CHAPTER

The Cardiovascular
1 System

In this chapter, you will learn:

READING The Cardiovascular System

LISTENING Myocardial Infarction & Advice about lifestyle changes

SPEAKING Role – play & Discussion

WRITING For and Against Essay

SELF-STUDY Concept map & Spiritual forces in healing

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 1.1. READING THE CARDIOVASCULAR SYSTEM

PATHOLOGY: THE HEART AND BLOOD VESSELS

Arrhythmias: Abnormal heart rhythms (dysrhythmias).

Arrhythmias are problems with the conduction or electrical system of the heart. More than
4 million Americans have recurrent cardiac arrhythmias.

Congenital heart disease: Abnormalities in the heart at birth.

The following conditions are congenital anomalies resulting from some failure in the
development of the fetal heart.

1. coarctation of the aorta (CoA)

Narrowing (coarctation) of the aorta.

Figure 11-14A shows coarctation of the aorta. Surgical treatment consists of removal of
the constricted region and end-to-end anastomosis of the aortic segments.

2. patent ductus arteriosus (PDA)

Passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open
(patent) after birth.

The ductus arteriosus normally closes after birth, but in this congenital condition it remains
open (see Figure 11-14B), resulting in the flow of oxygenated blood from the aorta into the
pulmonary artery. PDA occurs in premature infants, causing cyanosis, fatigue, and rapid
breathing. Although the defect often closes on its own within months after birth, treatment
may be necessary if patency continues. Treatments include use of a drug (indomethacin)
to promote closure; surgery via catheterization (with coil embolization to “plug” the
ductus); and ligation (tying off) via a small incision between the ribs.

3. septal defects: Small holes in the wall between the atria (atrial septal defects) or the
ventricles (ventricular septal defects).

Although many septal defects close spontaneously, others require open heart surgery to
close the hole between heart chambers. Septal defects are closed while maintaining a
general circulation by means of a heart-lung machine. This machine, connected to the
patient’s circulatory system, relieves the heart and lungs of pumping and oxygenation
functions during heart surgery.

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Alternatively, septal defects may be repaired with a less invasive catheter technique using
a device (Amplatzer device) in the defect to close it.

4. tetralogy of Fallot: Congenital malformation involving four (tetra-) distinct heart

defects.

The condition is named for Etienne Fallot, the French physician who described it in 1888.
The four defects are:

• Pulmonary artery stenosis. Pulmonary artery is narrow or obstructed.

• Ventricular septal defect. Large hole between two ventricles lets venous blood pass from
the right to the left ventricle and out to the aorta without oxygenation.

• Shift of the aorta to the right. Aorta overrides the interventricular septum. Oxygen-poor
blood passes from the right ventricle to the aorta.

• Hypertrophy of the right ventricle. Myocardium works harder to pump blood through a
narrowed pulmonary artery.

Congestive heart failure (CHF): Heart is unable to pump its required amount of
blood.

There are two types of congestive heart failure: systolic and diastolic. In systolic CHF, left
ventricular dysfunction results in a low ejection fraction (the amount of blood that leaves
the left ventricle). Less blood is pumped from the heart. In diastolic CHF, the heart can
contract normally but is “stiff” or less compliant when relaxed or filling with blood. Fluid
backs up in the lungs and other parts of the body. The most common cause of diastolic
CHF is hypertension.

Symptoms of CHF include shortness of breath, exercise intolerance, and fluid retention.
Pulmonary edema (fluid accumulation in the lungs) and swelling or edema in the legs, feet,
and ankles are common. Treatment includes lowering dietary intake of sodium and the use
of diuretics to promote fluid loss.

Angiotensin-converting enzyme (ACE) inhibitors (type I), beta-blockers, spironolactone

(increases excretion of water and sodium by the kidney), and digoxin are also used.

If drug therapy and lifestyle changes fail to control congestive heart failure, heart
transplantation may be the only treatment option. While waiting for a transplant, patients
may need a device to assist the heart’s pumping. A left ventricular assist device (LVAD)
is a booster pump implanted in the abdomen, with a cannula (tube) inserted into the left

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ventricle. It pumps blood out of the heart to all parts of the body. LVAD may be used either
as a “bridge to transplant” or as a “destination” therapy when heart transplantation is not
possible. Because of the severe shortage of donor hearts, research efforts are directed at
developing total artificial hearts.

Coronary artery disease (CAD): Disease of the arteries surrounding the heart.

The coronary arteries are a pair of blood vessels that arise from the aorta and supply
oxygenated blood to the heart. After blood leaves the heart via the aorta, a portion is at
once led back over the surface of the heart through the coronary arteries.

CAD usually is the result of atherosclerosis. This is the deposition of fatty compounds on
the inner lining of the coronary arteries (any other artery can be similarly affected). The
ordinarily smooth lining of the artery becomes roughened as the atherosclerotic plaque
collects in the artery.

The plaque first causes plugging of the coronary arterylining of the artery may rupture or
cause abnormal clotting of blood, leading to thrombotic occlusion (blocking of the
coronary artery by a clot). Blood flow is decreased (ischemia) or stopped entirely, leading
to death the myocardium. This sequence of events constitutes a heart attack, and the area
of dead myocardial tissue is known as an infarct. The infarcted area is eventually replaced
by scar tissue.

Acute coronary syndromes (ACSs) are conditions caused by myocardial ischemia. These
conditions are unstable angina (chest pain at rest or chest pain of increasing frequency) and
myocardial infarction.

Patients with ACSs benefit from early angiography (x-ray imaging of coronary arteries)
and PCI (percutaneous coronary intervention with a balloon catheter and stents) or CABG
(coronary artery bypass grafting) to improve blood flow to the heart muscle
(revascularization). Drugs used to treat ACSs are anticoagulants and antiplatelet agents
such as aspirin and clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta).

For acute attacks of angina, nitroglycerin is given sublingually (under the tongue). This
drug, one of several called nitrates, is a vasodilator that increases coronary blood flow and
lowers blood pressure. Nitrates also produce venodilation to reduce venous return and
decrease myocardial oxygen consumption, both of which help decrease the work of the
heart.

Physicians advise patients to avoid risk factors such as smoking, obesity, and lack of
exercise, and they prescribe effective drugs to prevent CAD and ACSs. These drugs include
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aspirin (to prevent clumping of platelets), beta-blockers (to reduce the force and speed of
the heartbeat and to lower blood pressure), ACE inhibitors (to reduce high blood pressure
and the risk of future heart attack even if the patient is not hypertensive), calcium channel
blockers (to relax muscles in blood vessels), and statins (to lower cholesterol levels).

Cardiac surgeons perform an open heart operation called coronary artery bypass grafting
(CABG) to treat CAD by replacing clogged vessels. Interventional cardiologists perform
percutaneous coronary intervention (PCI), in which catheterization with balloons and
stents opens clogged coronary arteries.

Endocarditis: Inflammation of the inner lining of the heart.

Damage to the heart valves from infection (bacterial endocarditis) produces lesions called
vegetations (resembling cauliflower) that break off into the bloodstream as emboli
(material that travels through the blood). The emboli can lodge in other vessels, leading to
a transient ischemic attack (TIA), or stroke, or in small vessels of the skin, where multiple
pinpoint hemorrhages known as petechiae (from the Italian petechio, a flea bite) form.
Antibiotics can cure bacterial endocarditis.

Hypertensive heart disease: High blood pressure affecting the heart.

This condition results from narrowing of arterioles, which leads to increased pressure in
arteries. The heart is affected (left ventricular hypertrophy) because it pumps more
vigorously to overcome the increased resistance in the arteries.

Mitral valve prolapse (MVP): Improper closure of the mitral valve.

This condition occurs because the mitral valve enlarges and prolapses into the left atrium
during systole. The physician hears a midsystolic click on auscultation (listening with a
stethoscope). Most people with MVP live normal lives, but prolapsed valves can on rare
occasion become infected.

Murmur: Extra heart sound, heard between normal beats.

Murmurs are heard with the aid of a stethoscope and usually are caused by a valvular defect
or disease that disrupts the smooth flow of blood in the heart. They also are heard in cases
of interseptal defects, in which blood flows abnormally between chambers through holes
in the septa. Functional murmurs are not caused by valve or septal defects and do not
seriously endanger a person’s health.

A bruit is an abnormal sound or murmur heard on auscultation. A thrill, which is a

vibration felt on palpation of the chest, often accompanies a murmur.
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Pericarditis: Inflammation of the membrane (pericardium) surrounding the heart.

In most instances, pericarditis results from disease elsewhere in the body (such as
pulmonary infection). Bacteria and viruses cause the condition, or the etiology may be
idiopathic. Malaise, fever, and chest pain occur, and auscultation with a stethoscope often
reveals a pericardial friction rub (heard as a scraping or grating sound). Compression of the
heart caused by collection of fluid in the pericardial cavity is cardiac tamponade (tăm-pō-
NŎD). Treatment includes anti-inflammatory drugs and other agents to manage pain. If the
pericarditis is infective, antibiotics or antifungals are prescribed, depending on the
microorganisms detected in specimens obtained by pericardiocentesis.

Rheumatic heart disease: Heart disease caused by rheumatic fever.

Rheumatic fever is a childhood disease that follows a streptococcal infection. The heart
valves can be damaged by inflammation and scarred (with vegetations), so that they do not
open and close normally. Mitral stenosis, atrial fibrillation, and congestive heart failure,
caused by weakening of the myocardium, also can result from rheumatic heart disease.
Treatment consists of reduced activity, drugs to control arrhythmia, surgery to repair a
damaged valve, and anticoagulant therapy to prevent emboli from forming. Artificial and
porcine (pig) valve implants can replace deteriorated heart valves.

Aneurysm: local widening (dilation) of an arterial wall.

An aneurysm (Greek aneurysma, widening) usually is caused by atherosclerosis and

hypertension or a congenital weakness in the vessel wall. Aneurysms are common in the
aorta but may occur in peripheral vessels as well. The danger of an aneurysm is rupture
and hemorrhage. Treatment depends on the vessel involved, the site, and the health of the
patient. In aneurysms of small vessels in the brain (berry aneurysms), treatment is occlusion
of the vessel with small clips.

For larger arteries, such as the aorta, the aneurysm is resected and a synthetic graft is sewn
within the affected vessel. Stent grafts also may be placed less invasively as an alternative
to surgery in some patients.

Deep vein thrombosis (DVT)

Blood clot (thrombus) forms in a large vein, usually in a lower limb. This condition may
result in a pulmonary embolism (clot travels to the lung) if not treated effectively.
Anticoagulants (blood-thinning drugs) such as heparin and warfarin (Coumadin) are used
to prevent DVTs and pulmonary emboli (PEs).

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Hypertension (htn): High blood pressure.

Most high blood pressure is essential hypertension, with no identifiable cause. In adults, a
blood pressure of 140/90 mm Hg or greater is considered high. Diuretics, ACE inhibitors,
calcium channel blockers, and beta-blockers, are used to treat essential hypertension.
Losing weight, limiting sodium (salt) intake, stopping smoking, and reducing fat in the diet
also can reduce blood pressure. In secondary hypertension, the increase in pressure is
caused by another associated lesion, such as glomerulonephritis, pyelonephritis, or disease
of the adrenal glands.

Peripheral arterial disease (PAD)

Blockage of arteries carrying blood to the legs, arms, kidneys and other organs. Any artery
can be affected, such as the carotid (neck), femoral (thigh), or popliteal (back of the knee).
A sign of PAD in the lower extremities is intermittent claudication (absence of pain or
discomfort in a leg at rest, but pain, tension, and weakness after walking has begun).
Treatment is exercise, avoidance of nicotine (which causes vessel constriction), and control
of risk factors such as hypertension, hyperlipidemia, and diabetes. Surgical treatment
includes endarterectomy and bypass grafting (from the normal proximal vessel around the
diseased area to a normal vessel distally).

Percutaneous treatments include balloon angioplasty, atherectomy, and stenting. Embolic

protection devices are parachute-like filters used to capture embolic debris during stenting.

Raynaud disease

Recurrent episodes of pallor and cyanosis primarily in fingers and toes. Of uncertain cause,
this disorder is marked by intense constriction and vasospasm of arterioles often of young,
otherwise healthy women. Episodes can be triggered by cold temperatures, emotional
stress, or cigarette smoking. Protecting the body from cold and use of vasodilators are
effective treatments.

Raynaud phenomenon is a similar condition of arterial insufficiency but is secondary to

arterial narrowing from other conditions, such as atherosclerosis, systemic lupus
erythematosus, or scleroderma.

Varicose veins

Abnormally swollen and twisted veins, usually occurring in the legs. This condition is
caused by damaged valves that fail to prevent the backflow of blood. The blood then
collects in the veins, which distend to many times their normal size. Because of the slow

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flow of blood in the varicose veins and frequent injury to the vein, thrombosis may occur
as well. Hemorrhoids (piles) are varicose veins near the anus.

Physicians now treat varicose veins with sclerotherapy (injections with sclerosing solution)
or laser and pulsed-light treatments to seal off veins. Surgical interventions such as vein
stripping and ligation are used less frequently.

PRACTICE

A. Match the following structures with their descriptions below.

Aorta arteriole atrium
Capillary inferior vena cava mitral valve
pulmonary artery pulmonary vein superior vena cava
tricuspid valve ventricle venule
1. valve that lies between the right atrium and the right ventricle
2. smallest blood vessel
3. carries oxygenated blood from the lungs to the heart
4. largest artery in the body
5. brings oxygen-poor blood into the heart from the upper parts of the body
6. upper chamber of the heart
7. carries oxygen-poor blood to the lungs from the heart
8. small artery
9. valve that lies between the left atrium and the left ventricle
10. brings blood from the lower half of the body to the heart
11. small vein
12. lower chamber of the heart
B. Complete the following terms using the given definitions.
1. hardening of arteries: arterio_____________________
2. disease condition of heart muscle: cardio_____________________
3. enlargement of the heart: cardio_____________________
4. inflammation of a vein: phleb_____________________
5. condition of rapid heartbeat: _____________________cardia
6. condition of slow heartbeat: _____________________cardia

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7. high levels of cholesterol in the blood: hyper_____________________
8. surgical repair of a valve: valvulo_____________________
9. condition of deficient oxygen: hyp_____________________
10. pertaining to an upper heart chamber: _____________________al
11. narrowing of the mitral valve: mitral _____________________
12. breakdown of a clot: thrombo_____________________

C. Match the following pathologic conditions of the heart with their meanings
below.
atrial septal defect coarctation of the aorta congestive heart failure
coronary artery disease endocarditis fibrillation
flutter hypertensive heart disease tetralogy of Fallot
mitral valve prolapse patent ductus arteriosus pericarditis
1. inflammation of the inner lining of the heart

2. rapid but regular atrial or ventricular contractions

3. small hole between the upper heart chambers; congenital anomaly

4. improper closure of the valve between the left atrium and ventricle during systole

5. blockage of the arteries surrounding the heart leading to ischemia

6. high blood pressure affecting the heart

7. rapid, random, ineffectual, and irregular contractions of the heart

8. inflammation of the sac surrounding the heart

9. inability of the heart to pump its required amount of blood

10. congenital malformation involving four separate heart defects

11. congenital narrowing of the large artery leading from the heart

12. a duct between the aorta and the pulmonary artery, which normally closes soon after
birth, remains open

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D. Match the following terms with their descriptions.
Aneurysm auscultation claudication
Emboli essential hypertension murmur
Vegetations secondary hypertension peripheral arterial disease
petechiae Raynaud disease rheumatic heart disease
1. lesions that form on heart valves after damage by infection
2. clots that travel to and suddenly block a blood vessel
3. small, pinpoint hemorrhages
4. an extra heart sound, heard between normal beats and caused by a valvular defect or
condition that disrupts the smooth flow of blood through the heart
5. listening with a stethoscope
6. heart disease caused by rheumatic fever
7. high blood pressure in arteries when the etiology is idiopathic
8. high blood pressure related to kidney disease
9. episodes of ischemia with pallor and numbness in fingers and toes caused by a
temporary constriction of arterioles in the skin
10. local widening of an artery
11. pain, tension, and weakness in a limb after walking has begun
12. blockage of arteries in the lower extremities; etiology is atherosclerosis
E. Match the following terms with their meanings below.
Aneurysmorrhaphy atherectomy BNP test CABG
catheter ablation embolectomy endarterectomy PCI
pericardiocentesis STEMI thrombolytic therapy valvotomy
1. incision of a heart valve
2. removal of a clot that has traveled into a blood vessel and suddenly caused occlusion
3. coronary artery bypass grafting (to relieve ischemia)
4. surgical puncture to remove fluid from the pericardial space
5. insertion of a balloon-tipped catheter and stents into a coronary artery
6. removal of the inner lining of an artery to make it wider
7. suture (repair) of a ballooned-out portion of an artery
8. removal of plaque from an artery

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9. type of acute coronary syndrome
10. use of streptokinase and tPA to dissolve clots
11. brief delivery of radiofrequency energy destroys areas of heart tissue to treat
arrhythmias
12. measures a peptide elevated in patients with heart failure
F. Match the operative treatment with the appropriate surgical indication
(diagnosis).
1. coronary artery bypass grafting _____
2. left carotid endarterectomy _____
3. sclerosing injections and laser treatment _____
4. LV aneurysmectomy _____
5. atrial septal defect repair _____
6. left ventricular assist device _____
7. pericardiocentesis _____
8. aortic valve replacement _____
9. pacemaker implantation _____
10. femoral-popliteal bypass grafting _____

A. Congestive heart failure

B. Cardiac tamponade (fluid in the space surrounding the heart)
C. Atherosclerotic occlusion of a main artery leading to the head
D. Congenital hole in the wall of the upper chamber of the heart
E. Disabling angina and extensive coronary atherosclerosis despite medical therapy
F. Peripheral vascular disease
G. Heart block
H. Varicose veins
I. Protrusion of the wall of a lower heart chamber
J. Aortic stenosis

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1.2 LISTENING DOCTOR – PATIENT DIALOGUES

LISTENING 1 ( Track 1)
A. Listen to Mr. Lawson’s wife talking to a doctor in A&E. What do you think the
patient’s condition is? Why? Mycardial infarction .Pain in the center of the chest,had it before but now
B. Listen again and write down notes on what is said about unrelieved by use of the GTN
The GTN spray spray,breathleesness,nusea,vomiting,sweating,pain in both arms
patient's husband gave himself a few puffs but the pain wouldn't go
…………………………………………………………………………………
…………………………………………………………………………………
The time when the pain started
…………………………………………………………………………………
at sevenish
…………………………………………………………………………………
Thrombolysis
…………………………………………………………………………………
…………………………………………………………………………………
Prognosis
…………………………………………………………………………………
By the looks of it,it's all gone very well and he'll be up and about in no time
…………………………………………………………………………………
For the moment he just needs a bit of a resst
C. Listen again and fill in each blank with NO MORE THAN TWO WORDS.
The patient and his wife were sitting at home when he started getting the pain in the center
of (1)his
________.
chest It was not the first time he had had it and as usual, he used the GTN spray,
but the pain wouldn’t go and he started feeling sick, (2)________
breathnessand agitated. He started
(3)________ and
vomitting began to (4)________.
sweat
And then he was immediately admitted to hospital
in an (5)________. According to his wife, he had no injuries or other major illness, no
bleeding andambulance
no (6)________ before. major sugery
majro sendary
The doctor diagnosed the risk of (7)________
stroke with the procedure and needed the
consent from his wife to help (9)________
(8)________ eliminate blood clots. It could have a (10)________
considerable
effect and the benefit could be dramatic if they got it down quickly.
LISTENING 2: ADVICE ABOUT LIFESTYLE CHANGES (Track 2)
A. Listen and write down as many details as you can about the patient. Then compare
your details in groups of four.
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

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B. Listen again and answer the following questions.
1. What is the problem with the patient according to the doctor’s diagnosis?
…………………………………………………………………………………
…………………………………………………………………………………
2. Why will the doctor run a few tests on her?
…………………………………………………………………………………
…………………………………………………………………………………
3. When did she retire?
…………………………………………………………………………………
…………………………………………………………………………………
4. How high and heavy is she now?
…………………………………………………………………………………
…………………………………………………………………………………
5. What’s the patient’s family history?
…………………………………………………………………………………
…………………………………………………………………………………
6. What kinds of sport did she use to do?
…………………………………………………………………………………
…………………………………………………………………………………

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 1.3 SPEAKING ROLE-PLAY / DISCUSSION

A. ROLEPLAY
I. Complete the following conversation with the words given. Then work with your
partner to practice this conversation.
a. symptoms b. exactly c. rest d. stressed
e. chest f. heavy g. better h. describe
i. move j. severe
Dr. Alain: So Mr. Daniels, how would you (1)________ h the pain in your chest?
Mr. Daniels: Well, it was very difficult to breathe and I felt as if there was a heavy weight
on my (2)________.
e
Dr. Alain: Can you explain where (3)________?
ab
Mr. Daniels: In my chest. Yes, right here in the centre of my chest.
Dr. Alain: I see. On a scale of one to ten, how bad was the pain?
Mr. Daniels: It wasn’t as bad this time - Let’s say four or five.
Dr. Alain: Four or five? Would you say that was moderate or (4)________?
j
Mr. Daniels: Moderate, I think.
Dr. Alain: And does the pain (5)________
i at all?
Mr. Daniels: Move? Um… yes, I suppose it does.
Dr. Alain: Go on…
Mr. Daniels: It moves down my left arm, sometimes it moves up –I feel it up the left side
of my face.
Dr. Alain: OK. How long did the pain last this time?
Mr. Daniels: I don’t know exactly around three minutes probably, not that long.
Dr. Alain: Can you tell me how it started?
Mr. Daniels: I was carrying something in the shop where I work. I work in a big
supermarket. They often ask me to carry (6)________
f things. It’s part of the job.
Dr. Alain: I see. Now, how often do you have these pains, Mr. Daniels? You said that
this isn’t the first time?
Mr. Daniels: Yes, this is the third time. I’ve had them for two months now.
Dr. Alain: Do you have any other (7)________? I can hear you’re having problems with
a
your breathing.
Mr. Daniels: Yes, there’s that, but no other problems, no.
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Dr. Alain: OK, I’ve just a couple more questions for you. What seems to make the pain
(8)________?
g
Mr. Daniels: If I sit down and (9)________,
c I usually feel a lot better.
Dr. Alain: Right. Is there anything that makes it worse?
Mr. Daniels: If I’m worried or (10)________, it’s worse.
d
Dr. Alain: How do you feel about your condition, Mr. Daniels?
Mr. Daniels: Well, I’m very worried, Doctor.
II. Answer the following questions.
1. What are the patient’s symptoms?
2. What do you think the patient is suffering from?
B. DISCUSSION
Work in groups of four. Make a list of questions you would ask the patient in the situation
below. Think about how the patient would feel, what his/ her anxieties might be, how you
differentiate the pain from angina pectoris.
Mr. Jeff, a 57-year-old patient, presents with a severe retrosternal burning pain which the
patient is convinced is connected with the heart. The pain comes after eating and drinking
alcohol and there is a history of dyspepsia. The pain is relieved by GTN spray, but only
after about twenty minutes. Take the history and reassure the patient that the pain is not
connected with his heart, but is esophageal spasm.

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 1.4 WRITING FOR AND AGAINST ESSAYS

A. DEFINITION
For and against essays (advantages and disadvantages) present both sides of an issue,
discussing points in favour of a particular topic as well as those against, or the advantages
and disadvantages of a particular question. Each point should be supported by
justifications, examples, and/or reasons. The writer's own opinion should be presented only
in the final paragraph. Three main parts of a “for and against” essay are as follows:
 An introductory paragraph in which you clearly state the topic to be discussed,
without giving your opinion.
 A main body in which the points for and against along with your justifications,
examples or reasons are presented in separate paragraphs.
 A closing paragraph in which you state your opinion or give a balanced
consideration of the topic.

Introduction
Paragraph 1: state topic (without stating your opinion)
Main body
Paragraph 2: arguments for and justifications, examples or reasons
Paragraph 3: arguments against and justifications, examples or reasons
Conclusion
Paragraph 4: balanced consideration or opinion
Note: Opinion words (I think, I believe, In my opinion, etc.) can only be used in the
closing paragraph where you give your opinion on the topic.
POINTS TO CONSIDER
 Make a list of points for and against a topic before you start writing.
 Write well-developed paragraphs in which the points you present are supported
with justification (i.e. reasons or examples). Make sure each paragraph has more
than one sentence.
 Do not use informal style (e.g. short forms, colloquial language, etc.) or strong
language (e.g. I firmly believe, etc.).
 Begin each paragraph with a topic sentence which summarizes the topic of the
paragraph.

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LINKAGE
One way of linking paragraphs is by discourse markers. Discourse Markers are words that
help you to structure your thoughts:
 To list points:
Firstly; First of all; In the first place; To begin/start with; Secondly; Thirdly; Finally
 To list advantages:
One/Another/A further/An additional (major) advantage of… is …
The main/greatest/first advantage of… is …
 To list disadvantages:
One/Another/A further/An additional (major) disadvantage/drawback of.
The main/greatest/most serious/first disadvantage /drawback of…
Another negative aspect of…
 To add more points to the same topic:
in addition (to this), furthermore, moreover, besides, apart from, what is more, as well as
not to mention (the fact) that, also, not only … but also/as well, both … and,
There is another side to the issue/question/argument of…
 To make contrasting points:
however, yet, but, nevertheless, although, in spite of, on the other hand, whilst
on the contrary, alternatively, despite ....
 To introduce examples:
for example; for instance; such as; like, in particular; particularly; especially
This is (clearly) illustrated/shown by the fact that…
One/A clear/striking/ typical example of (this)…
The fact that…. shows/illustrates that…
 To emphasise a point:
clearly; obviously, it is obvious, naturally, of course, needless to say, indeed
 To express reality:
In fact, the fact (of the matter) is, actually, in practice, it is a fact that, in effect
 To make general statements:
as a (general) rule, generally, in general, on the whole, by and large, in most cases

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PRACTICE
Read the essay on the advantages and disadvantages of water birth and do the following
tasks.
A.
Water birth is becoming increasingly popular and more and more hospitals are making this
option available to women. However, it is important for women to be aware that there are
potential problems as well as benefits before opting for a water birth.
B.
The main benefit of a water birth is that it makes labour more comfortable. It is easier for
the woman to move around, which gives her a feeling of control and therefore makes her
feel more relaxed and less anxious. The reduced pain of water birth also lowers anxiety.
For this reason, being in water lowers the blood pressure, which avoids a range of
complications.
C.
On the negative side, it is difficult to monitor the woman accurately during a water birth,
so it is not suitable for high-risk pregnancies. Also, it is easier for waterborne pathogens to
be transferred from mother to baby – or to medical staff. In addition to this, although
being in water reduces the mother’s pain, it can also weaken the contractions. Another
drawback is the risk of hypothermia unless water temperature is carefully monitored.
Finally, the risk of heavy blood loss is increased in water, as bleeding is difficult to measure
underwater.
D.
Despite these disadvantages, both patients and medical staff are very positive about water
birth and many women opt to do it again for subsequent children. With more training and
facilities, the limitations of water birth could be reduced.
Task 1: Read the essay on the advantages and disadvantages of water birth. Write the
letter of the paragraph where the writer makes each point below. Put a cross (X) if the
point is not included in the essay.
1. Doctors have a greater risk of infection with water births. _____
2. Water birth is becoming more widely available. _____
3. The mother’s anxiety is reduced in water. _____
4. Water births cause delays if emergency treatment is needed. _____
5. Women who have given birth in water often choose to do so again. _____
6. There is a risk of the baby breathing water into its lungs. _____
7. Bleeding is difficult to monitor. _____
8. The mother can change position more easily in water. _____

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Task 2: Connectors are used to join ideas together. Write the bold words and phrases
in the essay under the three headings.

Add Contrast Reason

In addition, However, Therefore,

................. ................. .................
................. ................. .................
................. ................. .................

Task 3: Write an essay of 200-250 words with the title “The advantages and
disadvantages of home birth”. Before you begin, brainstorm ideas with a partner. Write
the essay in four sections, as in the example.
A. Introduction
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
B. Advantages
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
C. Disadvantages
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
D. Conclusion
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

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Task 4: Write an essay of 200-250 words with the topic below.
You should spend about 40 minutes on this task.
Present a written argument to an educated reader with no specialist knowledge of the
following topic.
“Currently there is a trend towards the use of alternative forms of medicine. However,
at best these methods are ineffective, and at worst they may be dangerous.”
To what extent do you agree with this statement?
Give reasons for you answer and include any relevant examples from your own experience
or knowledge.
You should write at least 250 words.

Task 5. Write an essay of 200-250 words with each of the topic below.
 Advantages and disadvantages of antibiotics
 Advantages and disadvantages of childbirth anesthesia
 Advantages and disadvantages of birth control pills
 Advantages and disadvantages of taking sleeping pills
 Advantages and disadvantages of taking iron supplements

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1.5. SELF-STUDY

A. BUILDING LANGUAGE AND STUDY SKILLS

CONCEPT MAP
A concept map is a diagram that consists of shapes and links between the shapes. In a
concept map, each shape contains a concept or idea. Related ideas are linked together with
lines or “branches” The links show connections between ideas. Look at the concept map
below. You can see the word BLOOD in the square at the top of the map. This is the main
concept or idea of the map. The links coming from the word blood are the components of
the blood: Plasma and three types of cells. Further links and groupings show related ideas.
Can you see the relationships?

A concept map can be constructed in many different ways. The concept map above is a
hierarchy. It shows relationships from bigger to smaller.
Making a concept map is a good study technique because the maps visualize relationships
and connections between concepts. When you study with a concept map, you may have
nearly all the information you need on a single page of paper!
PRACTICE
Make a concept map. Use the words below and add more ideas of your own. First, pick
out the main idea. Write the word at the top of the page and draw a shape around it.
Then decide how and where you will place the other words along with your own ideas.
blood pressure hypertension hypotension baroreceptors
Show your map to a partner. How is your map different from your partners?

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B. CRITICAL THINKING

SPIRITUAL FORCES IN HEALING

Some people believe that if they wear a special piece of jewelry or if they carry something
such as a rabbit’s foot, it will bring them luck and keep them healthy. Many people also
believe in the power of prayer to help them get better when they feel sick. Other people
prefer to give birth or have surgery only on special dates because they believe some dates
are luckier than others.
The following story is about a cultural conflict that people may experience in a health-care
setting Read the story and then discuss the questions in small groups.
Michelle is a nurse in an emergency room. A patient named Gitta was brought into the ER
with an irregular heartbeat. Gitta was conscious, but very frantic. Michelle noticed that
Gitta was wearing a very interesting and beautiful stone on a cord around her neck. In an
effort to calm her patient, Michelle reached to touch the stone and commented on how
beautiful it was. This sent Gitta into an absolute panic. She pushed away Michelle’s hand
and said “NO! Don’t touch it”. As a result Gitta’s heartbeat became even more irregular.

QUESTIONS:
1. Why do you think Gitta doesn’t want Michelle to touch the stone?
2. Do you carry anything with you which you feel helps you to maintain your health and
luck?
3. If you had to go to the hospital for an operation, would you want to pray or be careful
about the date of the operation?

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