removal of tissue for microscopic pathological bı̄op-sē examination endoscopic biopsy removal of a specimen for biopsy during

an endoscopic procedure (e.g., colonoscopy) excisional biopsy removal of an entire lesion for examination ek-sizhŭn-ăl 458 Medical Terminology: The Language of Health Care A Figure 14.21 A. Abdominal sonography procedure. B. Abdominal sonogram of two stones present in the gallbladder (arrows). Test or Procedure Explanation incisional biopsy removal of a portion of a lesion for examination in-sizhŭn-ăl needle biopsy percutaneous removal of a core specimen of tissue using a special hollow needle (e.g., liver biopsy) (Fig. 14.22) stool culture and isolation of a stool specimen in a culture medium sensitivity (C&S) to identify disease-causing organisms; if present, the drugs to which they are sensitive are listed stool occult blood study chemical test of a stool specimen to detect the presence of blood; positive findings indicate bleeding in the gastrointestinal tract Lung 6th rib Diaphragm Liver 7th rib Figure 14.22 Liver biopsy procedure. Chapter 14 • Gastrointestinal System 459 Operative Terms Term Meaning bariatric surgery treatment of morbid obesity by surgery to the stomach bar-ē-atrik and/or intestines; procedures include restrictive techniques that limit the size of the stomach and malabsorptive techniques that limit the absorption of food (baros  weight; iatric  pertains to treatment) cheiloplasty repair of the lip kı̄lō -plas-tē glossectomy excision of all or part of the tongue glo-sektō-mē glossorrhaphy suture of the tongue glo-sōră-fē esophagoplasty repair of the esophagus ē-sofă-gō-plas-tē gastrectomy partial or complete removal of the stomach gas-trektō-mē gastric resection partial removal and repair of the stomach gastrik rē-sekshŭn abdominocentesis puncture of the abdomen for aspiration of fluid ab-domi-nō-sen-tēsis (e.g., fluid accumulated in ascites) paracentesis pară-sen-tēsis laparotomy incision into the abdomen lapă-rotō-mē laparoscopic surgery abdominal surgery using a laparoscope lapă-rō-skōpik herniorrhaphy repair of a hernia hernō-ōră-fē hernioplasty hernē-ō-plas-tē colostomy creation of an opening in the colon through the kō-lostō-mē abdominal wall to create an abdominal anus allowing stool to bypass a diseased portion of the colon; performed to treat ulcerative colitis, cancer, or obstructions (Fig. 14.23) anastomosis union of two hollow vessels; used in bowel surgery ă-nastō-mōsis ileostomy surgical creation of an opening on the abdomen to which ilē-ostō-mē the end of the ileum is attached, providing a passageway for ileal discharges; performed after removal of the colon (e.g., to treat chronic inflammatory bowel diseases such as ulcerative colitis) 460 Medical Terminology: The Language of Health Care 1. Ascending colostomy 2. Transverse colostomy 3. Descending colostomy 4. Sigmoid colostomy Figure 14.23 Common colostomy sites. Term Meaning appendectomy excision of a diseased appendix ap-pen-dektō -mē incidental appendectomy removal of the appendix during abdominal surgery for another procedure (e.g., a hysterectomy) polypectomy excision of polyps pol-i-pektō -mē proctoplasty repair of the anus and rectum proktō -plas-tē anal fistulectomy excision of an anal fistula fis-tyū-lektō -mē hemorrhoidectomy excision of hemorrhoids hemō -roy-dektō -mē hepatic lobectomy excision of a lobe of the liver he-patik lō -bektō -mē cholecystectomy excision of the gallbladder kō lē-sis-tektō -mē laparoscopic cholecystectomy excision of the gallbladder through a lapă-rō -skŏpik laparoscope cholelithotomy incision for removal of gallstones kō le-li-thotō -mē choledocholithotomy incision of the common bile duct for kō -ledō -kō -li-thotō -mē extraction of gallstones cholelithotripsy crushing of gallstones kō -lē-lithō -trip-sē pancreatectomy excision of the pancreas pankrē-ă-tektō -mē Chapter 14 • Gastrointestinal System 461 Therapeutic Terms Term Meaning gastric lavage oral insertion of a tube into the stomach for gastrik lă-vahzh examination and treatment [e.g., to remove blood clots from the stomach and monitor bleeding (lavage  to wash)] nasogastric (NG) intubation insertion of a tube through the nose into the nā-zō -gastrik in-tū-bāshŭn stomach for various purposes (e.g., to obtain a gastric fluid specimen for analysis) COMMON THERAPEUTIC DRUG CLASSIFICATIONS antacid drug that neutralizes stomach acid ant-asid antiemetic drug that prevents or stops vomiting antē-ĕ-metik antispasmodic drug that decreases motility in the gastrointestinal antē-spaz-modik tract to arrest spasm or diarrhea cathartic drug that causes movement of the bowels; also kă-thartik called a laxative Summary of Chapter 14 Acronyms/Abbreviations Bx .....................biopsy HBV ................hepatitis B virus C&S.................culture and sensitivity HCV ................hepatitis C virus CT .....................computed tomography LLQ .................left lower quadrant EGD ................esophagogastroduodenoscopy LUQ.................left upper quadrant ERCP .............endoscopic retrograde MRI .................magnetic resonance imaging cholangiopancreatography NG....................nasogastric GERD ............gastroesophageal reflux disease PUD.................peptic ulcer disease GI......................gastrointestinal RLQ.................right lower quadrant HAV ................hepatitis A virus RUQ ................right upper quadrant 462 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE sublingual ______/ ____________/ __________ P R S sub/lingu/al P R S DEFINITION: below or under/tongue/pertaining to 1. transabdominal __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 2. gastroenterostomy __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 3. sialolithotomy __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 4. glossorrhaphy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. hematemesis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 6. cheilostomatoplasty ___________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ Chapter 14 • Gastrointestinal System 463 7. appendicitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 8. celiotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 9. cholangiogram ___________________ / __________________ / __________________ R CF S DEFINITION: _________________________________________________________________ 10. colonoscopy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 11. anorectal ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 12. enterocolitis ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 13. orolingual ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 14. proctosigmoidoscopy ____________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 15. laparoscope __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 16. dysphagia ____________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 464 Medical Technology: The Language of Health Care 17. pancreatoduodenostomy ____________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 18. hernioplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. biliary __________________ / __________________ R S DEFINITION: _________________________________________________________________ 20. gastroesophageal ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 21. choledochotomy ___________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 22. steatorrhea __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 23. dentalgia __________________ / __________________ R S DEFINITION: _________________________________________________________________ 24. pylorospasm __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 25. hepatotoxic ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 26. ileojejunitis ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 14 • Gastrointestinal System 465 27. peritoneocentesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 28. buccogingival ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 29. cholecystectomy ___________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 30. perirectal ___________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ Complete the medical term by writing the missing part or word: 31. hemi ____________________ ectomy  removal of half of the colon 32. ____________________ itis  inflammation of the appendix 33. ____________________ rrhaphy  suture of the lip 34. cholelitho ____________________  incision for removal of gallstones 35. ____________________ plasty  surgical repair of the mouth 36. chol ____________________ gram  x-ray of bile ducts (vessels) 37. ____________________ bilirubin ____________________  excessive level of bilirubin in the blood 38. gastric ____________________  partial removal and repair of the stomach 39. diverticulo ____________________  the presence of diverticula For each of the following, circle the combining form that corresponds to the meaning given: 40. abdomen gastr/o lapar/o stomat/o 41. tongue gloss/o proct/o gingiv/o 42. small intestine col/o appendic/o enter/o 43. teeth dent/i chol/e lingu/o 466 Medical Terminology: The Language of Health Care 44. stomach lapar/o stomat/o gastr/o 45. cheek bucc/o or/o proct/o 46. bile col/o celi/o chol/e 47. mouth gastr/o stomat/o lapar/o 48. liver hepat/o nephr/o ren/o 49. eat phas/o phag/o gloss/o 50. stone scler/o steat/o lith/o 51. rectum an/o proct/o col/o Write the correct medical term for each of the following: 52. inflammation of the stomach ________________________________________________ 53. loss of appetite _____________________________________________________________ 54. inability to swallow _________________________________________________________ 55. in the cheek ________________________________________________________________ 56. gas in the stomach or intestines ______________________________________________ 57. rupture or protrusion of a part from its normal location _______________________ 58. black tarry stool ____________________________________________________________ 59. belch ______________________________________________________________________ 60. instrument used to examine the rectum _______________________________________ 61. inflammation of the large intestine ___________________________________________ 62. portion of upper GI series x-ray used to examine the esophagus only ___________ 63. accumulation of fluid in the peritoneal cavity _________________________________ 64. inflammation of the gallbladder ______________________________________________ 65. feces containing fat _________________________________________________________ 66. presence of inflamed abnormal side pockets in gastrointestinal tract ____________ 67. peptic ulcer located in the stomach ___________________________________________ 68. enlargement of the liver _____________________________________________________ 69. tongue-tie condition ________________________________________________________ Chapter 14 • Gastrointestinal System 467 Name the anatomical divisions of the abdomen: 70. lower lateral groin regions ___________________________________________________ 71. upper lateral regions beneath the ribs ________________________________________ 72. upper middle region below the sternum ______________________________________ 73. region below the navel ______________________________________________________ 74. middle lateral regions _______________________________________________________ 75. region of the navel __________________________________________________________ Name the clinical divisions of the abdomen: 76. _____________________________________________________________ 77. _____________________________________________________________ 78. _____________________________________________________________ 79. _____________________________________________________________ Match the following terms: 80. ________ cathartic a. cholelithotripsy 81. ________ herniorrhaphy b. barium swallow 82. ________ appendicitis c. bariatric surgery 83. ________ lower GI series d. appendectomy 84. ________ icterus e. colostomy 85. ________ peptic ulcer disease f. hernioplasty 86. ________ abdominocentesis g. H. pylori bacterial infection 87. ________ parotitis h. barium enema 88. ________ sublingual i. mumps 89. ________ upper GI series j. paracentesis 90. ________ ulcerative colitis k. jaundice 91. ________ cholelithiasis l. hypoglossal 92. ________ morbid obesity m. laxative 468 Medical Terminology: The Language of Health Care An endoscope is an instrument used to examine within the body. Name the specific type of endoscope used to examine the following body parts: 93. abdomen _________________________________________________________________ 94. anus _____________________________________________________________________ 95. stomach _________________________________________________________________ 96. colon ____________________________________________________________________ 97. peritoneal cavity __________________________________________________________ 98. esophagus ________________________________________________________________ 99. Which type of hernia is swollen and fixed within a sac, causing obstruction? ____________________________________________________________ 100. Which type of biopsy involves the removal of an entire growth? _______________ Write the full medical term for the following abbreviations: 101. NG tube __________________________________________________________________ 102. ERCP ____________________________________________________________________ 103. GERD ____________________________________________________________________ 104. LUQ ______________________________________________________________________ 105. GI ________________________________________________________________________ 106. MRI ______________________________________________________________________ 107. EGD ______________________________________________________________________ Chapter 14 • Gastrointestinal System 469 Write in the term components related to each of the gastrointestinal organs on the blank lines provided in the following illustration. 108–115. 108. 109. 112. 110. Esophagus (duodenum, jejunum, ileum) 113. Pancreas 111. 114. 115. For each of the following, circle the correct spelling of the term: 116. anorexia annorexia anorrexia 117. asites ascitis ascites 118. hematochesia hemochezia hematochezia 119. icterus ickterus icteris 120. ankleoglossia ankyloglosia ankyloglossia 121. volvulis volvulus volvolus 122. cirhosis cirrhosus cirrhosis 123. glossectomy glozectomy glosectomy 124. hernniorhaphy herniorraphy herniorrhaphy 125. hemorroidectomy hemroidectomy hemorrhoidectomy 470 Medical Terminology: The Language of Health Care 126. anteacid anacid antacid 127. antiemetic antemetic antaemetic 128. cathartik cathartic catarthic 129. melena melenna melana Give the noun that was used to form the following adjectives: 130. fecal _______________ 131. icteric _______________ 132. ileal _______________ 133. endoscopic _______________ 134. hemorrhoidal _______________ 135. pancreatic _______________ Chapter 14 • Gastrointestinal System 471 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 4 . 1 S: This is a 36 y.o.  with a complaint of abdominal pain. He describes having lifted a 75# beam yesterday at work. He noticed a sharp pain in his navel but continued to work. The pain intensified as the day went on and persisted through last night and today. He claims his navel now bulges forward. He denies fever, chills, dys- phagia, anorexia, or vomiting. PMH: No hospitalizations or surgeries Meds: none Allergies: NKDA O: T 97.5ºF, P 87, R18, BP 128/86 WDWN male in moderate distress secondary to abdominal pain. Upon palpation, the abdomen is soft with spasm of the muscles in the periumbilical region, and there is an obvious bulge in the umbilicus. The omentum is also palapable. There is no hepatosplenomegaly. A: Incarcerated umbilical hernia P: Admit for STAT umbilical hernia repair 1. Summarize the subjective information: 5. Which of the following best describes the diagno- a. pain in stomach sis? b. pain in abdomen a. portion of the bowel has protruded through the abdominal wall and has been cut off from cir- c. pain in the groin area culation d. generalized abdominal pain with chills and b. prolapse of one part of the

intestine into the lu- fever men of the adjoining part e. stomach pain and has difficulty swallowing c. portion of the intestine has protruded through a weakness in the abdominal wall around the 2. What kind of an appetite does the patient have? navel and is swollen and fixed in a sac a. normal d. portion of the bowel has twisted on itself caus- b. increased ing obstruction c. decreased e. inflammation of the stomach and small intes- tine 3. What is the condition of the patient’s liver? a. not stated 6. Which of the following medical terms describes b. enlarged the planned surgery? c. not enlarged a. laparotomy d. inflamed b. gastroenterostomy e. ruptured c. hernioplasty d. ileostomy 4. What were the objective findings? e. abdominocentesis a. involuntary contraction of the muscles around the navel b. pouching of the muscles under the navel c. contraction of abdominal muscles and enlarge- ment of the spleen d. protrusion of the navel and enlargement of the liver e. pouching of the stomach and omentum 472 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 1 4 . 2 Mr. Antonio Villata undergoes a comprehensive physical examination each year as part of a wellness program promoted by his employer. This year, after a routine sigmoidoscopic exam revealed a polyp in his intestine, he was referred to Dr. Blain, a gastroenterologist at Central Medical Center, for evaluation. Directions Read Medical Record 14.2 for Antonio Villata (page 475) and answer the following questions. This record is a procedure report dictated by Dr. Blain after his evaluation and treatment of Mr. Villata in the endoscopy suite at Central Medical Center. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 4 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in the progress note you have not yet encountered in this text. Underline each where it appears in the record and define below: cannulated __________________________________________________________________ pediculated _________________________________________________________________ verge _______________________________________________________________________ snare _______________________________________________________________________ 2. Describe the screening procedure performed by Dr. Kolima prior to Mr. Villata’s referral to Dr. Blain: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. In your own words, not using medical terminology, briefly describe the procedure performed by Dr. Blain and the indications for which the patient was referred: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. The procedure was performed with Mr. Villata in what position? a. lying flat, face down b. lying flat, face up c. lying on his side d. sitting Chapter 14 • Gastrointestinal System 473 5. Put the following actions in order by numbering them 1 to 12: _____ location of the cecum was confirmed by internal and external landmarks _____ video colonoscope was inserted in the rectum and advanced carefully to the cecum _____ hemorrhoids were noted _____ terminal ileum was then cannulated _____ scope was straightened, air was aspirated, and scope was withdrawn _____ scattered diverticula were noted in the sigmoid colon _____ lining of the colon was thoroughly inspected _____ polyp was removed using a snare and submitted to pathology lab for biopsy _____ pediculated 4 mm polyp was seen in the sigmoid colon _____ scope was brought back to the rectum and retroflexed _____ patient was placed in the left lateral decubitus position _____ scope was brought back to the cecum and then gradually withdrawn 6. Translate the statement noting that “a pediculated 4-mm polyp was seen in the sigmoid colon”: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. How many inches from the anal verge was the polyp? ______________ 8. Write the sentence that describes the polypectomy that was performed: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 9. Name and describe the condition for which a high-fiber diet was indicated in the Plan: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 474 Medical Terminology: The Language of Health Care 10. Describe the third condition Dr. Blain listed in his assessment of Mr. Villata. Include the degree of severity and any treatment planned: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 11. In your own words, describe the recommendations outlined in the Plan that will be made depending on the results of the biopsy: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 14 • Gastrointestinal System 475 CENTRAL MEDICAL CENTER ENDOSCOPY LABORATORY REPORT PATIENT: Villata, Antonio DATE: 4/29/20xx PROCEDURE PERFORMED: COLONOSCOPY WITH BIOPSY INDICATIONS: This is a 54-year-old white male referred to me for evaluation of a polyp found during a screening sigmoidoscopy by Dr. Kolima. A complete colonoscopy is being done to remove the polyp and rule out other concurrent lesions. CONSENT: The procedure and its risks including bleeding, infection, perforation, and sedative reaction have been explained to the patient, and informed consent was obtained. INSTRUMENT USED: Olympus video colonoscope. MEDICATIONS GIVEN: Demerol 50 mg and Versed 3 mg in divided doses. The patient had stable vital signs. A Fleets Phospho-Soda prep provided good visualization. PROCEDURE: The patient was placed in the left lateral decubitus position. After adequate sedation, a rectal examination was performed. No masses were felt. The video colonoscope was inserted in the rectum and advanced carefully to the cecum. The location of the cecum was confirmed by internal and external landmarks, and photographic documentation was obtained. The terminal ileum was then cannulated. This was normal to about 2 cm. The scope was brought back to the cecum and then gradually withdrawn. The lining of the colon was thoroughly inspected. There were scattered diverticula noted in the sigmoid colon. A pediculated 4 mm polyp was seen in the sigmoid colon at 30 cm from the anal verge. This was removed using a snare and submitted to pathology lab for biopsy. The scope was brought back to the rectum and retroflexed. Minimal hemorrhoids were noted. The scope was straightened, air was aspirated, and the scope was withdrawn. The patient tolerated the procedure well. IMPRESSION: 1. POLYP ON SIGMOID COLON AT 30 CM. 2. SIGMOID DIVERTICULAR DISEASE. 3. HEMORRHOIDS. PLAN: 1. A high-fiber diet is indicated. 2. Await pathology results. If adenomatous, a full colonoscopy is indicated in 3 years. If hyperplastic or normal, a colonoscopy is indicated in 10 years. _________________________________ Roger Blain, M.D. RB:mw D : 4/29/xx T: 5/1/xx cc: R. Kolima, M.D. Medical Record 14.2 476 Mediicall Terrmiinollogy:: The LLanguage off Healltth Carre M E D I C A L R E C O R D 1 4 . 3 At age 77, Kathleen Hillman has been in fairly good health. But 1 week ago, she devel- oped what she called “stomach problems” that led to frequent vomiting. She refused to seek medical help at first, until her daughter coaxed her into calling her family practi- tioner, Dr. Shigeda. Once she learned how serious Ms. Hillman’s problem had become, Dr. Shigeda urged her to go to the emergency room immediately. Directions Read Medical Record 14.3 for Kathleen Hillman (pages 479–481) and answer the fol- lowing questions. This record is the consultation report dictated by Dr. Flagstone after he examined her in the emergency room at Central Medical Center. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 4 . 3 Write your answers in the spaces provided. l. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: rebound tenderness _________________________________________________________ abdominal guarding _________________________________________________________ dehydration ________________________________________________________________ stasis dermatitis _____________________________________________________________ intractable _________________________________________________________________ 2. What was Ms. Hillman’s complaint that led her to call Dr. Shigeda, who then sent her to the emergency room at Central Medical Center? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. From the list of medications Ms. Hillman is taking, one includes an abbreviation that has been deemed error prone. Identify the abbreviation, potential problem, and preferred wording. Abbreviation Potential Problem Preferred Wording ____________ _________________ _________________ 4. According to Dr. Flagstone’s initial impression, which factor in Ms. Hillman’s present history might be a cause of her gastrointestinal symptoms? a. her drinking b. stress from living with her daughter c. her allergies d. her arthritis medications Chapter 14 • Gastrointestinal System 477 5. Describe the two previous operations Ms. Hillman has had involving the musculoskeletal system: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. Using nonmedical language, explain what Ms. Hillman does not remember exactly about her gastrointestinal history two decades ago: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. Check all of the findings below that Dr. Flagstone noted in the physical examination of Ms. Hillman: _____ dehydration _____ pulse 98 _____ icterus in the whites of the eyes _____ chronic stasis dermatitis _____ varicose veins _____ irregular heart rate _____ vaginal infection _____ possible atrial fibrillation _____ parotitis _____ yellowing of the skin _____ multiple ecchymoses _____ clear lungs 8. Does Ms. Hillman have blood in her stool? Write the phrase from the medical record that indicates this: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 478 Medical Terminology: The Language of Health Care 9. In your own words, explain the initial diagnoses, including the possibilities to eliminate: a. _________________________________________________________________________ b. _________________________________________________________________________ c. _________________________________________________________________________ 10. Dr. Flagstone’s plan calls for administering medications, checking tests, and performing a procedure. Fill in the details below: Administered to Ms. Hillman a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ Check Ms. Hillman’s d. ______________________________________________________________________ e. ______________________________________________________________________ f. ______________________________________________________________________ Perform g. ______________________________________________________________________ 11. In your own words, describe stool culture and sensitivity: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Chapter 14 • Gastrointestinal System 479 Medical Record 14.3 480 Medical Terminology: The Language of Health Care Medical Record 14.3 Continued. Chapter 14 • Gastrointestinal System 481 Medical Record 14.3 Continued. Chapter 15 Urinary System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the urinary system Describe the basic functions of the urinary system Define the basic anatomical terms referring to the urinary system Define common symptomatic and diagnostic terms referring to the urinary system List the common diagnostic tests and procedures related to the urinary system Define common operative terms referring to the male reproductive system Identify common therapeutic terms including drug classifications related to the urinary system Explain terms and abbreviations used in documenting medical records involving the urinary system Combining Forms Combining Form Meaning Example albumin/o protein albuminoid al-byūmin-oyd bacteri/o bacteria bacterium bak-tērē-ŭm cyst/o bladder or sac cystoscope sistō-skōp vesic/o vesicotomy vesi-kotō-mē dips/o thirst polydipsia pol-ē-dipsē-ă glomerul/o glomerulus (little ball) glomerular glō-māryū-lăr gluc/o sugar glucogenic gloo-kō-jenik glucos/o glucose glūkōs glyc/o glycolysis glı̄-koli-sis 482 Chapter 15 • Urinary System 483 Combining Form Meaning Example ket/o ketone bodies ketosis kē-tōsis keton/o ketonuria kē-tō-nūrē-ă lith/o stone lithiasis li-thı̄ă-sis meat/o meatus (opening) meatal mē-ātăl nephr/o kidney nephrosis ne-frōsis ren/o renal rēnăl pub/o pubic bone (lower front suprapubic portion of hip bone) soo-pră-pyubik (see Figs. 6.1 and 15.1) pyel/o renal pelvis (basin) pyelonephrosis pı̄ĕ-lō-ne-frōsis py/o pus pyonephritis pı̄ĕ-lō-ne-frı̄tis ureter/o ureter ureterolithiasis yū-rēter-ō-li-thı̄ă-sis urethr/o urethra urethrodynia yū-rē-thrō-dinē-ă ur/o urine urologist yū-rolō-jist urinary urin/o yūri-nār-ē Urinary System Overview The urinary system includes the organs and structures involved in the secretion and elimination of urine: kidneys, ureters, urinary bladder, and urethra (Fig. 15.1). The principal organs of the urinary system, the kidneys, are located on each side of the lum- bar region. They filter the blood and secrete water and nitrogenous wastes (e.g., urea, creatinine) in the form of urine. The functional unit of the kidney is called the nephron. Each nephron consists of a glomerulus, the little ball-shaped cluster of capillaries at the top; Bowman’s capsule, the top part that encloses the nephron; and a renal tubule, the stem portion of the nephron. Approximately one million nephrons make up the cortex, the outer part of each kidney. They gather waste substances by filtering the blood that enters the kid- ney through the renal artery at the hilum, the prominent indented portion. In the medulla, the inner portion of the kidney, the calyces collect urine from the tubules of the nephrons and drain their contents into the renal pelvis, the basin-like portion of the ureter within the kidney. 484 Medical Terminology: The Language of Health Care Right kidney Left kidney Inferior vena cava Abdominal aorta Ureters Urinary bladder Urethra Pubic bone Figure 15.1 Urinary system. The ureters, usually one for each kidney, are tubes that carry the urine from the kidney to the urinary bladder, where it

is held until being expelled during urination (micturition). The urethra is the single canal that carries urine from the bladder to the outside of the body. The urethral meatus is the opening in the urethra to the outside of the body. In addition to excreting waste products such as urea and creatinine, the kidneys play an essential life-sustaining role by regulating the levels of critical elements such as water, sodium, and potassium. Anatomical Terms Term Meaning kidneys two structures located on each side of the lumbar region that kidnēz filter blood and secrete impurities, forming urine (Fig. 15.2) cortex outer part of the kidney (cortex  bark) kōrteks hilum indented opening in the kidney where vessels enter and hı̄lŭm leave medulla inner part of the kidney me-dūlă calyces (calices) system of ducts carrying urine from the nephrons to the kali-sēz renal pelvis (kalyx  cup of a flower) nephron microscopic functional units of the kidney, comprised of nefron kidney cells and capillaries, each capable of forming urine (see Fig. 15.2) glomerulus little ball-shaped cluster of capillaries located at the top of glō-māryū-lŭs each nephron Bowman’s capsule top part of the nephron that encloses the glomerulus bō-mĕnz kapsūl Chapter 15 • Urinary System 485 Distal convoluted tubule Renal cortex Proximal convoluted tubule Renal medulla Bowman’s capsule (pyramid) Glomerulus Papilla of pyramid Afferent arteriole Minor calyx (calix) Major calyx (calix) Renal artery Renal vein Efferent Collecting arteriole tubule Renal pelvis Ureter Artery Vein Peritubular capillaries Loop of Henle Kidney Nephron Figure 15.2 Kidney and nephron. Term Meaning renal tubule stem portion of the nephron rēnăl tūbyūl ureter tube that carries urine from the kidney to the bladder ū-rēter renal pelvis basin-like portion of the ureter within the kidney rēnăl pelvis ureteropelvic junction point of connection between the renal pelvis and ureter yūrēter-ō-pelvik urinary bladder sac that holds the urine yūri-nār-ē urethra single canal that carries urine to the outside of the body yū-rēthră urethral meatus opening in the urethra to the outside of the body mē-ātŭs urine fluid produced by the kidneys containing water and yūrin waste products urea waste product formed in the liver, filtered out of the yū-rēă blood by the kidneys, and excreted in urine creatinine waste product of muscle metabolism filtered out of the krē-ati-nēn blood by the kidneys and excreted in urine 486 Medical Terminology: The Language of Health Care Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC albuminuria presence of albumin in the urine; occurs in renal al-byū-mi-nūrē-ă disease or in normal urine after heavy exercise proteinuria prō-tē-nūrē-ă anuria absence of urine formation an-yūrē-ă bacteriuria presence of bacteria in the urine bak-tēr-ē-ūrē-ă dysuria painful urination dis-yūrē-ă enuresis to void urine; involuntary discharge of urine, most en-yū-rēsis often refers to a lack of bladder control nocturnal enuresis bed wetting during sleep nok-ternăl hematuria presence of blood in the urine (Fig. 15.3) hē-mă-tūrē-ă glucosuria glucose (sugar) in the urine gloo-kōs-yurē-ă INCONTINENCE. incontinence involuntary discharge of urine or feces The Latin word in-konti-nens continent means to hold in, and the prefix in- stress urinary involuntary discharge of urine at the time of cough, means not. In Shakespeare’s incontinence (SUI) sneeze, and/or strained exercise time, incontinently was used to mean immediately. Today, ketonuria presence of ketone bodies in the urine incontinence specifically kē-tō-nūrē-ă refers to the inability to ketone bodies acetone, beta-hydroxybutyric acid, and acetoacetic prevent the discharge of kētōn acid are products of metabolism that appear in the excretions, especially urine ketone compounds urine as a result of an abnormal utilization of or feces. carbohydrates; seen in uncontrolled diabetes and starvation Figure 15.3 Hematuria. Microscopic urine showing a large number of red blood cells. One lone white blood cell is present in the center of the field. Chapter 15 • Urinary System 487 Term Meaning nocturia urination at night nok-tūrē-ă oliguria scanty production of urine ol-i-gūrē-ă polyuria condition of excessive urination pol-ē-yūrē-ă pyuria presence of white cells in the urine, usually indicating pı̄-yūrē-ă infection (Fig. 15.4) urinary retention retention of urine owing to the inability to void (urinate) yūri-nār-ē rē-tenshŭn naturally because of spasm, obstruction, etc. DIAGNOSTIC adult polycystic kidney inherited condition of multiple cysts that gradually disease (APKD) form in the kidney, causing destruction of normal tissue that leads to renal failure—diagnosed in adults presenting with hypertension, kidney enlargement, and recurrent urinary tract infections glomerulonephritis form of nephritis involving the glomerulus glō-māryū-lō-nef-r ı̄tis hydronephrosis dilation and pooling of urine in the renal pelvis and hı̄drō-ne-frōsis calyces of one or both kidneys caused by an obstruction in the outflow of urine (Fig. 15.5) nephritis inflammation of the kidney ne-frı̄tis pyelonephritis inflammation of the renal pelvis pı̄ĕ-lō-ne-frı̄tis Figure 15.4 Pyuria. Microscopic urine showing the presence of white blood cells (arrows). Figure 15.5 Collection of contrast media in the kidney displays an extraordinary amount of material, which indi- cates right-sided hydronephrosis caused by obstruction in the ureter. 488 Medical Terminology: The Language of Health Care Inferior vena cava Renal calculi (stones) Right kidney Stone blocking right ureter Right ureter Migrating pain Urethra Stone blocking urethra Figure 15.6 Kidney stone formation. Term Meaning nephrosis degenerative disease of the renal tubules ne-frōsis nephrolithiasis presence of renal stone or stones caused by mineral buildup nefrō-li-thı̄ă-sis in the kidneys—most commonly as a result of hyperuricuria (excessive amount of uric acid in the urine) or hypercalci- uria (excessive amount of calcium in the urine) (Fig. 15.6) cystitis inflammation of the bladder sistı̄tis urethritis inflammation of the urethra yū-rē-thrı̄tis urethrocystitis inflammation of the urethra and bladder yū-rēthrō-sis-tı̄tis urethral stenosis narrowed condition of the urethra yū-rēthrăl ste-nōsis urinary tract invasion of pathogenic organisms (commonly bacteria) in infection (UTI) the structures of the urinary tract, especially the urethra and bladder; symptoms include dysuria, urinary frequency, and malaise uremia excess of urea and other nitrogenous waste in the blood as yū-rēmē-ă a result of kidney failure azotemia az-ō-tēmē-ă Diagnostic Tests and Procedures Test or Procedure Explanation cystometrogram record that measures urinary volume, bladder pressure, and sis-tō-metrō-gram capacity to evaluate urinary dysfunction such as incontinence Chapter 15 • Urinary System 489 Bladder Calculi (stones) Urethra Cystoscope Figure 15.7. Cystoscopy. Test or Procedure Explanation cystoscopy examination of the bladder using a rigid or sis-toskŏ-pē flexible cystoscope (Fig. 15.7) kidney biopsy (Bx) removal of kidney tissue for pathological renal biopsy examination radiography x-ray studies commonly used in urology rādē-ogră-fē intravenous pyelogram (IVP) x-rays of the urinary tract taken after iodine is intră-vēnŭs pı̄el-ō-gram injected into the bloodstream and as the contrast intravenous urogram passes through the kidney, revealing obstruction, evidence of trauma, etc. (see Fig. 15.5) kidney, ureter, bladder (KUB) abdominal x-ray of kidney, ureter, and bladder typically used as a scout film before doing an IVP (Fig. 15.8) scout film plain x-ray taken to detect any obvious pathology before further imaging (e.g., a KUB before an IVP) renal angiogram (arteriogram) x-ray of the renal artery made after injecting anjē-ō-gram contrast material into a catheter in the artery retrograde pyelogram (RP) x-ray of the upper urinary tract taken after retrō-grād contrast medium is injected up to the kidney by way of a small catheter passed through a cystoscope—done to detect the presence of stones or obstruction voiding (urinating) x-ray of the bladder and urethra taken during cystourethrogram urination (VCU or VCUG) sis-tō-yū-rēthrō-gram abdominal sonogram ultrasound image of the urinary tract including sonō-gram the kidney, ureters, and bladder 490 Medical Terminology: The Language of Health Care Figure 15.8 KUB showing kidney stones in ureters and bladder (arrows). LABORATORY TESTING Test or Procedure Explanation urinalysis (UA) physical, chemical, and microscopic examination of yū-ri-nali-sis urine (Fig. 15.9) specific gravity (SpGr) measure of the kidney’s ability to concentrate or dilute urine pH measure of the acidity or alkalinity of urine glucose (sugar) chemical test used to detect sugar in the urine, used glūkōs most often to screen for diabetes albumin (alb) chemical test used to detect albumin in the urine al-byūmin protein ketones chemical test used to detect ketone bodies in the urine; if positive, fats are being utilized by the body instead of carbohydrates, which occurs in starvation or an unstable diabetic state Chapter 15 • Urinary System 491 Figure 15.9 Sample urinalysis report. 492 Medical Terminology: The Language of Health Care Test or Procedure Explanation occult blood, urine chemical test used to detect hidden blood in the urine resulting from red blood cell hemolysis— indicates bleeding in the kidneys (occult  hidden) bilirubin chemical test used to detect bilirubin in the urine— bil-i-rūbin seen in gallbladder and liver disease urobilinogen chemical test used to detect bile pigment in the yūr-ō-bı̄-linō-jen urine—increased amounts seen in gallbladder and liver disease nitrite chemical test used to detect bacteria in the urine nı̄trı̄t microscopic findings microscopic identification of abnormal constituents mı̄-krō-skopik in the urine (e.g., red blood cells, white blood cells, casts) as reported per high- or low-power field (hpf or lpf) (see Figs. 15.3 and 15.4) urine culture and isolation of a urine specimen in a culture medium sensitivity (C&S) that propagates the growth of microorganisms; organisms that grow in the culture are identified, and drugs to which they are sensitive are listed blood urea nitrogen (BUN) blood test to determine the level of urea in the yū-rēănı̄trō-jen blood—a high BUN indicates the kidney’s inability to excrete urea creatinine, serum test to determine the level of creatinine in the krē-ati-nēn sērŭm blood—useful in assessing kidney function creatinine, urine test to determine the level of creatinine in the urine creatinine clearance testing measurements of the level of creatinine in the blood and a 24-hour urine specimen to determine the rate that creatinine is “cleared” from the blood by the kidneys Operative Terms Term Meaning urologic endoscopic use of specialized endoscopes (e.g., resectoscope) surgery within the urinary tract to perform various surgical yū-rō-lojik-ăl procedures, such as resection of a tumor, repair of an obstruction, stone retrieval, or placement of a stent (Fig. 15.10) resectoscope urologic endoscope sent through the urethra to rē-sektō-skōp resect (cut and remove) lesions of the bladder, urethra, or prostate intracorporeal lithotripsy method of destroying stones within the urinary intră-kōr-pōrē-ăl tract using electrical energy discharges transmitted lithō-trip-sē to a probe within a flexible endoscope—most com- monly used to pulverize bladder stones (Fig. 15.11) nephrotomy incision into the kidney ne-frotō-mē Chapter 15 • Urinary System 493 Figure 15.10 Stone basket used in kidney stone retrieval. Term Meaning nephrorrhaphy suture of an injured kidney nef-rōră-fē nephrolithotomy incision into the kidney for the removal of stones nefrō-li-thotō-mē nephrectomy excision of a kidney ne-frektō-mē pyeloplasty surgical reconstruction of the renal pelvis pı̄e-lō-plas-tē stent placement use of a device to hold open vessels or tubes (e.g., an obstructed ureter) (Fig. 15.12) kidney transplantation transfer of a kidney from the body of one person renal transplantation (donor) to another (recipient) (Fig. 15.13) urinary diversion creation of a temporary or permanent diversion of the urinary tract to provide a new passage through which urine exits the body—used to treat defects or disease such as bladder cancer Figure 15.11 Simulation of the pulverizing of stones performed by intracorporeal lithotripsy. 494 Medical Terminology: The Language of Health Care Before After Ureteral Stent in obstruction place Figure 15.12 Placement of a double-J stent to relieve ureteral obstruction. Term Meaning common types of urinary diversion: noncontinent ileal removal of a portion of the ileum to use as a conduit conduit to which the ureters are attached at one non-konti-nent ilē-ăl end; the other end is brought through an opening kondū-it (stoma) created in the abdomen—urine drains continually into an external appliance (bag) (Fig 15.14) continent urostomy internal reservoir (pouch) constructed from a konti-nent yūr-ostō-mē segment of intestine that diverts urine through an opening (stoma) that is brought through the abdominal wall; a valve is created internally to prevent leakage, and the patient empties the pouch by catheterization orthotopic bladder bladder constructed from portions of intestine (neobladder) connected to the urethra, allowing “natural” voiding *Continent refers to the ability to hold or retain urine. Noncontinent indicates that urine cannot be held and drains continually. Right Left suprarenal suprarenal glands glands Site of diseased Left kidney right kidney Donor’s kidney External Internal iliac vein iliac artery Ureter Bladder Figure 15.13 Common site for donor kidney transplantation. Chapter 15 • Urinary System 495 Figure 15.14 Urostomy: ileal conduit. Therapeutic Terms Term Meaning extracorporeal shock procedure using ultrasound to penetrate the body wave lithotripsy (ESWL) from outside and bombard and disintegrate

a ekstră-kōr-pōrē-ăl stone within—most commonly used to treat lithō-trip-sē urinary stones above the bladder (Fig. 15.15) kidney dialysis methods of filtering impurities from the blood to dı̄-ali-sis replace the function of one or both kidneys due to renal failure hemodialysis method to remove impurities by pumping the hē-mō-dı̄-ali-sis patient’s blood through a dialyzer, the specialized filter of the artificial kidney machine (hemodialyzer) Dual-imaging system Computer display X-ray overhead Dual-imaging system X-ray film cassette Ultrasound system Shock-wave–generating system Figure 15.15 Shock wave system for extracorporeal lithotripsy of kidney stones. 496 Medical Terminology: The Language of Health Care Term Meaning peritoneal dialysis method of removing impurities using the per-i-tō-nēăl peritoneum as the filter; catheter insertion in the peritoneal cavity is required to deliver cleansing fluid (dialysate) that is washed in and out in cycles Kegel exercises specific exercises that strengthen the muscles of the pelvic floor to maintain proper organ placement and retain urine urinary catheterization methods of placing a tube into the bladder to drain or collect urine common types: straight catheter inserted through the urethra into the bladder to relieve urinary retention or collect a sterile specimen of urine for testing—removed immediately after the procedure Foley catheter indwelling catheter inserted through the urethra into the bladder; includes a collection system that allows urine to be drained into a bag—can remain in place for an extended time suprapubic catheter indwelling catheter inserted directly into the bladder through an abdominal incision above the pubic bone; includes a collection system that allows urine to be drained into a bag—used in patients requiring long-term catheterization COMMON THERAPEUTIC DRUG CLASSIFICATIONS analgesic drug that relieves pain an-ăl-jēzik antibiotic drug that kills or inhibits the growth of antē-bı̄-otik microorganisms antispasmodic drug that relieves spasm antē-spaz-modik diuretic drug that increases the secretion of urine dı̄-yū-retik Summary of Chapter 15 Acronyms/Abbreviations alb ..............................albumin KUB ...........................kidney, ureter, bladder APKD ........................adult polycystic kidney disease RP ................................retrograde pyelogram BUN ...........................blood urea nitrogen SpGr ..........................specific gravity Bx ................................biopsy SUI ..............................stress urinary incontinence C&S ............................urine culture and sensitivity UA................................urinalysis ESWL........................extracorporeal shock wave UTI..............................urinary tract infection lithotripsy VCU, VCUG .........voiding cystourethrogram IVP ..............................intravenous pyelogram Chapter 15 • Urinary System 497 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. example pericystitis _______ / _______ / _______ P R S peri/cyst/itis P R S DEFINITION: around/bladder or sac/inflammation 1. vesicoureteric __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 2. bacteriosis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 3. transurethral __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 4. urogram __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. urethrocystitis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 6. nephroptosis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 7. polydipsia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 498 Medical Terminology: The Language of Health Care 8. glomerulosclerosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 9. pyonephritis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 10. urology __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 11. ureterovesicostomy __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ 12. glycorrhea __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 13. meatotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 14. pyelonephrosis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 15. cystoscopy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 16. suprarenal __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 17. nephrolithiasis __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ Chapter 15 • Urinary System 499 18. ureterocele __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. albuminous __________________ / __________________ R S DEFINITION: _________________________________________________________________ 20. pyelography __________________ / __________________ CF S DEFINITION: _________________________________________________________________ Using nephr/o, the Greek combining form meaning kidney, identify the medical term for the following: 21. ____________________________ inflammation of the kidney 22. ____________________________ degenerative condition of the kidney 23. ____________________________ incision in the kidney 24. ____________________________ suture of a kidney 25. ____________________________ removal of the kidney 26. ____________________________ incision into the kidney for the removal of stones Complete the following: 27. urethral ________________osis  a narrowed condition of the urethra 28. extracorporeal shock wave _________________________  procedure for disintegration of kidney stones 29. _____________________ catheter  indwelling catheter inserted in the bladder through an abdominal incision above the pubic bone 30. _________________________scope  specialized endoscope to remove lesions from the bladder, prostate gland, and urethra 31. _________________________ exercises  strengthen muscles of the pelvic floor to maintain proper organ placement and retain urine 32. _________________________blood  hidden blood 33. _________________________  a record that measures urinary volume, bladder pressure, and capacity 34. peritoneal _________________  method of replacing the function of the kidneys to removing impurities from the blood using the peritoneum as a filter 35. ____________ film  plain x-ray taken to detect obvious pathology before further imaging 500 Medical Terminology: The Language of Health Care Identify the medical term for the following: 36. __________________________ inflammation of the bladder 37. __________________________ involuntary discharge of urine or feces 38. __________________________ involuntary discharge of urine 39. __________________________ bed wetting during sleep 40. __________________________ dilation and pooling of urine in the kidney caused by obstruction of outflow of urine 41. __________________________ inherited condition of multiple cysts that gradually form in the kidney in adult life Using the suffix -uria, name the following conditions of urine: 42. __________________________ urinating at night 43. __________________________ scanty urination 44. __________________________ painful urination 45. __________________________ presence of ketone bodies in the urine 46. __________________________ presence of blood in the urine 47. __________________________ presence of pus (white cells/infection) in the urine Match the following: 48. ________ sugar a. cyst/o 49. ________ proteinuria b. bacteriuria 50. ________ uremia c. renal Bx 51. ________ ren/o d. albuminuria 52. ________ vesic/o e. neobladder 53. ________ diuretic f. Foley 54. ________ kidney biopsy g. glyc/o 55. ________ nitrite h. nephr/o 56. ________ catheter i. azotemia 57. ________ urinary diversion j. urobilinogen 58. ________ bile pigment k. urination Chapter 15 • Urinary System 501 Define the following abbreviations: 59. alb ________________________________________________________________________ 60. IVP________________________________________________________________________ 61. ESWL _____________________________________________________________________ 62. UTI________________________________________________________________________ 63. SUI________________________________________________________________________ 64. BUN_______________________________________________________________________ For each of the following, circle the combining form that corresponds to the meaning given: 65. urine hydr/o ur/o ren/o 66. thirst dips/o crin/o hidr/o 67. pus pyel/o py/o albumin/o 68. bladder cyt/o vesic/o nephr/o 69. protein albumin/o lip/o bacteri/o 70. kidney hepat/o cyst/o nephr/o 71. opening or/o meat/o orth/o 72. basin meat/o vesic/o pyel/o 73. stone scler/o lip/o lith/o 502 Medical Terminology: The Language of Health Care Write in the missing words on the blank lines in the following illustration of the urinary anatomy. 74–78. 78. 74. Inferior vena cava Abdominal aorta 75. 76. Urinary 77. For each of the following, circle the correct spelling of the term: 79. cystascope cystoskope cystoscope 80. pyleogram pyelogram pielogram 81. oliguria oleguria oligouria 82. hydronefrosis hidronephrosis hydronephrosis 83. azootemia azothemia azotemia 84. urinalysis urinelysis uranalysis 85. glowmerular glomerular glomarular 86. nefrectomy nephrecktomy nephrectomy 87. diuretic dyuretic diuretik 88. hemadialysis hemodialysis hemidialysis 89. cathetersation catheterization cathterization Give the noun that was used to form the following adjectives: 90. urinary ___________________ 91. glomerular ___________________ 92. meatal ___________________ Chapter 15 • Urinary System 503 93. uremic ___________________ 94. urethral ___________________ 95. nephrotic ___________________ Write the abbreviation for the following terms: 96. urinalysis ________________________ 97. urine culture and sensitivity _______________ 98. retrograde pyelogram ______________ 99. x-ray of kidneys, ureters, and bladder ____________ 100. voiding cystourethrogram __________________ 504 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 5 . 1 S: This 70 y.o. female has had polyuria, nocturia, and dysuria  2-3 days. She had a similar infection 6 months ago and was treated with Macrobid, 50 mg, qid  3d. She has occasional stress incontinence with hard sneezing. O: The patient is afebrile. UA shows a trace of leukocytes and blood A: R/O recurrent UTI P: C&S Cipro 500 mg tab po bid pending culture pt instructed to ↑ fluid intake and call for culture results in 48 h 1. What is the patient’s CC? 4. Which medical terms describe the UA findings? a. the presence of red and white blood cells in a. pyuria and hematuria her urine b. dysuria and enuresis b. a urinary tract infection c. bacteriuria and hematuria c. pain when she urinates with the need to go d. bacteriuria and nocturia often, even at night d. urinary tract infection 5. To what does C&S refer? a. a condition of urinary stress 2. What were the objective findings? b. the isolation of microorganisms in the urine a. culture showed leukocytes and blood in the c. inflammation of the bladder urine d. physical, chemical, and microscopic study of b. urinalysis indicated red and white blood cells urine present in urine c. bladder infection 6. How should the Cipro be administered? d. return of bladder infection a. two, by mouth every day b. one, by mouth two times a day 3. What was the doctor’s impression? c. one, by mouth three times a day a. there were leukocytes and blood in the patient’s urine d. one, by mouth four times a day b. the patient has pain when she urinates with 7. Was the patient’s temperature elevated? the need to go often, even at night a. yes c. the pain has a bladder infection b. no d. the patient may have another bladder infection c. nothing is stated about the patient’s temperature Chapter 15 • Urinary System 505 M E D I C A L R E C O R D 1 5 . 2 Charles Mercier had urination problems and abdominal pain when he saw his doctor, who referred him to Central Medical Center for a possible kidney infection. Dr. Zlatkin performed surgery, and Mr. Mercier was soon doing fine and was discharged. As planned, he later returned for surgical removal of a device that had been temporarily placed during the first surgery. Directions Read Medical Record 15.2 for Mr. Mercier (pages 507–508) and answer the following questions. The first record is the discharge summary from the first surgery, dictated by Dr. Zlatkin. The second record is the operative report for Mr. Mercier’s return surgery 6 weeks later, also dictated by Dr. Zlatkin. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 5 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: stent (double J) ______________________________________________________________ drain (Jackson-Pratt)_________________________________________________________ lithotomy position ___________________________________________________________ ureteral catheter _____________________________________________________________ patency _____________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe the history of Mr. Mercier’s medical problems identified in the “Discharge Summary”: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Put the following events reported in the “Discharge Summary” in chronological or- der by numbering them from 1 to 5: _____ removal of drain _____ reconstruction of renal pelvis _____ difficulty with micturition _____ urine test for microorganisms _____ insertion of stent 506 Medical Terminology: The Language of Health Care 4. While at home after the operation, Mr. Mercier is instructed to do two things and not to do three things. List them below: Mr. Mercier should __________________________________________________________ ____________________________________________________________________________ Mr. Mercier should not_______________________________________________________ ____________________________________________________________________________ 5. When Mr. Mercier returned 6 weeks later for follow-up surgery, describe in your own words the preoperative diagnosis: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. During the second surgery, an endoscopic procedure and two different x-ray pro- cedures were used to visualize internal structures. List and define each procedure and describe the findings: Procedure Definition Finding _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ 7. The first surgery included insertion of a specialized device that was then removed in the second surgery. What was this device, and what function did it perform dur- ing the time between the two surgeries? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. In the second surgery, did Mr. Mercier experience any

complications? Write the sentence that supports your answer: ____________________________________________________________________________ ____________________________________________________________________________ Chapter 15 • Urinary System 507 Medical Record 15.2 508 Medical Terminology: The Language of Health Care Medical Record 15.2 Continued. Chapter 156 Male Reproductive System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the male reproductive system Describe the basic functions of the male reproductive system Define the basic anatomical terms referring to the male reproductive system Define common symptomatic and diagnostic terms referring to the male reproductive system List the common diagnostic tests and procedures related to the male reproductive system Define common operative terms referring to the male reproductive system Identify common therapeutic terms including drug classifications related to the male reproductive system Explain terms and abbreviations used in documenting medical records involving the male reproductive system Combining Forms Combining Form Meaning Example balan/o glans penis balanoplasty balan-ō-plas-tē epididym/o epididymis epididymitis ep-i-did-i-mı̄tis orch/o testis or testicle orchitis ORCHIO. ōr-kı̄tis Orchio is a Greek root for orchi/o orchiopexy testicle, so named for the ōrkē-ō-peksē resemblance of the gland to orchid/o orchidectomy the root of the orchid plant. At one time, orchid root was ōr-ki-dektō-mē used to treat diseases of the test/o testicle testicle. testĭ-kl perine/o perineum perineal peri-nēăl 509 510 Medical Terminology: The Language of Health Care Combining Form Meaning Example prostat/o prostate prostatodynia prostă-tō-dinē-ă sperm/o sperm (seed) oligospermia ol-i-gō-spermē-ă spermatic spermat/o sper-matik vas/o vessel vasorrhaphy vas-ōră-fē Male Reproductive System Overview The male reproductive system includes the scrotum, testes, epididymides, vas deferens, seminal vesicles, prostate gland, bulbourethral glands, urethra, and penis (Fig. 16.1). These parts produce and maintain sperm, the male reproductive cells, and introduce them into the female reproductive tract for the purpose of fertilizing the female ovum. The male reproductive organs also secrete certain hormones necessary for the main- tenance of secondary sexual characteristics in the male. TESTICLE. Anatomical Terms Testicle is from Term Meaning the Latin testis, a word that also meant a scrotum a bag; skin-covered pouch in the groin that is divided into witness or one who testifies. skrōtŭm two sacs, each containing a testis and an epididymis The presence of the testicles was evidence of virility, and testis (testicle) one of the two male reproductive glands, located in the it is said that under Roman testis scrotum, that produces sperm and the male hormone law, no man could witness testosterone in court unless his testicles were present. An oath was sperm male gamete or sex cell produced in the testes that unites taken with a hand on the spermatozoon with the ovum in the female to produce offspring testicles. The testicles are spermă-tō-zōon also associated with the epididymis coiled duct on top and at the side of the testis that stores swearing of oaths in the Old Testament of the Bible. ep-i-didi-mis sperm before emission penis erectile tissue covered with skin that contains the urethra pēnis for urination and ducts for the secretion of seminal fluid PENIS. Penis is a (semen) Latin word for tail. The name is glans penis bulging structure at the distal end of the penis (glans  also derived from pendere, glanz acorn) meaning to hang down. The Romans had a great many prepuce foreskin; loose casing covering the glans penis—removed terms for the male organ— prēpūs by circumcision e.g., cauda (tail), clava (club), gladius (sword), radix vas deferens duct that carries sperm from the epididymis to the (root), ramus (branch), and vas defer-ens ejaculatory duct (vas  vessel; deferens  carrying away) vomer (plough). Penis was seminal vesicle one of two sac-like structures lying behind the bladder and adopted as the anatomical semi-năl connected to the vas deferens on each side—secretes an term, and it has been used alkaline substance into the semen to enable the sperm to in English since the 17th century. live longer Chapter 16 • Male Reproductive System 511 THE MALE REPRODUCTIVE SYSTEM Sagittal view Urinary bladder Ampulla Frontal view Seminal vesicle Symphysis pubis Vas deferens Ejaculatory duct Prostate gland Corpus cavernosum Urethra Bladder Penis Glans penis Prepuce Seminal vesicles Urethral meatus Prostate gland Testis Vas deferens Scrotum Urethra Anus Bulbourethral gland Perineum Vas deferens Epididymis A typical sperm (magnified drawing) Acrosome Nucleus Tail Midpiece Head Figure 16.1 Male reproductive system. Term Meaning semen mixture of the secretions of the testes, seminal vesicles, sēmen prostate, and bulbourethral glands discharged from the male urethra during orgasm (semen  seed) ejaculatory duct duct formed by the union of the vas deferens with the duct ē-jakyū-lă-tōr-ē of the seminal vesicle; its fluid is carried into the urethra 512 Medical Terminology: The Language of Health Care Term Meaning prostate gland trilobular gland that encircles the urethra just below prostāt the bladder—secretes an alkaline fluid into the semen bulbourethral glands pair of glands below the prostate with ducts opening (Cowper glands) into the urethra—adds a viscid (sticky) fluid to the bŭlbō-yū-rēthrăl semen perineum external region between the scrotum and anus in a peri-nēŭm male and between the vulva and anus in a female spermatic cord cord containing the vas deferens, arteries, veins, sper-matik kōrd lymph vessels, and nerves that extends from the internal inguinal ring through the inguinal canal to each testicle Symptomatic and Diagnostic Terms Term Meaning SYMPTOMATIC aspermia inability to secrete or ejaculate sperm ā-spermē-ă azoospermia semen without living spermatozoa, a sign of ā-zō-ō-spermē-ă infertility in the male (zoo  life) oligospermia scanty production and expulsion of sperm ol-i-gō-spermē-ă mucopurulent discharge drainage of mucus and pus myū-kō-pūrū-lent DIAGNOSTIC anorchism absence of one or both testes an-ōrkizm balanitis inflammation of glans penis bal-ă-nı̄tis cryptorchism undescended testicle; failure of a testis to descend krip-tōrkizm into the scrotal sac during fetal development; it most often remains lodged in the abdomen or inguinal canal, requiring surgical repair (crypt  to hide) (Fig. 16.2) epididymitis inflammation of the epididymis ep-i-did-i-mı̄tis hydrocele hernia of fluid in the testis or tubes leading from the hı̄drō-sēl testis (Fig. 16.3B) hypospadias congenital opening of the male urethra on the hı̄pō-spādē-ăs undersurface of the penis (spadias  to draw away) (Fig. 16.4) 1 Deep 2 inguinal ring 3 Inguinal 4 canal Figure 16.2 Cryptorchism. Four de- Normal Superficial grees of incomplete descent of the testis. 1. descent inguinal In the abdominal cavity close to the deep in- ring guinal ring. 2. In the inguinal canal. 3. At the superficial inguinal ring. 4. In the upper part of the scrotum. A B Spermatic artery Hydrocele Vein Vas deferens Epididymis Tunica vaginalis C D Spermatocele Varicocele Figure 16.3 A. Normal testes and appendages. B. Hydrocele. C. Spermato- cele. D. Varicocele. 514 Medical Terminology: The Language of Health Care Term Meaning erectile dysfunction (ED) failure to initiate or maintain an erection until ejaculation because of physical or psychological dysfunction; formerly termed impotence (im  not; potis  able) Peyronie disease disorder characterized by a buildup of hardened pā-rōnē fibrous tissue in the corpus cavernosum causing pain and a defective curvature of the penis, especially during erection (Fig. 16.5) phimosis narrowed condition of the prepuce (foreskin) f ı̄-mōsis resulting in its inability to be drawn over the glans penis, often leading to infection—commonly requires circumcision (phimo means muzzle) (Fig. 16.6) benign prostatic enlargement of the prostate gland; frequently hyperplasia/hypertrophy seen in older men, causing urinary obstruction (BPH) (Fig. 16.7) bē-nı̄n pros-tatik hı̄-pĕr-plāzē-ă/hı̄-pertrō-fē prostate cancer malignancy of the prostate gland prostatitis inflammation of the prostate pros-tă-tı̄tis spermatocele painless, benign cystic mass containing sperm spermă-tō-sēl lying above and posterior to the testicle, but separate from it (see Fig. 16.3C) Fibrous cord Transverse section Balanic hypospadias Penile hypospadias Figure 16.4 Hypospadias. Figure 16.5 Peyronie disease. Chapter 16 • Male Reproductive System 515 Figure 16.6 Phimosis. Term Meaning testicular cancer malignant tumor in one or both testicles commonly tes-tikyŭ-lăr developing from the germ cells that produce sperm— classified in two groups according to growth potential seminoma most common type of testicular tumor, composed of sem-i-nōmă immature germ cells—highly treatable with early detection nonseminomas testicular tumors arising from more mature germ cells that have a tendency to be more aggressive than seminomas; often develop earlier in life (includes choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors) varicocele enlarged, swollen, herniated veins near the testis vari-kō-sēl (varico  twisted vein) (Fig. 16.3D) Bladder wall distention caused by urethral narrowing and pressure Bladder Prostatic enlargement Prostate compresses the urethra, Urethra making urination difficult A B Figure 16.7 A. Normal prostate. B. Hypertrophic prostate. 516 Medical Terminology: The Language of Health Care Term Meaning SEXUALLY TRANSMITTED DISEASE (STD) Major Bacterial STDs bak-tērē-ăl chlamydia most common sexually transmitted bacterial kla-midē-ă infection in North America; often occurs with no symptoms and is treated only after it has spread GONORRHEA. gonorrhea contagious inflammation of the genital mucous Derived from the gon-ō-rēă membranes caused by invasion of the gonococcus, Greek root Neisseria gonorrhoeae (gono  seed; rrhea  discharge) gono, meaning offspring or seed, and the suffix -rrhea, syphilis infectious disease caused by a spirochete transmitted meaning flow or discharge, sifi-lis by direct intimate contact that may involve any organ the word literally means flow or tissue over time; usually manifested first on the skin of semen. It was once with the appearance of small, painless red papules that thought that the urethral erode and form bloodless ulcers called chancres (Fig. discharge characteristic of 16.8) the infection was a leakage of semen. Although the Major Viral STDs reasoning is wrong, v ı̄răl attempts to change the term failed because its usage hepatitis B virus (HBV) virus that causes inflammation of the liver as a result was too firmly established. hep-ă-t ı̄tis of transmission through any body fluid, including vaginal secretions, semen, and blood herpes simplex virus type 2 virus that causes ulcer-like lesions of the genital and (HSV-2) anorectal skin and mucosa; after initial infection, herpēz the virus lies dormant in the nerve cell root and may recur at times of stress (see Fig. 17.9) Figure 16.8 Syphilitic chancre. Chapter 16 • Male Reproductive System 517 Term Meaning human immunodeficiency virus virus that causes acquired (HIV) immunodeficiency syndrome (AIDS), which imyū-nō-dē-fishen-sē permits various opportunistic infections, malignancies, and neurological diseases; contracted through exposure to contaminated blood or body fluid (e.g., semen, vaginal secretions) human papilloma virus (HPV) virus transmitted by direct sexual contact pap-i-lōmă that causes an infection that condyloma acuminatum can occur on the skin or mucous kon-di-lōmah ă-kyūmı̆-nātŭm membranes of the genitals; on the skin, the pl. condylomata acuminata lesions appear as cauliflower-like warts, and kon-di-lōmahtă ă-kyūmı̆-nahtă on the mucous membranes, they have a flat appearance (also known as venereal or genital warts) (see Fig. 17.10) Diagnostic Tests and Procedures Test or Procedure Explanation biopsy (Bx) tissue sampling used to identify neoplasia biopsy of the prostate needle biopsy of the prostate often performed using ultrasound guidance (see Fig. 16.10) testicular biopsy biopsy of a testicle tes-tikyū-lăr digital rectal exam (DRE) insertion of a finger into the male rectum to palpate the rectum and prostate (Fig. 16.9) Figure 16.9 Digital rectal examination. 518 Medical Terminology: The Language of Health Care Test or Procedure Explanation prostate-specific antigen (PSA) test blood test used to screen for prostate cancer; anti-jen an elevated level of the antigen indicates the possible presence of tumor urethrogram x-ray of the urethra and prostate yū-rēthrō-gram semen analysis study of semen, including a sperm count, sēmen with observation of morphology (form) and motility; usually performed to rule out male infertility endorectal (transrectal) sonogram scan of the prostate made after introducing of the prostate an ultrasonic transducer into the rectum— endō-rektăl trans-rektăl also used to guide needle biopsy (Fig. 16.10) Operative Terms Term Meaning circumcision removal of the foreskin (prepuce), exposing the ser-kŭm-sizhŭn glans penis epididymectomy removal of an epididymis epi-did-i-mektō-mē orchiectomy removal of a testicle ōr-kē-ektō-mē orchidectomy ōr-ki-dektō-mē Prostate Rectum Biopsy needle Probe Figure 16.10 Ultrasound and biopsy (inset) of prostate. Chapter 16 • Male Reproductive System 519 Resectoscope Prostate gland Figure 16.11 Transurethral resection of prostate (TURP). Term Meaning orchioplasty repair of a testicle ōrkē-ō-plas-tē orchiopexy fixation of an undescended testis in the scrotum ōrkē-ō-peksē prostatectomy excision of the prostate gland pros-tă-tektō-mē transurethral resection of removal of prostatic gland tissue through the the prostate (TURP) urethra using a resectoscope, a specialized trans-yū-rēthrăl re-sekshŭn urological endoscope—common treatment for benign prostatic hyperplasia/hypertrophy (BPH) (Fig. 16.11) Vas deferens Scrotum Testes A B C D Locating the vas deferens An incision

is made over The vas deferens is The vas deferens is the vas deferens withdrawn through the returned, and the incision, a section is scrotum incision is removed, and the ends closed with sutures. are tied. Figure 16.12 Vasectomy. 520 Medical Terminology: The Language of Health Care Term Meaning vasectomy removal of a segment of the vas deferens to va-sektō-mē produce sterility in the male (Fig. 16.12) vasovasostomy restoration of the function of the vas deferens to vāsō-vă-sostō-mē regain fertility after vasectomy Therapeutic Terms Term Meaning chemotherapy treatment of malignancies, infections, and other dis kemō-thār-ă-pē eases with chemical agents that destroy selected cells or impair their ability to reproduce cancer immunotherapy treatment of cancer by stimulating the patient’s own imū-nō-thār-ă-pē immune response by transfer of immune components such as antibodies or T cells from an outside source to kill cancer cells radiation therapy treatment of neoplastic disease by using radiation to rādē-āshŭn deter the proliferation of malignant cells brachytherapy radiation technique involving internal implantation of radioactive isotopes, such as radioactive seeds to treat prostate cancer (brachy, meaning short distance, refers to localized application) hormone replacement use of a hormone to remedy a deficiency or regulate therapy (HRT) production (e.g., testosterone) penile prosthesis implantation of a device designed to provide an pēnı̄l prosthē-sis erection of the penis—used to treat physical impotence penile self-injection intracavernosal injection therapy causing an erection—used in treatment of erectile dysfunction Summary of Chapter 16 Acronyms/Abbreviations BPH ..........benign prostatic hyperplasia/hypertrophy HPV ..........human papilloma virus Bx ...............biopsy HRT ..........hormone replacement therapy DRE ..........digital rectal exam HSV-2 ......herpes simplex virus type 2 ED ..............erectile dysfunction PSA............prostate-specific antigen HBV ..........hepatitis B virus STD ...........sexually transmitted disease HIV............human immunodeficiency virus TURP .......transurethral resection of the prostate Chapter 16 • Male Reproductive System 521 PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE synorchism _______ / _______ / _______ P R S syn/orch/ism P R S DEFINITION: together/testis or testicle/condition of 1. oligospermia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 2. perineoplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 3. testalgia __________________ / __________________ R S DEFINITION: _________________________________________________________________ 4. balanic __________________ / __________________ R S DEFINITION: _________________________________________________________________ 5. prostatomegaly __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 6. orchidectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 522 Medical Terminology: The Language of Health Care 7. anorchism __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 8. vasectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 9. aspermia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 10. cystoprostatectomy __________________ / __________________ / __________________ CF R S DEFINITION: _________________________________________________________________ 11. balanitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 12. orchioplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 13. spermatocele __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 14. epididymotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 15. vasovasostomy __________________ / __________________ / __________________ CF CF S DEFINITION: _________________________________________________________________ Chapter 16 • Male Reproductive System 523 Identify the medical term for the following: 16. ____________________________ absence of a testicle 17. ____________________________ inflammation of the glans penis 18. ____________________________ enlarged, herniated veins near the testicle 19. ____________________________ specialized endoscope used to approach the prostate when performing a TURP 20. ____________________________ enlargement of the prostate 21. ____________________________ removal of a portion of the vas deferens to pro- duce male sterility 22. ____________________________ disorder that causes a buildup of hardened fibrous tissue in the corpus cavernosa in the penis Match the following: 23. ________ fertility restoration a. prostatectomy 24. ________ phimosis b. seminoma 25. ________ BPH c. STD 26. ________ cryptorchism d. ED 27. ________ testicular cancer e. orchiopexy 28. ________ penile self-injection f. TURP 29. ________ prostate cancer g. circumcision 30. ________ condyloma acuminata h. vasovasostomy Complete the following: 31. _____________________ orchism  undescended testicle 32. _____________________ sonogram of prostate  ultrasound scan of the prostate made after introduction of a transducer into the rectum 33. _______________________ cele  fluid hernia in the testis 34. _______________________ spadias  condition of congenital opening of the male urethra on the undersurface of the penis 35. _______________________ _______________________ exam  insertion of a finger into the male rectum to palpate the rectum and prostate 36. _______________________ therapy  radiation technique involving implantation of radioactive “seeds” 524 Medical Terminology: The Language of Health Care Match the following terms related to sperm: 37. ________ semen analysis a. semen without living sperm 38. ________ oligospermia b. inability to secrete sperm 39. ________ azoospermia c. sperm morphology 40. ________ aspermia d. scanty production of sperm Write the term for the following abbreviations: 41. PSA _______________________________________________________________________ 42. Bx_________________________________________________________________________ 43. TURP______________________________________________________________________ 44. DRE_______________________________________________________________________ 45. ED ________________________________________________________________________ For each of the following, circle the combining form that corresponds to the meaning given: 46. testis prostat/o epididym/o orchi/o 47. perineum peritone/o perine/o prostat/o 48. sperm test/o orchi/o spermat/o 49. vessel aden/o angin/o vas/o 50. glans penis prostat/o orchid/o balan/o 51. epididymis sperm/o vas/o epididym/o Chapter 16 • Male Reproductive System 525 Write in the missing words on the blank lines in the following illustration of the male anatomy. 52–59. Sagittal view 56. Urinary Ampulla Seminal vesicle Symphysis pubis 52. Corpus cavernosum Ejaculatory duct 57. 53. gland Penis 54. Anus Prepuce Bulbourethral gland Urethral meatus 58. 55. Vas deferens Scrotum 59. For each of the following, circle the correct spelling of the term: 60. epididymis epididymus epedidimis 61. oligspermia oligospermia oligispermia 62. azospermia asospermia azoospermia 63. anorchesm anorchism anorschizm 64. balanitis balanitus balantis 65. creptorchism criptorchism cryptorchism 66. hypospadias hypospadeas hypespadias 67. clamidyia chlamidya chlamydia 68. syphilis syphillis syphyllis 69. fimosis phimosis phymosis 526 Medical Terminology: The Language of Health Care Give the noun that was used to form the following adjectives: 70. prostatic ____________________ 71. epididymal __________________ 72. perineal _____________________ 73. penile _______________________ 74. gonorrheal __________________ 75. testicular ____________________ Chapter 16 • Male Reproductive System 527 MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 6 . 1 Chart Note S: Twelve days ago this 34 y.o. male had a flu-like syndrome that lasted about 2–3 hours. For the past two days, he has felt lousy again and is experiencing left testicular pain and swelling s̄ avoiding Sx Allergies: none PH: negative Habits: smoking—no alcohol—occasional beer ROS: otherwise negative O: Slightly small testes bilaterally; tender L epididymis; normal circumcised penis UA: WNL A: L epididymitis P: Rx: Maxaquin 400 mg #16 Sig: STAT, then q.d.  14 d; return in two weeks for follow-up 1. What was the patient’s diagnosis? 4. Did the patient have any trouble urinating? a. testicular pain and swelling a. yes b. inflammation of the testicle b. no c. swollen veins near the testis 5. What was the condition of the right testicle? d. inflammation of the coiled duct that stores sperm a. inflamed e. fluid hernia in a testicle b. enlarged c. small 2. What was the condition of the patient’s penis? d. normal a. small but normal e. had been excised b. prepuce had been excised c. inflamed 6. What was the result of the urinalysis? d. swollen and tender a. not stated e. not stated b. normal c. not performed because the patient could not 3. What was the Sig: on the prescription? void a. two every other day for fourteen days d. hematuria b. two immediately, then one a day for fourteen e. glucosuria days c. one immediately, then one a day for fourteen days d. one as needed every day for fourteen days e. two a day for fourteen days 528 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 1 6 . 2 Larry Phelps, age 31, has been happily married to his wife Nancy for almost 5 years. They have two children. The second child caused some health problems for Nancy, and her obstetrician recommended that they have no more children because of the risk to her health. After trying different forms of birth control, Nancy and Larry decided that he would have a vasectomy. His doctor referred him to Dr. Jerard Derrick in the urology department at Central Medical Group. Directions Read Medical Record 16.2 for Larry Phelps (pages 530–531) and answer the following questions. This record is a series of three chart notes written by Dr. Derrick after first meeting with Mr. Phelps to schedule surgery, after the surgery and discharge, and after seeing Mr. Phelps in a follow-up 10 days later. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 6 . 2 Write your answers in the spaces provided. 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: sterility ____________________________________________________________________ infiltrated __________________________________________________________________ resect ______________________________________________________________________ ejaculation _________________________________________________________________ induration __________________________________________________________________ 2. The medical record suggests that Mr. Phelps signed which of these before surgery? a. last will and testament b. consent form c. application to sperm bank d. none of the above 3. In your own words, not using medical terminology, briefly summarize the proce- dure Dr. Derrick performed: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. Complications of the surgery included the following: a. sterility b. fever c. nausea and vomiting d. bleeding e. all of the above f. none of the above Chapter 16 • Male Reproductive System 529 5. Translate the instruction for the immediate postoperative medication (how much, how often): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 6. Mark any of the following that were symptoms Mr. Phelps reported to Dr. Derrick on his follow-up visit 10 days after surgery: a. fever b. bleeding c. pain in the scrotum d. impotence e. suture loosening 7. Dr. Derrick carefully examined Mr. Phelps in the follow-up visit and noted the fol- lowing objective findings (mark all that are appropriate): a. minor bruising in the scrotum b. small area of hard tissue at left vasectomy site c. bleeding at left vasectomy site d. pain at left vasectomy site e. very sore elevated mass at right vasectomy site f. bleeding at right vasectomy site g. pain at right vasectomy site h. hard tissue areas along upper scrotum i. black and blue penis 8. In your own words, define the diagnosis Dr. Derrick made in the follow-up visit: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 9. Translate Dr. Derrick’s medication instructions after the follow-up visit: Medication Amount How Often ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 530 Medical Terminology: The Language of Health Care Medical Record 16.2 Chapter 16 • Male Reproductive System 531 Medical Record 16.2 Continued 532 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 1 6 . 3 James Easley was having some difficulty urinating fully and was feeling gradually increasing pain in the perineal area. He went to see his personal physician, who after a digital rectal examination referred him to Dr. Lentz, a urologist at Central Medical Center. Directions Read Medical Record 16.3 for James Easley (page 534) and answer the following ques- tions. This record is the ultrasound report dictated by Dr. Lentz after his session with Mr. Easley in the ultrasound suite at Central Medical Center. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 6 . 3 Write your answers in the spaces provided: 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: needle biopsy ______________________________________________________________ MHz _____________________________________________________________________ bifocal ____________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe the ultrasound procedure Mr. Easley underwent: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. In your own words, describe the position Mr. Easley was put in for the ultrasound: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. Mark any of the following that are abnormal findings in Dr. Lentz’s report: a. enlarged prostate gland b. hemorrhage c. hypoechoic lesion d. obstructed urethra e. prostatic calculi f. multiplanar rectum Chapter 16 • Male Reproductive System 533 5. Because

of the results of the ultrasound, Dr. Lentz decided to perform an additional diagnostic procedure while Mr. Easley was in the ultrasound suite. In your own words, describe that procedure: __________________________________________________________________________ __________________________________________________________________________ 6. Explain why Dr. Lentz’s report does not include a plan or recommendations for further actions: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 7. When and for how long should Mr. Easley take the Noroxin? __________________________________________________________________________ _________________________________________________________________________ 534 Medical Terminology: The Language of Health Care Medical Record 16.3 Chapter 17 Female Reproductive System OBJECTIVES After completion of this chapter you will be able to Define common term components used in relation to the female reproductive system Describe the basic functions of the female reproductive system Define the basic anatomical terms referring to the female reproductive system Define common gynecological symptomatic and diagnostic terms List the common gynecological diagnostic tests and procedures Define common gynecological operative and therapeutic terms Define common obstetrical symptomatic and diagnostic terms List the common obstetrical diagnostic tests and procedures Define common obstetrical operative and therapeutic terms Explain terms and abbreviations used in documenting medical records involving the female reproductive system Combining Forms Combining Form Meaning Example cervic/o neck or cervix cervical servı̆ -kal colp/o vagina (sheath) colposcope kolpō-skōp vagin/o vaginal vaji-năl episi/o vulva (covering) episiotomy e-piz-ē-otō-mē vulv/o vulvar vŭlvăr gynec/o woman gynecology gı̄ -nĕ-kolō-jē hyster/o uterus hysteroscopy his-ter-oskŏ-pē metr/o metrorrhagia mē-trō-rājē-ă uter/o uterus ūter-ŭs 535 536 Medical Terminology: The Language of Health Care Combining Form Meaning Example lact/o milk lactogenic lak-tō-jenik mast/o breast mastodynia mas-tō-dinē-ă mamm/o mammogram mamō-gram men/o menstruation menopause menō-pawz obstetr/o midwife obstetric ob-stetrik oophor/o ovary oophoritis ō-of-ōr-ı̄ tis ovari/o ovarian ō-varē-an ov/i egg ovigenesis ō-vi-jenĕ-sis ov/o ovum ōvŭm pelv/i pelvic cavity pelvimetry pel-vimĕ-trē salping/o uterine (fallopian) tube salpingitis sal-pin-jı̄ tis toc/o labor or birth dystocia dis-tōsē-ă ADDITIONAL SUFFIX -arche beginning menarche me-narkē Female Reproductive System Overview The female reproductive system consists of the uterus, ovaries, uterine (fallopian) tubes, vagina, and vulva (Fig. 17.1). These structures are responsible for producing and main- taining female ova and providing a place for the implantation and nurturing of the fer- tilized ovum until birth. Treatment of the female reproductive system involves two medical specialties: gynecology and obstetrics. Anatomical Terms Term Meaning uterus womb; pear-shaped organ in the pelvic cavity in ūter-ŭs which the embryo develops fundus upper portion of the uterus above the entry to the fŭndŭs uterine tubes Chapter 17 • Female Reproductive System 537 Sagittal view Mons pubis Fallopian tube (uterine tube) Clitoris Ovary Labium major Fimbriae Labium minor Urethral opening Uterus Vaginal opening Round ligament (introitus) with Cervix hymen Urinary bladder Perineum Symphysis pubis Anus Urethra Clitoris Vagina Labium minor Labium major Uterus: Frontal view Rectum The right side shows a cutaway Anus view; the left side shows an external view. Fallopian tube Fundus (uterine tube) Fimbriae Follicle Ovary Developing eggs Broad ligament Ovary Ovarian ligament Body of uterus Endometrium Round ligament Myometrium Cervix Cervical os Corpus luteum Vagina Mature graafian follicle Ovulation (ovum released) Figure 17.1 Female reproductive system. Term Meaning endometrium lining of the uterus that is shed approximately endō-mētrē-ŭm every 28–30 days in the nonpregnant female during menstruation (see Table 17.1 on page 538) myometrium muscular wall of the uterus FALLOPIUS. mı̄ ō-mētrē-ŭm Gabriele uterine or fallopian tubes tubes extending from each side of the uterus Fallopius, a yūter-in fa-lōpē-an toward the ovary that provide a passage for ova to 16th-century Italian the uterus anatomist, made many important observations, adnexa uterine tubes and ovaries (uterine appendages) especially concerning the ad-neksă female reproductive organs. His classical descriptions right uterine appendage right tube and ovary resulted in his name being left uterine appendage left tube and ovary associated with the uterine ovary one of two glands located on each side of the pelvic tubes. He compared the abdominal end of each tube ōvă-rē cavity that produce ova and female sex hormones to a trumpet. 538 Medical Terminology: The Language of Health Care Table 17.1 Menstrual Cycle The menarche is the time in puberty when the female menstrual cycle begins and continues in a 28–30-day cycle throughout reproductive life, except at times of pregnancy, until menopause (generally occurring between 45 and 55 years of age). Hormones secreted by the anterior pituitary gland control the four stages of the menstrual cycle: Menstrual stage (period) Days 1–5 Shedding of unused endometrial tissue in a bloody discharge Follicular stage Days 6–13 Secretion of follicle-stimulating hormone (FSH), initiating growth of an ovum in the graafian follicle, and release of estrogen by the maturing follicle, causing thickening and revitalization of the endometrial lining Ovulatory stage Days 14–16 Secretion of luteinizing hormone causes the follicle to rupture and release the mature ovum into the uterine tube; the ruptured follicle, remaining in the ovary, transforms into the corpus luteum, which then secretes progesterone and estrogen to further nourish the endometrium. Premenstrual stage Days 17–28 If conception does not take place, the corpus luteum stops secreting progesterone and estrogen, thinning of the endometrial lining occurs, and tissue breakdown culminates in menstruation. Term Meaning cervix neck of the uterus serviks cervical os opening of the cervix to the uterus servı̆ -kăl os vagina tubular passageway from the cervix to the outside of the vă-jı̄ nă body vulva external genitalia of the female vŭlvă labia folds of tissue on either side of the vaginal opening lābē-ă known as the labia majora and labia minora clitoris female erectile tissue situated in the anterior portion of klitō-ris the vulva hymen fold of mucous membrane that encircles the entrance hı̄ men to the vagina introitus entrance to the vagina in-trōi-tŭs Bartholin glands two glands located on either side of the vaginal opening that secrete a lubricant during intercourse perineum region between the vulva and anus peri-nēŭm Chapter 17 • Female Reproductive System 539 Breast anatomy Rib Intercostal muscles Chest muscles Skin Adipose tissue Alveolar glands Areola Nipple Lactiferous duct Figure 17.2 Breast. Term Meaning mammary glands two glands of the female breasts capable of producing milk MAMMA. mamă-rē (Fig. 17.2) Mamma is Latin for breast; the mammary papilla nipple word is said to come from pă-pilă the cry of the infant for areola dark pigmented area around the nipple “mama,” which is a sound ă-rēō-lă common to most languages and is the root for mother in embryo developing organism from fertilization to the end of the many. The word “breast” is embrē-ō eighth week (Fig. 17.3) derived from the German word for “bursting forth” or fetus developing organism from the ninth week to birth (Fig. 17.4) “budding.” fētŭs placenta vascular organ that develops in the uterine wall during plă-sentă pregnancy that provides nourishment for the fetus (placenta  cake) Sperm and ovum A B Figure 17.3 A. Sperm and ovum. B. Two-dimensional sonogram of 8-week embryo. 540 Medical Terminology: The Language of Health Care Placenta Uterus Amniotic fluid Fetus Amnion A B Figure 17.4 A. Fetus in utero. B. Three-dimensional sonogram of fetus “waking up.” Term Meaning amnion innermost of the membranes surrounding the embryo amnē-on in the uterus filled with amniotic fluid amniotic fluid fluid within the amnion that surrounds and protects the fetus meconium intestinal discharges of the fetus that form the first stools in mē-kōnē-ŭm the newborn Gynecological Symptomatic Terms gı̄ nĕ-kō-loji-kăl Term Meaning amenorrhea absence of menstruation ă-men-ō-reă anovulation absence of ovulation an-ov-yū-lāshŭn dysmenorrhea painful menstruation dis-men-ōr-ēă dyspareunia painful intercourse (coitus) (dys  painful; dis-pa-rūnē-ă para  alongside of; eunia  a lying) leukorrhea abnormal white or yellow vaginal discharge lū-kō-rēă menorrhagia excessive bleeding at the time of menstruation (menses) men-ō-rājē-ă metrorrhagia bleeding from the uterus at any time other than normal mē-trō-rājē-ă menstruation oligomenorrhea scanty menstrual period oli-gō-men-ō-rēă oligo-ovulation irregular ovulation oli-gō-ovyū-lāshŭn Chapter 17 • Female Reproductive System 541 Gynecological Diagnostic Terms Term Meaning cervicitis inflammation of the cervix ser-vi-sı̄ tis congenital anomalies birth defects causing the abnormal development (irregularities) of a female organ or structure (e.g., double uterus, kon-jeni-tăl ă-nomă-lēz absent vagina) dermoid cyst congenital tumor composed of displaced embryonic dermoyd sist tissue (teeth, bone, cartilage, and hair) more commonly found in an ovary; it is usually benign displacement of uterus displacement of the uterus from its normal position (Fig. 17.5) anteflexion abnormal forward bending of the uterus an-tē-flekshŭn (ante  before; flexus  bend) retroflexion abnormal backward bending of the uterus re-trō-flekshŭn retroversion backward turn of the whole uterus—also called re-trō-verzhŭn tipped uterus Anteflexion Retroflexion The three degrees of retroversion 1st degree 2nd degree Normal 3rd degree Figure 17.5 Displacements of the uterus. 542 Medical Terminology: The Language of Health Care Term Meaning endometriosis condition characterized by migration of portions endō-mē-trē-ōsis of endometrial tissue outside the uterine cavity endometritis inflammation of the endometrium endō-mē-trı̄ tis fibroid benign tumor in the uterus composed of smooth fı̄ broyd muscle and fibrous connective tissue (Fig. 17.6) fibromyoma fı̄ brō-mı̄ -ōmă leiomyoma lı̄ ō-mı̄ -ōmă fistula abnormal passage such as from one hollow fistyū-lă organ to another (fistula  pipe) (Fig. 17.7) rectovaginal fistula abnormal opening between the vagina and rek-tō-vaji-năl rectum vesicovaginal fistula abnormal opening between the bladder and ves-i-kō-vaji-năl vagina cervical neoplasia abnormal development of cervical tissue cells cervical intraepithelial potentially cancerous abnormality of epithelial neoplasia (CIN) tissue of the cervix, graded according to the intră-ep-i-thēlē-ăl extent of abnormal cell formation: nē-ō-plāzē-ă CIN 1 mild dysplasia cervical dysplasia CIN 2 moderate dysplasia dis-plāzē-ă CIN 3 severe dysplasia (see Fig. 17.13B) Fallopian tube Fibroids connected to the uterine wall with stalks Ovary Serosa Fibroid extending from the uterine wall into the uterine cavity (submucosal) Intramural fibroid Fibroids inside the Cervix uterine wall (subserosal) Vagina Figure 17.6 Fibroids. Chapter 17 • Female Reproductive System 543 Rectovaginal fistula Vesicovaginal fistula Vagina Fistula Vagina Fistula Urinary Rectum bladder Figure 17.7 Fistulas. Term Meaning carcinoma in situ (CIS) malignant cell changes of the cervix of the cervix that are localized without any spread to adjacent kar-si-nōmă in sı̄ tū structures menopause cessation of menstrual periods owing to a lack of menō-pawz ovarian hormones oophoritis inflammation of one or both ovaries ō-of-ōr-ı̄ tis parovarian cyst cyst of the fallopian tube par-ō-varē-an pelvic adhesions scarring of tissue within the pelvic cavity as a pelvik ad-hēzhŭnz result of endometriosis, infection, or injury pelvic inflammatory inflammation of organs in the pelvic cavity usually disease (PID) including the fallopian tubes, ovaries, and endometrium—most often caused by bacteria pelvic floor relaxation relaxation of supportive ligaments of the pelvic organs (Fig. 17.8) cystocele pouching of the bladder into the vagina sistō-sēl rectocele pouching of the rectum into the vagina rektō-sēl enterocele pouching sac of peritoneum between the vagina enter-ō-sēl and rectum urethrocele pouching of the urethra into the vagina yū-rēthrō-sēl prolapse descent of the uterus down the vaginal canal prō-laps salpingitis inflammation of a fallopian tube sal-pin-jı̄ tis 544 Medical Terminology: The Language of Health Care Normal view of bladder Bladder with cystocele Rectocele Bladder falls or Rectum bulges descends from into wall of the normal position vagina Enterocele Urethrocele Prolapse Small intestine Urethra sags and Uterus descends bulges between eventually bulges from normal rectum and vagina into the vaginal wall position into vagina Figure 17.8 Pelvic floor relaxation. SEXUALLY TRANSMITTED DISEASES (STDs) Term Meaning Major Bacterial STDs chlamydia most common sexually transmitted bacterial kla-midē-ă infection in North America; often occurs with no symptoms and is treated only after it has spread, such as to cause pelvic inflammatory disease gonorrhea contagious inflammation of the genital mucous gon-ō-rēă membranes caused by invasion of the gonococcus, Neisseria gonorrhoeae (gono  seed; rrhea  discharge) syphilis infectious disease caused by a spirochete sifi-lis transmitted by direct intimate contact that may involve any organ or tissue over time; usually manifested first on the skin with the appearance of small, painless red papules that erode and form bloodless ulcers called chancres Major Viral STDs hepatitis B virus (HBV) virus that causes an inflammation of the liver as a hep-ă-tı̄ tis result of transmission through any body fluid, including vaginal secretions, semen, and blood herpes simplex virus virus that causes ulcer-like lesions of the genital type 2 (HSV-2) and anorectal skin and mucosa; after initial herpēz infection, the virus lies dormant in the nerve cell root and may recur at times of stress (Fig. 17.9) Chapter 17 • Female Reproductive System 545 Figure 17.9 Herpes simplex virus type 2. Term Meaning human immunodeficiency virus that causes acquired immunodeficiency virus (HIV) syndrome (AIDS), permitting various imyū-nō-dē-fishen-sē opportunistic infections, malignancies, and neurological

diseases—contracted through exposure to contaminated blood or body fluid (e.g., semen, vaginal secretions) human papilloma virus virus transmitted by direct sexual contact (HPV) that causes an infection that can occur on the pap-i-lōmă skin or mucous membranes of the genitals; condyloma acuminatum on the skin, the lesions appear as cauliflower- kon-di-lōmah ă-kyūmı̆ -nātŭm like warts, and on the mucous membranes, pl. condylomata acuminata they have a flat appearance (also known as kon-di-lōmahtă ă-kyūmı̆ -nahtă venereal or genital warts) (Fig. 17.10) Figure 17.10 Condylomata acuminata (genital warts) caused by HPV. 546 Medical Terminology: The Language of Health Care Term Meaning vaginitis inflammation of the vagina with redness, swelling, and vaj-i-nı̄tis irritation—often caused by a specific organism, such as Candida (yeast) or Trichomonas (sexually transmitted parasite) atrophic vaginitis thinning of the vagina and loss of moisture owing to ă-trofik depletion of estrogen, which causes inflammation of tissue vaginosis infection of the vagina with little or no inflammation vaji-nō-sis characterized by a milk-like discharge and an unpleasant odor—also known as nonspecific vaginitis BREASTS adenocarcinoma of the malignant tumor of glandular breast tissue breast adĕ-nō-kar-si-nōmă amastia absence of a breast ă-mastē-ă fibrocystic breasts benign condition of the breasts consisting of fı̆ -brō-sistik fibrous and cystic changes that render the tissue more dense—patient feels painful lumps that fluctuate in size during the menstrual cycle gynecomastia development of mammary glands in the male, gı̄ nĕ-kō-mastē-ă caused by altered hormone levels (Fig. 17.11) Figure 17.11 This 15-year-old boy presented with a 3-year history of gradual, bilateral breast enlargement known as gynecomastia. He was otherwise healthy and showed normal pubertal development. The cause in his case was idiopathic, but most are related to hormone imbalance as seen in tumors of the pituitary or adrenal glands. For cosmetic reasons and because of functional impairment (breast pain with running), he underwent breast reduction mammoplasty. Chapter 17 • Female Reproductive System 547 Term Meaning hypermastia abnormally large breasts hı̄ -per-mastē-ă macromastia mak-rō-mastē-ă hypomastia unusually small breasts hı̄ po-mastē-ă micromastia mı̄ kro-mastē-ă mastitis inflammation of the breast—most common in mas-tı̄ tis women when breast-feeding polymastia presence of more than two breasts pol-ē-mastē-ă polythelia presence of more than one nipple on a breast pol-ē-thēlē-ă supernumerary nipples sū-per-nūmer-ār-ē Gynecological Diagnostic Tests and Procedures Test or Procedure Explanation biopsy (Bx) removal of tissue for microscopic pathological bı̄ op-sē examination (Fig. 17.12) aspiration Bx needle draw of tissue or fluid from a cavity for as-pi-rāshŭn cytological examination—also called needle biopsy endoscopic Bx removal of a specimen for biopsy during an endō-skōpik endoscopic procedure (e.g., colposcopy) excisional Bx removal of an entire lesion for microscopic ek-sizhŭn-ăl examination incisional Bx removal of a piece of suspicious tissue for in-sizhŭn-ăl microscopic examination (e.g., cervical or endometrial biopsy) needle Bx removal of a core specimen of tissue using a special hollow needle stereotactic breast Bx use of x-ray or ultrasound imaging, a specialized stereotactic frame, and a computer to calculate, sterē-ō-taktik precisely locate, and direct a needle into a breast lesion for the removal of a core specimen for biopsy sentinel node breast Bx biopsy of the sentinel node (the first lymph node to sentinl nōd receive lymphatic drainage from a tumor) in a breast with early cancer to determine metastases and, if no malignancy is found, avoid the extensive removal of axillary nodes that causes lymphedema (swelling under the arms); includes radionuclide imaging to locate the sentinel node (sentinel refers to guarding a point of entry) 548 Medical Terminology: The Language of Health Care Incisional Excisional biopsy biopsy Aspiration biopsy Endometrial biopsy Suction curette Figure 17.12 Biopsy. Test or Procedure Explanation colposcopy examination of the vagina and cervix using a kol-poskŏ-pē colposcope, a specialized microscope used to examine the vagina and cervix, often with a camera attachment for photographs—used to document findings and follow-up treatments (Fig. 17.13) hysteroscopy use of a hysteroscope to examine the intrauterine his-ter-oskŏ-pē cavity for the assessment of abnormalities (e.g., polyps, fibroids, anomalies) (Fig. 17.14) magnetic resonance use of nonionizing images to detect gynecological imaging (MRI) conditions (e.g., anomalies of the pelvis or soft rezō-nans tissues of the breast) or stage tumors arising from the endometrium or cervix Papanicolaou smear (Pap) study of cells collected from the cervix to screen pa-pĕ-nēkĕ-low for cancer and other abnormalities Chapter 17 • Female Reproductive System 549 A Cervical colposcopy Normal cervix High-grade lesions (low magnification) High-grade lesions (high magnification) B Figure 17.13 A. Colposcopy. B. Photographs taken during cervical colposcopy. Biopsy of the high-grade lesions revealed CIN 3 (severe dysplasia). Hysteroscopic visualization of a fibroid in the uterus Figure 17.14 Hysteroscopy. 550 Medical Terminology: The Language of Health Care Test or Procedure Explanation radiography x-ray imaging rādē-ogră-fē hysterosalpingogram x-ray of the fallopian tubes after injection of a hister-ō-sal-ping-ō-gram contrast medium through the cervix—used to determine tubal patency mammogram low-dose x-ray of breast tissue done to detect mamō-gram neoplasms (Fig. 17.15) pelvic sonography ultrasound imaging of the female pelvis sŏ-nogră-fē (Fig. 17.16) endovaginal sonogram ultrasound image of the uterus, tubes, and ovaries endō-vaji-năl made after introduction of an ultrasonic transducer transvaginal sonogram within the vagina to detect conditions such as trans-vaji-năl sonō-gram ectopic pregnancy or missed abortion hysterosonogram transvaginal sonographic image made as sterile (saline infusion sonogram) saline is injected into the uterus; used to assess uterine pathology or determine tubal patency; also known as sonohysterogram transabdominal sonogram ultrasound image of the lower abdomen including trans-ab-domi-năl the bladder, uterus, tubes, and ovaries to detect conditions such as cysts and tumors Figure 17.15 A. Mammography procedure. B. Mammogram of a patient with an implant. Arrows, pectoralis muscle anterior to the implant. Chapter 17 • Female Reproductive System 551 A Endovaginal probe B Figure 17.16 Pelvic sonography. A. Transabdominal imaging procedure. Inset, simple ovarian cyst. B. Transvaginal imaging procedure. Inset, twin pregnancies. Gynecological Operative Terms Term Meaning adhesiolysis breaking down or severing of pelvic adhesions ad-hēzē-ōli-sis adhesiotomy ad-hē-sē-ot-ōmē cervical conization removal of a cone-shaped portion of the cervix servı̆ -kal kō-nı̄ -zāshŭn 552 Medical Terminology: The Language of Health Care Vaginal speculum Vagina Uterus Cryoprobe Insertion of speculum and introduction of Placement of cryosurgical probe Ice crystals seen immediately after cryoprobe into the vagina at treatment site freezing treatment A B C Figure 17.17 Cryosurgical procedure: cryoconization of the cervix. Term Meaning colporrhaphy suture to repair the vagina kol-pōră-fē anterior repair repair of a cystocele posterior repair repair of a rectocele A&P repair anterior and posterior repair of a cystocele and rectocele cryosurgery method of destroying tissue by freezing—used for krı̄ -ō-serjer-ē treating dysplasia and early cancers (Fig. 17.17) Speculum Vagina Forceps Uterus Speculum Needle Cul-de-sac Figure 17.18 Culdocentesis. Chapter 17 • Female Reproductive System 553 A curette (a spoon-shaped cutting Curetting (scraping) the instrument) is inserted after dilating endometrium the cervix. Figure 17.19 Dilation and curettage. Term Meaning culdocentesis aspiration of fluid from the cul-de-sac (cavity that kŭl-dō-sen-tēsis lies between the rectum and posterior wall of the uterus)—used for diagnosing ectopic pregnancy and pelvic inflammatory disease (Fig. 17.18) dilation and curettage (D&C) dilation of the cervix and scraping of the dı̄-lāshŭn kyū-rĕ-tahzh endometrium to control bleeding, obtain tissue for biopsy, or remove polyps or products of concep- tion (Fig. 17.19) hysterectomy removal of the uterus HYSTERIA. his-ter-ektō-mē Hysteria is a Greek word abdominal hysterectomy removal of the uterus through an incision in the meaning a uterine abdomen condition. Ancient Greeks vaginal hysterectomy removal of the uterus through the vagina believed that nervous symptoms were due to the total hysterectomy removal of the uterus and cervix uterus and therefore were experienced only by laparoscopy inspection of the abdominal or pelvic cavity with women. Plato described the lap-ă-roskŏ-pē a laparoscope, an endoscope used to examine the uterus as an animal abdominal and pelvic regions endowed with spontaneous sensation and emotion that laparoscopic surgery surgical procedures within the abdominal or was lodged in a woman, pelvic region using a laparoscope ardently desiring to produce laser surgery use of a laser to destroy lesions or dissect or cut children. If the uterus lāzer tissue—used frequently in gynecology remained sterile long after puberty, it became ill- loop electrosurgical excision use of electrosurgical or radio waves transformed tempered and caused a procedure (LEEP) through a loop-configured electrosurgical device general disturbance in the large loop excision of the to treat precancerous lesions by simultaneous body until it became transformation zone excisional biopsy and treatment of affected tissue pregnant. The common (LLETZ) (e.g., cervical dysplasia, human papilloma virus prescription for the hysterical lesions); note that the transformation zone is the female in those days was marriage and childbirth! area of the cervix where neoplasia (abnormal cell formation) is most likely to arise (Fig. 17.20) 554 Medical Terminology: The Language of Health Care Loop electrode Transformation zone Cervix A B C Figure 17.20 Loop electrosurgical excision procedure (LEEP) or large loop excision of the transformation zone (LLETZ). A. Electrode approach. B. Removal of the transformation zone. C. Excision site (region between the endocervix and ectocervix). Term Meaning myomectomy excision of fibroid tumors mı̄ -ō-mektō-mē oophorectomy excision of an ovary ō-of-ōr-ektō-mē ovarian cystectomy excision of an ovarian cyst ō-varē-an sis-tektō-mē salpingectomy excision of a uterine tube sal-pin-jektō-mē bilateral salpingo-oophorectomy excision of both uterine tubes and bı̄ -later-ăl sal-pinggō-ō-of-ō-rektō-mē ovaries salpingotomy incision into a fallopian tube—often sal-pin-gottō-mē performed to remove an ectopic pregnancy (Fig. 17.21) salpingostomy creation of an opening in the fallopian sal-ping-gostō-mē tube to open a blockage tubal ligation sterilization of a woman by cutting and lı̄ -gāshŭn tying (ligating) the uterine tubes Unruptured ectopic tubal pregnancy Surgical incision of uterine tube for Suture of incision site removal of products of conception Figure 17.21 Salpingotomy. Chapter 17 • Female Reproductive System 555 Term Meaning BREASTS lumpectomy excision of a breast tumor without removing lŭm-pektō-mē any other tissue or lymph nodes; most often followed by radiation and/or chemotherapy if cancerous mastectomy removal of a breast (Fig. 17.22) mas-tektō-mē simple mastectomy removal of an entire breast with underlying muscle and axillary lymph nodes left intact radical mastectomy removal of an entire breast, underlying chest muscles, and axillary lymph nodes modified radical mastectomy removal of an entire breast and axillary lymph nodes (Fig. 17.23A) Brachial nodes Axillary nodes Pectoralis major Subclavian nodes muscle Pectoralis major muscle Pectoralis minor muscle (under Internal mammary pectoralis major nodes muscle) A Mammary gland B Long thoracic nerve Subscapular nodes Anterior pectoral nodes Anatomy Simple Mastectomy The breast, the underlying muscles, and the lymph nodes Only the breast is removed. The underlying muscle and are the structures involved in breast cancer surgery. The lymph associated lymph nodes are not removed. nodes, which act as barriers against bacteria or tumor cells, are useful in staging breast cancer. Stump of pectoralis Brachial nodes major muscle Axillary nodes Axillary artery Subclavian nodes Stump of pectoralis minor muscle Axillary artery Cut edge of pectoralis major muscle Internal mammary nodes Intercostal muscle Rib Pathways to opposite breast C Long thoracic nerve D Long thoracic nerve Radical Mastectomy Modified Radical Mastectomy The breast, pectoralis muscles, and contents of the The breast and lymph nodes of the axilla are removed. axilla (including lymph nodes and adipose tissue) are removed. Occasionally, the pectoralis minor muscle is transected or removed to approach the lymph nodes. Figure 17.22 A. Anatomy of the breast. B–D. Mastectomy alternatives. 556 Medical Terminology: The Language of Health Care Figure 17.23 Augmentation mammoplasty. A. Left modified radical mastectomy in a 53-year-old woman (3 months postoperation). B. Same patient 10 months after augmentation mammoplasty. Term Meaning mammoplasty surgical reconstruction of a breast mamō-plas-tē augmentation mammoplasty reconstruction to enlarge the breast, often by insertion of an implant (see Fig. 17.23A and B) reduction mammoplasty reconstruction to remove excessive breast tissue (Fig. 17.24) mastopexy elevation of pendulous breast tissue mastō-pek-sē (see Fig. 17.24B) Therapeutic Terms Term Meaning chemotherapy treatment of malignancies, infections, and kemō-thār-ă-pē other diseases with chemical agents that destroy selected cells or impair their ability to reproduce radiation therapy treatment of neoplastic disease by using radiation, usually from a cobalt source, to deter the proliferation of malignant cells hormone replacement use of a hormone (e.g., estrogen, progesterone) therapy (HRT) to replace a deficiency or regulate production Chapter 17 • Female Reproductive System 557 Figure 17.24 Mammoplasty and mastopexy. A. Micromastia of one breast and macromastia of the opposite breast in a 22-year-old patient. B. Same patient 15 months postreduction mammoplasty and mastopexy. Term Meaning hormonal contraceptives hormones used to prevent conception

by suppressing ovulation oral contraceptive birth control pill pill (OCP) contraceptive injection injection of a hormone such as Depo-Provera into the body contraceptive implant insertion of a contraceptive capsule under the skin that provides a continual infusion over an extended time barrier contraceptives products that provide a physical barrier that prevents conception (e.g., condoms, diaphragms) intrauterine device (IUD) contraceptive device inserted into the intră-yūter-in uterus that prevents implantation of the fertilized egg spermicidals creams, jellies, lotions, or foams containing sper-mi-sı̄ dălz agents that kill sperm (cido  to kill) uterine fibroid catheter-guided injection of embolic agents embolization (UFE) into the arteries supplying blood to fibroid tumors, blocking circulation and causing shrinkage; minimally invasive procedure performed by a vascular and interventional radiologist in a angiographic laboratory 558 Medical Terminology: The Language of Health Care Obstetrical (OB) Symptomatic and Diagnostic Terms ob-stetri-kal Term Meaning SYMPTOMATIC gravida pregnant woman gravi-dă [Note: In an obstetrical history, gravida, or G, followed by a numeral indicates the number of pregnancies (Fig. 17.25).] nulligravida having never been pregnant nŭl-i-gravi-dă primigravida first pregnancy prı̄ -mi-gravi-dă para to bear; a woman who has produced one or more viable pară (live outside the uterus) offspring [Note: In an obstetrical history, para, or P, followed by a numeral indicates the number of times a pregnancy has resulted in a single or multiple birth (see Fig. 17.25).] nullipara woman who has not borne a child (nulli  none; nŭl-i-pară para  to bear) primipara first delivery (primi  first; para  to bear) pri-mipă-ră multipara woman who has given birth to two or more children mŭl-tipă-ră (multi  many; para  to bear) cervical effacement progressive obliteration of the endocervical canal during ĕ-fāsment delivery estimated date of expected date for delivery of the baby—normally 280 days confinement (EDC) or 40 weeks from conception kon-fı̄nment estimated date of delivery (EDD) meconium staining presence of meconium in amniotic fluid mē-kōnē-ŭm ruptured membranes rupture of the amniotic sac, usually at the onset of labor rŭpchūrd macrosomia large-bodied baby commonly seen in diabetic pregnancies mak-rō-sōmē-ă (macro  large; soma  body) polyhydramnios excessive amniotic fluid polē-hı̄ -dramnē-os DIAGNOSTIC abortion (AB) expulsion of the product of conception before the fetus ă-bōrshŭn can be viable (live outside the uterus) spontaneous miscarriage; expulsion of products of conception abortion (SAB) occurring naturally spon-tānē-ŭs Chapter 17 • Female Reproductive System 559 The following abbreviations are used in recording an obstetrical history. GPA terms: G gravida number of pregnancies P para number of viable birth experiences (may include multiple births) AB abortus abortions SAB spontaneous abortion TAB therapeutic abortion Arabic numerals are placed after each abbreviation to indicate the number of pregnancies, viable births, or abortions. Example: Obstetric history: G2, P1, AB1 or gravida 2, para 1, abortus 1. [The patient has been pregnant twice, had one birth experience that resulted in the delivery of at least one viable offspring, and had one abortion.] TPAL terms: T term infants P premature infants A abortions L living children Example: Obstetric history: 5 term infants, 0 premature infants, 0 abortions, 5 living children or Obstetric history: 5-0-0-5. [The patient has delivered five term infants, no premature infants, no abortions and has five living children.] Occasionally, combined GPA and TPAL abbreviations are used. For example: Obstetrical history: gravida 3, 4-0-0-4 [The patient has been pregnant three times, had four term infants, no premature infants, no abortions, and has 4 living children. (Numbers indicate one twin birth.)] Figure 17.25 Obstetrical history abbreviations. Term Meaning habitual abortion spontaneous abortion occurring in three or more consecutive pregnancies incomplete abortion incomplete expulsion of products of conception missed abortion death of a fetus or embryo within the uterus that is not naturally expelled after death threatened abortion bleeding with threat of miscarriage 560 Medical Terminology: The Language of Health Care Term Meaning cephalopelvic conditions preventing normal delivery through the disproportion (CPD) birth canal—either the baby’s head is too large or sefă-lō-pelvik the birth canal is too small ECLAMPSIA. eclampsia true toxemia of pregnancy characterized by high Eclampsia is a ek-lampsē-ă blood pressure, albuminuria, edema of the legs and Greek word feet, severe headaches, dizziness, convulsions, and meaning to flash out or coma shine forth suddenly, first used in the 18th century for preeclampsia toxemia of pregnancy characterized by high blood any sudden convulsion. prē-ē-klampsē-ă pressure, albuminuria, edema of the legs and feet, Today, it particularly refers pregnancy-induced and puffiness of the face, without convulsion or to toxemia of pregnancy. hypertension (PIH) coma ectopic pregnancy implantation of the fertilized egg outside the uterine ek-topik cavity, often in the tube, ovary, or (rarely) the abdominal cavity (Fig. 17.26) erythroblastosis fetalis disorder that results from the incompatibility of a ĕ-rithrō-blas-tōsis fētālis fetus with an Rh-positive blood factor and a mother who is Rh negative, causing red blood cell destruction in the fetus—necessitates a blood transfusion to save the fetus Rh factor presence, or lack, of antigens on the surface of red blood cells that may cause a reaction between the blood of the mother and fetus, resulting in fetal anemia (which causes erythroblastosis fetalis) Rh positive presence of antigens Rh negative absence of antigens Tubal (isthmic) Abdominal Interstitial Tubal (ampullar) Infundibular (ostial) Ovarian Figure 17.26 Ectopic pregnancy: sites of extrauterine implantation. Chapter 17 • Female Reproductive System 561 Term Meaning hyperemesis gravidarum severe nausea and vomiting in pregnancy that can hı̄ -per-emĕ-sis grav-i-dārŭm cause severe dehydration in the mother and fetus (emesis  vomit) meconium aspiration fetal aspiration of amniotic fluid containing mē-kōnē-ŭm as-pi-rāshŭn meconium placenta previa displaced attachment of the placenta in the lower plă-sentă prēvē-ă region of the uterine cavity (Fig. 17.27) abruptio placentae premature detachment of a normally situated ab-rŭpshē-ō pla-sentē placenta Obstetrical Diagnostic Tests and Procedures Test or Procedure Explanation chorionic villus sampling of placental tissue for microscopic and sampling (CVS) chemical examination to detect fetal kō-rē-onik vilus abnormalities (Fig. 17.28A) amniocentesis aspiration of a small amount of amniotic fluid for amnē-ō-sen-tēsis analysis of possible fetal abnormalities (Fig. 17.28B) fetal monitoring use of an electronic device for simultaneous recording of fetal heart rate and uterine contractions pelvimetry obstetrical measurement of the pelvis to evaluate pel-vimĕ-trē proper conditions for vaginal delivery pregnancy test test performed on urine or blood to detect the presence of human chorionic gonadotropin hormone (secreted by the placenta) that indicates pregnancy Marginal placenta previa Partial placenta previa Total placenta previa Figure 17.27 Placenta previa. 562 Medical Terminology: The Language of Health Care Ultrasound guidance Wall of uterus Chorionic villi Chorionic villi sampled Placenta Cells are grown in a Petri dish, A harvested for chromosomes, and stained for analysis Ultrasound guidance Placenta Amniotic fluid aspirated Wall of uterus Cells extracted from the fluid B are grown in a Petri dish, harvested for chromosomes, and stained for analysis Figure 17.28 A. Chorionic villus sampling (9–11 weeks). B. Amniocentesis (15–18 weeks). Term Meaning endovaginal sonogram ultrasound image of the uterus, tubes, and ovaries transvaginal sonogram made after introduction of an ultrasonic transducer within the vagina—useful in detecting pathology (e.g., ectopic pregnancy, missed abortion) (see Fig. 17.16) obstetrical sonogram ultrasound image of the pregnant uterus to determine fetal development (see Figs. 17.3B, 17.4B, and 17.16B) Chapter 17 • Female Reproductive System 563 Obstetrical Operative and Therapeutic Terms Term Meaning OPERATIVE cesarean section (C-section) surgical delivery of a baby by making an incision CESAREAN se-zārē-ăn through the abdomen and into the uterus SECTION. The fetus is removed episiotomy incision of the perineum to facilitate delivery from the uterus through an e-piz-ē-otō -mē incision in the abdomen. THERAPEUTIC The procedure was first used to save the baby when the amnioinfusion introduction of a solution into the amniotic sac— mother had died. Julius amnē-ō-in-fyūzhŭn most commonly an isotonic solution used to Caesar is said to have been relieve fetal distress born in this manner. therapeutic abortion (TAB) abortion induced by mechanical means or by drugs for medical consideration version manual method reversing the position of the fetus, usually done to facilitate delivery external version abdominal manipulation internal version intravaginal manipulation COMMON THERAPEUTIC DRUG CLASSIFICATIONS abortifacient drug that causes abortion (e.g., RU-486) ă-bōr-ti-fāshent oxytocin hormone secreted by the pituitary gland that ok-sē-tōsin causes myometrial contraction—used for induction of labor Rh immune globulin immunizing agent given to an Rh-negative mother globyū-lin within 72 hours after delivering an Rh-positive baby to suppress the Rh immune response tocolytic agent drug used to stop labor contractions tō-kō-litik Summary of Chapter 17 Acronyms/Abbreviations AB........................abortion IUD .....................intrauterine device Bx ........................biopsy LEEP .................loop electrosurgical excision CIS ......................carcinoma in situ procedure CIN .....................cervical intraepithelial neoplasia LLETZ ..............large loop excision of the transforma- CPD ....................cephalopelvic disproportion tion zone C-section ........cesarean section MRI ....................magnetic resonance imaging CVS ....................chorionic villus sampling OB .......................obstetrics D&C ...................dilation and curettage OCP ....................oral contraceptive pill EDC....................estimated date of confinement Pap......................Papanicolaou smear EDD ...................estimated date of delivery PID......................pelvic inflammatory disease GYN ...................gynecology PIH .....................pregnancy-induced hypertension HIV.....................human immunodeficiency virus SAB ....................spontaneous abortion HPV....................human papilloma virus STD ....................sexually transmitted disease HRT ...................hormone replacement therapy TAB ....................therapeutic abortion HSV-2 ...............herpes simplex virus type 2 UFE ....................uterine fibroid embolization 564 Medical Terminology: The Language of Health Care PRACTICE EXERCISES For the following terms, on the lines below the term, write out the indicated word parts: prefixes (P), combining forms (CF), roots (R), and suffixes (S). Then define the word. EXAMPLE ectocervical _______ / _______ / _______ P R S ecto/cervic/al P R S DEFINITION: outside/cervix or neck/pertaining to 1. vulvitis __________________ / __________________ R S DEFINITION: _________________________________________________________________ 2. polymastia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 3. ovoid __________________ / __________________ R S DEFINITION: _________________________________________________________________ 4. tocolysis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 5. salpingotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 6. mammoplasty __________________ / __________________ CF S DEFINITION: _________________________________________________________________ Chapter 17 • Female Reproductive System 565 7. transvaginal __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 8. hysterorrhexis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 9. colposcopy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 10. mammography __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 11. metrorrhagia __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 12. ovariocentesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 13. menarche __________________ / __________________ R S DEFINITION: _________________________________________________________________ 14. oophorectomy __________________ / __________________ R S DEFINITION: _________________________________________________________________ 15. oligomenorrhea __________________ / __________________ / __________________ P CF S DEFINITION: _________________________________________________________________ 16. dystocia __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 566 Medical Terminology: The Language of Health Care 17. gynecologist __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 18. pelvimeter __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 19. episiotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 20. colporrhaphy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 21. hysterospasm __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 22. lactorrhea __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 23. ovigenesis __________________ / __________________ CF S DEFINITION: _________________________________________________________________ 24. endocervical __________________ / __________________ / __________________ P R S DEFINITION: _________________________________________________________________ 25. uterotomy __________________ / __________________ CF S DEFINITION: _________________________________________________________________ Complete the following: 26. ____________________ pause  cessation of menstruation 27. ____________________ menorrhea  painful menstruation Chapter 17 • Female Reproductive System 567 28. ____________________ menorrhea  absence of menstruation 29. ____________________ menorrhea  scanty menstruation 30. ____________________ rrhagia  excessive bleeding at time of menstruation 31. ____________________ rrhagia  bleeding from the uterus at any time other than the normal period 32. ____________________ mastia  development of mammary glands in male 33. ____________________ mastia  absence of a breast 34. ____________________ mastia  unusually small breasts—a common surgical remedy is ____________________ mammoplasty 35. ____________________ mastia  unusually large breasts—a common surgical remedy is ____________________ mammoplasty 36. masto____________________  surgical fixation of a pendulous breast 37. ____________________ ectomy  removal of a breast 38. ____________________ ectomy  removal of a breast lump For each of the following, circle the combining form that corresponds to the meaning given: 39. birth or labor tox/o toc/o troph/o 40. vagina uter/o metr/o colp/o 41. uterine tube vagin/o oophor/o salping/o 42. menstruation men/o mamm/o mast/o 43. cervix colp/o cervic/o salping/o 44. egg oophor/o ov/i ovari/o 45. vulva episi/o vagin/o metr/o 46. uterus vagin/o metr/o oophor/o 47. milk lact/o leuk/o lip/o 48. ovary ov/o oophor/o salping/o 49. breast men/o metr/o mast/o 50. woman gen/o gynec/o hyster/o 568 Medical Terminology: The Language of Health Care Match the following: 51. ________ removal of a uterine tube a. PID and an ovary 52. ________ white vaginal discharge b.

chlamydia 53. ________ condition when the baby’s head c. colporrhaphy is too big for the birth canal 54. ________ presence of more than d. LEEP one nipple on a breast 55. ________ implantation of a fertilized e. CPD egg outside the uterus 56. ________ most common bacterial f. leukorrhea STD in North America 57. ________ excisional biopsy g. polythelia 58. ________ painful intercourse h. ectopic pregnancy 59. ________ surgical repair of a cystocele i. salpingo-oophorectomy 60. ________ inflammation of entire j. dyspareunia female pelvic cavity Give the medical term for the following: 61. condition of benign lumps in the breast that fluctuate in size during the menstrual cycle ____________________________________________________________ 62. abnormal opening between the bladder and vagina ___________________________ 63. cutting and tying the uterine tubes ___________________________________________ 64. having more than two breasts ______________________________________________ 65. bacterial STD caused by a spirochete ________________________________________ 66. study of cervical cells to screen for cancer ____________________________________ 67. condition of migration of endometrial tissue _________________________________ 68. abnormal opening between the rectum and vagina ____________________________ 69. surgical remedy for a rectocele ______________________________________________ Define the following abbreviations: 70. IUD _________________________________________________________ 71. HPV _________________________________________________________ 72. CVS _________________________________________________________ Chapter 17 • Female Reproductive System 569 73. D&C _________________________________________________________ 74. HBV _________________________________________________________ 75. EDC _________________________________________________________ 76. HSV _________________________________________________________ 77. STD _________________________________________________________ 78. TAB _________________________________________________________ 79. HRT ________________________________________________________ Identify terms related to abortion: 80. ________________________________ a naturally occurring miscarriage 81. ________________________________ a miscarriage occurring in three or more consecutive pregnancies 82. ________________________________ fetal expulsion with parts of the placenta remaining with bleeding 83. ________________________________ fetal death within the uterus 84. ________________________________ abortion induced by mechanical means or by drugs 85. ________________________________ bleeding with the threat of miscarriage Match the following: 86. ________ retroflexion a. forward bend of uterus 87. ________ condylomata b. toxemia of pregnancy 88. ________ para 2 c. backward bend of uterus 89. ________ prolapse d. a pregnant woman 90. ________ cystocele e. cancer 91. ________ gravida f. genital warts 92. ________ rectocele g. woman who has given birth twice 93. ________ eclampsia h. first delivery 94. ________ CIN 2 i. protrusion of the rectum into the vagina 95. ________ primipara j. descent of the uterus from its normal position 96. ________ anteflexion k. cervical dysplasia 97. ________ CIS l. pouching of the bladder into the vagina 570 Medical Terminology: The Language of Health Care Write in the missing words on the blank lines in the following illustration of the female reproductive anatomy. 98–105. Uterus: Frontal view The right side shows a cutaway view; the left side shows an external view. 100. Fallopian tube Fundus ( tube) Fimbriae Follicle 105. Broad ligament 101. Ovarian ligament 102. Body of Round ligament 98. 103. Cervical os 104. Corpus luteum 99. Mature graafian follicle Ovulation (ovum released) For each of the following, circle the correct spelling of the term: 106. gonoorhea gonorrhea ghonarhea 107. dyspareunia dyspariunia dysparunia 108. tokolytic toecolytic tocolytic 109. polithelia polythelia polytelia 110. meterorrhagia metrorrhagia metrorhagia 111. dialation dyelayshun dilation 112. salpingottomy salpingotomy salpigotomy 113. nulligravida nuligravida nulligraveda 114. meconeium meconium meconeum 115. macrosomia macrosomnia macrasomia 116. cureitage curettage curetage 117. eclampshea eklampsia eclampsia 118. amenorrhea amennorhea amenorhea 119. abortifacient abortafacient abortofacent Chapter 17 • Female Reproductive System 571 Give the noun that was used to form the following adjectives: 120. chlamydial __________________ 121. areolar ______________________ 122. syphilitic ____________________ 123. cervical _____________________ 124. dysplastic ___________________ 125. endometrial _________________ 572 Medical Terminology: The Language of Health Care MEDICAL RECORD ANALYSES M E D I C A L R E C O R D 1 7 . 1 GYN Chart Note S: This 44 y.o. female, gravida 2, para 2, c/o extremely heavy periods for the past several years that have been getting worse for the past 2 months and have been accompanied by moderately severe cramps. Pap smears have been normal. She has no bladder or bowel complaints. O: On pelvic exam, the uterus is found to be retroverted and irregularly enlarged with several large fibroids palpable. There are no adnexal masses. A: Leiomyomata uteri with secondary menorrhagia P: Schedule vaginal hysterectomy; donate 1 pint of blood for autologous transfusion, if necessary 1. What is the patient’s OB history? 4. What was the condition of the patient’s uterine a. never been pregnant tubes? b. been pregnant only once a. not stated c. had two miscarriages b. normal d. has been pregnant four times c. inflamed e. has had two live births d. enlarged e. had been previously removed 2. Identify the patient’s most significant symptom: a. amenorrhea 5. What was the Dx? b. dyspareunia a. congenital tumor composed of displaced embryonic tissue c. leukorrhea b. cyst of the uterine tube d. menorrhagia c. inflammation of the organs of the pelvic cavity e. metrorrhagia d. smooth muscle tumors in the uterus 3. Which of the following was one of the objective e. ovarian tumors findings? a. tipped uterus 6. What surgical procedure is planned? b. forward-bending uterus a. incision into uterine tube to remove the cyst c. backward-bending uterus b. excision of uterus d. presence of several ovarian tumors c. excision of ovaries e. migration of portions of endometrial tissue d. dilation of cervix and scraping of endometrium e. excision of tubes and ovaries Chapter 17 • Female Reproductive System 573 M E D I C A L R E C O R D 1 7 . 2 Jane Foley has seen her gynecologist, Dr. Phyllis Widetick, yearly for a routine ex- amination and Pap smear. Every year, the results have been normal. Jane is gener- ally a healthy, active woman. This year, however, Dr. Widetick’s examination and Pap smear found a problem. When the test results were in, Jane returned for addi- tional testing. Directions Read Medical Record 17.2 for Ms. Foley (pages 575–576) and answer the following questions. This record is the history and physical report dictated by Dr. Widetick after her examination. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 7 . 2 Write your answers in the spaces provided. 1. In your own words, not using medical terminology, briefly describe the patient’s chief complaint: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2. In your own words, not using medical terminology, briefly describe what a Pap smear is: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. Explain the result of Ms. Foley’s Pap smear: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. Because of this result, Dr. Widetick used colposcopy for further testing. Translate into nonmedical language what she discovered with this diagnostic procedure: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 574 Medical Terminology: The Language of Health Care 5. What was the positive finding from the biopsy? Define this in your own words: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 6. Ms. Foley underwent all the following procedures. Put these in correct sequence by numbering them 1 to 6 in the order they were performed: _____ follow-up examination _____ visualization with colposcope _____ ultrasound _____ Pap smear _____ routine physical examination _____ Bx 7. The sonogram definitely showed what finding? __________________________________________________________________________ What were the possible findings? __________________________________________________________________________ __________________________________________________________________________ 8. In nonmedical language, define the two previous surgeries Ms. Foley has had: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 9. How many children has Ms. Foley had? _________________________________________ 10. Mark any of the following abnormal findings from the present physical examination: a. enlarged uterus b. gross reflexes c. eroded cervix d. hypertension e. enlarged thyroid f. mobile right ovarian cyst 11. Define Dr. Widetick’s final diagnosis, and explain what she will do next to treat Ms. Foley: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Chapter 17 • Female Reproductive System 575 Medical Record 17.2 576 Medical Terminology: The Language of Health Care Medical Record 17.2 Continued Chapter 17 • Female Reproductive System 577 M E D I C A L R E C O R D 1 7 . 3 Kathleen Montegrande is pregnant with her first child. She has regularly seen her ob- stetrician, Dr. Linda Fenton, throughout the pregnancy. The pregnancy has gone well so far, although the fetus is in a breech presentation. She has come for a routine ob- stetrical examination by Dr. Fenton, which confirms the breech presentation. She then reports to Central Medical Center when labor begins. Directions Read Medical Record 17.3 for Ms. Montegrande (pages 579–581) and answer the fol- lowing questions. The first record is the history and physical examination report dic- tated by Dr. Fenton after Ms. Montegrande’s last routine examination and before de- livery. The second record is the discharge summary dictated from Central Medical Center by Dr. Fenton after Ms. Montegrande had her baby. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 7 . 3 Write your answers in the spaces provided: 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: Apgar score ________________________________________________________________ rubella vaccination _________________________________________________________ 2. In your own words, not using medical terminology, briefly describe a breech presentation: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. Which two tests that Dr. Fenton performed confirmed the breech presentation? a. sonography b. cesarean c. amniocentesis d. Bx e. pelvic examination f. colposcopy g. Pap smear 4. Mark any possible negative findings included in PMH: a. rheumatic fever b. closed cervix c. heart murmur d. mitral valve prolapse 5. Where did the autologous blood come from? __________________________________________________________________________ 578 Medical Terminology: The Language of Health Care 6. Explain what is important about the possibility of Ms. Montegrande’s baby being Rh positive: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 7. In your own words, explain what “80% effaced” means: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 8. What is the main reason for Dr. Fenton’s plan to perform a primary cesarean section? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 9. What two occurrences brought Ms. Montegrande to the Central Medical Center on March 6? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 10. In your own words, describe the surgery Ms. Montegrande underwent: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 11. What kind of suture did Dr. Fenton use to close the incision? __________________________________________________________________________ 12. Two other doctors were present in the surgical suite with Dr. Fenton: Dr. Nelson was there to help care for (whom?) ________________________________ Dr. O’Brien was there to help care for (whom?) _______________________________ 13. Mark any of the following surgical complications that occurred: a. uterine hemorrhage b. postop fever c. cervical erosion d. all of the above e. none of the above Chapter 17 • Female Reproductive System 579 Medical Record 17.3 580 Medical Terminology: The Language of Health Care Medical Record 17.3 Continued Chapter 17 • Female Reproductive System 581 Medical Record 17.3 Continued 582 Medical Terminology: The Language of Health Care M E D I C A L R E C O R D 1 7 . 4 Carla Woodward has been healthy all her life but is bothered by the unbalanced shape of her breasts. Finally, at age 23, she has chosen to see Dr. Karen McNeil, a plastic sur- geon recommended by her personal physician. Directions Read Medical Record 17.4 for Ms. Woodward (page 584) and answer the following questions. This record is the consultation report dictated by Dr. McNeil after meeting with and examining Ms. Woodward. Q U E S T I O N S A B O U T M E D I C A L R E C O R D 1 7 . 4 Write your answers in the spaces provided: 1. Below are medical terms used in this record you have not yet encountered in this text. Underline each where it appears in the record and define below: saline-filled ________________________________________________________________ silicone walled _____________________________________________________________ 2. In your own words, not using medical terminology, describe Ms. Woodward’s chief complaint: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. Summarize the two past surgeries Ms. Woodward has had. For each, identify the primary body system involved: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. Ms. Woodward told Dr. McNeil that she has never had a mammogram, a diagnos- tic procedure used primarily for what purpose? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Chapter 17 • Female Reproductive System 583 5. Dr. McNeil’s physical examination focuses on Ms. Woodward’s breasts. Describe the findings related to the breasts (first give the medical term for the finding, then define it): Medical Finding Definition Left breast ________________________ ___________________________________ ___________________________________ ___________________________________ Right breast _______________________ ___________________________________ ___________________________________ ___________________________________ 6. In your

own words, not using medical language, describe the surgery Dr. McNeil has proposed to Ms. Woodward: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 584 Medical Terminology: The Language of Health Care Medical Record 17.4 APPENDIX A Glossary of Prefixes, Suffixes, and Combining Forms Term Component to English balan/o ..................glans penis coron/o..................circle or crown a- ..........................without bi-..........................two or both cost/o ....................rib ab- ........................away from bil/i ........................bile crani/o ..................skull abdomin/o ............abdomen -blast ....................germ or bud crin/o ....................to secrete -ac ........................pertaining to blast/o ..................germ or bud cutane/o ................skin acous/o..................hearing blephar/o ..............eyelid cyan/o ..................blue acr/o ......................extremity or brachi/o ................arm cyst/o ....................bladder or sac topmost brady- ..................slow cyt/o ......................cell -acusis ..................hearing condition bronch/o ..............bronchus (airway) dacry/o ..................tear ad- ........................to, toward, or near bronchi/o ..............bronchus (airway) dactyl/o ................digit (finger or aden/o ..................gland bronchiol/o ..........bronchiole (little toe) adip/o....................fat airway) de- ........................from, down, or not adren/o..................adrenal gland bucc/o ..................cheek dent/i ....................teeth aer/o ......................air or gas capn/o ..................carbon dioxide derm/o ..................skin -al ..........................pertaining to carb/o....................carbon dioxide dermat/o ..............skin albumin/o ............protein carcin/o ................cancer -desis ....................binding -algia ....................pain cardi/o ..................heart dextr/o ..................right, or on the allo- ......................other cata- ......................down right side alveol/o..................alveolus (air sac) -cele........................pouching or hernia dia- ........................across or through ambi- ....................both celi/o ....................abdomen diaphor/o ..............profuse sweat an- ........................without -centesis ................puncture for dips/o ....................thirst ana- ......................up, apart aspiration dis- ........................separate from or an/o ......................anus cephal/o ................head apart andr/o ..................male cerebell/o ..............cerebellum (little doch/o ..................duct angi/o ....................vessel brain) duoden/o ..............duodenum ankyl/o ..................crooked or stiff cerebr/o ................cerebrum (largest -dynia....................pain ante- ......................before part of brain) dys- ......................painful, difficult, anti- ......................against or opposed cerumin/o ............wax or faulty to cervic/o ................neck or cervix -e ..........................noun marker aort/o ....................aorta cheil/o ..................lip e- ..........................out or away appendic/o ............appendix chir/o ....................hand -eal ........................pertaining to aque/o ..................water chol/e ....................bile ec- ........................out or away -ar..........................pertaining to chondr/o ..............cartilage (gristle) -ectasis ..................expansion or -arche....................beginning chrom/o ................color dilation arteri/o ..................artery chromat/o ............color ecto- ......................outside arthr/o ..................joint, articulation chyl/o ....................juice -ectomy ................excision (removal) articul/o ................joint circum- ................around -emesis..................vomiting -ary........................pertaining to cis/o ......................cut -emia ....................blood condition -ase........................enzyme col/o ......................colon en- ........................within -asthenia ..............weakness colon/o ..................colon encephal/o ............entire brain ather/o ..................fatty paste colp/o ....................vagina (sheath) endo- ....................within -ation ....................process con- ......................together or with enter/o ..................small intestine atri/o ....................atrium conjunctiv/o..........conjunctiva (to epi- ........................upon audi/o....................hearing join together) epididym/o............epididymis aur/i ......................ear contra- ..................against or opposed episi/o ..................vulva (covering) auto-......................self to erythr/o ................red bacteri/o................bacteria corne/o..................cornea esophag/o..............esophagus 585 586 Medical Terminology: The Language of Health Care esthesi/o................sensation infra- ....................below or under meta- ....................beyond, after, or eu- ........................good or normal inguin/o ................groin change ex- ........................out or away inter- ....................between -meter ..................instrument for exo- ......................outside intra- ....................within measuring extra- ....................outside ir/o ........................iris (colored metr/o ..................uterus fasci/o ..................fascia (a band) circle) -metry ..................process of femor/o ................femur irid/o ....................iris (colored measuring fibr/o ....................fiber circle) micro- ..................small gangli/o ................ganglion (knot) -ism ......................condition of mono- ..................one gastr/o ..................stomach iso- ........................equal, like morph/o ................form -gen ......................origin or -ist ........................one who multi- ....................many production specializes in muscul/o ..............muscle -genesis ................origin or -itis ........................inflammation my/o ......................muscle production -ium ......................structure or tissue myc/o ....................fungus gen/o ....................origin or jejun/o ..................jejunum (empty) myel/o ..................bone marrow or production kerat/o ..................hard or cornea spinal cord ger/o ......................old age ket/o ......................ketone bodies myos/o ..................muscle gingiv/o ................gums keton/o..................ketone bodies myring/o ..............eardrum gli/o ......................glue kinesi/o ................movement narc/o....................stupor, sleep glomerul/o ............glomerulus (little kyph/o ..................humpback nas/o ....................nose ball) lacrim/o ................tear nat/i ......................birth gloss/o ..................tongue lact/o ....................milk necr/o....................death glott/o....................opening lapar/o ..................abdomen neo- ......................new gluc/o ....................sugar laryng/o ................larynx (voice box) nephr/o ................kidney glyc/o ....................sugar lei/o ......................smooth neur/o ..................nerve glycos/o ................sugar -lepsy ....................seizure obstetr/o................midwife gnos/o ..................knowing leuc/o ....................white ocul/o ....................eye -gram ....................record leuk/o ....................white -oid........................resembling -graph ..................instrument for lex/o ......................word or phrase -ole ........................small recording lingu/o ..................tongue olig/o ....................few or deficient -graphy ................process of lip/o ......................fat -oma......................tumor recording lith/o......................stone or calculus onych/o ................nail gynec/o..................woman lob/o ......................lobe (a portion) oophor/o ..............ovary hem/o....................blood -logist ....................one who ophthalm/o ..........eye hemat/o ................blood specialized in -opia......................condition of vision hemi- ....................half the study or opt/o......................eye hepat/o..................liver treatment of or/o........................mouth hepatic/o ..............liver -logy ......................study of orch/o....................testis (testicle) herni/o ..................hernia lord/o ....................bent orchi/o ..................testis (testicle) hetero- ..................different lumb/o ..................loin (lower back) orchid/o ................testis (testicle) hidr/o ....................sweat lymph/o ................clear fluid orth/o ....................straight, normal, hist/o ....................tissue -lysis......................breaking down or or correct histi/o ....................tissue dissolution -osis ......................condition or homo- ..................same macro- ..................large or long increase hormon/o..............hormone (an -malacia ................softening oste/o ....................bone urging on) mamm/o ..............breast ot/o........................ear hydr/o ..................water -mania ..................abnormal impulse -ous ......................pertaining to hyper-....................above or excessive (attraction) ov/i ........................egg hypn/o ..................sleep toward ov/o ......................egg hypo- ....................below or deficient mast/o ..................breast ovari/o ..................ovary hyster/o ................uterus meat/o ..................opening ox/o ......................oxygen -ia ..........................condition of mega- ....................large pachy- ..................thick -iasis......................formation of or megal/o ................large palat/o ..................palate presence of -megaly ................enlargement pan- ......................all iatr/o ....................treatment melan/o ................black pancreat/o ............pancreas -iatrics ..................treatment men/o....................menstruation para-......................alongside of or -iatry ....................treatment mening/o ..............meninges abnormal -ic ..........................pertaining to (membrane) -paresis ................slight paralysis -icle ......................small meningi/o ............meninges patell/o ..................knee cap ile/o ......................ileum (membrane) path/o....................disease immun/o ..............safe meso- ....................middle pector/o ................chest Appendix A • Glossary of Prefixes, Suffixes, and Combining Forms 587 ped/o ....................child or foot ren/o......................kidney tachy- ....................fast pelv/i, pelv/o ........hip bone reticul/o ................a net tax/o ......................order or -penia....................abnormal retin/o ..................retina coordination reduction retro- ....................backward or ten/o ......................tendon (to stretch) per-........................through behind tend/o....................tendon (to stretch) peri- ......................around rhabd/o ................rod shaped or tendin/o ................tendon (to stretch) perine/o ................perineum striated test/o ....................testis (testicle) peritone/o ............peritoneum (skeletal) thalam/o................thalamus (a room) -pexy ....................suspension or rhin/o ....................nose therm/o ................heat fixation -rrhage ..................to burst forth thorac/o ................chest phac/o ..................lens (lentil) -rrhagia ................to burst forth thromb/o ..............clot phag/o ..................eat or swallow -rrhaphy................suture thym/o ..................thymus gland phak/o ..................lens (lentil) -rrhea ....................discharge thyr/o, thyroid/o ..thyroid gland pharyng/o ............pharynx (throat) -rrhexis ................rupture (shield) phas/o ..................speech salping/o ..............uterine (fallopian) -tic ........................pertaining to -phil ......................attraction for tube; also toc/o ......................labor or birth -philia ..................attraction for eustachian tube tom/o ....................to cut phleb/o..................vein sarc/o ....................flesh -tomy ....................incision phob/o ..................exaggerated fear schiz/o ..................split, division ton/o......................tone or tension or sensitivity scler/o ..................hard or sclera tonsill/o ................tonsil (almond) phon/o ..................voice or sound scoli/o....................twisted top/o......................place phor/o ..................to carry or bear -scope....................instrument for tox/o ......................poison phot/o....................light examination toxic/o ..................poison phren/o ................diaphragm (also -scopy....................examination trache/o ................trachea mind) seb/o......................sebum (oil) (windpipe) physi/o ..................physical, nature semi- ....................half trans- ....................across or through plas/o ....................formation sial/o ....................saliva tri- ........................three -plasia ..................formation sigmoid/o..............sigmoid colon trich/o ..................hair -plasty ..................surgical repair or sinistr/o ................left, or on the left -tripsy....................crushing reconstruction side troph/o ..................nourishment or -plegia ..................paralysis sinus/o ..................hollow (cavity) development pleur/o ..................pleura somat/o ................body tympan/o ..............eardrum -pnea ....................breathing somn/i ..................sleep -ula, -ule................small pneum/o................air or lung somn/o ..................sleep uln/o......................ulna (a bone of the pneumon/o ..........air or lung son/o ....................sound forearm) pod/o ....................foot -spasm ..................involuntary ultra- ....................beyond or -poiesis..................formation contraction excessive poly- ......................many sperm/o ................sperm (seed) uni-........................one post- ......................after or behind spermat/o..............sperm (seed) ur/o ......................urine pre-........................before sphygm/o ..............pulse ureter/o ................ureter presby/o ................old age spin/o ....................spine (thorn) urethr/o ................urethra pro- ......................before spir/o ....................breathing urin/o ....................urine proct/o ..................anus and rectum splen/o ..................spleen uter/o ....................uterus prostat/o ..............prostate spondyl/o ..............vertebra vagin/o ..................vagina (sheath) psych/o..................mind squam/o ................scale varic/o ..................swollen or twisted -ptosis ..................falling or -stasis ....................stop or stand vein downward steat/o ..................fat vas/o......................vessel displacement sten/o ....................narrow vascul/o ................vessel pulmon/o ..............lung stere/o ..................three-dimensional ven/o ....................vein purpur/o ..............purple or solid ventricul/o ............ventricle (belly or py/o ......................pus stern/o ..................sternum pouch) pyel/o ....................basin (breastbone) vertebr/o ..............vertebra pylor/o ..................pylorus steth/o ..................chest vesic/o ..................bladder or sac (gatekeeper) stomat/o................mouth vesicul/o................bladder or sac quadri- ..................four -stomy ..................creation of an vitre/o....................glassy radi/o ....................radius (a bone of opening vulv/o ....................vulva (covering) the forearm); sub- ......................below or under xanth/o..................yellow radiation (espe- super-....................above or excessive xeno- ....................strange cially x-ray) supra-....................above or excessive xer/o ......................dry re-..........................again or back sym- ......................together or with -y ..........................condition or rect/o ....................rectum syn- ......................together or with process of 588 Medical Terminology: The Language of Health Care English to Term Component bone ......................oste/o disease ..................path/o abdomen ..............abdomin/o, celi/o, bone marrow........myel/o dissolution............-lysis lapar/o both ......................ambi-, bi- division ................schiz/o abnormal ..............para- brain ....................cerebr/o (largest down ....................cata-, de- abnormal part), downward impulse encephal/o displacement ....-ptosis (attraction) (entire brain) dry ........................xer/o toward ..............-mania breaking down ....-lysis duct ......................doch/o abnormal breast ....................mamm/o, mast/o duodenum ............duoden/o reduction ..........-penia breathing ..............-pnea, spir/o ear ........................aur/i, ot/o above ....................hyper-, super-, bronchus ..............bronch/o, eardrum................myring/o, supra- bronchi/o tympan/o across....................dia-, trans- bud........................-blast, blast/o eat, swallow..........phag/o adrenal gland ......adren/o, adrenal/o burst forth ............-rrhage, -rrhagia egg ........................ov/i, ov/o after ......................meta-, post- calculus ................lith/o enlargement ........-megaly again ....................re- cancer ..................carcin/o enzyme ................-ase against ..................anti-, contra- carbon dioxide ....capn/o, carb/o epididymis............epididym/o air..........................aer/o, pneum/o, carry......................phor/o equal ....................iso- pneumon/o cartilage................chondr/o esophagus ............esophag/o air sac ..................alveol/o cavity (sinus) ........atri/o, sin/o eustachian tube....salping/o airway ..................bronch/o, cell ........................cyt/o examination ........-scopy bronchi/o cerebellum............cerebell/o excessive ..............hyper-, super-, all ..........................pan- cerebrum ..............cerebr/o supra-, ultra- alongside of ..........para- cervix ....................cervic/o excision alveolus ................alveol/o change ..................meta- (removal) ..........-ectomy anus ......................an/o cheek ....................bucc/o expansion or anus and rectum ..proct/o chest......................pectoro, steth/o, dilation..............-ectasis aorta......................aort/o thorac/o extremity ..............acr/o apart ....................ana-, dis- child ......................ped/o eye ........................ocul/o, appendix ..............appendic/o circle ....................coron/o ophthalm/o, arm ......................brachi/o clear fluid ............lymph/o opt/o around ..................circum-, peri- clot ........................thromb/o eyelid ....................blephar/o artery ....................arteri/o colon ....................col/o, colon/o falling....................-ptosis articulation ..........arthr/o colon, sigmoid......sigmoid/o fallopian tube ......salping/o atrium ..................atri/o color......................chrom/o, fascia ....................fasci/o attraction for ........-phil, -philia chromat/o fast ........................tachy- away......................e-, ec-, ex- colored circle........ir/o, irid/o fat..........................adip/o, away from ............ab- condition ..............-osis lip/o, steat/o back ......................re- condition of ..........-ia, -ism, ium, -y fatty paste ............ather/o, backward ..............retro- contraction, faulty ....................dys- bacteria ................bacteri/o involuntary ......-spasm fear, exaggerated..phob/o basin ....................pyel/o coordination ........tax/o femur ....................femor/o bear ......................phor/o cornea ..................corne/o, kerat/o few ........................olig/o before....................ante-, pre-, pro- correct ..................ortho- fiber ......................fibr/o beginning..............-arche creation of an fixation ................-pexy behind ..................post-, retro- opening ............-stomy flesh ......................sarc/o below ....................hypo-, infra-, sub- crooked ................ankyl/o foot........................ped/o, pod/o bent ......................lord/o crown....................coron/o form ......................morph/o between ................inter- crushing................-tripsy formation..............plas/o, -plasia, beyond ..................meta-, ultra- cut ........................cis/o, tom/o -poiesis bile ........................bil/i, chol/e death ....................necr/o formation of ........-iasis bile duct................choledoch/o deficient................hypo-, olig/o four ......................quadri- binding ................-desis development ........troph/o from ......................de- birth ......................nat/i, toc/o diaphragm ............phren/o fungus ..................myc/o black ....................melan/o different ................hetero- ganglion................gangli/o bladder..................cyst/o, vesic/o, difficult ................dys- gas ........................aer/o vesicul/o digit (finger germ or bud..........-blast, blast/o blood ....................hem/o, hemat/o or toe)................dactyl/o gland ....................aden/o blood condition....-emia dilation or glans penis............balan/o blue ......................cyan/o expansion..........-ectasis glassy ....................vitre/o body ......................somat/o discharge ..............-rrhea glomerulus............glomerul/o Appendix A • Glossary of Prefixes, Suffixes, and Combining Forms 589 glue ......................gli/o milk ......................lact/o process..................-ation good ......................eu- mind ....................phren/o, psych/o, process of ............-y groin ....................inguin/o thym/o production............-gen, gen/o, gums ....................gingiv/o mouth ..................or/o, stomat/o -genesis hair ......................trich/o movement ............kinesi/o prostate ................prostat/o half........................hemi-, semi- muscle ..................muscul/o, my/o, protein ..................albumin/o hand......................chir/o myos/o pulse ....................sphygm/o hard ......................kerat/o, scler/o nail ........................onych/o puncture for head ......................cephal/o narrow ..................sten/o aspiration..........-centesis hearing..................acous/o, audi/o nature ..................physi/o purple ..................purpur/o hearing near ......................ad- pus ........................py/o condition ..........-acusis neck ......................cervic/o pylorus..................pylor/o heart......................cardio/o nerve ....................neur/o radius....................radi/o heat ......................therm/o net ........................reticul/o record ..................-gram hernia ..................-cele, herni/o new ......................neo- recording, hip bone................pelv/i, pelv/o normal ..................eu-, ortho- process of..........-graphy hormone ..............hormon/o nose ......................nas/o, rhin/o rectum ..................rect/o humpback ............kyph/o not ........................de- red ........................erythr/o ileum ....................ile/o nourishment ........troph/o resembling............-oid incision ................-tomy oil ..........................seb/o reticulum..............reticul/o increase ................-osis old age ..................ger/o, geront/o, retina ....................retin/o inflammation ......-itis presby/o rib ........................cost/o instrument for one ........................mono-, uni- right, or on the examination......-scope one who right side ..........dextr/o instrument for specializes in ....-ist rod shaped............rhabd/o measuring ........-meter one who rupture..................-rrhexis instrument for specializes in sac ........................cyst/o, vesic/o, recording ..........-graph the study or vesicul/o jejunum (empty) ..jejun/o treatment of ......-logist safe........................immun/o joint ......................arthr/o, articul/o opening ................glott/o, meat/o saliva ....................sial/o juice ......................chyl/o opening, scale ......................squam/o ketone bodies ......ket/o, keton/o creation of ........-stomy sclera ....................scler/o kidney ..................nephr/o, ren/o opposed to ............anti-, contra- sebum ..................seb/o kneecap ................patell/o order ....................tax/o secrete ..................crin/o knowing................gnos/o origin ....................-gen, -genesis, seizure ..................-lepsy labor......................toc/o gen/o self ........................auto- large ......................macro-, mega-, other ....................allo- sensation ..............esthesi/o megal/o out ........................e-, ec-, ex- sensitivity, larynx....................laryng/o outside ..................ecto-, exo-, extra- exaggerated ......phob/o left, or on the ovary ....................oophor/o, ovari/o separate from ......dis- left side..............sinistr/o oxygen ..................ox/o sheath ..................vagin/o lens........................phac/o, phak/o pain ......................-algia, -dynia sigmoid colon ......sigmoid/o light ......................phot/o painful ..................dys- sinus......................sinus/o like ........................iso- palate ....................palat/o skeletal..................rhabd/o lip ..........................cheil/o pancreas ..............pancreat/o skin ......................cutane/o, derm/o, liver ......................hepat/o, hepatic/o paralysis................-plegia dermat/o lobe ......................lob/o paralysis, slight ....-paresis skull ......................crani/o loin (lower back) ..lumb/o perineum ..............perine/o sleep......................hypn/o, narc/o, long ......................macro- peritoneum ..........peritone/o somn/i, somn/o lung ......................pneum/o, pertaining to ........-ac, -al, -ar, -ary, slow ......................brady- pneumon/o, -eal, -ic, -ous, small ....................-icle, micro-, -ole, pulmon/o -tic -ula, -ule male ......................andr/o pharynx ................pharyng/o small intestine......enter/o many ....................multi-, poly- phrase ..................lex/o smooth..................lei/o measuring, physical ................physi/o softening ..............-malacia instrument for ..-meter place......................top/o sound ....................phon/o, son/o measuring, pleura....................pleur/o specializes, process of..........-metry poison ..................tox/o, toxic/o one who ............-ist meninges ..............mening/o, portion..................lob/o speech ..................phas/o meningi/o pouching ..............-cele sperm....................sperm/o, menstruation........men/o presence of ..........-iasis spermat/o 590 Medical Terminology: The Language of Health Care spinal cord............myel/o thalamus ..............thalam/o urethra..................urethr/o spine ....................spin/o thick......................pachy- urine ....................ur/o, urin/o spleen....................splen/o thirst ....................dips/o uterine tube ..........salping/o split ......................schiz/o three......................tri- uterus....................hyster/o, metr/o, sternum ................stern/o three- uter/o stiff........................ankyl/o dimensional vagina ..................colp/o, vagin/o stomach ................gastr/o or solid ..............stere/o vein

......................phleb/o, ven/o stone ....................lith/o throat ....................pharyng/o vein, swollen or stop or stand ........-stasis through ................dia-, per-, trans- twisted ..............varic/o straight ................orth/o thymus gland........thym/o ventricle ................ventricul/o strange ..................xeno- thyroid gland........thyr/o, thyroid/o vertebra ................vertebr/o, striated..................rhabd/o tissue ....................hist/o, -ium spondyl/o structure ..............-ium to or toward..........ad- vessel ....................angi/o, vas/o, study of ................-logy together ................con-, sym-, syn- vascul/o study of, tone ......................ton/o vision, one who tongue ..................gloss/o, lingu/o condition of ......-opia specializes in ....-logist tonsil ....................tonsill/o voice......................phon/o stupor ..................narc/o topmost ................acr/o voice box ..............laryng/o sugar ....................gluc/o, glyc/o, trachea..................trache/o vomiting ..............-emesis glycos/o treatment..............iatr/o, -iatrics, vulva ....................episi/o, vulv/o surgical repair or -iatry water ....................aque/o, hydr/o reconstruction ..-plasty treatment, wax........................cerumin/o suspension............-pexy one who weakness ..............-asthenia suture....................-rrhaphy specializes in ....-logist white ....................leuc/o, leuk/o swallow ................phag/o trop/o ....................to turn windpipe ..............trache/o sweat ....................hidr/o tumor....................-oma with ......................con-, sym-, syn- sweat, profuse ......diaphor/o turn ......................trop/o within ..................en-, endo-, intra- tear........................dacry/o, lacrim/o twisted ..................scoli/o without ................a-, an- teeth ......................dent/i two ........................bi- woman..................gynec/o tendon ..................ten/o, tend/o, ulna ......................uln/o word......................lex/o tendin/o under ....................infra-, sub- yellow....................xanth/o tension ..................ton/o up ..........................ana- testis (testicle) ......orch/o, orchi/o, upon......................epi- orchid/o, test/o ureter ....................ureter/o APPENDIX B Abbreviations and Symbols Abbreviations deemed error prone are printed in red. ā . . . . . . . . . . . . . . before AST . . . . . . . . . . aspartate aminotrans- c/o . . . . . . . . . . . . complains of A . . . . . . . . . . . . . anterior; assessment ferase (enzyme) COPD . . . . . . . . chronic obstructive A&P . . . . . . . . . . auscultation and AU. . . . . . . . . . . . both ears pulmonary disease percussion AV. . . . . . . . . . . . atrioventricular CP . . . . . . . . . . . . chest pain; cerebral A&W . . . . . . . . . alive and well B . . . . . . . . . . . . . bilateral palsy AB. . . . . . . . . . . . abortion BAEP. . . . . . . . . brainstem auditory CPAP . . . . . . . . . continuous positive ABG . . . . . . . . . . arterial blood gas evoked potentials airway pressure a.c. . . . . . . . . . . . before meals BCC . . . . . . . . . . basal cell carcinoma CPD . . . . . . . . . . cephalopelvic ACE . . . . . . . . . . angiotensin-converting BD . . . . . . . . . . . bipolar disorder disproportion enzyme b.i.d.. . . . . . . . . . twice a day CPR . . . . . . . . . . cardiopulmonary ACP . . . . . . . . . . American College of BKA . . . . . . . . . . below-knee resuscitation Physicians amputation CSF . . . . . . . . . . cerebrospinal fluid ACS . . . . . . . . . . American College of BM . . . . . . . . . . . black male; bowel C-section . . . . . cesarean section Surgeons movement CSII . . . . . . . . . . continuous ACTH . . . . . . . . adrenocorticotrophic BP . . . . . . . . . . . . blood pressure subcutaneous hormone BPH . . . . . . . . . . benign prostatic insulin infusion AD. . . . . . . . . . . . right ear hyperplasia/ CT . . . . . . . . . . . . computed tomography ADH. . . . . . . . . . antidiuretic hormone hypertrophy cu mm . . . . . . . cubic millimeter ADHD . . . . . . . . attention-deficit/ BRP . . . . . . . . . . bathroom privileges CVA . . . . . . . . . . cerebrovascular hyperactivity BS . . . . . . . . . . . . blood sugar accident disorder BUN. . . . . . . . . . blood urea nitrogen CVS . . . . . . . . . . chorionic villus ad lib. . . . . . . . . as desired Bx . . . . . . . . . . . . biopsy sampling AIDS . . . . . . . . . acquired immuno- c̄ . . . . . . . . . . . . . . with CXR . . . . . . . . . . chest x-ray deficiency syndrome C . . . . . . . . . . . . . Celsius; centigrade d. . . . . . . . . . . . . . day AKA . . . . . . . . . . above-knee C&S . . . . . . . . . . culture and sensitivity D&C. . . . . . . . . . dilation and curettage amputation CABG . . . . . . . . coronary artery bypass DC. . . . . . . . . . . . Doctor of Chiropractic alb. . . . . . . . . . . . albumin graft Medicine ALS . . . . . . . . . . amyotrophic lateral CAD . . . . . . . . . . coronary artery DC, D/C . . . . . discharge; discontinue sclerosis disease DDS . . . . . . . . . . Doctor of Dental ALT . . . . . . . . . . alanine aminotrans- cap . . . . . . . . . . . capsule Surgery ferase (enzyme) CAT . . . . . . . . . . computed axial DEXA . . . . . . . . dual-energy x-ray a.m. . . . . . . . . . . morning tomography absorptiometry AMBS . . . . . . . . American Board of CBC . . . . . . . . . . complete blood count DJD . . . . . . . . . . degenerative joint Medical Specialties cc . . . . . . . . . . . . cubic centimeter disease amt. . . . . . . . . . . amount CC. . . . . . . . . . . . chief complaint; car- DKA . . . . . . . . . . diabetic ketoacidosis ANS . . . . . . . . . . autonomic nervous diac catheterization DM . . . . . . . . . . . diabetes mellitus system CCU . . . . . . . . . . coronary (cardiac) DO . . . . . . . . . . . Doctor of Osteopathic AOA . . . . . . . . . . American Osteopathic care unit; critical Medicine Association care unit DPM . . . . . . . . . Doctor of Podiatric AP . . . . . . . . . . . . anterior posterior CHF . . . . . . . . . . congestive heart failure Medicine APKD . . . . . . . . adult polycystic kidney CIN. . . . . . . . . . . cervical intraepithelial dr. . . . . . . . . . . . . dram disease neoplasia DRE . . . . . . . . . . digital rectal aq . . . . . . . . . . . . water CIS . . . . . . . . . . . carcinoma in situ examination AS . . . . . . . . . . . left ear cm. . . . . . . . . . . . centimeter DTR . . . . . . . . . . deep tendon reflex ASD . . . . . . . . . . atrial septal defect CNS . . . . . . . . . . central nervous system DVT . . . . . . . . . . deep vein thrombosis ASHD . . . . . . . . arteriosclerotic heart CO. . . . . . . . . . . . cardiac output Dx . . . . . . . . . . . . diagnosis disease CO2. . . . . . . . . . . carbon dioxide ECG . . . . . . . . . . electrocardiogram 591 592 Medical Terminology: The Language of Health Care ECHO . . . . . . . . echocardiogram HCV. . . . . . . . . . hepatitis C virus MD . . . . . . . . . . . muscular dystrophy; ECT . . . . . . . . . . electroconvulsive HD . . . . . . . . . . . Huntington disease Medical Doctor therapy HEENT . . . . . . head, eyes, ears, nose, mg. . . . . . . . . . . . milligram ECU . . . . . . . . . . emergency care unit throat MI . . . . . . . . . . . . myocardial infarction ED . . . . . . . . . . . erectile dysfunction HGB or Hgb . hemoglobin ml, mL . . . . . . . milliliter EDC . . . . . . . . . . estimated date of HIV . . . . . . . . . . human immuno- mm. . . . . . . . . . . millimeter confinement deficiency virus MRA . . . . . . . . . magnetic resonance EDD. . . . . . . . . . estimated date of HPI. . . . . . . . . . . history of present angiography delivery illness MRI . . . . . . . . . . magnetic resonance EEG . . . . . . . . . . electroencephalogram HPV . . . . . . . . . . human papilloma imaging EGD. . . . . . . . . . esophagogastro- virus MS . . . . . . . . . . . multiple sclerosis; duodenoscopy HRT . . . . . . . . . . hormone replacement musculoskeletal EIA . . . . . . . . . . . enzyme immunoassay therapy MSH . . . . . . . . . melanocyte- EKG. . . . . . . . . . electrocardiogram h.s.. . . . . . . . . . . bedtime (hour of stimulating EMG . . . . . . . . . electromyogram sleep); half strength hormone ENT . . . . . . . . . . ear, nose, throat HSV-1 . . . . . . . . herpes simplex virus MVP. . . . . . . . . . mitral valve prolapse EPS . . . . . . . . . . electrophysiological type 1 NCV . . . . . . . . . . nerve conduction study HSV-2 . . . . . . . . herpes simplex virus velocity ER. . . . . . . . . . . . emergency room type 2 NG . . . . . . . . . . . nasogastric ERCP . . . . . . . . endoscopic retrograde Ht . . . . . . . . . . . . height NKA. . . . . . . . . . no known

allergy cholangio- HTN. . . . . . . . . . hypertension NKDA . . . . . . . . no known drug allergy pancreatography Hx . . . . . . . . . . . . history noc. . . . . . . . . . . night ESR . . . . . . . . . . erythrocyte I&D . . . . . . . . . . incision and drainage NPO . . . . . . . . . . nothing by mouth sedimentation rate ICD. . . . . . . . . . . implantable NSAID . . . . . . . nonsteroidal anti- ESWL . . . . . . . . extracorporeal shock cardioverter inflammatory drug wave lithotripsy defibrillator NSR . . . . . . . . . . normal sinus rhythm ETOH ICU. . . . . . . . . . . intensive care unit O . . . . . . . . . . . . . objective . . . . . . . . ethyl alcohol F ID . . . . . . . . . . . . intradermal O2 . . . . . . . . . . . . oxygen . . . . . . . . . . . . . Fahrenheit FACP . . . . . . . . . Fellow of the Ig . . . . . . . . . . . . . immunoglobulins OA. . . . . . . . . . . . osteoarthritis American College of IM . . . . . . . . . . . . intramuscular OB . . . . . . . . . . . obstetrics IMP . . . . . . . . . . impression OB/GYN. . . . . . obstetrics and Physicians FACS IOL. . . . . . . . . . . intraocular lens gynecology . . . . . . . . . Fellow of the American College of implant OCD . . . . . . . . . . obsessive-compulsive IP. . . . . . . . . . . . . inpatient disorder Surgeons IUD. . . . . . . . . . . intrauterine device OCP . . . . . . . . . . oral contraceptive pill FBS . . . . . . . . . . fasting blood sugar IV . . . . . . . . . . . . intravenous OD . . . . . . . . . . . right eye; Doctor of Fe . . . . . . . . . . . . iron (ferrous) IVP . . . . . . . . . . . intravenous pyelogram Optometry FH. . . . . . . . . . . . family history kg . . . . . . . . . . . . kilogram OH . . . . . . . . . . . occupational history fl oz . . . . . . . . . . fluid ounce KUB. . . . . . . . . . kidney, ureter, bladder OP. . . . . . . . . . . . outpatient FS . . . . . . . . . . . . frozen section L . . . . . . . . . . . . . left; liter OR . . . . . . . . . . . operating room FSH . . . . . . . . . . follicle-stimulating L&W . . . . . . . . . living and well ORIF . . . . . . . . . open reduction, hormone LASIK. . . . . . . . laser-assisted in situ internal fixation Fx . . . . . . . . . . . . fracture keratomileusis OS. . . . . . . . . . . . left eye g. . . . . . . . . . . . . . gram lb . . . . . . . . . . . . . pound OU . . . . . . . . . . . both eyes GAD . . . . . . . . . . generalized anxiety LEEP. . . . . . . . . loop electrosurgical oz . . . . . . . . . . . . ounce disorder excision procedure p̄. . . . . . . . . . . . . . after GERD . . . . . . . . gastroesophageal LH . . . . . . . . . . . luteinizing hormone P . . . . . . . . . . . . . plan; posterior; pulse reflux disease LLETZ . . . . . . . large loop excision of PA . . . . . . . . . . . . posterior anterior GH . . . . . . . . . . . growth hormone transformation zone PaCO2 . . . . . . . . arterial partial GI . . . . . . . . . . . . gastrointestinal LLQ . . . . . . . . . . left lower quadrant pressure of gm. . . . . . . . . . . . gram LP . . . . . . . . . . . . lumbar puncture carbon dioxide gr. . . . . . . . . . . . . grain LTB . . . . . . . . . . laryngotracheo- PACU. . . . . . . . . postanesthetic care gt . . . . . . . . . . . . . drop bronchitis unit gtt . . . . . . . . . . . . drops LUQ . . . . . . . . . . left upper quadrant PaO2 . . . . . . . . . arterial partial GTT . . . . . . . . . . glucose tolerance test m. . . . . . . . . . . . . meter pressure of oxygen GYN. . . . . . . . . . gynecology m . . . . . . . . . . . . murmur PAP . . . . . . . . . . Papanicolaou test h. . . . . . . . . . . . . . hour MCH . . . . . . . . . mean corpuscular (smear) H&H . . . . . . . . . hemoglobin and (cell) hemoglobin PAR . . . . . . . . . . postanesthetic hematocrit MCHC. . . . . . . . mean corpuscular recovery H&P. . . . . . . . . . history and physical (cell) hemoglobin p.c. . . . . . . . . . . . after meals HAV . . . . . . . . . . hepatitis A virus concentration PD. . . . . . . . . . . . panic disorder HBV. . . . . . . . . . hepatitis B virus MCV . . . . . . . . . mean corpuscular PDA . . . . . . . . . . patent ductus HCT or Hct . . hematocrit (cell) volume arteriosus Appendix B • Abbreviations and Symbols 593 PE . . . . . . . . . . . . physical examination; q.s. . . . . . . . . . . . quantity sufficient TIA . . . . . . . . . . . transient ischemic pulmonary qt . . . . . . . . . . . . . quart attack embolism; R . . . . . . . . . . . . . right; respiration t.i.d. . . . . . . . . . . three times a day polyethylene RA. . . . . . . . . . . . rheumatoid arthritis TM . . . . . . . . . . . tympanic membrane PEFR. . . . . . . . . peak expiratory flow RBC . . . . . . . . . . red blood cell; red TMR . . . . . . . . . transmyocardial rate blood count revascularization per . . . . . . . . . . . by RIA. . . . . . . . . . . radioimmunoassay tPA, TPA . . . . . tissue plasminogen PERRLA . . . . . pupils equal, round, RLQ . . . . . . . . . . right lower quadrant activator and reactive to light R/O. . . . . . . . . . . rule out TPR . . . . . . . . . . temperature, pulse, and accommodation ROM . . . . . . . . . range of motion respiration PET . . . . . . . . . . positron emission ROS . . . . . . . . . . review of symptoms Tr . . . . . . . . . . . . treatment tomography RP. . . . . . . . . . . . retrograde pyelogram TSH . . . . . . . . . . thyroid-stimulating PF . . . . . . . . . . . . peak flow RRR. . . . . . . . . . regular rate and hormone PFT. . . . . . . . . . . pulmonary function rhythm TURP . . . . . . . . transurethral resection testing RSD . . . . . . . . . . reflex sympathetic of the prostate pH. . . . . . . . . . . . potential of hydrogen dystrophy TV . . . . . . . . . . . . tidal volume PH. . . . . . . . . . . . past history RTC Tx . . . . . . . . . . . . treatment; traction . . . . . . . . . . return to clinic Ph.D. . . . . . . . . . Doctor of Philosophy UA. . . . . . . . . . . . urinalysis RTO . . . . . . . . . . return to office PI. . . . . . . . . . . . . present illness UCHD . . . . . . . . usual childhood RUQ. . . . . . . . . . right upper quadrant PID . . . . . . . . . . . pelvic inflammatory diseases Rx . . . . . . . . . . . . recipe; take thou disease UFE . . . . . . . . . . uterine fibroid s̄ . . . . . . . . . . . . . . without PIH. . . . . . . . . . . pregnancy-induced embolization S . . . . . . . . . . . . . subjective hypertension URI. . . . . . . . . . . upper respiratory SA . . . . . . . . . . . . sinoatrial PLT . . . . . . . . . . platelet (count) infection SAB . . . . . . . . . . spontaneous abortion p.m. . . . . . . . . . . afternoon UTI . . . . . . . . . . . urinary tract infection SAD . . . . . . . . . . seasonal affective PMH . . . . . . . . . past medical history VC. . . .

. . . . . . . . vital capacity disorder PMN . . . . . . . . . polymorphonuclear VCU, VCUG . . voiding SC . . . . . . . . . . . . subcutaneous leukocyte cystourethrogram SCC . . . . . . . . . . squamous cell PNS . . . . . . . . . . peripheral nervous VS . . . . . . . . . . . . vital signs carcinoma system VSD . . . . . . . . . . ventricular septal SH. . . . . . . . . . . . social history p.o. defect . . . . . . . . . . . by mouth Sig: . . . . . . . . . . . instruction to patient post op VT . . . . . . . . . . . . tidal volume . . . . . . . after operation SLE . . . . . . . . . . systemic lupus PPBS . . . . . . . . . postprandial blood w.a.. . . . . . . . . . . while awake erythematosus sugar WBC . . . . . . . . . white blood cell; white PR SOB . . . . . . . . . . shortness of breath . . . . . . . . . . . . per rectum blood count pre-op, preop before operation SPECT . . . . . . . single photon WDWN. . . . . . . well developed and p.r.n. emission computed . . . . . . . . . as needed well nourished PSA tomography wk . . . . . . . . . . . . week . . . . . . . . . . prostate-specific antigen SpGr . . . . . . . . . specific gravity WNL . . . . . . . . . within normal limits PSG SQ. . . . . . . . . . . . subcutaneous Wt . . . . . . . . . . . . weight . . . . . . . . . . polysomnography x-ray. . . . . . . . . . radiography pt . . . . . . . . . . . . . patient SR. . . . . . . . . . . . systems review PT . . . . . . . . . . . . physical therapy; ss . . . . . . . . . . . . . one-half y.o. . . . . . . . . . . . year old prothrombin time STAT . . . . . . . . . immediately yr . . . . . . . . . . . . . year PTCA . . . . . . . . . percutaneous STD . . . . . . . . . . sexually transmitted  . . . . . . . . . . . . . female transluminal disease  . . . . . . . . . . . . . male #. . . . . . . . . . . . . . number or pound coronary angioplasty Sub-Q . . . . . . . . subcutaneous PTH . . . . . . . . . . parathyroid hormone SUI . . . . . . . . . . . stress urinary ° . . . . . . . . . . . . . . degree or hour ↑. . . . . . . . . . . . . . increased; above PTSD. . . . . . . . . posttraumatic stress incontinence disorder suppos . . . . . . . suppository ↓. . . . . . . . . . . . . . decreased; below PTT . . . . . . . . . . partial thromboplastin SV . . . . . . . . . . . . stroke volume . . . . . . . . . . . . none or negative time Sx . . . . . . . . . . . . symptom . . . . . . . . . . . . . standing PUD . . . . . . . . . . peptic ulcer disease T . . . . . . . . . . . . . temperature . . . . . . . . . . . . sitting PV . . . . . . . . . . . . per vagina T3 . . . . . . . . . . . . triiodothyronine . . . . . . . . . . lying PVC . . . . . . . . . . premature ventricular T4 . . . . . . . . . . . . thyroxine  . . . . . . . . . . . . . times or for contraction T&A . . . . . . . . . . tonsillectomy and  . . . . . . . . . . . . . greater than Px . . . . . . . . . . . . physical examination adenoidectomy  . . . . . . . . . . . . . less than q. . . . . . . . . . . . . . every tab . . . . . . . . . . . tablet . . . . . . . . . . . . one q2h . . . . . . . . . . . every 2 hours TAB . . . . . . . . . . therapeutic abortion . . . . . . . . . . . . two qd . . . . . . . . . . . . every day TB. . . . . . . . . . . . tuberculosis qh . . . . . . . . . . . . every hour TEDS. . . . . . . . . thromboembolic . . . . . . . . . . . three q.i.d.. . . . . . . . . . four times a day disease stockings . . . . . . . . . . . four q.n.s. . . . . . . . . . quantity not sufficient TEE . . . . . . . . . . transesophageal I, II, III, IV, V, VI, VII, VIII, IX, X q.o.d.. . . . . . . . . every other day echocardiogram uppercase Roman numerals 1–10 APPENDIX C Commonly Prescribed Drugs The following alphabetical list of commonly prescribed drugs (trade and generic) is based on listings of prescriptions dispensed in the United States in 2003. The classifi- cation and major therapeutic uses for each are also provided. Trade name drugs begin with a capital letter; their generic names accompany them in parentheses. All generic names are set in lowercase. Name Classification Major Therapeutic Uses Accupril angiotensin-converting hypertension, congestive (quinapril hydrochloride) enzyme (ACE) inhibitor heart failure (CHF) Accutane (isotretinoin) retinoid acne acetaminophen and codeine analgesic/antipyretic and moderate to severe pain, opiate (narcotic) fever combination Aciphex (rabeprazole) proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid secretion gastroesophageal reflux inhibitor) disease (GERD) Actonel (risedronate) bisphosphonate (bone osteoporosis, Paget disease resorption inhibitor) Actos (pioglitazone) oral antidiabetic type 2 diabetes mellitus Adderall XR amphetamine attention-deficit/ (amphetamine mixed salts) hyperactivity disorder (ADHD) Advair Diskus adrenergic agonist asthma (salmeterol/fluticasone) (bronchodilator) and glucocorticoid (anti-inflammatory) albuterol adrenergic agonist asthma, bronchitis (bronchodilator) Allegra (fexofenadine) antihistamine allergy Allegra D (fexofenadine/ antihistamine and allergy with nasal pseudoephedrine) decongestant combination congestion allopurinol xanthine oxidase inhibitor gout Alphagan P (brimonidine) 2-adrenergic agonist glaucoma ophthalmic solution (antihypertensive) alprazolam benzodiazepine (anxiolytic, anxiety sedative, hypnotic) 594 Appendix C • Commonly Prescribed Drugs 595 Name Classification Major Therapeutic Uses Altace (ramipril) angiotensin-converting hypertension, congestive enzyme (ACE) inhibitor heart failure (CHF) Amaryl (glimepiride) oral antidiabetic type 2 diabetes mellitus Ambien (zolpidem) hypnotic insomnia amitriptyline antidepressant depression amoxicillin penicillin (antibiotic) bacterial infections amoxicillin/clavulanate penicillin (antibiotic) and bacterial infections -lactamase inhibitor combination Apri (desogestrel/ oral contraceptive birth control ethinyl estradiol) Aricept (donepezil) acetylcholinesterase Alzheimer disease inhibitor Atacand (candesartan) angiotensin receptor hypertension blocker (antihypertensive) atenolol cardioselective  blocker/ hypertension, angina 1-adrenergic antagonist pectoris, cardiac (antihypertensive, arrhythmias antiarrhythmic, antianginal) Atrovent (ipratropium) anticholinergic chronic obstructive (bronchodilator) pulmonary disease (COPD) Augmentin (amoxicillin/ penicillin (antibiotic) and bacterial infections clavulanate) -lactamase inhibitor combination Avalide (irbesartan/ angiotensin receptor hypertension hydrochlorothiazide) blocker (antihypertensive) and diuretic combination Avandia (rosiglitazone) oral antidiabetic type 2 diabetes mellitus Avapro (irbesartan) angiotensin receptor blocker hypertension (antihypertensive) Avelox (moxifloxacin) fluoroquinolone (antibiotic) bacterial infections Aviane (levonorgestrel/ oral contraceptive birth control ethinyl estradiol) Bactrim (trimethoprim/ antibacterial and sulfonamide bacterial infections sulfamethoxazole) (antibiotic) combination Bactroban (mupirocin) topical antibiotic bacterial skin infections Bextra (valdecoxib) cox-2 inhibitor (nonsteroidal pain, inflammation, fever, anti-inflammatory drug arthritis [NSAID]) Biaxin (clarithromycin) macrolide (antibiotic) bacterial infections carisoprodol skeletal muscle relaxant skeletal muscle spasms and spasticity Cartia XT (diltiazem) calcium channel blocker hypertension, angina pectoris, cardiac arrhythmias 596 Medical Terminology: The Language of Health Care Name Classification Major Therapeutic Uses Cefzil (cefprozil) cephalosporin (antibiotic) bacterial infections Celebrex (celecoxib) cox-2 inhibitor (nonsteroidal pain, inflammation, fever, anti-inflammatory drug arthritis [NSAID]) Celexa (citalopram) selective serotonin reuptake depression inhibitor (SSRI) (antidepressant) cephalexin cephalosporin (antibiotic) bacterial infections Cipro (ciprofloxacin) fluoroquinolone (antibiotic) bacterial infections ciprofloxacin fluoroquinolone (antibiotic) bacterial infections clonazepam benzodiazepine (sedative/ epilepsy, seizures, anxiety hypnotic, anticonvulsant, (panic disorder) anxiolytic) clonidine 2-adrenergic agonist hypertension (antihypertensive) clotrimazole and topical antifungal and anti- fungal infections, some betamethasone inflammatory combination parasites Combivent (ipratropium/ anticholinergic and asthma, chronic bronchitis, albuterol) inhalation adrenergic agonist combi- emphysema aerosol nation (bronchodilators) Concerta (methylphenidate) central nervous system attention-deficit/ extended release stimulant hyperactivity disorder (ADHD) Coreg (carvedilol) cardioselective  blocker/ hypertension, congestive 1-adrenergic antagonist heart failure (CHF) (antihypertensive, antiarrhythmic, antianginal) Coumadin (warfarin sodium) anticoagulant thromboembolic disorders Cozaar (losartan) angiotensin receptor blocker hypertension (antihypertensive) cyclobenzaprine skeletal muscle relaxant skeletal muscle spasms and spasticity Depakote (divalproex) anticonvulsant epilepsy, migraine prophylaxis, bipolar mania Detrol LA (tolterodine) anticholinergic overactive bladder diazepam benzodiazepine (sedative/ anxiety, skeletal muscle hypnotic, anticonvulsant, spasm, epilepsy, seizures anxiolytic) Diflucan (fluconazole) antifungal fungal infections Digitek (digoxin) cardiac glycoside congestive heart failure (CHF), cardiac tachyarrhythmias Dilantin (phenytoin) hydantoin (anticonvulsant) epilepsy, seizures diltiazem hydrochloride calcium channel blocker hypertension, angina pectoris, cardiac arrhythmias Appendix C • Commonly Prescribed Drugs 597 Name Classification Major Therapeutic Uses Diovan (valsartan) angiotensin receptor blocker hypertension (antihypertensive) Diovan HCT (valsartan/ angiotensin receptor blocker hypertension hydrochlorothiazide) and diuretic combination (antihypertensive) Ditropan XL (oxybutynin) anticholinergic (urinary overactive bladder antispasmodic) doxycycline tetracycline (antibiotic) bacterial, rickettsial, and chlamydial infections Duragesic (fentanyl) analgesic, opiate (narcotic) pain, sedation Effexor XR (venlafaxine) antidepressant depression Elidel (pimecrolimus) immunosuppressant agent atopic dermatitis topical cream enalapril angiotensin-converting hypertension, congestive enzyme (ACE) inhibitor heart failure (CHF) Endocet (oxycodone/ opiate (narcotic) and moderate to severe pain acetaminophen) nonsteroidal anti- inflammatory (NSAID) (analgesic/antipyretic) combination Evista (raloxifene) selective estrogen receptor prevention and treatment of modulator (SERM) osteoporosis Flomax (tamsulosin) 1-adrenergic antagonist benign prostatic (antihypertensive, hypertrophy (BPH) vasodilator) Flonase (fluticasone) glucocorticoid (anti- allergic rhinitis nasal spray inflammatory, immunosuppressant) Flovent (fluticasone) glucocorticoid (anti- asthma control oral inhalation inflammatory, immunosuppressant) fluoxetine selective serotonin reuptake depression inhibitor (SSRI) (antidepressant) folic acid vitamin nutritional supplement Fosamax (alendronate) bisphosphonate (bone osteoporosis, Paget disease resorption inhibitor) furosemide diuretic hypertension, edema associated with congestive heart failure (CHF) or renal disease gemfibrozil antihyperlipidemic hypertriglyceridemia, hyperlipidemia Glucophage XR (metformin) oral antidiabetic type 2 diabetes mellitus Glucotrol XL (glipizide) oral antidiabetic type 2 diabetes mellitus Glucovance (glyburide/ oral antidiabetic type 2 diabetes mellitus metformin) (combination product) 598 Medical Terminology: The Language of Health Care Name Classification Major Therapeutic Uses glyburide oral antidiabetic type 2 diabetes mellitus Humalog (insulin lispro) insulin; antidiabetic type 1 and 2 diabetes mellitus Humulin (insulin insulin; antidiabetic type 1 and 2 diabetes preparation) mellitus hydrochlorothiazide diuretic hypertension, edema associated with congestive heart failure (CHF) or renal disease hydrocodone and opiate (narcotic) and moderate to severe pain acetaminophen nonsteroidal anti- inflammatory drug (NSAID) (analgesic/ antipyretic)

combination Hyzaar (losartan/ angiotensin receptor blocker hypertension hydrochlorothiazide) and diuretic combination (antihypertensive) ibuprofen analgesic; nonsteroidal anti- pain, inflammation, fever inflammatory drug (NSAID) Imitrex (sumatriptan triptan (antimigraine agent) migraine headache succinate) Inderal LA (propranolol)  blocker (antihypertensive, hypertension, angina antiarrhythmic, antianginal) pectoris, cardiac arrhythmias, migraine headache prophylaxis isosorbide mononitrate coronary vasodilator angina pectoris (antianginal) Kariva (desogestrel/ oral contraceptive birth control ethinyl estradiol) Klor-Con (potassium potassium salt; electrolyte potassium deficiency chloride) supplement Lanoxin (digoxin) cardiac glycoside congestive heart failure (CHF), cardiac tachyarrhythmias Lantus (insulin glargine) insulin; antidiabetic type 1 and 2 diabetes mellitus Lescol XL (fluvastatin) HMG-CoA reductase hyperlipidemia, inhibitor (statin) hypercholesterolemia Levaquin (levofloxacin) fluoroquinolone (antibiotic) bacterial infections Levothroid (levothyroxine) thyroid hormone hypothyroidism Levoxyl (levothyroxine thyroid hormone hypothyroidism sodium) Lexapro (escitalopram) selective serotonin reuptake depression inhibitor (SSRI) (antidepressant) Lipitor (atorvastatin) HMG-CoA reductase hyperlipidemia, inhibitor (statin) hypercholesterolemia Appendix C • Commonly Prescribed Drugs 599 Name Classification Major Therapeutic Uses lisinopril angiotensin-converting hypertension enzyme (ACE) inhibitor lorazepam benzodiazepine (sedative/ anxiety, preop sedation, hypnotic, anticonvulsant, epilepsy, seizures anxiolytic) Lotensin (benazepril) angiotensin-converting hypertension enzyme (ACE) inhibitor Lotrel (amlodipine/ calcium channel blocker and hypertension benazepril) angiotensin-converting enzyme (ACE) inhibitor combination Low-Ogestrel (norgestrel/ oral contraceptive birth control ethinyl estradiol) Macrobid (nitrofurantoin) antibiotic bacterial infections of urinary tract meclizine anticholinergic motion sickness, vertigo metformin oral antidiabetic type 2 diabetes mellitus methylprednisolone glucocorticoid (anti- inflammation, inflammatory, immunological disorders, immunosuppressant) allergies metoprolol cardioselective  blocker hypertension, angina (1-adrenergic antagonist) pectoris Miacalcin (calcitonin) hormone osteoporosis, Paget disease Microgestin Fe oral contraceptive birth control (norethindrone ethinyl estradiol) MiraLax (polyethylene glycol) laxative constipation Mobic (meloxicam) nonsteroidal anti- osteoarthritis inflammatory drug (NSAID) Monopril (fosinopril) angiotensin-converting hypertension enzyme (ACE) inhibitor naproxen analgesic, nonsteroidal pain, fever, arthritis anti-inflammatory drug (NSAID) Nasacort (triamcinolone) glucocorticoid allergic rhinitis AQ topical nasal spray (anti-inflammatory, immunosuppressant) Nasonex (mometasone) glucocorticoid (anti- allergic rhinitis topical nasal spray inflammatory, immunosuppressant) Necon (ethinyl estradiol/ oral contraceptive birth control norethindrone) Neurontin (gabapentin) anticonvulsant postherpetic neuralgia, epilepsy (partial seizures) Nexium (esomeprazole) proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid secretion gastroesophageal reflux inhibitor) disease (GERD) 600 Medical Terminology: The Language of Health Care Name Classification Major Therapeutic Uses Niaspan (niacin) vitamin dyslipidemia nifedipine calcium channel blocker hypertension, angina pectoris NitroQuick (nitroglycerin) antianginal coronary vasodilator Norvasc (amlodipine) calcium channel blocker hypertension, angina pectoris omeprazole proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid gastroesophageal reflux secretion inhibitor) disease (GERD) Omnicef (cefdinir) cephalosporin (antibiotic) bacterial infections Ortho Evra contraceptive patch birth control (norelgestromin/ ethinyl estradiol) Ortho Novum oral contraceptive birth control (norethindrone/ ethyl estradiol) Ortho Tri-Cyclen oral contraceptive birth control (norgestimate/ ethyl estradiol) oxycodone and opiate (narcotic) and moderate to severe pain acetaminophen nonsteroidal anti- inflammatory drug (NSAID) (analgesic/ antipyretic) combination OxyContin (oxycodone) opiate (narcotic) analgesic moderate to severe pain Patanol (olopatadine) ophthalmic antihistamine allergic conjunctivitis Paxil (paroxetine) selective serotonin reuptake depression inhibitor (SSRI) (antidepressant) Penicillin VK (penicillin penicillin (antibiotic) bacterial infections V potassium) Percocet (oxycodone and opiate (narcotic) and moderate to severe pain acetaminophen) nonsteroidal anti- inflammatory drug (NSAID) (analgesic/ antipyretic) combination phenobarbital barbiturate (sedative/ insomnia, epilepsy, seizures, hypnotic, anticonvulsant, anxiety anxiolytic) phenytoin hydantoin (anticonvulsant) epilepsy, seizures Plavix (clopidogrel) antiplatelet agent reduction in stroke or myo- cardial infarction risk by excessive clot prevention Plendil (felodipine) calcium channel blocker hypertension, angina pectoris potassium chloride potassium salt; electrolyte potassium deficiency supplement Pravachol (pravastatin) HMG-CoA reductase hyperlipidemia, inhibitor (statin) hypercholesterolemia Appendix C • Commonly Prescribed Drugs 601 Name Classification Major Therapeutic Uses prednisone glucocorticoid (anti- inflammation, inflammatory, immunological disorders, immunosuppressant) allergy Premarin (conjugated estrogen derivative hormone replacement estrogens) Prempro (estrogen/ estrogen/progestin hormone replacement medroxyprogesterone) Prevacid (lansoprazole) proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid secretion gastroesophageal reflux inhibitor) disease (GERD) Prilosec (omeprazole) proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid secretion gastroesophageal reflux inhibitor) disease (GERD) promethazine antihistamine; sedative and allergy; motion sickness, antiemetic nausea promethazine and codeine antihistamine and opiate cold and cough (narcotic) antitussive combination propoxyphene and opiate (narcotic) analgesic mild to moderate pain acetaminophen and nonsteroidal anti- inflammatory drug (NSAID) (analgesic/antipyretic) combination propranolol  blocker (antihypertensive, hypertension, angina antiarrhythmic, pectoris, cardiac antianginal) arrhythmias, migraine headache prophylaxis Proscar (finasteride) 5-reductase inhibitor benign prostatic hyperplasia (BPH) Protonix (pantoprazole) proton pump inhibitor (PPI) peptic ulcer disease (PUD), (gastric acid secretion gastroesophageal reflux inhibitor) disease (GERD) Pulmicort (budesonide) glucocorticoid (anti- asthma inhalant inflammatory, immunosuppressant) ranitidine hydrochloride H2 receptor antagonist peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD) Remeron (mirtazapine) atypical antidepressant depression Rhinocort Aqua (budesonide) glucocorticoid (anti- allergic rhinitis nasal spray inflammatory, immunosuppressant) Risperdal (risperidone) atypical antipsychotic psychoses (e.g., (neuroleptic) schizophrenia) Roxicet (oxycodone and opiate (narcotic) and moderate to severe pain acetaminophen) nonsteroidal anti- inflammatory drug (NSAID) (analgesic/ antipyretic) combination 602 Medical Terminology: The Language of Health Care Name Classification Major Therapeutic Uses Seroquel (quetiapine) atypical antipsychotic psychoses (e.g. (neuroleptic) schizophrenia) Singulair (montelukast) leukotriene receptor asthma antagonist Skelaxin (metaxalone) skeletal muscle relaxant skeletal muscle spasms and spasticity spironolactone potassium sparing diuretic hypertension, edema Strattera (atomoxetine) selective norepinephrine attention-deficit/ reuptake inhibitor (SNRI) hyperactivity disorder (ADHD) Synthroid (levothyroxine) thyroid product hypothyroidism temazepam benzodiazepine (hypnotic) insomnia terazosin 1-adrenergic antagonist hypertension, benign (antihypertensive, prostatic hypertrophy vasodilator) timolol  blocker (antihypertensive, hypertension, angina antiarrhythmic, pectoris, cardiac antianginal) arrhythmias, glaucoma (ophthalmic solution) TobraDex (tobramycin antibiotic and corticosteroid external ocular bacterial and dexamethasone) combination infections ophthalmic solution Topamax (topiramate) anticonvulsant epilepsy (partial seizures) Toprol-XL (metoprolol) cardioselective  blocker hypertension, angina (1-adrenergic antagonist) pectoris, congestive heart failure (CHF) trazodone atypical antidepressant depression triamcinolone glucocorticoid (anti- inflammation, inflammatory, immunological disorders, immunosuppressant) allergy triamterene and diuretic combination hypertension, edema in hydrochlorothiazide congestive heart failure (HCTZ) (CHF) Tricor (fenofibrate) fibric acid derivative hyperlipidemia, hypertriglyceridemia, hypercholesterolemia trimethoprim/ antibacterial and bacterial infections sulfamethoxazole sulfonamide (antibiotic) (TMP-SMX or combination co-trimoxazole) Trimox (amoxicillin) penicillin (antibiotic) bacterial infections Trivora-28 (levonorgestrel/ oral contraceptive birth control ethinyl estradiol) Tussionex (hydrocodone narcotic antitussive and cough and cold and chlorpheniramine) antihistamine combination Appendix C • Commonly Prescribed Drugs 603 Name Classification Major Therapeutic Uses Ultracet (tramadol/ opioid analgesic and pain acetaminophen) nonsteroidal anti- inflammatory drug (NSAID) (analgesic/ antipyretic) combination Valtrex (valacyclovir) antiviral herpes viruses verapamil calcium channel blocker hypertension, cardiac arrhythmias, angina pectoris Viagra (sildenafil) phosphodiesterase (type 5) erectile dysfunction (ED) enzyme inhibitor Vioxx (rofecoxib) cox-2 inhibitor (nonsteroidal pain, inflammation, fever, anti-inflammatory drug arthritis [NSAID]) warfarin anticoagulant thromboembolic disorders Wellbutrin SR (bupropion) atypical antidepressant depression Xalatan (latanoprost) prostaglandin glaucoma ophthalmic solution Yasmin 28 (drospirenone/ oral contraceptive birth control ethinyl estradiol) Zetia (ezetimibe) cholesterol absorption hypercholesterolemia inhibitor Zithromax (azithromycin macrolide (antibiotic) bacterial infections dihydrate) Zocor (simvastatin) HMG-CoA reductase hyperlipidemia, inhibitor (statin) hypercholesterolemia Zoloft (sertraline) selective serotonin reuptake depression inhibitor (SSRI) (antidepressant) Zyprexa (olanzapine) atypical antipsychotic psychoses (e.g., (neuroleptic) schizophrenia) Zyrtec (cetirizine) antihistamine allergy References Quick Look Drug Book. Baltimore: Lippincott Williams & Wilkins, 2004. Copyright ©2004 by Lexi-Comp, Inc. RxList Top 200 Drugs of 2003, www.rxlist.com/top200.htm. Stedman’s Medical Dictionary for the Health Professions and Nursing, 5th ed. Baltimore: Lippincott Williams & Wilkins, Appendix: Commonly Prescribed Drugs and Their Applica- tions, 2005. APPENDIX D Answers to Practice Exercises CHAPTER 1 (PP. 7–8) 1. personal commitment 7. stress reduction and mental stamina 2. Answers will vary. 8. see it, say it, write it. 3. a. Act immediately to focus on goals. 9. Preparation and the use of flash cards provide visual, b. Don’t try to take on too much at once. kinesthetic, and auditory reinforcement of the senses c. Divide materials into smaller, more manageable helpful in memorization. Flash cards are portable and portions. can be carried at all times. d. Celebrate progress along the way, and look 10. When you annotate text material, you make notes in forward to future benefits for learning (note: class the margin as you read. This includes drawing lines to discussion will bring out other good ideas). separate component parts of key terms and writing 4. It promotes positive thinking and self-confidence that out their meanings. lead to success. 11. a. Draw pictures of word components. 5. Answers will vary. b. Listen to audiotapes/pronunciations on 6. a. Find a comfortable place to study, and organize CD-ROM. your study area. c. Make up songs or rhymes. b. Listen to enjoyable music while studying. d. Find a person or group to study with. c. Replace negative self-talk with “can do” affirmatives. d. Think positively, and visualize yourself as a suc- cessful learner. CHAPTER 2 (PP. 30–37) 1. pan / cyto / penia 8. tachy / card / ia P CF S P R S DEFINITION: all / cell / abnormal reduction DEFINITION: fast / heart / condition of 2. leuk / emia 9. pyo / poiesis R S CF S DEFINITION: white / blood condition DEFINITION: pus / formation 3. tox / oid 10. aden / itis R S R S DEFINITION: poison / resembling DEFINITION: gland / inflammation 4. meso / morph / ic 11. macro / cephal / ous P R S P R S DEFINITION: middle / form / pertaining to DEFINITION: large or long / head / pertaining to 5. acro / dynia 12. para / centesis CF S P S DEFINITION: extremity / pain DEFINITION: alongside of / puncture for aspiration 6. meta / stasis 13. micro / lith / iasis P S P R S DEFINITION: beyond, after, or change / stop or stand DEFINITION: small / stone / formation or presence of 7. ultra / sono / graphy 14. ortho /ped / ic P CF S CF R S DEFINITION: beyond or excessive / sound / process of DEFINITION: straight, normal, or correct / foot / recording pertaining to 604 Appendix D • Answers to Practice Exercises 605 15. angio / megaly 41. b. pro CF S 42. d. circum DEFINITION: vessel / enlargement 43. c. hemi 16. psych / iatry 44. f. ab- R S 45. g. inter- DEFINITION: mind / treatment 46. h. para- 17. carcino /genesis 47. b. peri- CF S 48. a. retro- DEFINITION: cancer / origin or production 49. j. intra- 18. nephro / logist 50. c. anti- CF S 51. i. an- DEFINITION: kidney / one who specializes in the study 52. d. ecto- or treatment of 53. e. dia- 19. rhino / sten / osis 54. many CF R S 55. below or deficient DEFINITION: nose / narrow / condition or increase 56. few or deficient 20. hypo / hydr / ation 57. one P R S 58. all DEFINITION: below or deficient / water / process 59. beyond or excessive 21. aero / gastr / algia 60. two or both CF R S 61. four DEFINITION: air or gas / stomach / pain 62. half 22. fibr / oma 63. below or under R S 64. above or excessive DEFINITION: fiber / tumor 65. c. ante- 23. necro / philia 66. d. post- CF S 67. e. tachy- DEFINITION: death / attraction for 68. a. brady- 24. scler / osis 69. b. re- R S 70. d. without DEFINITION: hard / condition or increase 71. b. foot 25. hemo / lysis 72. d. mouth CF S 73. d. new DEFINITION: blood / breaking down or dissolution 74. a. surgical repair 26. acro / phob / ia 75. e. process CF R S 76. c. crushing DEFINITION: topmost (or extremity) / exaggerated 77. c. expansion fear or sensitivity / condition of 78. c. right 27. cyto / meter 79. f. melan/o CF S 80. a. tri- DEFINITION: cell / instrument for measuring 81. j. erythr/o 28. cyano / tic 82. g. quadri- CF S 83. b. leuk/o DEFINITION: blue / pertaining to 84. e. uni- 29. extra / vascul / ar 85. c. cyan/o P R S 86. k. bi- DEFINITION: outside / vessel / pertaining to 87. i. oligo- 30. hyper / troph / y 88. d. dextr/o P R S 89. h. sinistr/o DEFINITION: above or excessive / nourishment or 90. c. -gram development / condition or process of 91. c. -osis 31. c. supra 92. c. -ectomy 32. d. re 93. b. -ar 33. c. pre 94. d. -rrhexis 34. b. de 95. c. -ula 35. e. trans 96. a. -ism 36. c. super 97. nephritis 37. b. infra 98. nephrolysis 38. a. exo 99. nephrotomy 39. b. dys 100. nephrogenous 40. b. ab 101. nephropexy 606 Medical Terminology: The Language of Health Care 102. nephrostomy 112. ovaries, ova 103. nephrectomy 113. metastases 104. nephrolithiasis 114. verrucae 105. nephroma 115. condyloma 106. nephrocele 116. index 107. nephrorrhaphy 117. thrombi 108. nephroptosis 118. c. nephrorrhaphy 109. d. colostomy 119. a. abdominoscopy 110. a. vasorrhaphy 120. b. pericardium

111. c. abdominocentesis CHAPTER 3 (PP. 50–53) 1. onco / logy 15. cardio / logy CF S CF S DEFINITION: tumor / study of DEFINITION: heart / study of 2. immuno / logist 16. dermato / logy CF S CF S DEFINITION: safe / one who specializes in the study DEFINITION: skin / study of or treatment of 17. ped / iatrics 3. oto / laryngo / logy R S CF CF S DEFINITION: child / treatment DEFINITION: ear / voice box / study of 18. endo / crino / logist 4. opto / metry P CF S CF S DEFINITION: within / to secrete / one who specializes DEFINITION: eye / process of measuring in the study or treatment of 5. gyneco / logy 19. nephro / logist CF S CF S DEFINITION: woman / study of DEFINITION: kidney / one who specializes in the study 6. patho / logy or treatment of CF S 20. gastro / entero / logy DEFINITION: disease / study of CF CF S 7. ortho / ped / ic DEFINITION: stomach / small intestine / study of CF R S 21. hemato / logist DEFINITION: straight, normal, or correct / foot / CF S pertaining to DEFINITION: blood / one who specializes in the study 8. uro / logist or treatment of CF S 22. j DEFINITION: urine / one who specializes in the study 23. q or treatment of 24. l 9. neuro / logy 25. p CF S 26. f DEFINITION: nerve / study of 27. n 10. psycho / logist 28. o CF S 29. e DEFINITION: mind / one who specializes in the study 30. b or treatment of 31. d 11. osteo / path / y 32. i CF R S 33. h DEFINITION: bone / disease / condition or process of 34. g 12. ophthalmo / logist 35. a CF S 36. k DEFINITION: eye / one who specializes in the study or 37. c treatment of 38. m 13. obstetr / ic 39. obstetrics and gynecology R S 40. Doctor of Dental Surgery DEFINITION: midwife / pertaining to 41. ears, nose, and throat 14. an / esthesio / logy 42. American Board of Medical Specialties P CF S 43. Doctor of Optometry DEFINITION: without / sensation / study of 44. Fellow of the American College of Surgeons Appendix D • Answers to Practice Exercises 607 45. American College of Physicians 54. c 46. Doctor of Chiropractic Medicine 55. a 47. Doctor of Podiatric Medicine 56. e 48. Doctor of Osteopathic Medicine 57. g 49–53. 58. f gynecologist 59. b ophthalmologist 60. d otolaryngologist orthopaedist urologist CHAPTER 4 (PP. 97–101) 1. chief complaint 50. two and one-half grains of aspirin 2. occupational history 51. 650 milligrams by mouth every 4 hours as needed for 3. per rectum temperature more than 101° 4. bathroom privileges 52. one suppository through the rectum every night as 5. postanesthetic recovery unit needed 6. past history 53. one drop in both eyes 3 times a day for 7 days 7. *discontinue or discharge 54. two capsules immediately, then one every 6 hours 8. instructions to patient 55. tab po tid 7 d or tab po tid 7 d 9. emergency room 56. suppos PV hs or suppos PV hs 10. intensive care unit 11. rule out 57. 5 mL po qid 12. nothing by mouth 58. or po q 3–4 h prn 13. living and well 59. gtt AS q 3 h or gtt AS q 3 h 14. blood pressure 60. cap po bid am and pm or cap po bid am and pm 15. *both ears 61. po STAT, then q 6 h 16. symptom 62. 30 mg po hs prn 17. vital signs 63. 0100 hours 18. review of systems 64. 1430 hours 19. patient 65. 2400 hours 20. *right eye 66. 1300 hours 21. subcutaneous 67. 1900 hours 22. history and physical 68. 0450 hours 23. treatment or traction 69. e 24. diagnosis 70. h 25. history of present illness 71. g 26. female 72. f 27. decreased 73. i 28. d 74. d 29. e 75. b 30. g 76. j 31. a 77. a 32. j 78. c 33. i 79. every day, daily 34. b 80. every other day, every other day 35. c 81. left eye, left eye 36. f 82. right ear, right ear 37. h 83. both ears, both ears 38. d 84. greater than, greater than 39. h 85. discharge or discontinue, discharge or discontinue 40. f 86. yes 41. i 87. no 42. g 88. yes 43. j 89. yes 44. b 90. no 45. c 91. e 46. a 92. d 47. e 93. a 48. vital signs every hour for 4 hours, then every 2 hours 94. b 49. one by mouth, 4 times a day, after meals and at bed- 95. c time 608 Medical Terminology: The Language of Health Care CHAPTER 5 (PP. 125–133) 1. dermato / logist 20. melano / cyt / e CF S CF R S DEFINITION: skin / one who specializes in the study DEFINITION: black / cell / noun marker or treatment of 21. xer / osis 2. ichthy / oid R S R S DEFINITION: dry / condition or increase DEFINITION: fish / resembling 22. purpur / ic 3. onycho / lysis R S CF S DEFINITION: purple / pertaining to DEFINITION: nail / breakdown or dissolution 23. sebo / rrhea 4. histo / troph / ic CF S CF R S DEFINITION: sebum (oil) / discharge DEFINITION: tissue / nourishment of development / 24. xanth / oma pertaining to R S 5. dys / plas / ia DEFINITION: yellow / tumor P R S 25. a / steat / osis DEFINITION: painful, difficult, or faulty / formation / P R S condition of DEFINITION: without / fat / condition or increase 6. hyper / kerat / osis 26. melanoma P R S 27. hypodermic DEFINITION: above or excessive / hard / condition 28. cherry angioma or increase 29. excoriation 7. leuko / trich / ia 30. frozen section CF R S 31. closed comedo DEFINITION: white / hair / condition of 32. antipruritic 8. myco / logy 33. onychomycosis CF S 34. excisional biopsy DEFINITION: fungus / study of 35. autograft 9. epi / derm / al 36. sclerotherapy P R S 37. hyperpigmentation DEFINITION: upon / skin / pertaining to 38. steat/o 10. lip / oma 39. melan/o R S 40. myc/o DEFINITION: fat / tumor 41. onych/o 11. sub / cutane / ous 42. erythr/o P R S 43. trich/o DEFINITION: below or under / skin / pertaining to 44. xer/o 12. an / hidr / osis 45. seb/o P R S 46. gangrene DEFINITION: without / sweat / condition or increase 47. pruritus 13. histo / patho / logy 48. carbuncle CF CF S 49. alopecia DEFINITION: tissue / disease / study of 50. curettage 14. par / onych / ia 51. acne P R S 52. psoriasis DEFINITION: alongside of / nail / condition of 53. cellulitis 15. adip / osis 54. f R S 55. i DEFINITION: fat / condition or increase 56. h 16. squam / ous 57. g R S 58. j DEFINITION: scale / pertaining to 59. c 17. erythro / dermat / itis 60. a CF R S 61. d DEFINITION: red / skin / inflammation 62. b 18. de / squam / ation 63. e P R S 64. leukoderma DEFINITION: from, down, or not / scale / process 65. xanthoderma 19. histo / tox / ic 66. xeroderma CF R S 67. erythroderma DEFINITION: tissue / poison / pertaining to 68. scleroderma Appendix D • Answers to Practice Exercises 609 69. rubella 109. cicatrix—scar; mark left by the healing of a sore or 70. varicella wound showing the replacement of destroyed tissue 71. rubeola by fibrous tissue; keloid—an abnormal overgrowth 72. f of scar tissue that is thick and irregular 73. i 110. dermatosis—any disorder of the skin; dermatitis— 74. c inflammation of the skin 75. h 111. incisional biopsy—removal of a selected portion 76. d of a lesion for microscopic pathological analysis; 77. g excisional biopsy—removal of an entire lesion for 78. a analysis 79. j 112. heterograft—graft transfer from one animal species 80. b to one of another species; allograft—donor transfer 81. e between individuals of the same species such as 82. Bx human to human 83. I&D 113. closed comedo—below the skin surface with a 84. BCC white center; open comedo—open to the skin 85. HSV-1 surface with a black center caused by the presence of 86. C&S melanin exposed to air 87. SLE 114. cutaneous lupus—lupus limited to the skin; 88. m evidenced by a characteristic rash especially on 89. k the face, neck, and scalp; systemic lupus 90. g erythematosus—more severe form of lupus 91. l involving the skin, joints, and often vital organs 92. d 115. dysplastic nevus—mole with precancerous changes; 93. h malignant melanoma—cancerous tumor composed 94. j of melanocytes; most develop from a pigmented 95. b nevus over time 96. i 116. squamous layer (stratum corneum) 97. e 117. basal layer (stratum germinativum) 98. a 118. epidermis 99. f 119. dermis 100. c 120. subcutaneous tissue 101. keratoses 121. cicatrix 102. bullae 122. pruritus 103. nevi 123. petechia 104. maculae 124. verruca 105. ecchymoses 125. ecchymosis 106. electrodesiccation—use of short, high-frequency, 126. excision electric currents to destroy tissue by drying; the 127. psoriasis active electrode makes direct contact with the skin 128. impetigo lesion; fulguration—use of long, high-frequency, 129. eczema electric sparks to destroy tissue; the active electrode 130. debridement does not touch the skin 131. keratosis 107. actinic keratoses—localized thickening of the skin 132. bulla caused by excessive exposure to sunlight; seborrheic 133. nodule keratoses—benign, wart-like lesions seen especially 134. seborrhea on elderly skin 135. petechia 108. vitiligo—condition caused by the destruction of 136. ecchymosis melanin that results in the appearance of white 137. urticaria patches on the skin; albinism—a hereditary 138. eczema condition characterized by a partial or total lack 139. macula (macule) of melanin pigment 140. suppuration CHAPTER 6 (PP. 175–184) 1. thorac / ic 3. arthro / path / y R S CF R S DEFINITION: chest / pertaining to DEFINITION: joint / disease / condition or process of 2. myo / fasci / al 4. spondylo / lysis CF R S CF S DEFINITION: muscle / fascia (a band) / pertaining to DEFINITION: vertebra / breaking down or dissolution 610 Medical Terminology: The Language of Health Care 5. osteo / penia 24. arthro / scopy CF S CF S DEFINITION: bone / abnormal reduction DEFINITION: joint / process of examination 6. a / chondro / plas / ia 25. lord / osis P CF R S R S DEFINITION: without / cartilage / formation / condition of DEFINITION: bent / condition or increase 7. oste / algia 26. intercostal R S 27. arthralgia DEFINITION: bone / pain 28. myotomy 8. poly / myos / itis 29. spondylosyndesis P R S 30. leiomyoma DEFINITION: many / muscle / inflammation 31. osteomalacia 9. leio / myo / sarc / oma 32. spondylolisthesis CF CF R S 33. arthrogram or arthrograph DEFINITION: smooth / muscle / flesh / tumor 34. osteotomy 10. myelo / cyt / e 35. epiphysitis CF R S 36. cervical DEFINITION: bone marrow or spinal cord / cell / 37. bony necrosis noun marker 38. chondroma 11. costo / vertebr / al 39. arthrocentesis CF R S 40. osteoplasty DEFINITION: rib / vertebra / pertaining to 41. chondr/o 12. musculo / tendin / ous 42. spondyl/o CF R S 43. myel/o DEFINITION: muscle / tendon / pertaining to 44. cervic/o 13. orth / osis 45. arthr/o R S 46. thorac/o DEFINITION: straight, normal, or correct / condition 47. my/o or increase 48. cost/o 14. kypho / plasty 49. scoliosis CF S 50. osteoma DEFINITION: humpback / surgical repair or 51. crepitation or crepitus reconstruction 52. sequestrum 15. crani / ectomy 53. sagittal R S 54. traction DEFINITION: skull / excision (removal) 55. gout or gouty arthritis 16. arthr / desis 56. subluxation CF S 57. proximal DEFINITION: joint / binding 58. rickets 17. fibro / my / algia 59. radiologist CF R

S 60. h DEFINITION: fiber / muscle / pain 61. f 18. rhabdo / my / oma 62. c CF R S 63. e DEFINITION: rod-shaped or striated (skeletal) / 64. a muscle / tumor 65. g 19. sterno / cost / al 66. b CF R S 67. d DEFINITION: sternum (breastbone) / rib / pertaining to 68. arthrogram—x-ray of a joint; arthroscopy— 20. intra / articul / ar procedure using an arthroscope to examine, P R S diagnose, and repair a joint from within DEFINITION: within / joint / pertaining to 69. rhabdomyoma—skeletal (striated) muscle tumor; 21. syn / dactyl / ism rhabdomyosarcoma—malignant skeletal muscle P R S tumor DEFINITION: together or with / digit (finger or toe) / 70. osteoarthritis—most common form of arthritis condition of that especially affects weight-bearing joints 22. lumbo / dynia characterized by the erosion of articular CF S cartilage; rheumatoid arthritis—most DEFINITION: loin (lower back) / pain crippling form of arthritis characterized by a 23. cervico / brachi / al chronic, systemic inflammation affecting joints CF R S and synovial membranes causing ankylosis and DEFINITION: neck / arm / pertaining to deformity Appendix D • Answers to Practice Exercises 611 71. osteomalacia—disease marked by softening of the 104. posterior bone; osteoporosis—condition of decreased bone 105. superior density and increased porosity 106. inferior 72. orthosis—use of an orthopedic appliance to 107. transverse maintain a bone’s position or provide limb support; 108. flexion prosthesis—an artificial replacement for a diseased 109. extension or missing body part such as a hip, joint, or limb 110. abduction 73. closed reduction, external fixation of a Fx— 111. adduction external manipulation of a fracture to regain 112. rotation alignment along with application of an external 113. eversion device to protect and hold the bone in place while 114. inversion healing; open reduction internal fixation of a 115. pronation Fx—internal surgical repair of a fracture by bringing 116. supination bones back into alignment and fixing them into 117. dorsiflexion place, often utilizing plates, screws, and pins 118. plantar flexion 74. ankylosis—stiff joint condition; spondylosis—stiff, 119. skull immobile condition of vertebrae 120. cranium 75. leiomyoma—smooth muscle tumor; 121. phalanges leiomyosarcoma—malignant smooth muscle tumor 122. clavicle 76. lordosis—abnormal anterior curvature of the 123. scapula lumbar spine (sway-back condition); kyphosis— 124. sternum abnormal posterior curvature of the thoracic spine 125. xiphoid process (humpback condition) 126. humerus 77. spondylolisthesis—diagnostic term describing a 127. ilium forward slipping of a lumbar vertebra; 128. ischium spondylosyndesis—operative (surgical) term for 129. ulna spinal fusion 130. radius 78. b 131. carpals 79. d 132. metacarpals 80. a 133. trochanter 81. c 134. femur 82. computed tomography 135. patella 83. physical therapy 136. tibia 84. traction 137. fibula 85. range of motion 138. tarsals 86. fracture 139. metatarsals 87. electromyogram 140. phalanges 88. spondylosis 141. sacrum 89. scoliosis 142. coccyx 90. arthrodynia 143. calcaneus 91. ostealgia 144. orthosis 92. sagittal 145. hypertrophy 93. flaccid 146. radius 94. sequestrum 147. kyphosis 95. ankylosis 148. bursa 96. chondral 149. dystrophy 97. dorsiflexion 150. necrosis 98. osteoporosis 151. osteoporosis 99. rhabdomyoma 152. lordosis 100. medial 153. ulna 101. sagittal 154. scoliosis 102. anterior 155. prosthesis 103. frontal CHAPTER 7 (PP. 222–228) 1. angio / graphy 3. pector / al CF S R S DEFINITION: vessel / process of recording DEFINITION: chest / pertaining to 2. varic / osis 4. vaso / spasm R S CF S DEFINITION: swollen, twisted vein / condition or DEFINITION: vessel / involuntary contraction increase 612 Medical Terminology: The Language of Health Care 5. ven / ous 25. athero / thromb / osis R S CF R S DEFINITION: vein / pertaining to DEFINITION: fatty (lipid) paste / clot / condition or 6. aorto / coron / ary increase CF R S 26. congenital anomalies DEFINITION: aorta / circle or crown / pertaining to 27. arteriosclerosis 7. thrombo / phleb / itis 28. arrhythmia or dysrhythmia CF R S 29. cardiomyopathy DEFINITION: clot / vein / inflammation 30. anastomosis 8. peri / cardio / centesis 31. gallop P CF S 32. echocardiogram DEFINITION: around / heart / puncture for aspiration 33. cor pulmonale 9. vasculo / path / y 34. coronary angiogram CF R S 35. stress ECG DEFINITION: vessel / disease / condition or process of 36. intracardiac catheter ablation 10. athero / genesis 37. pector/o CF S 38. phleb/o DEFINITION: fatty (lipid) paste / origin or production 39. angi/o 11. stetho / scope 40. cardi/o CF S 41. ather/o DEFINITION: chest / instrument for examination 42. coron/o 12. myo / card / ium 43. sphygm/o CF R S 44. thromb/o DEFINITION: muscle / heart / structure or tissue 45. arteri/o 13. aorto / plasty 46. ventricul/o CF S 47. h DEFINITION: aorta / surgical repair or 48. o reconstruction 49. n 14. veno / stomy 50. i CF S 51. g DEFINITION: vein / creation of an opening 52. j 15. arterio / sten / osis 53. a CF R S 54. c DEFINITION: artery / narrow / condition or increase 55. l 16. phlebo / tomy 56. e CF S 57. m DEFINITION: vein / incision 58. d 17. cardio / aort / ic 59. k CF R S 60. f DEFINITION: heart / aorta / pertaining to 61. b 18. ventriculo / gram 62. premature ventricular contraction CF S 63. patent ductus arteriosus DEFINITION: ventricle / record 64. arteriosclerotic heart disease 19. phleb / itis 65. implantable cardioverter-defibrillator R S 66. congestive heart failure DEFINITION: vein / inflammation 67. coronary artery disease 20. angio / plasty 68. hypertension CF S 69. mitral valve prolapse DEFINITION: vessel / surgical repair or 70. magnetic resonance angiography reconstruction 71. ventricular septal defect 21. endo / vascul / ar 72. atrial septum P R S 73. right atrium DEFINITION: within / vessel / pertaining to 74. tricuspid valve 22. cardio / tox / ic 75. right ventricle CF R S 76. left atrium DEFINITION: heart / poison / pertaining to 77. aortic valve 23. arterio / gram 78. pulmonary semilunar valve CF S 79. left ventricle DEFINITION: artery / record 80. ventricular septum 24. ather / ectomy 81. e R S 82. h DEFINITION: fatty (lipid) paste / excision removal 83. b Appendix D • Answers to Practice Exercises 613 84. a 98. occlusion 85. j 99. infarct 86. c 100. aneurysm 87. i 101. atherosclerotic 88. d 102. thrombophlebitis 89. f 103. angiogram 90. g 104. defibrillation 91. ventricle 105. antiarrhythmic 92. aorta 106. vasodilation 93. thrombus 107. anticoagulant 94. myocardial 108. hypertension 95. hypotension 109. tachycardia 96. diastole 110. systole 97. ischemia CHAPTER 8 (PP. 256–263) 1. erythro / blast / osis 14. splen / ectomy CF R S R S DEFINITION: red / germ or bud / condition or increase DEFINITION: spleen / excision (removal) 2. myelo / dys / plas / ia 15. chylo / poiesis CF P R S CF S DEFINITION: bone marrow / faulty (bad, difficult) / DEFINITION: juice / formation formation / condition of 16. lymph / oma 3. hemo / cyto / meter R S CF CF S DEFINITION: clear fluid / tumor DEFINITION: blood / cell / instrument for measuring 17. cyto / morpho / logy 4. spleno / rrhagia CF CF S CF S DEFINITION: cell / form / study of DEFINITION: spleen / to burst forth 18. hemo / lysis 5. lymph / aden / itis CF S R R S DEFINITION: blood / breaking down or dissolution DEFINITION: clear fluid / gland / inflammation 19. an / emia 6. immuno / tox / ic P S CF R S DEFINITION: without / blood condition DEFINITION: safe / poison / pertaining to 20. meta / stasis 7. reticulo / cyt / osis P S CF R S DEFINITION: beyond, after, or change / stop or stand DEFINITION: a net / cell / condition or increase 21. neutropenia 8. thymo / path / y 22. leukocyte CF R S 23. hematopoiesis DEFINITION: thymus gland / disease / condition 24. splenomegaly or process of 25. erythropenia, erythrocytopenia 9. leuko / cyt / ic 26. thymic CF R S 27. agranulocytes DEFINITION: white / cell / pertaining to 28. eosinophil 10. lymph / angio / gram 29. erythrocyte R CF S 30. pancytopenia DEFINITION: clear fluid / vessel / record 31. phag/o 11. spleno / megaly 32. thromb/o CF S 33. chyl/o DEFINITION: spleen / enlargement 34. plas/o 12. pro / myelo / cyt / e 35. chrom/o P CF R S 36. hem/o DEFINITION: before / bone marrow / cell / noun 37. immun/o marker 38. blast/o 13. leuko / cyto / penia 39. white blood count, WBC CF CF S 40. hemoglobin, HGB or Hgb DEFINITION: white / cell / abnormal 41. hematocrit, HCT or Hct reduction 42. differential count 614 Medical Terminology: The Language of Health Care 43. mean corpuscular (cell) volume, mean corpuscular 71. vasoconstrictor—drug that causes a narrowing of (cell) hemoglobin, mean corpuscular (cell) blood vessels, decreasing blood flow; vasodilator— hemoglobin concentration, anemia drug that causes dilation of blood vessels, increasing 44. phlebotomy blood flow 45. lymphoma 72. anticoagulant—drug that prevents clotting of the 46. prothrombin time blood; hemostatic—drug that stops the flow of 47. erythrocyte sedimentation rate blood within the vessels 48. partial thromboplastin time 73. polycythemia—increase in the number of 49. complete blood count erythrocytes and hemoglobin in the blood; 50. l hemochromatosis—hereditary disorder that 51. j results in an excessive buildup of iron deposits in 52. k the body 53. g 74. plasma 54. c 75. leukocytes 55. e 76. erythrocytes 56. f 77. thrombocytes 57. b 78. serum 58. d 79. right lymphatic duct 59. i 80. thymus gland 60. h 81. thoracic duct 61. a 82. lymphatic vessels 62. immunosuppression 83. cervical lymph nodes 63. cross matching 84. spleen 64. acquired immunodeficiency syndrome (AIDS) 85. hematopoiesis 65. mononucleosis 86. platelets 66. plasmapheresis 87. anisocytosis 67. plasma—liquid portion of the blood and lymph 88. poikilocytosis containing water, proteins, salts, nutrients, hormones, 89. hemolysis vitamins, and cellular components; serum—liquid 90. lymphadenopathy portion of the blood left after the clotting process 91. myelodysplasia 68. anemia—condition affecting red blood cells that 92. thrombocytopenia results in their diminished ability to transport 93. hematocrit oxygen to the tissues; leukemia—cancer of the blood- 94. splenectomy forming organs marked by abnormal white blood 95. plasmapheresis cells in the blood and bone marrow 96. vasodilator 69. autologous blood—blood donated by a person and 97. venipuncture stored for his or her future use; homologous 98. leukemia blood—blood voluntarily donated by any person for 99. immunosuppression transfusion 100. thymus 70. antibody—substance produced by the body that 101. hematopoiesis destroys or inactivates an antigen that has entered 102. spleen the body; antigen—a substance that, when 103. septicemia introduced into the body, causes the formation of 104. hemophilia antibodies against it 105. myelodysplasia CHAPTER 9 (PP. 289–296) 1. pulmono / logy 5. pleur / itis CF S R S DEFINITION: lung / study of DEFINITION: pleura / inflammation 2. thoraco / centesis 6. hyper / carb / ia CF S P R S DEFINITION: chest / puncture for aspiration DEFINITION: above or excessive / carbon dioxide / 3. naso / sinus / itis condition of CF R S 7. alveol / ar DEFINITION: nose / sinus / inflammation R S 4. hyp / ox / emia DEFINITION: alveolus (air sac) / pertaining to P R S 8. tracheo / tomy DEFINITION: below or deficient / oxygen / blood CF S condition DEFINITION: trachea / incision Appendix D • Answers to Practice Exercises 615 9. oro / nas / al 29. pneumonitis CF R S 30. spirometry DEFINITION: mouth / nose / pertaining to 31. hypoventilation 10. rhino / rrhea 32. eupnea CF S 33. bradypnea DEFINITION: nose / discharge 34. dyspnea 11. thoraco / stomy 35. orthopnea CF S 36. apnea DEFINITION: chest / creation of an opening 37. tachypnea 12. tonsill / ectomy 38. rhin/o R S 39. pneum/o DEFINITION: tonsil / excision (removal) 40. pharyng/o 13. tracheo / bronch / itis 41. thorac/o CF R S 42. laryng/o DEFINITION: trachea (windpipe) / bronchus 43. spir/o (airway) / inflammation 44. phren/o 14. broncho / spasm 45. or/o CF S 46. pneumothorax DEFINITION: bronchus (airway) / involuntary 47. empyema, pyothorax contraction 48. hemothorax 15. laryngo / sten / osis 49. auscultation

c 7. salpingo / scope 35. b CF S 36. labyrinthitis DEFINITION: eustachian tube / instrument for 37. vertigo examination 38. tinnitus 8. hyper / acusis 39. stapedectomy P S 40. cerumen impaction DEFINITION: above or excessive / hearing condition 41. audiology 9. audio / metry 42. lavage CF S 43. auricle DEFINITION: hearing / process of measuring 44. eustachian 10. tympano / centesis 45. pharynx CF S 46. malleus DEFINITION: eardrum / puncture for aspiration 47. incus 11. oto / dynia 48. stapes CF S 49. cochlea DEFINITION: ear / pain 50. tympanic 12. aur / icle 51. aerotitis R S 52. cerumen DEFINITION: ear / small 53. myringotomy 13. myringo / tomy 54. presbyacusis CF S 55. vertigo DEFINITION: eardrum / incision 56. antihistamine 14. cerumin / osis 57. tinnitus R S 58. stapedectomy DEFINITION: wax / condition or increase 59. deafness 15. audio / logy 60. eustachian CF S DEFINITION: hearing / study of Appendix D • Answers to Practice Exercises 621 CHAPTER 14 (PP. 462–470) 1. trans / abdomin / al 19. bili / ary P R S R S DEFINITION: across or through / abdomen / DEFINITION: bile / pertaining to pertaining to 20. gastro / esophag / eal 2. gastro / entero / stomy CF R S CF CF S DEFINITION: stomach / esophagus / pertaining to DEFINITION: stomach / small intestine / creation of 21. chole / docho / tomy an opening CF CF S 3. sialo / litho / tomy DEFINITION: bile / duct / incision CF CF S 22. steato / rrhea DEFINITION: saliva / stone / incision CF S 4. glosso / rrhaphy DEFINITION: fat / discharge CF S 23. dent / algia DEFINITION: tongue / suture R S 5. hemat / emesis DEFINITION: teeth / pain R S 24. pyloro / spasm DEFINITION: blood / vomiting CF S 6. cheilo / stomato / plasty DEFINITION: pylorus (gatekeeper) / involuntary CF CF S contraction DEFINITION: lip / mouth / surgical repair or 25. hepato / tox / ic reconstruction CF R S 7. appendic / itis DEFINITION: liver / poison / pertaining to R S 26. ileo / jejun / itis DEFINITION: appendix / inflammation CF R S 8. celio / tomy DEFINITION: ileum / jejunum / inflammation CF S 27. peritoneo / centesis DEFINITION: abdomen / incision CF S 9. chol / angio / gram DEFINITION: peritoneum / puncture for aspiration R CF S 28. bucco / gingiv / al DEFINITION: bile / vessel / record CF R S 10. colono / scopy DEFINITION: cheek / gum / pertaining to CF S 29. chole / cyst / ectomy DEFINITION: colon / process of examination CF R S 11. ano / rect / al DEFINITION: bile / bladder or sac / excision (removal) CF R S 30. peri / rect / al DEFINITION: anus / rectum / pertaining to P R S 12. entero / col / itis DEFINITION: around / rectum / pertaining to CF R S 31. hemicolectomy DEFINITION: small intestine / colon / inflammation 32. appendicitis 13. oro / lingu / al 33. cheilorrhaphy CF R S 34. cholelithotomy DEFINITION: mouth / tongue / pertaining to 35. stomatoplasty 14. procto / sigmoido / scopy 36. cholangiogram CF CF S 37. hyperbilirubinemia DEFINITION: anus and rectum / sigmoid colon / 38. gastric resection process of examination 39. diverticulosis 15. laparo / scope 40. lapar/o CF S 41. gloss/o DEFINITION: abdomen / instrument for examination 42. enter/o 16. dys / phag / ia 43. dent/i P R S 44. gastr/o DEFINITION: painful, difficulty, or faulty / eat or 45. bucc/o swallow / condition of 46. chol/e 17. pancreato / duodeno / stomy 47. stomat/o CF CF S 48. hepat/o DEFINITION: pancreas / duodenum / creation of an 49. phag/o opening 50. lith/o 18. hernio / plasty 51. proct/o CF S 52. gastritis DEFINITION: hernia / surgical repair or reconstruction 53. anorexia 622 Medical Terminology: The Language of Health Care 54. aphagia 95. gastroscope 55. buccal 96. colonoscope 56. flatulence 97. peritoneoscope 57. hernia 98. esophagoscope 58. melena 99. incarcerated hernia 59. eructation 100. excisional biopsy 60. proctoscope or rectoscope 101. nasogastric tube 61. colitis 102. endoscopic retrograde cholangiopancreatography 62. barium swallow 103. gastroesophageal reflux disease 63. ascites 104. left upper quadrant 64. cholecystitis 105. gastrointestinal 65. steatorrhea 106. magnetic resonance imaging 66. diverticulitis 107. esophagogastroduodenoscopy 67. gastric ulcer 108. hepat/o or hepatic/o 68. hepatomegaly 109. cholecyst 69. ankyloglossia 110. enter/o 70. inguinal regions 111. col/o or colon/o 71. hypochondriac regions 112. gloss/o or lingu/o 72. epigastric region 113. gastr/o 73. hypogastric region 114. proct/o or rect/o 74. lumbar regions 115. an/o 75. umbilical region 116. anorexia 76. right upper quadrant 117. ascites 77. right lower quadrant 118. hematochezia 78. left upper quadrant 119. icterus 79. left lower quadrant 120. ankyloglossia 80. m 121. volvulus 81. f 122. cirrhosis 82. d 123. glossectomy 83. h 124. herniorrhaphy 84. k 125. hemorrhoidectomy 85. g 126. antacid 86. j 127. antiemetic 87. i 128. cathartic 88. l 129. melena 89. b 130. feces 90. e 131. icterus 91. a 132. ileum 92. c 133. endoscopy, endoscope 93. laparoscope 134. hemorrhoid 94. anoscope or proctoscope 135. pancreas CHAPTER 15 (PP. 497–503) 1. vesico / ureter / ic 6. nephro / ptosis CF R S CF S DEFINITION: bladder / ureter / pertaining to DEFINITION: kidney / falling or downward 2. bacteri / osis displacement R S 7. poly / dips / ia DEFINITION: bacteria / condition or increase P R S 3. trans / urethr / al DEFINITION: many / thirst / condition of P R S 8. glomerulo / scler / osis DEFINITION: across or through / urethra / pertaining to CF R S 4. uro / gram DEFINITION: glomerulus (little ball) / hard / condition CF S or increase DEFINITION: urine / record 9. pyo / nephr / itis 5. urethro / cyst / itis CF R S CF R S DEFINITION: pus / kidney / inflammation DEFINITION: urethra / bladder / inflammation Appendix D • Answers to Practice Exercises 623 10. uro / logy 44. dysuria CF S 45. ketonuria DEFINITION: urine / study of 46. hematuria 11. uretero / vesico / stomy 47. pyuria CF CF S 48. g DEFINITION: ureter / bladder / creation of an opening 49. d 12. glyco / rrhea 50. i CF S 51. h DEFINITION: sugar / discharge 52. a 13. meato / tomy 53. k CF S 54. c DEFINITION: meatus (opening) / incision 55. b 14. pyelo / nephr / osis 56. f CF R S 57. e DEFINITION: renal pelvis (basin) / kidney / condition 58. j or increase 59. albumin 15. cysto / scopy 60. intravenous pyelogram CF S 61. extracorporeal shock wave lithotripsy DEFINITION: bladder / process of examination 62. urinary tract infection 16. supra / ren / al 63. stress urinary incontinence P R S 64. blood urea nitrogen DEFINITION: above / kidney / pertaining to 65. ur/o 17. nephro / lith / iasis 66. dips/o CF R S 67. py/o DEFINITION: kidney / stone / formation or presence of 68. vesic/o 18. uretero / cele 69. albumin/o CF S 70. nephr/o DEFINITION: ureter / pouching or hernia 71. meat/o 19. albumin / ous 72. pyel/o R S 73. lith/o DEFINITION: protein / pertaining to 74. right kidney 20. pyelo / graphy 75. ureters CF S 76. urinary bladder DEFINITION: renal pelvis (basin) / process of recording 77. urethra 21. nephritis 78. left kidney 22. nephrosis 79. cystoscope 23. nephrotomy 80. pyelogram 24. nephrorrhaphy 81. oliguria 25. nephrectomy 82. hydronephrosis 26. nephrolithotomy 83. azotemia 27. urethral stenosis 84. urinalysis 28. extracorporeal shock wave lithotripsy 85. glomerular 29. suprapubic catheter 86. nephrectomy 30. resectoscope 87. diuretic 31. Kegel exercises 88. hemodialysis 32. occult blood 89. catheterization 33. cystometrogram 90. urine 34. peritoneal dialysis 91. glomerulus 35. scout film 92. meatus 36. cystitis 93. uremia 37. incontinence 94. urethra 38. enuresis 95. nephrosis 39. nocturnal enuresis 96. UA 40. hydronephrosis 97. C&S 41. adult polycystic kidney disease 98. RP 42. nocturia 99. KUB 43. oliguria 100. VCU or VCUG 624 Medical Terminology: The Language of Health Care CHAPTER 16 (PP. 521–526) 1. oligo / sperm / ia 23. h P R S 24. g DEFINITION: few or deficient / sperm / condition of 25. f 2. perineo / plasty 26. e CF S 27. b DEFINITION: perineum / surgical repair or reconstruction 28. d 3. test / algia 29. a R S 30. c DEFINITION: testis or testicle / pain 31. cryptorchism 4. balan / ic 32. endorectal or transrectal sonogram of prostate R S 33. hydrocele DEFINITION: glans penis / pertaining to 34. hypospadias 5. prostato / megaly 35. digital rectal exam CF S 36. brachytherapy DEFINITION: prostate / enlargement 37. c 6. orchid / ectomy 38. d R S 39. a DEFINITION: testis or testicle / excision (removal) 40. b 7. an / orch / ism 41. prostate-specific antigen P R S 42. biopsy DEFINITION: without / testis or testicle / condition of 43. transurethral resection of the prostate 8. vas / ectomy 44. digital rectal examination R S 45. erectile dysfunction DEFINITION: vessel / excision (removal) 46. orchi/o 9. a / sperm / ia 47. perine/o P R S 48. spermat/o DEFINITION: without / sperm (seed) / condition of 49. vas/o 10. cysto / prostat / ectomy 50. balan/o CF R S 51. epididym/o DEFINITION: bladder / prostate / excision (removal) 52. vas deferens 11. balan / itis 53. urethra R S 54. glans penis DEFINITION: glans penis / inflammation 55. testis 12. orchio / plasty 56. urinary bladder CF S 57. prostate gland DEFINITION: testis or testicle / surgical repair or recon- 58. perineum struction 59. epididymis 13. spermato / cele 60. epididymis CF S 61. oligospermia DEFINITION: sperm (seed) / pouching or hernia 62. azoospermia 14. epididymo / tomy 63. anorchism CF S 64. balanitis DEFINITION: epididymis / incision 65. cryptorchism 15. vaso / vaso / stomy 66. hypospadias CF CF S 67. chlamydia DEFINITION: vessel / vessel / creation of an opening 68. syphilis 16. anorchism 69. phimosis 17. balanitis 70. prostate 18. varicocele 71. epididymis 19. resectoscope 72. perineum 20. benign prostatic hyperplasia or hypertrophy 73. penis 21. vasectomy 74. gonorrhea 22. Peyronie disease 75. testicle or testis Appendix D • Answers to Practice Exercises 625 CHAPTER 17 (PP. 564–571) 1. vulv / itis 20. colpo / rrhaphy R S CF S DEFINITION: vulva (covering) / inflammation DEFINITION: vagina (sheath) / suture 2. poly / mast / ia 21. hystero / spasm P R S CF S DEFINITION: many / breast / condition of DEFINITION: uterus / involuntary contraction 3. ov / oid 22. lacto / rrhea R S CF S DEFINITION: egg / resembling DEFINITION: milk / discharge 4. toco / lysis 23. ovi / genesis CF S CF S DEFINITION: birth or labor / breaking down or dissolu- DEFINITION: egg / origin or production tion 24. endo / cervic / al 5. salpingo / tomy P R S CF S DEFINITION: within / cervix / pertaining to DEFINITION: uterine (fallopian) tube / incision 25. utero / tomy 6. mammo / plasty CF S CF S DEFINITION: uterus / incision DEFINITION: breast / surgical repair or reconstruction 26. menopause 7. trans / vagin / al 27. dysmenorrhea P R S 28. amenorrhea DEFINITION: across or through / vagina (sheath) / 29. oligomenorrhea pertaining to 30. menorrhagia 8. hystero / rrhexis 31. metrorrhagia CF S 32. gynecomastia DEFINITION: uterus / rupture 33. amastia 9. colpo / scopy 34. hypomastia or micromastia; augmentation CF S mammoplasty DEFINITION: vagina (sheath) / process of examination 35. hypermastia or macromastia; reduction 10. mammo / graphy mammoplasty CF S 36. mastopexy DEFINITION: breast / process of recording 37. mastectomy 11. metro / rrhagia 38. lumpectomy CF S 39. toc/o DEFINITION: uterus / to burst forth 40. colp/o 12. ovario / centesis 41. salping/o CF S 42. men/o DEFINITION: ovary / puncture for aspiration 43. cervic/o 13. men / arche 44. ov/i R S 45. episi/o DEFINITION: menstruation / beginning 46. metr/o 14. oophor / ectomy 47. lact/o R S 48. oophor/o DEFINITION: ovary / excision (removal) 49. mast/o 15. oligo / meno / rrhea 50. gynec/o P CF S 51. i DEFINITION: few or deficient

Urinalysis (UA), 490, 491 Time and date recording, 95, 95 Tricuspid valve, 196, 197 Urinalysis report, 491 Time management, 1–2 Triiodothyronine (T3), 361, 363 Urinary bladder, 484, 485 Timolol, 602 Trimethoprim/sulfamethoxazole, 602 inflammation of (cystitis), 488 Tinea, 119 Trimox, 602 Urinary catheterization, 496 Tinnitus, 418 Trivora-28, 602 Urinary diversion, 493–494 Tipped uterus (uterine retroversion), 541 TSH (thyroid-stimulating hormone), Urinary retention, 487 Tissue, subcutaneous, 109, 111, 118 361, 362 Urinary stones (calculi), 495 Tissue plasminogen activator (tPA, TPA), Tubal ligation, 554 Urinary system, 482–508 221, 332 Tubes abbreviations/acronyms, 496 TMR (transmyocardial auditory, 416, 417 anatomical terms, 484–485 revascularization), 217 eustachian, 416, 417 combining forms, 482–483 TobraDex, 602 uterine (fallopian), 537 diagnostic terms, 487–488 Tocolytic agents, 563 Tubules, renal, 483, 485 diagnostic tests and procedures, Tomography (see also Computed Tumors 488–494 tomography [CT]) epidermal, 114 (see also Neoplasia and drug classifications, 496 positron emission (PET), 212, 328 specific types) medical record analyses, 504–508 Tongue, 440, 441 fibroid, 542 operative terms, 492–495 Tongue-tie (ankyloglossia), 447 skin, 111, 112, 113 overview, 483–485 Tonic-clonic epilepsy, 322 Tunic, of eye, 387, 388 practice exercises, 497–503 Tonometry/tonometer, 399, 399 Tunica externa, 198, 200 symptomatic terms, 486–487 Tonsillectomy, 285 Tunica intima, 198, 200 therapeutic terms, 495–496 Tonsillectomy and adenectomy, 285 Tunica media, 198, 200 Urinary tract infection (UTI), 488 Tonsillitis, 279 Tuning fork tests, 421, 422 Urination, 484 Tonsils, 271, 272 TURP (transurethral resection of Urine, 483, 485 Topamax, 602 prostate), 519 microscopic findings in, 492, 496, 497 Topical administration, 89 Tussionex, 602 Urine culture and sensitivity (C & S), 492, Toprol-XL, 602 TV (tidal volume), 283 496, 497 Total hysterectomy, 553 Tympanic membrane, 417, 420 Urine sugar and ketone studies, 369 Toxemia of pregnancy (eclampsia), 560 Tympanitis, 418 Urobilinogen, 492 648 Medical Terminology: The Language of Health Care Urologic endoscopic surgery, 492, 493 Venereal warts (condylomata acuminata), Voiding cystourethrogram (VCU, Urology, 47 517, 545 VCUG), 489 Urostomy, continent/noncontinent, 494 Venipuncture, 253 Volvulus, 449, 451 Urticaria (hives), 115 Venogram, 213 Vowels, combining, 10, 11–12 Usual childhood diseases (UCHD), 56 Venous circulation, 200 VSD (ventricular septal defect), 207 Uterine adnexa, 537 Ventilation (breathing) (see also Respira- VT, 283 Uterine fibroid embolization (UFE), 557 tory system) Vulva, 537, 538 Uterine fibroids, 542 mechanical, 286, 287 Uterine fundus, 536–537 normal, 271, 272 W Uterine prolapse, 543 Ventral (anterior) direction, 155 Warfarin, 603 Uterine (fallopian) tubes, 537 Ventricles Warts, genital (venereal warts, Uterus, 536–537 of brain, 314, 316 condylomata acuminata), 517, 545 displacement of, 541 of heart, 193, 194, 195 Warts (verrucae), 114, 115 UTI (urinary tract infection), 488 Ventricular failure WBC (white blood count), 250 Utricle, 418 left (congestive heart failure), 207 Weber test, 422 Uvula, 272, 440, 441 right (cor pulmonale), 207 Wellbutrin SR, 603 Ventricular septal defect (VSD), 207 Wheals, skin, 111, 112, 113 V Ventriculogram, 213 Wheezes, 274 Vagina, 537, 538 Venules, 199 White blood count (WBC), 250 Vaginal fistula, 542 Verapamil, 603 Windpipe (trachea), 271, 272 Vaginal hysterectomy, 553 Vermiform appendix, 440, 442 Word structure analysis, 13–14 Vaginal introitus, 537, 538 Verruca (wart), 114, 115 Vaginitis, 546 Vertebrae, 150 X atrophic, 546 Vertebral lamina, 330 Xalatan, 603 Vaginosis, 546 Valtrex, 603 Vertebrobasilar TIA, 321, 322 Xenografts, 123 Vertigo, 418 X-ray report analyses, 190–191 Valves, heart, 193, 194, 195, 196, 197 Valvuloplasty, 217 Vesicles X-rays, 81, 82 Varicella (chickenpox), 117 seminal, 510, 511 cardiovascular, 213, 214 skin, 111, 112, 113 chest (CXR), 284, 284 Varices, esophageal, 447, 453 Varicocele, 513, 515 Vesicovaginal fistula, 542, 543 gastrointestinal tract, 455, 455, 456 Vessels gynecological/pelvic, 550 Varicose veins, 209, 210 Vascular lesions, of skin, 113, 114 blood, 197, 197, 198, 199 musculoskeletal system, 168–169 Vas deferens, 510, 511 lymph, 246 nervous system, 329 Vasectomy, 519, 520 Vestibule, of ear, 418 Vasoconstrictors, 221, 255 Viagra, 603 Y Vasodilators, 221, 255 Viral diseases Yasmin 28, 603 Vasopressin (antidiuretic hormone, sexually transmitted, 516–517, 544–545 ADH), 363 of skin, 117 Z Vasovasostomy, 520 Visceral pericardium, 195 Zeis, glands of, 388, 389 VC (vital capacity), 283 Visual acuity, 396 Zetia, 603 VCU, VCUG (voiding Visual sense, 2 Zithromax, 603 cystourethrogram), 489 Vital capacity (VC), 283 Zocor, 603 Vegetations, valvular, 204, 205 Vital signs record, 74 Zoloft, 603 Veins, 199, 200 Vitiligo, 119 Zyprexa, 603 Vena cava, 200 Vitreous, 390 Zyrtec, 603 Medical Terminology: The Language of Health Care Second Edition Marjorie Canfield Willis QUICK STUDY REFERENCE Term Basics Term Component to English a- without cardi/o heart -emia blood condition Most medical terms have three ab- away from cata- down en- within basic components: root, suffix, abdomin/o abdomen -cele pouching or hernia encephal/o entire brain and prefix. -ac pertaining to celi/o abdomen endo- within The root is the foundation or acous/o hearing -centesis puncture for aspiration enter/o small intestine subject of the term. All medical acr/o extremity or topmost cephal/o head epi- upon terms have one or more roots. -acusis hearing condition cerebell/o cerebellum (little brain) epididym/o epididymis ad- to, toward, or near cerebr/o cerebrum (largest part of episi/o vulva (covering) The suffix is the term ending that aden/o gland brain) erythr/o red modifies and gives essential meaning adip/o fat cerumin/o wax esophag/o esophagus to the root. All terms have a suffix. adren/o adrenal gland cervic/o neck or cervix esthesi/o sensation The prefix is a term beginning aer/o air or gas cheil/o lip eu- good or normal used only when needed to further -al pertaining to chir/o hand ex- out or away modify the root or roots. Not all albumin/o protein chol/e bile exo- outside medical terms have a prefix. -algia pain chondr/o cartilage (gristle) extra- outside A combining vowel (usually o or i) allo- other chrom/o color fasci/o fascia (a band) connects a root to another root or to a alveol/o alveolus (air sac) chromat/o color femor/o femur suffix (term ending). A combining ambi- both chyl/o juice fibr/o fiber vowel is not used if the suffix begins an- without circum- around gangli/o ganglion (knot) with a vowel, but is retained when ana- up, apart cis/o cut gastr/o stomach the suffix begins with a consonant. an/o anus col/o colon -gen origin or production andr/o male colon/o colon gen/o origin or production A combining form is a root plus angi/o vessel colp/o vagina (sheath) ger/o old age a combining vowel. Remembering ankyl/o rooked or stiff con- together or with -genesis origin or production combining forms makes it easy to ante- before conjunctiv/o conjunctiva (to join together) gingiv/o gums form and spell medical terms. anti- against or opposed to contra- against or opposed to gli/o glue Most medical terms can be defined aort/o aorta corne/o cornea glomerul/o glomerulus (little ball) by determining the meaning of the appendic/o appendix coron/o circle or crown gloss/o tongue suffix first, then the prefix (if aque/o water cost/o rib glott/o opening present), then the root or roots. -ar pertaining to crani/o skull gluc/o sugar Consult a good medical dictionary -arche beginning crin/o to secrete glyc/o sugar for the meaning of terms that are arteri/o artery cutane/o skin glycos/o sugar exceptions to this general rule. arthr/o joint, articulation cyan/o blue gnos/o knowing articul/o joint cyst/o bladder or sac -gram record -ary pertaining to cyt/o cell -graph instrument for recording Rules for Forming and -ase enzyme dacry/o tear -graphy process of recording Spelling Medical Terms -asthenia weakness dactyl/o digit (finger or toe) gynec/o woman 1 A combining vowel is used to ather/o fatty paste de- from, down, or not hem/o blood join root to root as well as root to -ation process dent/i teeth hemat/o blood any suffix beginning with a consonant, atri/o atrium derm/o skin hemi- half e.g., electr/o/cardi/o/gram. audi/o hearing dermat/o skin hepat/o, hepatic/o liver aur/i ear -desis binding herni/o hernia 2 A combining vowel is not used auto- self dextr/o right, or on the right side hetero- different before a suffix that begins with a bacteri/o bacteria dia- across or through hidr/o sweat vowel, e.g., vas/ectomy. balan/o glans penis diaphor/o profuse sweat hist/o tissue 3 If the root ends in a vowel and bi- two or both dips/o thirst histi/o tissue the suffix begins with the same vowel, bil/i bile dis- separate from or apart homo- same drop the final vowel from the root -blast germ or bud doch/o duct hormon/o hormone (an urging on) and do not use a combining vowel, blast/o germ or bud duoden/o duodenum hydr/o water e.g., card/itis. blephar/o eyelid -dynia pain hyper- above or excessive brachi/o arm dys- painful, difficult, or faulty hypn/o sleep 4 Most often, a combining vowel brady- slow -e noun marker hypo- below or deficient is inserted between two roots even bronch/o bronchus (airway) e- out or away hyster/o uterus when the second root begins with a vowel, e.g., cardi/o/esophageal. bronchi/o bronchus (airway) -eal pertaining to -ia condition of bronchiol/o bronchiole (little airway) ec- out or away -iasis formation of or presence of 5 Occasionally, when a prefix ends bucc/o cheek -ectasis expansion or dilation iatr/o treatment in a vowel and the root begins with capn/o carbon dioxide ecto- outside -iatrics treatment a vowel, the final vowel is dropped carb/o carbon dioxide -ectomy excision (removal) -iatry treatment from the prefix, e.g., par/enter/al. carcin/o cancer -emesis vomiting -ic pertaining to Term Component to English -icle small myos/o muscle -plasty surgical repair or reconstruction -stasis stop or stand ile/o ileum myring/o eardrum -plegia paralysis steat/o fat immun/o safe narc/o stupor, sleep pleur/o pleura sten/o narrow infra- below or under nas/o nose -pnea breathing stere/o three dimensional or solid inguin/o groin nat/i birth pneum/o air or lung stern/o sternum (breastbone) inter- between necr/o death pneumon/o air or lung steth/o chest intra- within neo- new pod/o foot stomat/o mouth ir/o iris (colored circle) nephr/o kidney -poiesis formation -stomy creation of an opening irid/o iris (colored circle) neur/o nerve poly- many sub- below or under -ism condition of obstetr/o midwife post- after or behind super- above or excessive iso- equal, like ocul/o eye pre- before supra- above or excessive -ist one who specializes in -oid resembling presby/o old age sym- together or with -itis inflammation -ole small pro- before syn- together or with -ium structure or tissue olig/o few or deficient proct/o anus and rectum tachy- fast jejun/o jejunum (empty) -oma tumor prostat/o prostate tax/o order or coordination kerat/o hard or cornea onych/o nail psych/o mind ten/o tendon (to stretch) ket/o ketone bodies oophor/o ovary -ptosis falling or downward tend/o tendon (to stretch) keton/o ketone bodies ophthalm/o eye displacement tendin/o tendon (to stretch) kinesi/o movement -opia condition of vision pulmon/o lung test/o testis (testicle) kyph/o humped opt/o eye purpur/o purple thalam/o thalamus (a room) lacrim/o tear orch/o testis (testicle) py/o pus therm/o heat lact/o milk orchi/o testis (testicle) pyel/o basin thorac/o chest lapar/o abdomen orchid/o testis (testicle) pylor/o pylorus (gatekeeper) thromb/o clot laryng/o larynx (voice box) or/o mouth quadri- four thym/o mind, thymus gland lei/o smooth orth/o straight, normal, or correct radi/o radius (a bone of the forearm); thyr/o, thyroid/o thyroid gland -lepsy seizure -osis condition or increase radiation (especially x-ray) (shield) leuc/o white oste/o bone re- again or back -tic pertaining to leuk/o white ot/o ear rect/o rectum toc/o labor or birth lex/o word or phrase -ous pertaining to ren/o kidney tom/o to cut lingu/o tongue ovari/o ovary reticul/o a net -tomy incision lip/o fat ov/i egg retin/o retina ton/o tone or tension lith/o stone or calculus ov/o egg retro- backward or behind tonsill/o tonsil (almond) lob/o lobe (a portion) ox/o oxygen rhabd/o rod shaped or top/o place -logist one who specialized in the pachy- thick striated (skeletal) tox/o poison study or treatment of palat/o palate rhin/o nose toxic/o poison -logy study of pan- all -rrhage to burst forth trache/o trachea (windpipe) lord/o bent pancreat/o pancreas -rrhagia to burst forth trans- across or through lumb/o loin (lower back) para- alongside of or abnormal -rrhaphy suture tri- three lymph/o clear fluid -paresis slight paralysis -rrhea discharge trich/o hair -lysis breaking down or dissolution patell/o knee cap -rrhexis rupture -tripsy crushing macro- large or long path/o disease salping/o uterine (fallopian) tube; troph/o nourishment or development -malacia softening pector/o chest also eustachian tube tympan/o eardrum mamm/o breast ped/o child or foot sarc/o flesh -ula, -ule small -mania abnormal impulse (attraction) pelv/i, pelv/o hip bone schiz/o split, division uln/o ulna (a bone of the forearm) toward -penia abnormal reduction scler/o hard or sclera ultra- beyond or excessive mast/o breast per- through scoli/o twisted uni- one meat/o opening peri- around -scope instrument for examination ur/o urine mega- large perine/o perineum -scopy

issues. In the case of adenovirus, there is as yet no atomic structure for the intact virion. In 1985, a prelimi­ nary X-ray crystallographic density map of the Ad2 hexon showed that the capsomer was a trimer of polypeptide II with a triangular top and a pseu- dohexagonal base [19]. Together with the early electron microscopy of the intact virion [1], the crystallographically observed hexon symmetry fixed the copy number of polypeptide II at 720 in the Ad virion. The stoichiometry of eight other structural proteins (III, Ilia, IV, V, VI, VII, VIII, and IX) was inferred by careful sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) analyses of radiolabeled virions ([^^S] methionine) using hexon as the standard [20]. After adenovirus protease cleavage sites were found in the sequences of polypeptides Ilia, VI, and VIII [18], changing the number of methionines in the mature proteins, their predicted copy numbers were revised [21]. The molecular stoichiometry indicated that there is symmetry mismatch in the Ad penton [20]. Symmetry mismatches are not unheard of in icosahedral viruses. One example is SV40, which has pentamers of VPl at sites of both local fivefold and sixfold symmetry in the crystal structure [22]. The conformationally flexible C-termini of VPl are able to adapt to the position of the pentamer within the SV40 capsid. In the case of adenovirus, three copies of polypeptide IV form the fiber and five copies of polypeptide III form the penton base. The fiber and penton base together compose the penton, which sits at the fivefold symmetry axes of the icosahedral capsid. Microheterogeneity in the Ad penton base has been offered as an explanation for the symmetry mismatch [20]. 1. Adenovirus Structure More recently a reversed-phase high-performance Hquid chromato­ graphic (RP-HPLC) assay was developed in order to more fully characterize the Ad5 proteome [23]. N-terminal protein sequencing and matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectroscopy were used to identify each component protein contributing at least 2% to the total protein mass of the virus. Peaks for the fiber protein, which contributes only 1.8% of the total protein mass, as well as the terminal protein and the protease, were not identified. The mass of the remaining structural proteins was determined to within ± 0 . 1 % . Their copy numbers were estimated using hexon as the standard and with the exception of the copy number for the core polypeptide VII, which was significantly reduced, the new copy numbers are in good agreement with the SDS-PAGE numbers [20, 21]. The precise mass measurements confirmed the proteolytic processing of polypeptides Ilia, VI, VII, VIII, and mu and interestingly cleaved precursor products of all but polypeptide Ilia were found to be present in the purified Ad5 virions. III. Structure of the Intact Virion In 1991 the first structure of an intact Ad particle was determined by cryo- electron microscopy (cryo-EM) and three-dimensional image reconstruction methods [24]. The technique of cryo-EM was developed in the mid-1980s by Dubochet and colleagues [25] for imaging viruses and other macromolecular assemblies in a native-like, frozen-hydrated state. Since then it has proven to be a powerful approach for studying icosahedral viruses and it has been applied to numerous members of over 20 different viral families [26]. The method involves placing a droplet of concentrated virus on an EM grid layered with a holey carbon film (carbon with holes 1-10 ixm in diameter), blotting with a piece of filter paper to leave a thin (~1000 A) layer of water and sample stretched across the holes of the grid, and then plunge freezing into a cryogen such as ethane slush chilled by liquid nitrogen. This rapid freezing causes formation of vitreous (amorphous) ice rather than crystalline ice. Formation of normal crystalline (hexagonal) ice would be harmful to the biological sample because of its expansion relative to liquid water. After cryo-freezing the sample grids are maintained at liquid nitrogen temperature to preserve the vitreous state. Transmission electron micrographs are collected using a low dose of electrons to avoid significant radiation damage to the frozen, unstained sample. The real power of the technique lies in the fact that many particle images can be computationally combined to generate a three-dimensional density map [26-28]. In the early 35-A-resolution reconstruction of Ad2, the features of the icosahedral protein capsid were clear and its dimensions without the fiber were measured as 914, 884, and 870 A along the five-, two-, and threefold symmetry Phoebe L. Stev^art axes, respectively [24]. The reconstruction showed the trimeric shape of the hexon, the pentameric shape of the penton base, and a short portion (^^88 A) of the fiber shaft. The full-length fiber, ~300 A long including the knob at the distal end, was occasionally visible in cryo-electron micrographs. Comparison of these particle images with projections of modeled full-length fibers indicated that the knobs were not positioned as would be expected if the fibers were straight. This suggested that the Ad fibers in the intact Ad2 particle are bent or flexible. Electron micrographs of negatively stained Ad2 fibers show a bend close to the N-terminal end, which binds the penton base [29]. A pseudo repeat of 15 residues was noted in the central section of the Ad2 fiber sequence [30] and later analysis of the fiber sequences from a variety of Ad serotypes revealed a range of 6-23 pseudorepeats in the shaft [31]. A long, nonconsensus repeat at motif 3 was proposed to induce a bend in the shaft of many Ad serotypes [31]. The idea that the fiber is bent for many Ad serotypes is consistent with both negative-stain electron micrographs [29] and the fact that only a short rigid portion of the Ad2 fiber shaft was reconstructed [24]. A more recent cryo-EM reconstruction of Ad2 [3] is shown in Fig. 1 (see color insert) with modeled full-length fibers. Reconstructions have now been pubHshed of Ad2 at 17-A resolution [32], Ad5 [33], Adl2 [3], Ad2 complexed with a Fab fragment from a monoclonal antibody directed against the integrin-binding region of the penton base [34], both Ad2 and Adl2 complexed with a soluble form of avp5 integrin, the internalization receptor for many Ad serotypes [3], and a fiberless Ad5 vector [33]. The capsids of these Ad serotypes appear quite similar, with only subtle differences observed in the size and flexibility of the surface protrusions of the hexon and penton base [3]. IV. Structure of the Capsid Components A. Hexon, Polypeptide II Crystal structures have been published for hexon of serotype Ad2 [5] and Ad5 [6], two members of subgroup C. The sequences of these hexons (967 amino acids for Ad2, 951 for Ad5) are closely related with 86% amino acid identity. Both structures show that the monomer has two eight-stranded P-barrels at the base and long loops that intertwine in the trimer to form a triangularly shaped top (Fig. 2). The high degree of interlocking observed between the monomers might explain why an adenovirus-encoded 100-kDa protein is required for trimer assembly [35]. In the trimer the six ^-barrels, two from each monomer, form a ring with pseudohexagonal symmetry that allows for close packing with six neighboring capsomers in the icosahedral capsid. Regions of the electron density for the Ad2 hexon, refined to 2.9-A resolution. 1. Adenovirus Structure Figure 2 The crystallographic structure of the Ad5 hexon trimer [6] with one monomer shown in block (PDB ID: 1RUX [90]). (A) A side view showing the two p-borrels near the bottom of the block monomer. Note that there are several gaps in the atomic model at the top of the molecule. (B) A top view revealing the pseudohexagonal shape of the bottom of the trimer. This figure was generated with the program MOLSCRIPT [91 ]. were unclear and gaps were left in the atomic model. During refinement of the Ad5 hexon to 2.5-A resolution, significant changes were made in the atomic model involving reassignment of greater than 25% of the sequence. In light of this result and the high homology between the two hexons, it has been suggested that the Ad2 atomic model should be revised [6], The most significant change was a shift of the first 130 amino acids leaving a gap of just four residues at the N-terminus of the Ad5 structure vs an N-terminal gap of 43 residues in the initial Ad2 model. Phoebe L. Ste>vart Revision of the hexon structure has cleared up several mysteries in the lit­ erature. First, a comprehensive comparison of hexon sequences from serotypes in all six human subgroups as v^ell as bovine and mouse serotypes found seven hypervariable regions [36]. Alignment vv̂ ith the Ad2 hexon structure indicated that five regions w êre in exposed loops as expected, v^hile tw ô regions w êre buried. The Ad5 hexon structure nov^ show ŝ all seven hypervariable loops exposed on the top of the molecule [6]. Second, trypsin cleavage sites v^ere identified at Arg-142 and Arg-165 in Ad2 [37] and these are nov\̂ located in the exposed top of the hexon molecule [6]. Similarly a pH-dependent cleavage site for the proteolytic enzyme dispase w âs found somew^here betw^een residues 135 and 150 of the Ad2 hexon [38]. In the original Ad2 hexon structure this stretch w âs buried and far from the top of the molecule. In the Ad5 hexon structure this region is likely exposed on the molecule, although it is in an unmodeled region of the structure [6]. The Ad5 structure places a previously buried highly acidic stretch of residues, 133-161 for Ad2, at the top of the molecule and accessible to solvent [6]. The acidic region is also found in the Ad5 hexon sequence, but not in those of Ad9, Adl2, or Ad37. In the Ad8 hexon sequence there is a longer, slightly basic insertion at this position [36]. It has been suggested that the acidic stretch may create an electrostatic repulsion betw^een the exterior of the Ad2 or Ad5 virion and acidic cell surface proteins [39]. Others have proposed that perhaps the acidic region plays a role in tissue tropism for the subgroup C viruses [40]. B. Penton Base, Polypeptide III In the absence of a crystal structure for the penton base, structural information on this protein comes mainly from cryo-EM reconstructions of the dodecahedron formed by Ad3 pentons [41] and intact Ad virions of various serotypes [3, 32-34]. Alignment of the know^n penton base sequences from subgroups A, B, C, and E shoves high homology throughout the protein except for a central variable length region that contains the nearly alw^ays conserved Arg-Gly-Asp (RGD) sequence, residues 340-342 for Ad2 [4,42]. The Ad2 and Ad5 penton bases (571 residues each) have among the longest variable RGD regions [4,43,44]. The RGD sequence, utilized for interaction w îth cellular av integrins [4,45], is lacking from the enteric Ad40 and Ad41 serotypes of subgroup F [46]. Presumably these tv^o serotypes don't interact with av integrins during viral cell entry. Site-directed mutagenesis of the Ad2 penton base has indicated particular residues that are important for various functions including pentamerization and stable fiber-penton base interaction [47]. While recombinantly expressed Ad2 penton base is knov^n to self-assemble into homo-pentamers, tw ô mutations in the N-terminal portion of penton base, R254E and W119 H, and several 1. Adenovirus Structure in the C-terminal region, W439 H, Y553F, and K556E, reduce or abolish pentamerization. Several mutations, C432S, W439 H, RRR(547-549)EQQ, and K556E, completely abolish the association of fiber with penton base. Other mutations throughout the penton base (W119 H, Wl 65 H, R245E, R340E, and W406H) reduce the penton base interaction with fiber. Screening with a filamentous phage-display library indicated that the Ad2 penton base sequence RLSNLLG, residues 254-260, is important for fiber binding [48]. One of these residues, R245E, was also identified by mutagenesis, but clearly residues throughout the penton base play a role in fiber association. Electron micrographs of negatively stained penton base, fiber, and the penton complex indicate that the isolated fiber is '^40 A longer than the fiber that extends from the penton base [29]. It is not clear whether or not the N-terminal end of the fiber inserts into a central cavity of the penton base or merely attaches to the outer surface. Cryo-EM reconstructions of the Ad3 penton dodecahedron both with and without the fiber reveal a subtle shift of the RGD protrusions outward by ^^15

A when the fiber is present, but no open hole in the fiberless complex [41]. A similar observation was made for an Ad5 vector both with and without the fiber [33]. These results indicate a subtle conformational change of the penton base during fiber binding and possible expansion of the penton base to allow insertion of the N-terminal end of the fiber. Numerous Ad serotypes are known to utilize the RGD residues for infection via interaction with cell surface av integrins [4,45]. The position of RGD on the penton base has been determined by a cryo-EM reconstruction of Ad2 complexed with Fab fragments of the DAV-1 monoclonal antibody [34]. Curiously, Fab fragments of DAV-1 are capable of neutralizing Ad2 infection, but the biologically relevant DAV-1 IgG molecules are not. MALDI mass spectroscopy identified the DAV-1 binding site as containing a linear epitope of nine residues including RGD [34]. The cryo-EM structure of the Ad2/DAV-1 complex localized the RGD residues to the top of five 22-A protrusions on the penton base. The observation of weak density at the top of the protrusions in the control uncomplexed Ad2 reconstruction, as well as the diffuse nature of the bound Fab density, indicated that the RGD residues are in a highly mobile surface loop [34]. Perhaps the mobility of the RGD loops, as well as their relatively close spacing around the central protruding fiber (Fig. 3, see color insert), contributes to the ability of the virus to evade antibody neutralization at this exposed receptor binding site [34]. The combined steric hindrance of the fiber and a few bulky IgG molecules bound to flexible epitopes effectively shields the remaining RGD sites from saturation by IgG, while the less bulky Fab fragments can bind to all five protrusions. Prior to complexing adenovirus with a soluble form of avp5 integrin, a comparison between the known penton base sequences indicated that Ad 12 has the conserved RGD residues within a much shorter variable region than 8 Phoebe L Stewart Ad2 [3]. Cryo-EM reconstructions of both Ad2 and Ad 12 complexed with avp5 revealed better defined integrin density in the Ad 12 reconstruction, sug­ gestive of a less mobile RGD loop for Adl2. A careful analysis of the penton base density in the control Ad2 and Ad 12 reconstructions also supported this idea w îth a smaller region of weak, diffuse density over the Ad 12 protrusions than the Ad2 protrusions (Fig. 4, see color insert). The spacing of the RGD protrusions on the penton base is thought to be important for the clustering of integrin molecules, thus triggering signaling events required for virus inter­ nalization [3]. Notably a monomeric RGD peptide (50-mer) derived from the penton base is unable to activate p72 Syk kinase or promote adhesion of B lymphoblastoid cells, two demonstrated functions of the pentameric penton base [49]. Structural support for the importance of the RGD spacing comes from the crystal structure of foot-and-mouth disease virus, which also utilizes av integrins for cell entry [50, 51]. The RGD loops of both the Ad penton base and foot-and-mouth disease virus have the same spacing, 60 A, around the fivefold symmetry axes despite these two viruses being structurally and evolutionarily unrelated [3]. C. Fiber, Polypeptide IV All human Ad serotypes have 12 fibers, one protruding from each penton base at the vertices of the icosahedral capsid. The length of the fiber protein varies from 320 to 587 residues and the sequence can be broken down into three segments: an N-terminal tail, a central shaft of variable length, and the C-terminal domain, which forms the distal knob of the fiber [31]. Biopanning of a phage-library peptide library has shown that the conserved N-terminal motif (FNPVYP, residues 11-16 in Ad2) interacts with the penton base [48]. The knob of most, but not all, serotypes [52] has a high affinity for the cellular receptor known as Coxsackie and adenovirus receptor (CAR) [53, 54]. Although a single fiber gene is the norm, Ad40 and Ad41 have two fiber genes of different length[31,55]. Perhaps the expression of two different fibers enables the virus to interact with a wider array of cell receptors as the knobs are quite different [55] and only one fiber type binds CAR [11]. Although there are two fiber genes in Ad40 and Ad41, only one fiber is found per penton. Notably, avian adenoviruses have two fibers per penton and they may have evolved distinct cell-entry strategies [56-58]. The first atomic resolution information for the fiber was a crystal structure of the Ad5 knob domain (residues 386-581 of the intact fiber protein) [7, 8]. The structure revealed a trimer with an eight-stranded antiparallel p-sandwich in each monomer (Fig. 5). More recently, crystal structures have been published of the Ad2 knob [9], and the Ad 12 knob both alone and complexed with the Dl domain of CAR [11]. The main differences between the knob structures are found in the N-terminal region and the loops. The Adl2 knob/CAR-Dl 1 . Adenov i rus Structure Figure 5 The crystallographic structure of the Ad2 fiber knob and a portion of the fiber shaft [10] (PDB ID: IQIU [90]). The trimeric molecule is shown with one monomer in black and two in gray. (A) A side view oriented to show the eight-stranded p sandwich in the knob domain of the black monomer and four repeats of the triple p-spiral fold in the shaft. (B) A top view looking along the molecular threefold axis in the direction of the virus. This figure was generated with the program MOLSCRIPT[91]. complex reveals that the CAR binding site is on the side of the knob and involves primarily the AB-loop [11]. Two models, both high in ^-strand content, were predicted for the fiber shaft [30, 59] before a crystal structure was published for a portion of the Ad2 shaft in 1999 [10]. The structure shows a novel triple ^-spiral motif (Fig. 5) that is different from either model in that the P-strands lie more along the fiber axis. The hydrogen bonding pattern observed in the structure suggests that 1 0 Phoebe L. Stewart the basic repeating structural motif should be redefined. Also a linker region was observed between the shaft and the knob, indicating that Ad2 has only 21 repeats, as opposed to 22 suggested by the earlier sequence analysis [30]. As noted in section III, fiber shafts of various serotypes appear by both negative stain electron microscopy [29] and cryo-EM [24] to be bent near the N-terminus, presumably in the region of the third fiber shaft repeat [31]. Some of the fibers with short shafts may, however, be relatively straight. The cryo- EM reconstruction of the Ad3 penton dodecahedron showed the full-length straight fiber including the knob extending 136 A from the penton base [41]. D. Polypeptide Ilia Polypeptide Ilia plays an important role in the assembly of adenovirus, as a temperature-sensitive mutation in polypeptide Ilia produces only empty capsids [60]. The full-length polypeptide Ilia, prior to proteolytic cleavage, is 585 residues for Ad2 [43]. A protease cleavage site was predicted after residue 570 [18] and the MALDI-TOF mass spectroscopic analysis of Ad5 confirms that this cleavage does occur [23]. According to both the SDS-PAGE analysis [20, 21] and the RP-HPLC analysis [23] there are approximately 60 copies of polypeptide Ilia in one adenovirus virion. The position of polypeptide Ilia within the capsid has been tentatively assigned in a cryo-EM difference map [61]. The difference map was generated by positioning 240 copies of the crystallographic Ad2 hexon [5] within the cryo-EM reconstruction of Ad2 [24] and then subtracting the hexon density. The hexon positions in the calculated capsid, published in [21], were optimized for their agreement with the cryo-EM reconstruction rather than for optimum contacts between hexons and as such represent only a crude pseudoatomic model for the hexon portion of the capsid. Approximately 65% of the density assigned to polypeptide Ilia was observed on the external surface of the capsid and the other 35% on the inner surface [21,61]. Contradictory biochemical information indicated that polypeptide Ilia is exposed on both the inner and outer capsid surfaces and thus it had been suggested that this protein might span the capsid [62]. The external density assigned to polypeptide Ilia is clearly visible without difference mapping in the recent 17-A resolution of Ad2 [32] (Fig. 6, see color insert). Two elongated density regions are observed along each of the 30 edges of the icosahedral capsid. E. Polypeptide VI The full-length precursor form of the Ad2 polypeptide VI has 250 residues [63], but 33 residues are cleaved by the protease from the N-terminus and 11 residues from the C-terminus [18, 23], Interestingly the cleaved C- terminal peptide functions as a cofactor for the protease [64, 65]. Analysis of 1. Adenovirus Structure 1 1 the Ad2 cryo-EM difference map led to an assignment for polypeptide VI on the inner capsid surface [61]. Trimeric density regions were observed spanning the bottoms of the five hexons around each penton, often called the peripentonal hexons on the basis of their location in the capsid. The assigned positions are indicated on the outer surface of the 17 A Ad2 reconstruction [32] (Fig. 7, see color insert). In order to account for ^360 copies of polypeptide VI in the virion [20, 21, 23], each trimeric density region w âs suggested to be a trimer of dimers [61]. In other v^ords, six copies of polypeptide VI might form each observed trimeric density region. Five trimeric regions found in one vertex w^ould contain 30 copies of polypeptide VI, and all 12 vertices w^ould have a total of 360 copies. The observed volume of one trimeric region is too lov^ to account for six copies of polypeptide VI, but a large portion of the protein may be loosely ordered and interacting w îth the viral core. It has been know^n for some time that polypeptide VI can bind nonspecifically to DNA [66] and thus the proposed location on the inner capsid surface seems logical. F. Polypeptide VIII The sequence of polypeptide VIII in both Ad2 [67, 68] and Ad5 [44] indicates an uncleaved precursor molecule of 227 amino acid residues. Protease cleavage sites are predicted for molecules of both serotypes follow^ing Gly- 111, v^hich implies a much smaller mature protein [18]. MALDI-TOF mass spectroscopy confirms this cleavage site for Ad5 and also indicates a second cleavage site after Ala-15 7, as the fragment from Gly-158 through the C- terminus is found in the virion [23]. Polypeptide VIII is present in roughly 127 copies per virion [20, 21], but little is knov^n about its structure or its position v^ithin the virion other than the general observation that it is associated v^ith hexons [69]. G. Polypeptide IX Polypeptide IX is thought to help stabilize adenovirus as mutant virions lacking this protein are less stable than vŝ ild type [70]. In Ad2, polypeptide IX is 140 residues [71] and it is not cleaved by the viral protease. This capsid component can be isolated from both intact virions and from the viral dissociation product known as the group-of-nine hexons [69]. Scanning transmission electron microscopy (STEM) analysis of the group-of-nine hexons indicated that there are 12 copies of polypeptide IX arranged as four trimers within this capsid fragment [72]. The Ad2 cryo-EM difference map confirmed this arrangement and showed that polypeptide IX is on the outer surface of the capsid [61]. The locations of the polypeptide IX trimers are indicated on the 17-A resolution Ad2 cryo-EM reconstruction [32] (Fig. 8, see color insert). The copy number for polypeptide IX has been measured as approximately 1 2 Phoebe L Stewart 240 [20, 21, 23] and this is consistent with four trimers in each of the 20 triangular facets of the icosahedral capsid. V. Core Structure The first cryo-EM reconstruction of Ad2 showed that the DNA/protein core does not follow icosahedral symmetry throughout, although the outer sur­ face of the core does interact with the capsid and may be partially ordered [24]. There is presently no atomic structure known for any of the core proteins (V, VII, mu, and terminal protein). Ad2 was the first serotype to be completely sequenced and its DNA genome has 35,937 base pairs [43]. The two 5̂ ends of the DNA genome are covalently linked to the terminal protein [73]

via Ser-562 [74]. Terminal protein (488 residues in Ad2) is the proteolytically cleaved form of the preterminal protein (653 amino acids in Ad2) [74-76]. It has been proposed that the terminal protein-DNA complex, present in the mature virion, serves as a template for early transcription and the first round of DNA replication, while the preterminal protein-DNA complex formed after DNA replication serves only for subsequent rounds of DNA replication [77]. In the Ad core the terminal protein-DNA complex is associated with ^^160 copies of polypeptide V [20, 23], ^633 copies of polypeptide VII [23], and -^104 copies of late L2 mu, also known as polypeptide X [78]. Little is known about polypeptide V (369 amino acids in Ad2) [79]other than the fact that it is moderately basic [69]. The polypeptide VII precursor (198 amino acids in Ad2) [44]and mu precursor (79 amino acids in Ad2) [80]are both cleaved by the viral protease. Of the three core proteins that are noncovalently linked to the viral DNA, polypeptide VII is most tightly bound [81] and it is sometimes referred to as the major core protein since it contributes the most protein mass to the core. VI . Adenovirus Protease The adenovirus protease plays a role in maturation of the virus, cleaving six virion precursors (Ilia, VI, VII, VIII, mu, and terminal protein) [18]. Analysis of the temperature-sensitive mutant virion, ts 1 [82], indicates that the protease also plays a role during Ad cell entry [83, 84]. The observation that the cleavage products of polypeptides VI, VII, VIII, and mu are present in the mature Ad5 virion [23] is consistent with the idea that the adenovirus protease is incorporated inside of the viral capsid and that peptide cleavage takes place either on the inner surface of the capsid or in the core of the virion [18]. The cleaved C-terminal tail of polypeptide VI serves as a cofactor for the protease [64, 65] increasing its catalytic rate constant (^cat) by 300- fold [85]. It has also been reported that viral DNA is a cofactor [64, 85] 1. Adenovirus Structure 1 3 Figure 9 The crystallographic structure of the Ad2 protease (gray) with its 11 -amino-acid cofac- tor (black), a proteolytic cleavage product of polypeptide VI [12] (PDB ID: 1AVP[90]). Note that the cofactor extends a p-sheet in the enzyme. This figure was generated with the program MOLSCRIPT[91]. although this is disputed in the Uterature. Other studies suggest that DNA may not be necessary for catalysis, but rather might enhance the interaction of protease and substrates in vivo [86]. Either way, the apoenzyme is relatively inactive and thus the cofactor(s) may help to control the activity of the enzyme so that the virion proteins are cleaved at the appropriate time during the viral life cycle. A crystal structure has been determined for the protease of Ad2 (204 amino acids) complexed vv̂ ith its 11-amino-acid cofactor (Fig. 9) [12]. The structure reveals that the peptide cofactor becomes the sixth p-strand in a P-sheet and forms a disulfide bond and numerous hydrogen bonds with the protease. The hydrophobic pockets observed in the structure help to explain the known consensus sequences for cleavage, which are (M,L,I)XGX/G or (M,L,I)XGG/X where X is any residues and "/" indicates the cleavage site [87, 88]. The active site contains a Cys-His-Glu triplet and an oxyanion hole similar to papain and the Ad protease probably has a similar catalytic mechanism to papain. However, the fold as well as the order of the catalytic residues in the sequence is different in the two enzymes. The Ad protease is considered to be the first member of a fifth group of cysteine proteases [12]. VII. Summary Adenovirus is a complex human virus whose structure still holds many mysteries. The synthesis of results from a diverse array of experimental tech­ niques has led to our current level of understanding. MALDI-TOF mass spectroscopy [23] has confirmed the predicted protease cleavage sites [18] of 1 4 Phoebe L. Stewart several structural proteins. The use of phage-display libraries has pinpointed the residues involved in the interaction betv^een penton base and fiber [48], w^hich w âs first observed by negative stain electron microscopy [2]. X-ray crys­ tallography [6] and sequence analysis [36] together reveal the hypervariable regions of hexon at the top of the molecule w^here the most variation is toler­ ated. The early biochemical characterization of the component molecules [69] was advantageous for interpreting the first cryo-EM reconstruction [24] and difference map [61]. Identification of the CAR receptor [53, 54] and the crys­ tal structure of a fiber knob complexed with one domain of CAR [11] have advanced our understanding of cell attachment. The finding that av integrins are utilized as internalization receptors by many serotypes [89] led to the observations by cryo-EM that the penton base ROD protrusions are located appropriately to both evade antibody neutralization [34] and facilitate receptor clustering [3]. Clearly the more we learn about adenovirus structure, assembly, and cell entry, the better our position will be for designing the adenoviral vectors of the future. Acknowledgments Hundreds of people have contributed to our understanding of adenovirus structure over the past 40+ years and I acknowledge their efforts even though they may not all be cited in this chapter. I gratefully thank Dr. Charles Chiu, a talented and productive former member of my laboratory; Dr. Glen Nemerow, a supportive collaborator; and John Ho and Moin Vera for their assistance with figure preparation. References 1. Home, R. W., Brenner, S., Waterson, A. P., and Wildy, P. (1959). The icosahedral form of adenovirus./. Mo/. Biol. 1, 84-86. 2. Valentine, R. C , and Pereira, H. G. (1965). Antigens and structure of the adenovirus./. Mol. Biol 13, 13-20. 3. Chiu, C. Y., Mathias, P., Nemerow, G. R., and Stewart, P. L. (1999). Structure of adenovirus complexed with its internalization receptor, avp5 integrin. / . Virol. 73, 6759-6768. 4. Nemerow, G. R., and Stewart, P. L. (1999). Role of av integrins in adenovirus cell entry and gene delivery. Microbiol. Mol. Biol. Rev. 63, 725-734. 5. Athappilly, F. K., Murali, R., Rux, J. J., Cai, Z., and Burnett, R. M. (1994). The refined crystal structure of hexon, the major coat protein of adenovirus type 2, at 2.9 A resolution. / . Mol. Biol. 242, 430-455. 6. Rux, J. J., and Burnett, R. M. (2000). Type-specific epitope locations revealed by X-ray crystallographic study of adenovirus type 5 hexon. Mol. Ther. 1, 18-30. 7. Xia, D., Henry, L. J., Gerard, R. D., and Deisenhofer, J. (1994). 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