STUDENT GUIDE

BLOCK 1.5 : CARDIOVASCULAR, RESPIRATORY AND RENAL SYSTEMS

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PART A
GENERAL INFORMATION
Introduction

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In this block, some examples of man's normal function are explained. In cases of disturbance or
deregulation of this normal function, there is the possibility for compensation and recovery. All
these will be discussed.

The block about “Attack and Defense” deals with man’s function at the cellular level. This block
discusses this function at the highest integration level. This means that, the block pays much
attention to the interactions among organ systems (for example the interaction that occurs among
organs of the circulatory system) and also addresses man's function in his environment and
society.

The first theme of this block talks about the regulation of three organic systems: first circulation
and the role of the heart, lungs and regulation of breathing and the kidneys and water regulation,
as well as other homeostatic mechanisms.

The second theme of this block talks about the factors that threaten man's normal functions daily,
as can be illustrated using the risk concepts and factors of cardiovascular diseases.

The last theme talks about the regulation of an individual's psychological stress and his/her
ability to react when the relationship with other people is altered. The psychic threat in the
society and its regulation is also demonstrated.

The block thus guides us through the operation of the various regulatory mechanisms at a higher
level. The mechanisms, such as the hormonal and nervous regulation (block 1.4), the
immunological and coagulation regulation (block 2.1) and the mechanisms discussed in this
block will give a general view of man's function.

The object of study in this block is not the threat and deregulation, but particularly the
compensatory and recovery possibilities in the normal functioning of the organ systems.
In this block the origin, role and the limitations of medical technology is also discussed.

OBJECTIVES OF THE BLOCK:

At the end of the block students are expected to:
1 Describe the structure, functions and mechanisms of regulation of the heart;
2 Describe the structure, functions and mechanisms of regulation of the kidneys;
3 Describe the structure, functions and mechanisms of regulation of the chest wall and lungs;
4 Define and explain the mechanisms of homeostasis.
5 Explain perfusion and its effects on the tissues;
6 Describe lipid metabolism
7 Explain the compensatory role of the heart in cases of imbalance (e.g. shock);
8 Define and identify the risk factors of cardiovascular diseases;
9 Define and identify the risk factors of renal diseases
10 Define and identify the risk factors for respiratory diseases

ACTIVITIES OF THE BLOCK

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PART B
LECTURES
1. The anatomy of the heart and the great veins
The heart can be studied according to its morphology, function and topography.
The morphology and topography will be discussed in this lecture while the physiology is
discussed in the second lecture. While studying the morphology of the heart, we should bear in
mind which membranes cover the heart, its structure, its divisions (compartments, valves), the
structure of the wall; the various tissues, that enable the wall to cause rhythmic contractions
(conducting system), and the system that supplies blood to the coronary wall (coronary arteries,
veins).
For the topography of the heart, it is important to know the position of the heart in relation to the
neighbouring organs, to the wall of the chest and other structures. It is also important, for
purposes of physical and diagnostic examination, to know about the heart’s projection and its
position in the chest wall. Finally it’s necessary to know the position and drainage of the great
veins.
2. Physiology of the heart
The title shows the duality of heart’s function. On one hand, the heart is an autonomous organ,
that can work (temporarily) out of the body, and, doesn't depend on the other organs with regard
to its regulation.
On the other hand, the heart can only function well when it’s adapted to the peripheral demands
(output and rate). In order to guarantee this, the heart possesses countless chemo and
baroreceptors and it is influenced by mechanical factors (filling of the ventricular cavity,
enlargement of the atrium), nervous factors (sympathetic and parasympathetic), local factors
(vasodilatation, vasoconstriction, autoregulation) and hormonal factors (epinephrine). The
lecture also addresses the limitations of the heart’s adaptive mechanisms during stressful
circumstances like shock and exercise.
3. Regulation of blood pressure
Adequate perfusion of tissues is essential for metabolism at the cellular level. The regulation of
blood pressure occurs through different regulatory mechanisms: the sympathetic nervous system;
the rennin-angiotensin-aldosterone system (RAAS), atrial naturetic peptide and hormonal
mechanisms (ADH and aldosterone). The interaction among the regulation of these different
volume and pressure effectors and receptors as well as volume conservation is also discussed.
4. Macroscopic anatomy of the kidney
To approach and study renal function and physiology well, a good understanding of the
macroscopic and microscopic anatomy of the kidneys is indispensable.
5. Microscopic anatomy of the kidneys
To approach and study renal function and physiology well, a good understanding of the
macroscopic and microscopic anatomy of the kidneys is indispensable.
5. Renal physiology
The kidney is very essential for the regulation of water and sodium. It is important to understand
the mechanisms that result in the regulation of blood volume. The only part of the morphology of
the kidney that is discussed are those that control glomerular filtration, selective reabsorption and
the changes in urine composition in the distal tubule and the collecting ducts. There are two
central aspects: a) what happens in the nephron and b) how these processes are regulated in the
kidney.

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6. Diuretics
In this lecture, the definition of a diuretic will be given. The different classes of diuretics, their
mechanism of action, their relative efficacies and indications will be described. The lecture also
will also deal with the common adverse effects to be expected by patients and the actions to be
taken when these reaction occur.
7. Anatomy of the lungs
The macroscopic anatomy of the lungs are first discussed. Laboratory preparations of some lung
diseases which show the effect lung damage has on the ventilation and perfusion of lung tissue
are presented. The damage does not only affect the lungs but some other organ systems as well.
The macroscopic changes in the lungs can be demonstrated through preparations and slides.
Lung damage at the microscopic level are also discussed.
8. Physiology of respiration
The physiology and pathology of breathing are presented with examples linked to the pulmonary
gaseous transport.
Areas to be covered include ventilation, diffusion, breathing regulation, and breathing
mechanics. Ventilation has to do with the exchange of air in the lungs. Diffusion involves O 2 and
CO2 transport through the alveolar capillary membrane or the exchange of gases between the
lungs and blood (capillary). Regulation of breathing, which is treated in connection with
regulation of ventilation, is to make gaseous exchange in the lungs always linked to the
metabolic needs for O2 and to the production of CO2.
Mechanisms of breathing, comprising air resistance and the expansion of the lung and thorax
during breathing, will also be discussed.

9. Medical technology
What techniques are there to investigate the heart, the lungs and the kidneys? The idea is that the
doctor is going to be more dependent on ultra-modern technology to make a diagnosis. It is good
to reflect about the need and sovereignty of the clinical findings above all other things.
10. Lipid metabolism and its effects on cardiovascular function

This lecture will look at lipid metabolism in general and how the various classes of lipids affects
the cardiovascular system. The fact that not all lipids are harmful will be emphasised.

11. Epidemiology
Risk factors, interpretation of raw data. The objective of this lecture is to help the student in
handling frequency measures. The student should be able to define these measures in
comprehensible terms, use them to interpret and make calculations on medical data and apply
this knowledge to practical problems (in health).
12. Stress, hypertension and myocardial infarctions
The question is always whether stress belongs to the high risk factors of heart infarction and
sudden death. This cannot be answered easily, because the stress concept is not clearly defined.
Stress consists of many different elements; what happens to a person, how he/she reacts and what
help he/she receives from the environment. This lecture illustrates how each individual element
and the interaction among them increases the risk of coronary infarctions. The following terms
stand out: depression and exhaustion, socio-economic situation, and, aggressiveness.

13. Stress management

How does an individual manage stress in this world that we live in. The lecture will look at
various ways we use to manage stress and stress related issue.
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14. The reaction of society to deviant behaviours.
The main question in this lecture is how the society reacts to divergent behaviour.
A definition is first given to divergent behaviour which according to sociologists includes
examples like criminality, disease, homosexuality, radicalism and deficiency. The justification
given is that the society in general reacts to these forms of behaviour in a particular way.
But within the same society, there can be different ideas on what is or is not normal.

PART C
CLINICAL SKILLS:
1. Cardiovascular system I (Thorax I)
This skill is a continuation of block 1.4 where you learned to measure a patient's blood pressure.
Cardiovascular system II and III will follow up on this and 'complete' the examination of the
cardiovascular system. This session will focus on the inspection of the cardiovascular system and
then palpation, percussion and auscultation of the heart.
Preparation:
Make sure that you are thoroughly familiar with the anatomy of the heart before this session.
You should also have studied the student guide: 'Examination of the cardiovascular system' that
was handed out to you. Students who come unprepared to class will be sacked and made to do an
extra assignment.
For all the skills sessions in this block you will be required to fully undress the chest of a subject
during the practical part. Women and men will do the practical part in different rooms.

2. Cardiovascular system II (Thorax II)

This session will continue on the previous skill session and will mainly focus on auscultation of
the heart and the palpation of the peripheral pulses. It will also give you the opportunity to revise
what was taught in the previous session.
3. Preparation:
- As in cardiovascular system II
- [Link]: and choose heart sounds. This website will allow you to
listen to different abnormal heart sounds, including heart murmers. NB: the audio is much better
when you use a headphone.
4. Assessment of shock (Capillary refill time and skin tugor, etc)

5. The respiratory system (Thorax III)

During this session you will learn how to examine the respiratory system. Before the session you
are required to have studied the anatomy of the lungs and the student guide ‘Examination of the
respiratory system’.
6. History taking of the cardiovascular and respiratory systems (Thorax IV)
During this session you will practice taking history from a patient with a problem related to the
cardiovascular or the respiratory system. The goal of this session is that you will become familiar
with relevant questions for these very important two body systems. It will also give you another
chance to practice history taking and how to communicate with a patient in general.

Preparation:-

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Continuing education: history taking in the cardiovascular system (handed out with the student
guides)
7. Medical communication
8. Revision of the cardiovascular and respiratory system
This session will allow you to revise a full examination of both systems
PART D
LABORATORY PRACTICAL SESSIONS
Macroscopic anatomy of the heart and great vessels.
Macroscopic anatomy of the kidney and urinary tract
Microscopic anatomy of the kidney and urinary tract
1. Urine analysis: to evaluate the macroscopic anatomy, the use of the urine test, quantitative
examination (pH, proteins, glucose and kenotic bodies).
2. Macroscopic anatomy of the lungs and thorax:
This deals with the morphology and normal function and linked to the pathophysiology of these
organs.
Pulmonary diseases are presented, the ones that affect the perfusion of the pulmonary tissue. This
deregulation does not only affect the lungs, but also needs the adaptations of some other organs.
3. Microscopic anatomy of the lungs:
This deals with the morphology and normal function with a link to the pathophysiology of this
organ. Pulmonary diseases are presented, the ones which affect the perfusion of the pulmonary
tissue. This deregulation does not only affect the lungs, but also needs the adaptations of some
other organs.

PART E
Tasks
The threat and regulation of the cardiovascular circulation
Introduction
This is the first of three chapters where the mechanisms of regulation of 3 organ systems: the
heart and cardiovascular circulation, renal function and the lung function are studied.
In this first chapter the functions of the heart and cardiovascular circulation should be
understood. The first task consists of acquiring enough data to study the aspects of the heart’s
function (for example, hypotension).
The second task presents a scenario of a strong threat, the result of a shock.
Task 3 is about the effects of circulatory problems (shocks) on the function of the heart.
The data presented should be understood based on the heart’s anatomy (structure of the atria,
ventricles, heart valves, myocardium, and innervation), and its function (anatomy of the
sinoatrial node, the transmission of electric stimulus and the contraction of the heart).
Some forms of shock such as anaphylactic shock should also be understood. It is however not
necessary to go deep into the pathophysiology of the different forms of shock. What is necessary
is to understand the regulatory functions of the heart during alterations of the normal blood
pressure caused by shock. This function of the heart as a corrector is done through different
regulatory mechanisms, such as the mechanism of Frank-Starling.
The beginning of this mechanism is the intrinsic adaptation of the cardiac output to the rate of
filling. Here, the return of the venous blood to the heart has a crucial role. This supply is called
preload of the heart.

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The level of systemic blood pressure also has its influence on this mechanism. This depends on
the output of the heart and on the peripheral resistance. The arterial blood pressure from the heart
also influences the post-load.
Finally, one should understand the role of the nervous system, sympathetic and parasympathetic,
on the regulation of the heart function. Any influence on heart muscle occurs both through the
effects of the heart rate and the force of contraction.
Task 1
Monday morning
Dr. Mahama is 50 years of age and the director of a rural hospital. After a calm weekend, he
slept early.
At night, his pulse is regular at 55 beats per minute. At five he wakes up. He looks at his alarm
clock and he sees that he can still sleep 2 more hours. Now his pulse goes to 95 pulsations per
minute, but very soon it decreases to 60 beats per minute.
At seven fifteen the alarm clock rings. Dr. Mahama is still in bed and he starts thinking about the
coming day.
He will have meetings, he needs to dismiss somebody and he knows that this won't be an easy
task. He is very concerned. Now his pulse goes to 95 beats per minute, but it decreases again 60
beats per minute.
At half past seven, Dr. Mahama leaps from bed gets up quickly and opens the curtains. For one
moment he feels lightheaded, but this disappears quickly. His pulse rises to 85 beats per minute.
He wonders if that is normal or not, and what the cause of the high pulse rate is.
Task 2
A thorny incident
Alhaji Issah has a quite interesting pastime, although with no danger.
He has some beehives in the garden. Every morning, before going to work, he watches how his
bees are. Yesterday, he stumbled on a stone and fell against a beehive. The bees came out,
agitated and one can guess what happened! He goes back home quickly and tells his wife. He
feels bad because of the strong pains from the bites and 5 minutes later he begins to feel very
weak. He begins to sweat and is indisposed.
His wife takes him to the hospital and they arrive 15 minutes later. His breathing is a bit fast.
The physician counts a pulse of 90 beats per minute, and he measures the blood pressure: 120/80
mm Hg. He decides to wait for 5 minutes, and measures the pulse again: 100 beats per minute.
At that moment the blood pressure is 110/75 mmHg. Five (5) minutes later the pulse goes to 120
beats per minute, and the blood pressure: 85/55 mmHg. His forehead is hot. The physician
injects intravenous adrenaline.
NB. We are going to use this task for the training of study skills.
Choose 2 students who will make a presentation of the self-study results at the beginning of the
next tutorial session with regard to the learning objectives formulated in the present tutorial
session.
Note: the presentation should not take more than 5 to 10 minutes, and it cannot be a substitute for
the discussion of the learning objectives by the entire group tutorial.
The kidney as a regulatory organ of the volume of extracellular fluid
Introduction
After the study of circulation and heart function in chapter I, the first task of chapter II will talk
about the same subject, but now focuses on the effects of the deficiencies of circulation on the
unction of the kidney. Particular attention is given to the concept of auto regulation and the

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effects of the deficiencies of cardiovascular circulation on the perfusion of the kidney and on its
function.
The chapter also talks about regulation of the volume of the extracellular fluid, the operation of
the rennin-angiotensin-aldosterone system and antidiuretic hormone, as well as the concept and
rate of glomerular filtration.
Task 3
The Sharp Wound
Abdul, 28 years, falls down on a piece of glass and is lacerated/cut in the groin. Blood spurts
from the wound and forms a big puddle. A nurse who is his neighbour is close by and helps him.
She applied pressure to his groin with her fist and is able to control the bleeding but the wound
still drips a little. Abdul has a wet and pale skin, a fast and weak pulse (120 beats per minute), a
fast breathing (30 cycles per minute) and dilated pupils. He is however still conscious.
Transportation is arranged and he is taken to the hospital, where, intravenous infusions are given
to him. His blood pressure is measured (70/40 mmHg) and blood is readied for an eventual
transfusion. Abdul complains that he is thirsty. To monitor his urine production, a catheter is
inserted into his bladder. After the surgical repair of the vessel he is sent to the recovery room.
The central venous pressure measured through a catheter in the superior vena cava is 3 mmHg.
The urine produced after one hour is 10 ml. The blood pressure and Central Venous Pressure are
low: 100/50 mmHg, and 1 mmHg respectively. Consequently, the surgeon decides to increase
the infusion rate.

Task 4
The continuation
After some hours, a normal blood pressure was re-established (120/70 mm Hg), the Central
Venous Pressure (CVP) has a normal value (5 mm Hg) and the urine produced increased to 90
ml per hour. Abdul’s recovery goes on well.
At the same time that Abdul was hospitalized, two students of medicine on clinical training
received from their tutor the task of studying this phenomenon, using urine and blood samples.
They decide to do it by observing the urine production, the osmolarity, and the concentration of
ions in the urine. They also tried to have an idea of the Glomerular Filtration Rate (GFR) by
measuring the concentration of creatinine in plasma and in the urine. They managed to construct
a table with data from the intensive care unit. Unfortunately the last urine sample was lost after 3
hours.
Unit of measurement 1hr 2hr 3hr ?
Urine Osmolarity (mosm/L) 300 1100 800 ?
Sodium Ions (mmol/L) 60 6 15 ?
Urine production (ml/hour) ? 10 40 90
Creatinine in urine (mmol/L) - 24,0 10,5 ?
Plasma creatinine (umol/L) - 80 70 65
GFR (ml/min) - 50 100 ?
CVP (mm Hg) -3 -1 3 5
Blood pressure (mm Hg) 70/40 90/55 100/60 120/70
Pulse (beats/min) 120 105 90 80
Breathing (resp/min) 30 25 20 18
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Haematocrit (%) 45 38 34 33

Discussing this table with the tutor, he asks the students to describe the mechanisms responsible
for the changes described in the parameters in the table above and predict the values that will be
recorded in three hours’ time. He also asks for an explanation of how the GFR was calculated.
The lungs and the regulation of respiration
This section pays attention to the regulation of breathing. The first task studies the anatomic
structure of the lungs, the pleura and the central regulation of breathing.
The second task studies the composition of the alveolar air, ventilation, perfusion and diffusion
and their roles in the regulation of breathing.
Task 5
A serious fall
Mr. Mohammed, 35 years of age, a sugarcane transporter, falls off his bicycle with his chest
hitting the handle bar, on the highway.
It hurts a lot when he breathes, especially on the left side of the chest. Therefore, breathing is
difficult. He gets up with difficulty and manages to get home. The pain doesn't disappear and he
decides to go to the clinic. The physician assistant listens to the sounds of his lungs. There is pain
over the fourth and the fifth ribs. He has contusion of the chest wall.
He goes back home and after one hour he begins to feel bad: his pulse and breathing increases,
he feels stuffy and starts sweating. Finally, he begins to feel dizzy and his wife takes him back to
the clinic. Now the physician assistant doesn't hear any sound on the left side of the lungs and
quickly refers him to the hospital. With a chest x-ray, a pneumothorax was diagnosed. Two
broken ribs are observed on the x-ray film. The analysis of his arterial gases shows the following
values:
pH: 7.47, PO2: 9.7kPa, PCO2: 3.9 Kpa, O2 saturation: 95%
Waiting for the pneumothorax treatment, Mr. Mohammed was given a tablet for the pain and a
sedative. A few hours later a sample of arterial blood gases shows the following values:
pH: 7.44; PO2: 9.3 kPa; PCO2: 4.8 kPa; O2 saturation; 94%
Normal values of the analysis of the arterial gases
pH 7.35-7.45
PO2 (kPa) 8.7-13.1
PCO2 (kPa) 4.5- 5.9
HCO3 - (mmol/L) 22.0-28.0
The O2 saturation 93.0-98.0
N.B. you should note that from author to author there are variations of these values. Always take
time to carefully review these values when working with them.

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Task 6
Stuffy
Mr Opoku has worked for many years in the mines in Obuasi. Occasionally, he has breathing
difficulties which worsened with time. This prompted him to seek medical attention at the
hospital. The doctor decides to measure various respiratory parameters after making him do
various types of exercises.
Rest Walking Jogging Running fast
Ventilation (L/min) 5 20 47 78
V/Q 1 2 3 4
PAO2 (mmHg) 103 103 106 110
PaO2 (mmHg) 100 100 100 100
PaCO2 (mmHg) 40 40 36 25
pH 7.4 7.4 7.4 7.32

What is the difference between the kPa measurement and mmHg as pressure indicators?
Think of how/why the concentrations of the gases (increase, decrease, remain stable) with effort.
Continuing with the training of study skills, this task is used to determine the source of
documentation and consultation in the next tutorial session. What are the sources of
information?
How did you collect this information (write, photocopied, summarized, etc)?
How can this documentation taken from the sources always be accessible?

Risk Factors
This section talks about the second theme of this block: risk factors. The risk factors of
cardiovascular diseases have been chosen as an example.
The objective is that after this week one can have a clear idea about the definition of risk, how to
compare risk measurements, and what are the most important risk factors for cardiovascular
diseases.
Task 7
The other side of chest angina
Mr. Agbabla, 43 years of age, resident in Sogakope, is a Director of a furniture manufacturing
company. For some time now he has been feeling some heaviness and pain in the chest,
particularly when he plays soccer at weekends. The pain diminishes when he stops playing the
football, but recurs on exertion. One day he visits the doctor. After listening to Mr. Agbabla, the
doctor suspects arteriosclerosis of the coronary arteries. He explains it to him but the director
said that he thought that this type of heart disease was related to bad life habits, for example,
smoking a lot of cigarettes and eating fatty foods. He mentioned that his neighbour, a very fat,
chain smoker, 60 years of age, never suffered from these problems.

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The doctor had difficulty giving a clear explanation and, for that reason, he decides to check the
hospital statistics. Over a number of years, from all the consultations in the hospital, smokers and
non-smokers have been registered. He uses the information of the deaths from cardiovascular
diseases during the last 6 years, and he observes who were the smokers and non-smokers.
He decides to limit the group to patients who were more than 30 years in 2007, because in this
group the habit of smoking is known.

Age 30-39 40-49 50-59 All the ages

CVD total CVD total CVD total CVD total

Smokers 7 212 12 160 14 128 33 500
Non smokers 1 320 11 347 28 333 40 1000
Total 8 532 23 507 42 461 73 1500
Total = number of people by age group in 2007
CVD = number of –Cardiovascular disease diagnosed in the years 2007-2012 in the
respective groups

With this data from the table it can be determined that Mr. Agbabla stands the risk of suffering
from cardio vascular disease within six years.
That is 40/1000 = 4% and for his neighbour it is 33/500 = 6.6%. He wonders whether he should
calculate the difference or the proportion of these risks to compare the risks of Mr. Agbabla and
his neighbour. For the smoker the doctor thinks the result is not so bad, but he observes that this
comparison in the category of the younger smoker is much unfavourable.
He also wonders whether the age should be taken into account as a risk factor for cardio-vascular
diseases.
The doctor is surprised at the large number of cases of cardiovascular diseases, and he would like
to know how many cases in that period are the consequences of the smoking habit.
The regulation mechanisms of the individual's behaviour and society
Psychic and social mechanisms of defense
This section approaches the theme of regulation mechanisms of the individual's behaviour, as
well as the society, and takes the study of the homeostasis mechanisms to a higher integration
level. There are presented the social processes linked to the threat and defense (stigmatization,
stereotype, social continence of the divergent behaviour).
This is followed by the illustration of the mechanisms of individual defense like reaction to the
threat factors, the psyche (psychodynamic). It also discusses the phenomenon of stress and
vegetative adaptation, as a result of a high psychological pressure.
Task 8
Merging of two banks
Two banks (Access Bank and Inter-Continental) have agreed to merge. Both directors have their
own interests. Mr. Awuni, the director of Access Bank wants to promote national privatized
companies, and Mr. Majeed, director of Inter-Continental wants more foreign investment. They
don't agree and, besides, they have to decide who will be the general director of the New Bank.
There are big problems, which gets to the point that Mr. Majeed begins to suffer from chest
pains, palpitations with migraines, and profuse perspiration. He is hospitalized and investigations
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reveal indicators of significant risks factors for coronary artery disease that have been caused by
the negative psychosocial factors.
Mr. Awuni reacts in a different way. Now he is constipated a lot of the time, and he wonders if
his ill health is as a result of the tension at the work place.

Task 9
The pig’s head
Dr. Addo has just been posted to the Karaga Polyclinic. The next day he went on ward rounds,
during which he came across a patient admitted with a very ‘strange face.’ Dr. Addo was unable
to determine the cause of that strange appearance on his face. He tried everything possible to
improve the man’s condition to no avail. He was unable to find a solution to the man’s condition.
The nurses of the polyclinic liked their new Doctor and wanted to help by giving him some
‘filla’. They explained, “Doctor, don't worry! This man has a very bad character and he behaved
badly in the past, because of this some witches hid his head and substituted it with a pig’s head.
This happened many years ago. Nobody can find his head.”

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 References

1. Guyton and Hall; Textbook of Medical Physiology, 12e 2010

2. Kim E. Barrett, Susan M. Barman, Ganong’s Review of medical physiology, 24th Edition,
2012
3. Lippincott Williams & Wilkins Basic Immunology Edition 11998
4. Ian Todd, Gavin Spickett Lecture: Immunology .6th Edition 2011
5. Kumar, Abbas, Fausto and Mitchell Robbins, Basic Pathology 9th Edition, 2012
6. Keith L. Moore, Anne M. R. Agur Clinically oriented anatomy 7th Edition, 2013
7. Sarah Nettleton, The Sociology of Health and Illness, 3rd Edition, 2013.
8. Cockerham, William C, Medical Sociology, 10th Edition, 2006.

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