<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Menstrual disorder and can you explain it in depth? [/INST] A menstrual disorder is characterized as any abnormal condition with regards to a persons menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.Though menstrual disorders were once considered more of a nuisance problem, they are now widely recognized as having a serious impact on society in the form of days lost from work brought about by the pain and suffering experienced by women. These disorders can arise from physiologic sources (pregnancy etc.), pathologic sources (stress, excessive exercise, weight loss, endocrine or structural abnormalities etc.), or iatrogenic sources (secondary to contraceptive use etc.).

Types of menstrual disorders
Premenstrual Disorders
Premenstrual syndrome (PMS) or premenstrual tension refers to the emotional and physical symptoms that routinely occur in the two weeks leading up to menstruation. Symptoms are usually mild, but 5-8% of women experience moderate to severe symptoms that significantly affect daily activities. Symptoms may include anxiety, irritability, mood swings, depression, headache, food cravings, increased appetite, and bloating.
Premenstrual dysphoric disorder (PMDD) is a severe mood disorder that affects cognitive and physical functions in the week leading up to menstruation. Premenstrual dysphoric disorder is diagnosed with at least one affective, or mood, symptom and at least five physical, mood, and/or behavioral symptoms.

Disorders of cycle length
Normal menstrual cycle length is 22–45 days.
Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Physiologic states of amenorrhoea are seen during pregnancy and lactation (breastfeeding). Outside of the reproductive years there is absence of menses during childhood and after menopause.
Irregular menstruation is where there is variation in menstrual cycle length of more than approximately 8 days for a woman. The term metrorrhagia is often used for irregular menstruation that occurs between the expected menstrual periods.
Oligomenorrhea is the medical term for infrequent, often light menstrual periods (intervals exceeding 35 days).
Polymenorrhea is the medical term for cycles with intervals of 21 days or fewer.

Disorders of flow
Normal menstrual flow length is 3–7 days.
Abnormal uterine bleeding (AUB) is a broad term used to describe any disruption in bleeding that involves the volume, duration, and/or regularity of flow. Bleeding may occur frequently or infrequently, and can occur between periods, after sexual intercourse, and after menopause. Bleeding during pregnancy is excluded.
Hypomenorrhea is abnormally light menstrual bleeding.
Menorrhagia (meno = prolonged, rrhagia = excessive flow/discharge) is an abnormally heavy and prolonged menstrual period.
Metrorrhagia is bleeding at irregular times, especially outside the expected intervals of the menstrual cycle. If there is excessive menstrual and uterine bleeding other than that caused by menstruation, menometrorrhagia (meno = prolonged, metro = time, rrhagia = excessive flow/discharge) may be diagnosed. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods.

Disorders of ovulation
Disorders of ovulation include oligoovulation and anovulation:
Anovulation is absence of ovulation when it would be normally expected (in a post-menarchal, premenopausal woman). Anovulation usually manifests itself as irregularity of menstrual periods, that is, unpredictable variability of intervals, duration, or bleeding. Anovulation can also cause cessation of periods (secondary amenorrhea) or excessive bleeding (dysfunctional uterine bleeding).
Oligoovulation is infrequent or irregular ovulation (usually defined as cycles of >35 days or <8 cycles a year).

Other menstrual disorders
Dysmenorrhea (or dysmenorrhoea), cramps or painful menstruation, involves menstrual periods that are accompanied by either sharp, intermittent pain or dull, aching pain, usually in the pelvis or lower abdomen.

Signs and symptoms of menstrual disorders
The signs and symptoms of menstrual disorders can cause significant stress. Abnormal uterine bleeding (AUB) has the potential to be one of the most urgent gynecological problems during menstruation. Dysmenorrhea is the most common.

Premenstrual Syndrome (PMS)
Symptoms may include irritability, bloating, depression, food cravings, aggressiveness, and mood swings. Fluid retention and fluctuating weight gain are also reported.Precipitating risk factors include: stress, alcohol consumption, exercise, smoking, and some medications.

Amenorrhea
Lack of a menses by the age of 16 where secondary sexual characteristics have developed or by the age of 14 where no secondary sexual characteristics have developed (primary amenorrhea), or lack of a menses for more than 3–6 months after first menstruation cycle. Although missing a period is the main sign, other symptoms can include: excess facial, hair loss, headache, changes to vision, milky discharge from the breasts, or absence of breast development.

Abnormal Uterine Bleeding
One-third of women will experience abnormal uterine bleeding in their life. Normal menstrual cycle has a frequency of 24 to 38 days, lasts 7 to 9 days, so bleeding that lasts longer could be considered abnormal. Very heavy bleeding (for example, needing to use 1 or more tampons or sanitary pads every hour) is another symptom.

Dysmenorrhea
Especially painful or persistent menstrual cramping that occurs in the absence of any underlying pelvic disease.Pain radiating to the low back or upper thighs with onset of menstruation and lasting anywhere from 12 to 72 hours. Headache, nausea, vomiting, diarrhea, and fatigue may also accompany the pain. Pain may begin gradually, with the first several years of menses, and then intensified as menstruation becomes regular. Patients who also have secondary amenorrhea report symptoms beginning after age 20 and lasting 5–7 days with progressive worsening of pain over time. Pelvic pain is also reported.

Causes of menstrual disorders
There are many causes of menstrual disorders, including uterine fibroids, hormonal imbalances, clotting disorders, cancer, sexually-transmitted infections, polycystic ovary syndrome, and genetics. Uterine fibroids are benign, non-cancerous growths in the uterus that affect most women at some point in their lives and usually does not require treatment unless they cause intolerable symptoms. Stress and lifestyle factors commonly impact menstruation, which includes weight changes, dieting, changes in exercise, travel, and illness.Hyperprolactinaemia can also cause menstrual disorders.

Amenorrhea
There are different causes depending on the type of menstrual(period) disorder. Amenorrhea, or the absence of menstruation, is subdivided into primary and secondary amenorrhea. In primary amenorrhea, in which there is a failure to menstruate by the age of 16 with normal sexual development or by 14 without normal sexual development, causes can be from developmental abnormalities of the uterus, ovaries, or genital tract, or endocrine disorders. In secondary amenorrhea, or the absence of menstruation for greater than 6 months, can be caused by the same reasons as primary amenorrhea, as well as polycystic ovary syndrome, pregnancy, chronic illness, and certain drugs like cocaine and opioids.

Hypomenorrhea
Causes of hypomenorrhea, or irregular light periods, include periods around menopause, eating disorders, excessive exercise, thyroid dysfunction, uncontrolled diabetes, Cushings syndrome, hormonal birth control, and certain medications to treat epilepsy or mental health conditions.

Menorrhagia
Causes of menorrhagia, or heavy menstrual bleeding, include polycystic ovary syndrome, uterine fibroids, endometrial polyps, bleeding disorders, and miscarriage.

Dysmenorrhea
Causes of dysmenorrhea, or menstrual pain, include endometriosis, pelvic scarring due to chlamydia or gonorrhea, and intrauterine devices or IUDs. Primary dysmenorrhea is when there is no underlying cause that is identified, and secondary dysmenorrhea is when the menstrual pain is caused by other conditions such as endometriosis, fibroids, or infection.

Diagnosis of menstrual disorders
Diagnosis begins with an in-depth medical history and physical exam, including a pelvic exam and sometimes a Pap smear.Additional testing may include but are not limited to blood tests, hormonal tests, ultrasound, gynecologic ultrasound, magnetic resonance imaging (MRI), hysteroscopy, laparoscopy, endometrial biopsy, and dilation and curettage (D&C).

Treatment of menstrual disorders
Premenstrual syndrome and premenstrual dysphoric disorder
Due to the unclear etiology of premenstrual syndrome and premenstrual dysphoric disorder, symptom relief is the primary goal of treatment. Selective serotonin reuptake inhibitors and spironolactone decrease physical and psychological symptoms associated with premenstrual syndrome. Oral contraceptives may ameliorate physical symptoms of breast tenderness and bloating. Ovarian suppression treatment with gonadotropin-releasing hormone agonist as an off-label use may reduce symptoms but have adverse side effects including decreased bone density. Other less commonly use medications such as alprazolam may reduce anxiety symptoms but has potential for dependence, tolerance, and abuse. Pyridoxine, a form of vitamin B6, may be used as a dietary supplement to relieve overall symptoms.

Amenorrhea
Successful treatment varies depending on the diagnosis of amenorrhea. In patients with functional hypothalamic amenorrhea due to physical or psychological stress, non-pharmacological options include weight gain, resolution of emotional issues, or decreased intensity of exercise. Patients experiencing amenorrhea due to hypothyroidism may be started with thyroid replacement therapy </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Hyperkinesia and can you explain it in depth? [/INST] Hyperkinesia refers to an increase in muscular activity that can result in excessive abnormal movements, excessive normal movements, or a combination of both. Hyperkinesia is a state of excessive restlessness which is featured in a large variety of disorders that affect the ability to control motor movement, such as Huntingtons disease. It is the opposite of hypokinesia, which refers to decreased bodily movement, as commonly manifested in Parkinsons disease.
Many hyperkinetic movements are the result of improper regulation of the basal ganglia–thalamocortical circuitry. Overactivity of a direct pathway combined with decreased activity of indirect pathway results in activation of thalamic neurons and excitation of cortical neurons, resulting in increased motor output. Often, hyperkinesia is paired with hypotonia, a decrease in muscle tone. Many hyperkinetic disorders are psychological in nature and are typically prominent in childhood. Depending on the specific type of hyperkinetic movement, there are different treatment options available to minimize the symptoms, including different medical and surgical therapies. The word hyperkinesis comes from the Greek hyper, meaning "increased," and kinein, meaning "to move."

Classification
Basic hyperkinetic movements can be defined as any unwanted, excess movement. Such abnormal movements can be distinguished from each other on the basis of whether or not, or to what degree they are, rhythmic, discrete, repeated, and random. In evaluating the individual with a suspected form of hyperkinesia, the physician will record a thorough medical history, including a clear description of the movements in question, medications prescribed in the past and present, family history of similar diseases, medical history, including past infections, and any past exposure to toxic chemicals. Hyperkinesia is a defining feature of many childhood movement disorders, yet distinctly differs from both hypertonia and negative signs, which are also typically involved in such disorders. Several prominent forms of hyperkinetic movements include:

Ataxia
The term ataxia refers to a group of progressive neurological diseases that alter coordination and balance. Ataxias are often characterized by poor coordination of hand and eye movements, speech problems, and a wide-set, unsteady gait. Possible causes of ataxias may include stroke, tumor, infection, trauma, or degenerative changes in the cerebellum. These types of hyperkinetic movements can be further classified into two groups. The first group, hereditary ataxias, affect the cerebellum and spinal cord and are passed from one generation to the next through a defective gene. A common hereditary ataxia is Friedreichs ataxia. in contrast, sporadic ataxias occur spontaneously in individuals with no known family history of such movement disorders.

Athetosis
Athetosis is defined as a slow, continuous, involuntary writhing movement that prevents the individual from maintaining a stable posture. These are smooth, nonrhythmic movements that appear random and are not composed of any recognizable sub-movements. They mainly involve the distal extremities, but can also involve the face, neck, and trunk. Athetosis can occur in the resting state, as well as in conjunction with chorea and dystonia. When combined with o, as in cerebral palsy, the term "choreoathetosis" is frequently used.

Chorea
Chorea is a continuous, random-appearing sequence of one or more discrete involuntary movements or movement fragments. Although chorea consists of discrete movements, many are often strung together in time, thus making it difficult to identify each movements start and end point. These movements can involve the face, trunk, neck, tongue, and extremities. Unlike dystonic movements, chorea-associated movements are often more rapid, random and unpredictable. Movements are repeated, but not rhythmic in nature. Children with chorea appear fidgety and will often try to disguise the random movements by voluntarily turning the involuntary, abnormal movement into a seemingly more normal, purposeful motion. Chorea may result specifically from disorders of the basal ganglia, cerebral cortex, thalamus, and cerebellum. It has also been associated with encephalitis, hyperthyroidism, anticholinergic toxicity, and other genetic and metabolic disorders. Chorea is also the prominent movement featured in Huntingtons disease.

Dystonia
Dystonia is a movement disorder in which involuntarily sustained or intermittent muscle contractions cause twisting or repetitive movements, abnormal postures, or both. Such abnormal postures include foot inversion, wrist ulnar deviation, or lordotic trunk twisting. They can be localized to specific parts of the body or be generalized to many different muscle groups. These postures are often sustained for long periods of time and can be combined in time. Dystonic movements can augment hyperkinetic movements, especially when linked to voluntary movements.Blepharospasm is a type of dystonia characterized by the involuntary contraction of the muscles controlling the eyelids. Symptoms can range from a simple increased frequency of blinking to constant, painful eye closure leading to functional blindness.Oromandibular dystonia is a type of dystonia marked by forceful contractions of the lower face, which causes the mouth to open or close. Chewing motions and unusual tongue movements may also occur with this type of dystonia.Laryngeal dystonia or spasmodic dysphonia results from abnormal contraction of muscles in the voice box, resulting in altered voice production. Patients may have a strained-strangled quality to their voice or, in some cases, a whispering or breathy quality.Cervical dystonia (CD) or spasmodic torticollis is characterized by muscle spasms of the head and neck, which may be painful and cause the neck to twist into unusual positions or postures.Writers cramp and musicians cramp is a task-specific dystonia, meaning that it only occurs when performing certain tasks. Writers cramp is a contraction of hand and/or arm muscles that happens only when a patient is writing. It does not occur in other situations, such as when a patient is typing or eating. Musicians cramp occurs only when a musician plays an instrument, and the type of cramp experienced is specific to the instrument. For example, pianists may experience cramping of their hands when playing, while brass players may have cramping or contractions of their mouth muscles.

Hemiballismus
Typically caused by damage to the subthalamic nucleus or nuclei, hemiballismus movements are nonrhythmic, rapid, nonsuppressible, and violent. They usually occur in an isolated body part, such as the proximal arm.

Hemifacial spasm
Hemifacial spasm (HFS) is characterized by involuntary contraction of facial muscles, typically occurring only on one side of the face. Like blepharospasm, the frequency of contractions in hemifacial spasm may range from intermittent to frequent and constant. The unilateral blepharospasm of HFS may interfere with routine tasks such as driving. In addition to medication, patients may respond well to treatment with Botox. HFS may be due to vascular compression of the nerves going to the muscles of the face. For these patients, surgical decompression may be a viable option for the improvement of symptoms.

Myoclonus
Myoclonus is defined as a sequence of repeated, often nonrhythmic, brief, shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles. These movements may be asynchronous, in which several muscles contract variably in time, synchronous, in which muscles contract simultaneously, or spreading, in which several muscles contract sequentially. It is characterized by a sudden, unidirectional movement due to muscle contraction, followed by a relaxation period in which the muscle is no longer contracted. However, when this relaxation phase is decreased, as when muscle contractions become faster, a myoclonic tremor results. Myoclonus can often be associated with seizures, delirium, dementia, and other signs of neurological disease and gray matter damage.

Stereotypies
Stereotypies are repetitive, rhythmic, simple movements that can be voluntarily suppressed. Like tremors, they are typically back and forth movements, and most commonly occur bilaterally. They often involve fingers, wrists, or proximal portions of the upper extremities. Although, like tics, they can stem from stress or excitement, there is no underlying urge to move associated with stereotypies and these movements can be stopped with distraction. When aware of the movements, the child can also suppress them voluntarily. Stereotypies are often associated with developmental syndromes, including the autism spectrum disorders. Stereotypies are quite common in preschool-aged children and for this reason are not necessarily indicative of neurological pathology on their own.

Tardive dyskinesia / tardive dystonia
Tardive dyskinesia or tardive dystonia, both referred to as "TD", refers to a wide variety of involuntary stereotypical movements caused by the prolonged use of dopamine receptor-blocking agents. The most common types of these agents are antipsychotics and anti-nausea agents. The classic form of TD refers to stereotypic movements of the mouth, which resemble chewing. However, TD can also appear as other involuntary movements such as chorea, dystonia, or tics.

Tics
A tic can be defined as a repeated, individually recognizable, intermittent movement or movement fragments that are almost always briefly suppressible and are usually associated with awareness of an urge to perform the movement. These abnormal movements occur with intervening periods of normal movement. These movements are predictable, often triggered by stress, excitement, suggestion, or brief voluntary suppressibility. Many children say that the onset of tics can stem from the strong urge to move. Tics can be either muscular (alter normal motor function) or vocal (alter normal speech) in nature and most commonly involve the face, mouth, eyes, head, neck or shoulder muscles. Tics can also be classified as simple motor tics (a single brief stereotyped movement or movement fragment), complex motor tics (a more complex or sequential movement involving multiple muscle
groups), or phonic tics (including simple, brief phonations or vocalizations).When both motor and vocal tics are present and persist for more than one year, a diagnosis of Tourette syndrome (TS) is likely. TS is an inherited neurobehavioral disorder characterized by both motor and vocal tics. Many individuals with TS may also develop obsessions, compulsions, inattention and hyperactivity. TS usually begins in childhood. Up to 5% of the population has tics, but at least 20% of boys will have developed tics at some point in their lifetimes.

Tremor
A tremor can be defined as a rhythmic, back and forth or oscillating involuntary movement about a joint axis. Tremors are symmetric about a midpoint within the movement, and both portions of the movement occur at the same speed. Unlike the other hyperkinetic movements, tremors lack both the jerking associated movements and posturing.Essential tremor (ET), also known as benign essential tremor, or familial tremor, is the most common movement disorder. It is estimated that 5 percent of people worldwide have this condition, affecting those of all ages but typically staying within families. ET typically affects the hands and arms but can also affect the head, voice, chin, trunk and legs. Both sides of the body tend to be equally affected. The tremor is called an action tremor, becoming noticeable in the arms when they are being used. Patients often report that alcohol helps lessen the symptoms. Primary medical treatments for ET are usually beta-blockers. For patients who fail to respond sufficiently to medication, deep brain stimulation and thalamotomy can be highly effective.A "flapping tremor," or asterixis, is characterized by irregular flapping-hand movement, which appears most often with outstretched arms and wrist extension. Individuals with this condition resemble birds flapping their wings.

Volitional hyperkinesia
Volitional hyperkinesia refers to any type of involuntary movement described above that interrupts an intended voluntary muscular movement. These movements tend to be jolts that present suddenly during an otherwise smoothly coordinated action of skeletal muscle.

Pathophysiology
The causes of the majority of the above hyperkinetic movements can be traced to improper modulation of the basal ganglia by the subthalamic nucleus. In many cases, the excitatory output of the subthalamic nucleus is reduced, leading to a reduced inhibitory outflow of the basal ganglia. Without the normal restraining influence of the basal ganglia, upper motor neurons of the circuit tend to become more readily activated by inappropriate signals, resulting in the characteristic abnormal movements.There are two pathways involving basal ganglia-thalamocortical circuitry, both of which originate in the neostriatum. The direct pathway projects to the internal globus pallidus (GPi) and to the substantia nigra pars reticulata (SNr). These projections are inhibitory and have been found to utilize both GABA and substance P. The indirect pathway, which projects to the globus pallidus external (GPe), is also inhibitory and uses GABA and enkephalin. The GPe projects to the subthalamic nucleus (STN), which then projects back to the GPi and GPe via excitatory, glutaminergic pathways. Excitation of the direct pathway leads to disinhibition of the GABAergic neurons of the GPi/SNr, ultimately resulting in activation of thalamic neurons and excitation of cortical neurons. In contrast, activation of the indirect pathway stimulates the inhibitory striatal GABA/enkephalin projection, resulting in suppression of GABAergic neuronal activity. This, in turn, causes disinhibition of the STN excitatory outputs, thus triggering the GPi/SNr inhibitory projections to the thalamus and decreased activation of cortical neurons. While deregulation of either of these pathways can disturb motor output, hyperkinesia is thought to result from overactivity of the direct pathway and decreased activity from the indirect pathway.Hyperkinesia occurs when dopamine receptors, and norepinephrine receptors to a lesser extent, within the cortex and the brainstem are more sensitive to dopamine or when the dopaminergic receptors/neurons are hyperactive. Hyperkinesia can be caused by a large number of different diseases including metabolic disorders, endocrine disorders, heritable disorders, vascular disorders, or traumatic disorders. Other causes include toxins within the brain, autoimmune disease, and infections, which include meningitis.Since the basal ganglia often have many connections with the frontal lobe of the brain, hyperkinesia can be associated with neurobehavioral or neuropsychiatric disorders such as mood changes, psychosis, anxiety, disinhibition, cognitive impairments, and inappropriate behavior.In children, primary dystonia is usually inherited genetically. Secondary dystonia, however, is most commonly caused by dyskinetic cerebral palsy, due to hypoxic or ischemic injury to the basal ganglia, brainstem, cerebellum, and thalamus during the prenatal or infantile stages of development. Chorea and ballism can be caused by damage to the subthalamic nucleus. Chorea can be secondary to hyperthyroidism. Athetosis can be secondary to sensory loss in the distal limbs; this is called pseudoathetosis in adults but is not yet proven in children.

Diagnosis
Definition
There are various terms which refer to specific movement mechanisms that contribute to the differential diagnoses of hyperkinetic disorders.
As defined by Hogan and Sternad, "posture" is a nonzero time period during which bodily movement is minimal. When a movement is called "discrete," it means that a new posture is assumed without any other postures interrupting the process. "Rhythmic" movements are those that occur in cycles of similar movements. "Repetitive," "recurrent," and "reciprocal" movements feature a certain bodily or joint position that occur more than once in a period, but not necessarily in a cyclic manner.Overflow refers to unwanted movements that occur during a desired movement. It may occur in situations where the individuals motor intention spreads to either nearby or distant muscles, taking away from the original goal of the movement. Overflow is often associated with dystonic movements and may be due to a poor focusing of muscle activity and inability to suppress unwanted muscle movement. Co-contraction refers to a voluntary movement performed to suppress the involuntary movement, such as forcing ones wrist toward the body to stop it from involuntarily moving away from the body.In evaluating these signs and symptoms, one must consider the frequency of repetition, whether or not the movements can be suppressed voluntarily (either by cognitive decisions, restraint, or sensory tricks), the awareness of the affected individual during the movement events, any urges to make the movements, and if the affected individual feels rewarded after having completed the movement. The context of the movement should also be noted; this means that a movement could be triggered in a certain posture, while at rest, during action, or during a specific task. The movements quality can also be described in observing whether or not the movement can be categorized as a normal movement by an unaffected individual, or one that is not normally made on a daily basis by unaffected individuals.

Differential diagnosis
Diseases that feature one or more hyperkinetic movements as prominent symptoms include:

Huntingtons disease
Hyperkinesia, more specifically chorea, is the hallmark symptom of Huntingtons disease, formerly referred to as Huntingtons chorea. Appropriately, chorea is derived from the Greek word, khoros, meaning "dance." The extent of the hyperkinesia exhibited in the disease can vary from solely the little finger to the entire body, resembling purposeful movements but occurring involuntarily. In children, rigidity and seizures are also symptoms.
Other hyperkinetic symptoms include:

Head turning to shift eye position
Facial movements, including grimaces
Slow, uncontrolled movements
Quick, sudden, sometimes wild jerking movements of the arms, legs, face, and other body parts
Unsteady gait
Abnormal reflexes
"prancing," or a wide walkThe disease is characterized further by the gradual onset of defects in behavior and cognition, including dementia and speech impediments, beginning in the fourth or fifth decades of life. Death usually occurs within 10–20 years after a progressive worsening of symptoms. Caused by the Huntington gene, the disease eventually contributes to selective atrophy of the Caudate nucleus and Putamen, especially of GABAergic and acetylcholinergic neurons, with some additional degeneration of the frontal and temporal cortices of the brain. The disrupted signaling in the basal ganglia network is thought to cause the hyperkinesia. There is no known cure for Huntingtons disease, yet there is treatment available to minimize the hyperkinetic movements. Dopamine blockers, such as haloperidol, tetrabenazine, and amantadine, are often effective in this regard.

Wilsons disease
Wilsons disease (WD) is a rare inherited disorder in which patients have a problem metabolizing copper. In patients with WD, copper accumulates in the liver and other parts of the body, particularly the brain, eyes and kidneys. Upon accumulation in the brain, patients may experience speech problems, incoordination, swallowing problems, and prominent hyperkinetic symptoms including tremor, dystonia, and gait difficulties. Psychiatric disturbances such as irritability, impulsiveness, aggressiveness, and mood disturbances are also common.

Restless leg syndrome
Restless leg syndrome is a disorder in which patients feel uncomfortable or unpleasant sensations in the legs. These sensations usually occur in the evening, while the patient is sitting or lying down and relaxing. Patients feel like they have to move their legs to relieve the sensations, and walking generally makes the symptoms disappear. In many patients, this can lead to insomnia and excessive daytime sleepiness. This is a very common problem and can occur at any age.Similarly, the syndrome akathisia ranges from mildly compulsive movement usually in the legs to intense frenzied motion. These movements are partly voluntary, and the individual typically has the ability to suppress them for short amounts of time. Like restless leg syndrome, relief results from movement.

Post-stroke repercussions
A multitude of movement disorders have been observed after either ischemic or hemorrhagic stroke.  Some examples include athetosis, chorea with or without hemiballismus, tremor, dystonia, and segmental or focal myoclonus, although the prevalence of these manifestations after stroke is quite low.  The amount of time that passes between stroke event and presentation of hyperkinesia depends on the type of hyperkinetic movement since their pathologies slightly differ.  Chorea tends to affect older stroke survivors while dystonia tends to affect younger ones.  Men and women have an equal chance of developing the hyperkinetic movements after stroke.  Strokes causing small, deep lesions in the basal ganglia, brain stem and thalamus are those most likely to be associated with post-stroke hyperkinesia.

Dentatorubral-pallidoluysian atrophy
DRPLA is a rare trinucleotide repeat disorder (polyglutamine disease) that can be juvenile-onset (< 20 years), early adult-onset (20–40 years), or late adult-onset (> 40 years). Late adult-onset DRPLA is characterized by ataxia, choreoathetosis and dementia. Early adult-onset DRPLA also includes seizures and myoclonus. Juvenile-onset DRPLA presents with ataxia and symptoms consistent with progressive myoclonus epilepsy
(myoclonus, multiple seizure types and dementia). Other symptoms that have been described include cervical dystonia, corneal endothelial degeneration autism, and surgery-resistant obstructive sleep apnea.

Management
Athetosis, chorea and hemiballismus
Before prescribing medication for these conditions which often resolve spontaneously, recommendations have pointed to improved skin hygiene, good hydration via fluids, good nutrition, and installation of padded bed rails with use of proper mattresses.  Pharmacological treatments include the typical neuroleptic agents such as fluphenazine, pimozide, haloperidol and perphenazine which block dopamine receptors; these are the first line of treatment for hemiballismus.  Quetiapine, sulpiride and olanzapine, the atypical neuroleptic agents, are less likely to yield drug-induced parkinsonism and tardive dyskinesia.  Tetrabenazine works by depleting presynaptic dopamine and blocking postsynaptic dopamine receptors, while reserpine depletes the presynaptic catecholamine and serotonin stores; both of these drugs treat hemiballismus successfully but may cause depression, hypotension and parkinsonism.  Sodium valproate and clonazepam have been successful in a limited number of cases. Stereotactic ventral intermediate thalamotomy and use of a thalamic stimulator have been shown to be effective in treating these conditions.

Essential tremor
The medical treatment of essential tremor at the Movement Disorders Clinic at Baylor College of Medicine begins with minimizing stress and tremorgenic drugs along with recommending a restricted intake of beverages containing caffeine as a precaution, although caffeine has not been shown to significantly intensify the presentation of essential tremor.  Alcohol amounting to a blood concentration of only 0.3% has been shown to reduce the amplitude of essential tremor in two-thirds of patients; for this reason it may be used as a prophylactic treatment before events during which one would be embarrassed by the tremor presenting itself.  Using alcohol regularly and/or in excess to treat tremors is highly inadvisable, as there is a purported correlation between tremor and alcoholism.  Alcohol is thought to stabilize neuronal membranes via potentiation of GABA receptor-mediated chloride influx.  It has been demonstrated in essential tremor animal models that the food additive 1-octanol suppresses tremors induced by harmaline, and decreases the amplitude of essential tremor for about 90 minutes.Two of the most valuable drug treatments for essential tremor are propranolol, a beta blocker, and primidone, an anticonvulsant.  Propranolol is much more effective for hand tremor than head and voice tremor.  Some beta-adrenergic blockers (beta blockers) are not lipid-soluble and therefore cannot cross the blood–brain barrier (propranolol being an exception), but can still act against tremors; this indicates that this drugs mechanism of therapy may be influenced by peripheral beta-adrenergic receptors.  Primidones mechanism of tremor prevention has been shown significantly in controlled clinical studies.  The benzodiazepine drugs such as diazepam and barbiturates have been shown to reduce presentation of several types of tremor, including the essential variety.  Controlled clinical trials of gabapentin yielded mixed results in efficacy against essential tremor  while topiramate was shown to be effective in a larger double-blind controlled study, resulting in both lower Fahn-Tolosa-Marin tremor scale ratings and better function and disability as compared to placebo.It has been shown in two double-blind controlled studies that injection of botulinum toxin into muscles used to produce oscillatory movements of essential tremors, such as forearm, wrist and finger flexors, may decrease the amplitude of hand tremor for approximately three months  and that injections of the toxin may reduce essential tremor presenting in the head and voice.  The toxin also may help tremor causing difficulty in writing, although properly adapted writing devices may be more efficient.  Due to high incidence of side effects, use of botulinum toxin has only received a C level of support from the scientific community.Deep brain stimulation toward the ventral intermediate nucleus of the thalamus and potentially the subthalamic nucleus and caudal zona incerta nucleus have been shown to reduce tremor in numerous studies.  That toward the ventral intermediate nucleus of the thalamus has been shown to reduce contralateral and some ipsilateral tremor along with tremors of the cerebellar outflow, head, resting state and those related to hand tasks; however, the treatment has been shown to induce difficulty articulating thoughts (dysarthria), and loss of coordination and balance in long-term studies.  Motor cortex stimulation is another option shown to be viable in numerous clinical trials.

Dystonia
Treatment of primary dystonia is aimed at reducing symptoms such as involuntary movements, pain, contracture, embarrassment, and to restore normal posture and improve the patients function.  This treatment is therefore not neuroprotective.  According to the European Federation of Neurological Sciences and Movement Disorder Society, there is no evidence-based recommendation for treating primary dystonia with antidopaminergic or anticholinergic drugs although recommendations have been based on empirical evidence.   Anticholinergic drugs prove to be most effective in treating generalized and segmental dystonia, especially if dose starts out low and increases gradually.  Generalized dystonia has also been treated with such muscle relaxants as the benzodiazepines.  Another muscle relaxant, baclofen, can help reduce spasticity seen in cerebral palsy such as dystonia in the leg and trunk.  Treatment of secondary dystonia by administering levodopa in dopamine-responsive dystonia, copper chelation in Wilsons disease, or stopping the administration of drugs that may induce dystonia have been proven effective in a small number of cases.  Physical therapy has been used to improve posture and prevent contractures via braces and casting, although in some cases, immobilization of limbs can induce dystonia, which is by definition known as peripherally induced dystonia.  There are not many clinical trials that show significant efficacy for particular drugs, so medical of dystonia must be planned on a case-by-case basis. Botulinum toxin B, or Myobloc, has been approved by the US Food and Drug Administration to treat cervical dystonia due to level A evidential support by the scientific community. Surgery known as GPi DBS (Globus Pallidus Pars Interna Deep Brain Stimulation) has come to be popular in treating phasic forms of dystonia, although cases involving posturing and tonic contractions have improved to a lesser extent with this surgery.  A follow-up study has found that movement score improvements observed one year after the surgery was maintained after three years in 58% of the cases.  It has also been proven effective in treating cervical and cranial-cervical dystonia.

Tics
Treatment of tics present in conditions such as Tourettes syndrome begins with patient, relative, teacher and peer education about the presentation of the tics.  Sometimes, pharmacological treatment is unnecessary and tics can be reduced by behavioral therapy such as habit-reversal therapy and/or counseling.  Often this route of treatment is difficult because it depends most heavily on patient compliance.  Once pharmacological treatment is deemed most appropriate, lowest effective doses should be given first with gradual increases.  The most effective drugs belong to the neuroleptic variety such as monoamine-depleting drugs and dopamine receptor-blocking drugs.  Of the monoamine-depleting drugs, tetrabenazine is most powerful against tics and results in fewest side effects.  A non-neuroleptic drug found to be safe and effective in treating tics is topiramate. Botulinum toxin injection in affected muscles can successfully treat tics; involuntary movements and vocalizations can be reduced, as well as life-threatening tics that have the potential of causing compressive myelopathy or radiculopathy. Surgical treatment for disabling Tourettes syndrome has been proven effective in cases presenting with self-injury.  Deep Brain Stimulation surgery targeting the globus pallidus, thalamus and other areas of the brain may be effective in treating involuntary and possibly life-threatening tics.

History
In the 16th century, Andreas Vesalius and Francesco Piccolomini were the first to distinguish between white matter, the cortex, and the subcortical nuclei in the brain. About a century later, Thomas Willis noticed that the corpus striatum was typically discolored, shrunken, and abnormally softened in the cadavers of people who had died from paralysis. The view that the corpus striatum played such a large role in motor functions was the most prominent one until the 19th century when electrophysiologic stimulation studies began to be performed. For example, Gustav Fritsch and Eduard Hitzig performed them on dog cerebral cortices in 1870, while David Ferrier performed them, along with ablation studies, on cerebral cortices of dogs, rabbits, cats, and primates in 1876. During the same year, John Hughlings Jackson posited that the motor cortex was more relevant to motor function than the corpus striatum after carrying out clinical-pathologic experiments in humans. Soon it would be discovered that the theory about the corpus striatum would not be completely incorrect.By the late 19th century, a few hyperkinesias such as Huntingtons chorea, post-hemiplegic choreoathetosis, Tourettes syndrome, and some forms of both tremor and dystonia were described in a clinical orientation.  However, the common pathology was still a mystery.  British neurologist William Richard Gowers called these disorders "general and functional diseases of the nervous system" in his 1888 publication entitled A Manual of Diseases of the Nervous System. It was not until the late 1980s and 1990s that sufficient animal models and human clinical trials were utilized to discover the specific involvement of the basal ganglia in the hyperkinesia pathology. In 1998, Wichmann and Delong made the conclusion that hyperkinesia is associated with decreased output from the basal ganglia, and in contrast, hypokinesia is associated with increased output from the basal ganglia. This generalization, however, still leaves a need for more complex models to distinguish the more nuanced pathologies of the numerous diverse hyperkinesias which are still being studied today.In the 2nd century, Galen was the first to define tremor as "involuntary alternating up-and-down motion of the limbs." Further classification of hyperkinetic movements came in the 17th and 18th centuries by Franciscus Sylvius and Gerard van Swieten. Parkinsons disease was one of the first disorders to be named as a result of the recent classification of its featured hyperkinetic tremor. The subsequent naming of other disorders involving abnormal motions soon followed.

Research directions
Studies have been done with electromyography to trace skeletal muscle activity in some hyperkinetic disorders </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Vertebral compression fracture and can you explain it in depth? [/INST] A compression fracture is a collapse of a vertebra. It may be due to trauma or due to a weakening of the vertebra (compare with burst fracture). This weakening is seen in patients with osteoporosis or osteogenesis imperfecta, lytic lesions from metastatic or primary tumors, or infection. In healthy patients, it is most often seen in individuals suffering extreme vertical shocks, such as ejecting from an ejection seat. Seen in lateral views in plain x-ray films, compression fractures of the spine characteristically appear as wedge deformities, with greater loss of height anteriorly than posteriorly and intact pedicles in the anteroposterior view.

Signs and symptoms
Acute fractures will cause severe back pain. Compression fractures which develop gradually, such as in osteoporosis, may initially not cause any symptoms, but will later often lead to back pain and loss of height.

Diagnosis
Compression fractures are usually diagnosed on spinal radiographs, where a wedge-shaped vertebra may be visible or there may be loss of height of the vertebra. In addition, bone density measurement may be performed to evaluate for osteoporosis. When a tumor is suspected as the underlying cause, or the fracture was caused by severe trauma, CT or MRI scans may be performed.

Treatment
Conservative treatment
Back brace for support while the bone heals—either a Jewett brace for relatively stable and mild injuries, or a thoracic lumbar sacral orthosis (TLSO) for more severe ones.
Opioids or non-steroidal anti-inflammatory drugs (NSAIDs) for pain. For osteoporotic patients, calcitonin may be helpful.

Surgical
Kyphoplasty and vertebroplasty are minimally invasive procedures that inject cement into the bone of the back that is fractured </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Lung abscess and can you explain it in depth? [/INST] Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
This pus-filled cavity is often caused by aspiration, which may occur during anesthesia, sedation, or unconsciousness from injury.  Alcoholism is the most common condition predisposing to lung abscesses.
Lung abscess is considered primary (60%) when it results from existing lung parenchymal process and is termed secondary when it complicates another process e.g. vascular emboli or follows rupture of extrapulmonary abscess into lung.

Signs and symptoms
Onset of symptoms is often gradual, but in necrotizing staphylococcal or gram-negative bacillary pneumonias patients can be acutely ill. Cough, fever with shivering, and night sweats are often present. Cough can be productive of foul smelling purulent mucus (≈70%) or less frequently with blood  in one third of cases). Affected individuals may also complain of chest pain, shortness of breath, lethargy and other features of chronic illness.Those with a lung abscess are generally cachectic at presentation. Finger clubbing is present in one third of patients. Dental decay is common especially in alcoholics and children. On examination of the chest there will be features of consolidation such as localized dullness on percussion and bronchial breath sounds.

Complications
Although rare in modern times, can include spread of infection to other lung segments, bronchiectasis, empyema, and bacteremia with metastatic infection such as brain abscess.

Causes
Conditions contributing to lung abscessAspiration of oropharyngeal or gastric secretion
Septic emboli
Necrotizing pneumonia
Vasculitis: Granulomatosis with polyangiitis
Necrotizing tumors: 8% to 18% are due to neoplasms across all age groups, higher in older people; primary squamous carcinoma of the lung is the most common.OrganismsIn the post-antibiotic era pattern of frequency is changing </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Irritation and can you explain it in depth? [/INST] Irritation, in biology and physiology, is a state of inflammation or painful reaction to allergy or cell-lining damage. A stimulus or agent which induces the state of irritation is an irritant. Irritants are typically thought of as chemical agents (for example phenol and capsaicin) but mechanical, thermal (heat), and radiative stimuli (for example ultraviolet light or ionising radiations) can also be irritants. Irritation also has non-clinical usages referring to bothersome physical or psychological pain or discomfort.
Irritation can also be induced by some allergic response due to exposure of some allergens for example contact dermatitis, irritation of mucosal membranes and pruritus. Mucosal membrane is the most common site of irritation because it contains secretory glands that release mucous which attracts the allergens due to its sticky nature.
Chronic irritation is a medical term signifying that afflictive health conditions have been present for a while. There are many disorders that can cause chronic irritation, the majority involve the skin, vagina, eyes and lungs.

Irritation in organisms
In higher organisms, an allergic response may be the cause of irritation. An allergen is defined distinctly from an irritant, however, as allergy requires a specific interaction with the immune system and is thus dependent on the (possibly unique) sensitivity of the organism involved while an irritant, classically, acts in a non-specific manner.
It is a form of stress, but conversely, if one is stressed by unrelated matters, mild imperfections can cause more irritation than usual: one is irritable; see also sensitivity (human).
In more basic organisms, the status of pain is the perception of the being stimulated, which is not observable although it may be shared (see gate control theory of pain).

It is not proven that oysters can feel pain, but it is known that they react to irritants. When an irritating object becomes trapped within an oysters shell, it deposits layers of calcium carbonate (CaCO3), slowly increasing in size and producing a pearl. This is purely a defense mechanism, to trap a potentially threatening irritant such as a parasite inside its shell, or an attack from outside, injuring the mantle tissue. The oyster creates a pearl sac to seal off the irritation.
It has also been observed that an amoeba avoids being prodded with a pin, but there is not enough evidence to suggest how much it feels this. Irritation is apparently the only universal sense shared by even single-celled creatures.
It is postulated that most such beings also feel pain, but this is a projection – empathy. Some philosophers, notably René Descartes, denied it entirely, even for such higher mammals as dogs or primates like monkeys; Descartes considered intelligence a pre-requisite for the feeling of pain.

Types
Eye irritation
Modern office work with use of office equipment has raised concerns about possible adverse health effects. Since the 1970s, reports have linked mucosal, skin, and general symptoms to work with self-copying paper. Emission of various particulate and volatile substances has been suggested as specific causes. These symptoms have been related to Sick Building Syndrome, which involves symptoms such as irritation to the eyes, skin, and upper airways, headache and fatigue.The eye is also a source of chronic irritation. Disorders like Sjögrens syndrome, where one does not make tears, can cause a dry eye sensation which feels very unpleasant. The condition is difficult to treat and is lifelong. Besides artificial tears, there is a drug called Restasis which may help.Blepharitis is dryness and itching on the upper eyelids. This condition is often seen in young people and can lead to reddish dry eye and scaly eyebrows. To relieve the itching sensation, one may need to apply warm compresses and use topical corticosteroid creams.

Skin
Eczema is another cause of chronic irritation and affects millions of individuals. Eczema simply means a dry skin which is itchy. The condition usually starts at an early age and continues throughout life. The major complaint of people with eczema is an itchy dry skin. Sometimes, the itching will be associated with a skin rash. The affected areas are always dry, scaly, reddish and may ooze sometimes. Eczema cannot be cured, but its symptoms can be controlled. One should use moisturizers, use cold compresses and avoid frequent hot showers. There are over the counter corticosteroids creams which can be applied. Sometimes, an anti histamine has to be used to prevent the chronic itching sensations. There are also many individuals who have allergies to a whole host of substances like nuts, hair, dander, plants and fabrics. For these individuals, even the minimal exposure can lead to a full blown skin rash, itching, wheezing and coughing. Unfortunately, other than avoidance, there is no other cure. There are allergy shots which can help desensitize against an allergen but often the results are poor and the treatments are expensive. Most of these individuals with chronic irritation from allergens usually need to take anti histamines or use a bronchodilator to relieve symptoms.Another common irritation disorder in females is intertrigo. This disorder is associated with chronic irritation under folds of skin. This is typically seen under large breasts, groins and folds of the abdomen in obese individuals. Candida quickly grows in warm moist areas of these folds and presents as a chronic itch. Over time, the skin becomes red and often oozes.
Perspiration is also a chronic type of irritation which can be very annoying. Besides being socially unacceptable, sweat stain the clothes and can present with a foul odor. In some individuals, the warm moist areas often become easily infected. The best way to treat excess sweating is good hygiene, frequent change of clothes and use of deodorants/antiperspirants.

Vaginal irritation
One of the most common areas of the body associated with irritation is the vagina. Many women complain of an itch, dryness, or discharge in the perineum at some point in their lives. There are several causes of vaginal irritation including fungal vaginitis (like candida) or trichomoniasis. Often, herpes simplex infection of the mouth or genitalia can be recurrent and prove to be extremely irritating.
Sometimes, the irritation can be of the chronic type and it can be so intense that it also causes painful intercourse. Aside from infections, chronic irritation of the vagina may be related to the use of contraceptives and condoms made from latex. The majority of contraceptives are made of synthetic chemicals which can induce allergies, rash and itching. Sometimes the lubricant used for intercourse may cause irritation.
Another cause of irritation in women is post menopausal vaginitis. The decline in the female sex hormones leads to development of dryness and itching in the vagina. This is often accompanied by painful sexual intercourse. Cracks and tears often develop on outer aspects of the labia which becomes red from chronic scratching. Post menopausal vaginitis can be treated with short term use of vaginal estrogen pessary and use of a moisturizer.

Lungs
Individuals who smoke or are exposed to smog or other airborne pollutants can develop a condition known as COPD. In this disorder, there is constant irritation of the breathing tubes (trachea) and the small airways. The constant irritation results in excess production of mucus which makes breathing difficult. Frequently, these individuals wake up in the morning with copious amounts of foul smelling mucus and a cough which lasts all day. Wheeze and heavy phlegm are common findings. COPD is a lifelong disorder and there is no cure </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Voice change and can you explain it in depth? [/INST] A voice change or voice mutation, sometimes referred to as a voice break or voice crack, commonly refers to the deepening of the voice of people as they reach puberty. Before puberty, both sexes have roughly similar vocal pitch, but during puberty the male voice typically deepens an octave, while the female voice usually deepens only by a few tones.A similar effect is a "voice crack", during which a persons voice suddenly and unintentionally enters a higher register (usually falsetto) for a brief period of time. This may be caused by singing or talking at a pitch outside the persons natural vocal range, stress, fatigue, emotional tension, or the physical changes associated with puberty. An instance of a voice crack (when associated with puberty) lasts for only a moment and generally occurs less frequently as a person grows into maturity.

Anatomical changes
Most of the voice change begins around puberty. Adult pitch is reached 2–3 years later but the voice does not stabilize until the early years of adulthood. It usually happens months or years before the development of significant facial hair. Under the influence of sex hormones, the voice box, or larynx, grows in both sexes. This growth is far more prominent in males than in females and is more easily perceived. It causes the voice to drop and deepen. Along with the larynx, the vocal folds (vocal cords) grow significantly longer and thicker.
The facial bones begin to grow as well. Cavities in the sinuses, the nose, and the back of the throat grow bigger, thus creating more space within the head to allow the voice to resonate. Occasionally, voice change is accompanied by unsteadiness of vocalization in the early stages of untrained voices </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Abdominal pain and can you explain it in depth? [/INST] Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues.
Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy. In a third of cases the exact cause is unclear.Given that a variety of diseases can cause some form of abdominal pain, a systematic approach to the examination of a person and the formulation of a differential diagnosis remains important.

Differential diagnosis
The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). More common in those who are older, ischemic colitis, mesenteric ischemia, and abdominal aortic aneurysms are other serious causes.

Acute abdominal pain
Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis.

Selected causes
Traumatic: blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney
Inflammatory:
Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, Peritonitis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess
Perforation of a peptic ulcer, a diverticulum, or the caecum
Complications of inflammatory bowel disease such as Crohns disease or ulcerative colitis
Mechanical:
Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms
Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia
Vascular: occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery

By system
A more extensive list includes the following:
Gastrointestinal
GI tract
Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohns disease, ulcerative colitis, microscopic colitis
Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumors, severe constipation, hemorrhoids
Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), superior mesenteric artery syndrome, postural orthostatic tachycardia syndrome
Digestive: peptic ulcer, lactose intolerance, celiac disease, food allergies, indigestion
Glands
Bile system
Inflammatory: cholecystitis, cholangitis
Obstruction: cholelithiasis, tumours
Liver
Inflammatory: hepatitis, liver abscess
Pancreatic
Inflammatory: pancreatitis
Renal and urological
Inflammation: pyelonephritis, bladder infection
Obstruction: kidney stones, urolithiasis, urinary retention, tumours
Vascular: left renal vein entrapment
Gynaecological or obstetric
Inflammatory: pelvic inflammatory disease
Mechanical: ovarian torsion
Endocrinological: menstruation, Mittelschmerz
Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer
Pregnancy: ruptured ectopic pregnancy, threatened abortion
Abdominal wall
muscle strain or trauma
muscular infection
neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis
Referred pain
from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
from the spine: radiculitis
from the genitals: testicular torsion
Metabolic disturbance
uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
Blood vessels
aortic dissection, abdominal aortic aneurysm
Immune system
sarcoidosis
vasculitis
familial Mediterranean fever
Idiopathic
irritable bowel syndrome (IBS)(affecting up to 20% of the population, IBS is the most common cause of recurrent and intermittent abdominal pain)

By location
The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include:
Diffuse
Peritonitis
Vascular: mesenteric ischemia, ischemic colitis, Henoch-Schonlein purpura, sickle cell disease, systemic lupus erythematosus, polyarteritis nodosa
Small bowel obstruction
Irritable bowel syndrome
Metabolic disorders: ketoacidosis, porphyria, familial Mediterranean fever, adrenal crisis
Epigastric
Heart: myocardial infarction, pericarditis
Stomach: gastritis, stomach ulcer, stomach cancer
Pancreas: pancreatitis, pancreatic cancer
Intestinal: duodenal ulcer, diverticulitis, appendicitis
Right upper quadrant
Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess
Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis
Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer
Other: pneumonia, Fitz-Hugh-Curtis syndrome
Left upper quadrant
Splenomegaly
Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer
Peri-umbilical (the area around the umbilicus, aka the belly button)
Appendicitis
Pancreatitis
Inferior myocardial infarction
Peptic ulcer
Diabetic ketoacidosis
Vascular: aortic dissection, aortic rupture
Bowel: mesenteric ischemia, Celiac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction
Lower abdominal pain
Diarrhea
Colitis
Crohns
Dysentery
Hernia
Right lower quadrant
Colon: intussusception, bowel obstruction, appendicitis (McBurneys point)
Renal: kidney stone (nephrolithiasis), pyelonephritis
Pelvic: cystitis, bladder stone, bladder cancer, pelvic inflammatory disease, pelvic pain syndrome
Gynecologic: endometriosis, intrauterine pregnancy, ectopic pregnancy, ovarian cyst, ovarian torsion, fibroid (leiomyoma), abscess, ovarian cancer, endometrial cancer
Left lower quadrant
Bowel: diverticulitis, sigmoid colon volvulus, bowel obstruction, gas accumulation, Toxic megacolon
Right low back pain
Liver: hepatomegaly
Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
Left low back pain
Spleen
Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
Low back pain
kidney pain (kidney stone, kidney cancer, hydronephrosis)
Ureteral stone pain

Pathophysiology
Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut. The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas. The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon. The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal.Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves. The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific. Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved.

Diagnosis
A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.
The process of gathering a history may include:
Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough gynecologic history.
Learning about the patients past medical history, focusing on any prior issues or surgical procedures.
Clarifying the patients current medication regimen, including prescriptions, over-the-counter medications, and supplements.
Confirming the patients drug and food allergies.
Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patients current presentation.
Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.
Using Carnetts sign to differentiate between visceral pain and pain originating in the muscles of the abdominal wall.After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.Additional investigations that can aid diagnosis include:
Blood tests including complete blood count, basic metabolic panel, electrolytes, liver function tests, amylase, lipase, troponin I, and for females, a serum pregnancy test.
Urinalysis
Imaging including chest and abdominal X-rays
ElectrocardiogramIf diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:
Computed tomography of the abdomen/pelvis
Abdominal or pelvic ultrasound
Endoscopy and/or colonoscopy

Management
The management of abdominal pain depends on many factors, including the etiology of the pain </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Ischemia and can you explain it in depth? [/INST] Ischemia or ischaemia is a restriction in blood supply to any tissues, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive).  Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also means local hypoxia in a given part of a body sometimes resulting from constriction (such as vasoconstriction, thrombosis or embolism). Ischemia comprises not only insufficiency of oxygen, but also reduced availability of nutrients and inadequate removal of metabolic wastes. Ischemia can be partial (poor perfusion) or total blockage. The inadequate delivery of oxygenated blood to the organs must be resolved either by treating the cause of the inadequate delivery or reducing the oxygen demand of the system that needs it. For example, patients with myocardial ischemia have a decreased blood flow to the heart and are prescribed with medications that reduce chronotrophy and ionotrophy to meet the new level of blood delivery supplied by the stenosed so that it is adequate.

Signs and symptoms
The signs and symptoms of ischemia vary, as it can occur anywhere in the body and depends on the degree to which blood flow is interrupted. For example, clinical manifestations of acute limb ischemia (which can be summarized as the "six Ps") include pain, pallor, pulseless, paresthesia, paralysis, and poikilothermia.Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. Paralysis is a very late sign of acute arterial ischemia and signals the death of nerves supplying the extremity. Foot drop may occur as a result of nerve damage. Because nerves are extremely sensitive to hypoxia, limb paralysis or ischemic neuropathy may persist after revascularization and may be permanent.

Cardiac ischemia
Cardiac ischemia may be asymptomatic or may cause chest pain, known as angina pectoris. It occurs when the heart muscle, or myocardium, receives insufficient blood flow. This most frequently results from atherosclerosis, which is the long-term accumulation of cholesterol-rich plaques in the coronary arteries. In most Western countries, Ischemic heart disease is the most common cause of death in both men and women, and a major cause of hospital admissions.

Bowel
Both large and small intestines can be affected by ischemia. The blockage of blood flow to the large intestine (colon) is called ischemic colitis. Ischemia of the small bowel is called mesenteric ischemia.

Brain
Brain ischemia is insufficient blood flow to the brain, and can be acute or chronic. Acute ischemic stroke is a neurological emergency typically caused by a blood clot blocking blood flow in a vessel in the brain. Chronic ischemia of the brain may result in a form of dementia called vascular dementia. A sudden, brief episode (symptoms lasting only minutes) of ischemia affecting the brain is called a transient ischemic attack (TIA), often called a mini-stroke. TIAs can be a warning of future strokes, with approximately 1/3 of TIA patients having a serious stroke within one year.

Limb
Inadequate blood supply to a limb may results in acute limb ischemia or chronic limb threatening ischemia.

Cutaneous
Reduced blood flow to the skin layers may result in mottling or uneven, patchy discoloration of the skin.

Kidney Ischemia
Kidney Ischemia is a loss of blood flow to the kidney cells. Several physical symptoms include shrinkage of one or both kidneys, renovascular hypertension, acute renal failure, progressive azotemia, and acute pulmonary edema. It is a disease with high mortality rate and high morbidity. Failure to treat could cause chronic kidney disease and a need for renal surgery.

Causes
Ischemia is a vascular disease involving an interruption in the arterial blood supply to a tissue, organ, or extremity that, if untreated, can lead to tissue death. It can be caused by embolism, thrombosis of an atherosclerotic artery, or trauma. Venous problems like venous outflow obstruction and low-flow states can cause acute arterial ischemia.  An aneurysm is one of the most frequent causes of acute arterial ischemia. Other causes are heart conditions including myocardial infarction, mitral valve disease, chronic atrial fibrillation, cardiomyopathies, and prosthesis, in all of which thrombi are prone to develop.

Occlusion
The thrombi may dislodge and may travel anywhere in the circulatory system, where they may lead to pulmonary embolus, an acute arterial occlusion causing the oxygen and blood supply distal to the embolus to decrease suddenly. The degree and extent of symptoms depend on the size and location of the obstruction, the occurrence of clot fragmentation with embolism to smaller vessels, and the degree of peripheral arterial disease (PAD).
Thromboembolism (blood clots)
Embolism (foreign bodies in the circulation, e.g. amniotic fluid embolism)

Trauma
Traumatic injury to an extremity may produce partial or total occlusion of a vessel from compression, shearing, or laceration. Acute arterial occlusion may develop as a result of arterial dissection in the carotid artery or aorta or as a result of iatrogenic arterial injury (e.g., after angiography).

Other
An inadequate flow of blood to a part of the body may be caused by any of the following:

Thoracic outlet syndrome (compression of the brachial plexus)
Atherosclerosis (lipid-laden plaques obstructing the lumen of arteries)
Hypoglycemia (lower than normal level of glucose)
Tachycardia (abnormally rapid beating of the heart)
Radiotherapy
Hypotension (low blood pressure, e.g. in septic shock, heart failure)
Outside compression of a blood vessel, e.g. by a tumor or in the case of superior mesenteric artery syndrome
Sickle cell disease (abnormally shaped red blood cells)
Induced g-forces which restrict the blood flow and force the blood to the extremities of the body, as in acrobatics and military flying
Localized extreme cold, such as by frostbite or improper cold compression therapy
Tourniquet application
An increased level of glutamate receptor stimulation
Arteriovenous malformations and peripheral artery occlusive disease
rupture of significant blood vessels supplying a tissue or organ.
Anemia vasoconstricts the periphery so that red blood cells can work internally on vital organs such as the heart, brain, etc., thus causing lack of oxygen to the periphery.
Premature discontinuation of any oral anticoagulant.
Unconsciousness, such as due to the ingestion of excessive doses of central depressants like alcohol or opioids, can result in ischemia of the extremities due to unusual body positions that prevent normal circulation

Pathophysiology
Ischemia results in tissue damage in a process known as ischemic cascade. The damage is the result of the build-up of metabolic waste products, inability to maintain cell membranes, mitochondrial damage, and eventual leakage of autolyzing proteolytic enzymes into the cell and surrounding tissues.
Restoration of blood supply to ischemic tissues can cause additional damage known as reperfusion injury that can be more damaging than the initial ischemia. Reintroduction of blood flow brings oxygen back to the tissues, causing a greater production of free radicals and reactive oxygen species that damage cells.  It also brings more calcium ions to the tissues causing further calcium overloading and can result in potentially fatal cardiac arrhythmias and also accelerates cellular self-destruction. The restored blood flow also exaggerates the inflammation response of damaged tissues, causing white blood cells to destroy damaged cells that may otherwise still be viable.

Treatment
Early treatment is essential to keep the affected organ viable. The treatment options include injection of an anticoagulant, thrombolysis, embolectomy, surgical revascularization, or partial amputation. Anticoagulant therapy is initiated to prevent further enlargement of the thrombus. Continuous IV unfractionated heparin has been the traditional agent of choice.If the condition of the ischemic limb is stabilized with anticoagulation, recently formed emboli may be treated with catheter-directed thrombolysis using intra-arterial infusion of a thrombolytic agent (e.g., recombinant tissue plasminogen activator (tPA), streptokinase, or urokinase) </s>