We are all guilty of pushing ourselves too hard and burning the candle on both ends. But while blaming being tired on a too-hectic lifestyle is commonplace, there is a difference between feeling sleepy and being continuously exhausted.

Maintaining a consistent sleeping routine is essential for your well-being and for bringing about all aspects of a healthy life. Your sleep cycle can make or break your life, which is why it can be frustrating when the pattern is off.

If you are one of the many people who find it challenging to wake up in the morning and then spend the rest of the day feeling exhausted, you may also find it impossible to shut down and sleep soundly in the evening.

How do you fix this seemingly endless, unhealthy and unhappy cycle? Here are some possible reasons for your exhaustion and ways for you to get your energy right.

Reasons for Exhaustion

There are a variety of reasons why you may be suffering from exhaustion, and the causes are going to be varied for every person. However, here are six common reasons.

- A crazy work schedule

Certain work schedules severely disrupt sleep cycles. If you work in a bar, or have overnight or rotating shifts, then there is a high chance your sleeping routine is non-existent. However, working long days or being severely stressed can also disrupt your ability to shut off at night.

- Lifestyle hours that disturb your sleep cycle

If you are a new parent or are overseeing a busy social life, then you probably don't have a set "going to bed" time. Burning the midnight oil over the weekend and then sleeping in will lead to a struggle to fall asleep on a Sunday night, which then directs you to a sleep-deprived Monday morning.

- Constant travel

Traveling is exhausting and is a sure way to say "bye" to any semblance of a routine. Jet lag can wreak havoc on your body and can cause tiredness for a long time after the flight has touched the ground.

- Medical reasons/illnesses

There are several medical-related reasons that you may be suffering from constant exhaustion. Problems such as anemia, thyroid disease, diabetes, depression, and sleep apnea all affect someone's ability to sleep.

- Stimulants like drugs, alcohol, coffee, etc.

Consuming too many stimulants or digesting them at the wrong time are guaranteed means to ruin your sleeping schedule. Don't drink coffee six hours before bedtime, and stop sipping alcohol three to four hours before you try to snooze.

The truth is that you are going to have to be honest with yourself about your lifestyle and the causes of your exhaustion. Only you know how you spend your days, what you consume, and the lifestyle you are living. Being honest with yourself is the first step to tackling the problem.

Fixes for Exhaustion

- Exercise

While you may think that exercising is the last thing you want to do when you are exhausted, it actually is a beneficial way to maintain a sleep schedule and will help you to feel less tired in the long run. Even if you only do a daily 30-minute walk, you will have an energy boost, and then will be more likely to be able to fall asleep at night.

- Natural caffeine

A natural caffeine supplement not only battles exhaustion but also gives you improved cognitive functions, helps with blood sugar and weight management, and encourages healthy aging.

- LIfestyle and environmental changes

Stop checking your phone while in bed, cut down on your alcohol consumption, reduce stress, and eat regular meals. Make sure your bedroom is tidy, purchase some soothing candles and pillow sprays, and implement a night-time routine to help you wind down and relax.

How do you deal with exhaustion? What lifestyle changes have helped you get better quality sleep? Let us know your tips and tricks in the comments below.

Sputum examination refers to the laboratory examination or test of the material or substance coughed out from the lungs, bronchi, trachea, and larynx. Normally, sputum is mainly composed of mucus and also certain cellular and non-cellular components of host origin. During expectoration, sputum gets contaminated with normal bacterial flora and cells from pharynx and mouth.

Waste products discharged from the digestive tract are composed of up to 75% water, food which is digested but not absorbed, indigestible residue, undigested food, epithelial cells, bile, bacteria, secretion from the digestive tract and inorganic bacteria. Normally an adult human excretes 100-200 grams of feces in a day.

Examination of stool is very helpful in the diagnosis of disease of the gastrointestinal tract as listed below.

Detection of parasites

Stool examination is performed for the detection and identification of worms (adult worms, larvae, segments of worms, ova) and protozoa (cyst or trophozoites). See also: Microscopic Examination of Feces

Bacteriologic examination

Stool culture is performed for the evaluation of bacterial infection such as Clostridium difficile, Yersinia, Salmonella, Shigella or Vibrio. Bacterial toxins (such as those released by Clostridium difficile or Clostridium botulinum) can also be identified. See also: Microscopic Examination of Feces

Evaluation of chronic diarrhea

Chronic diarrhea defined as a passage of three or more liquid or loose stools in a day lasting for more than four weeks. Acute diarrhea refers to the passing of three or more liquid or loose stools in a day for less than four weeks. In diarrhea, stool examination is very important part of laboratory investigations. Depending on the nature of the investigation, either a random stool sample or 72- sample or 48-hour sample is collected. A random stool sample is used for the tests of occult blood, pH, fat, white blood cells, microscopy, or culture. A 72- or 48-hour sample is collected and examined for the weight, carbohydrate, fat content, osmolality, or chymotrypsin activity. Causes of chronic and acute diarrhea are listed in Table 988.1 and Figure 988.1 respectively.

Table 988.1 Classification and causes of chronic diarrhea
1. Watery diarrhea
  1. Osmotic
    • Carbohydrate malabsorption
    • Osmotic laxatives
  2. Secretory
    • Bacterial toxins
    • Bile acid malabsorption
    • Laxative abuse
    • Hormonal disorders: VIPoma, carcinoid syndrome, gastrinoma, hyperthyroidism
2. Inflammatory diarrhea
  1. Invasive bacterial and parasitic infections
  2. Inflammatory bowel disease
  3. Pseudomembranous colitis
  4. Infectious diseases
  5. Neoplasia
3. Fatty diarrhea
  • Malabsorption syndromes


Figure 988.1 Classification of causes of acute diarrheaFigure 988.1 Classification and causes of acute diarrhea


Evaluation of dysentery

Differentiate between bacillary dysentery and amebic dysentery is done by the identification of the causative organism in the stool. See also: Microscopic Examination of Feces

Identification of Rotavirus

In infants and young children, Rotavirus is the most common cause of diarrhea. Rotavirus can be identified by the electron microscopic examination of stool. Other techniques, such as latex agglutination, immunofluorescence, or enzyme-linked immunosorbent assay (ELISA) are also used for the detection of Rotavirus in stool.

Chemical examination

Chemical tests can be applied on feces to detect excess fat excretion (malabsorption syndrome), occult blood (in ulcerated lesions of the gastrointestinal tract, especially occult carcinoma of the colon) and presence or absence of urobilinogen (obstructive jaundice). See also: Chemical Examination of Feces

Differentiating infection by invasive bacteria (like Salmonella or Shigella) from that due to toxin-producing bacteria (like Vibrio cholerae or Escherichia coli)

Feces is examined for the presence of white blood cells. Increased numbers of polymorphonuclear neutrophils (identified by methylene blue stain from the presence of granules in their cytoplasm) are seen as shown in Figure 988.2. See also: Causes, symptoms, diagnosis, and treatment of Cholera

Figure 988.2 Preliminary evaluation of acute diarrhea. Examination of feces for white blood cells is helpful in narrowing differential diagnosis in intestinal infections in acute diarrhea
Figure 988.2 Preliminary evaluation of acute diarrhea. Examination of feces for white blood cells is helpful in narrowing differential diagnosis in intestinal infections in acute diarrhea

Leukemia is a malignant clonal hematopoietic stem cell disorders characterized by the rapid increase in the number of blast cells in the bone marrow and rapidly progressive fatal course if untreated. Acute leukemia (AL) are primary disorders of the bone marrow, also known as blood cancer.

Why are these tests performed?

  1. These tests are performed for the diagnosis of bleeding disorders.
  2. APTT is performed to distinguished the functionality of the clotting factors I, II, V, VII, IX, X, XI, and XII.
  3. APTT is used to check the treatment of the patient taking heparin or other medicine for blood thinning.

See: Role of laboratory tests is bleeding disorders

Collection of Sample

Venous blood sample is collected from antecubital fossa in a test tube containing trisodium citrate (3.2%), with the anticoagulant to blood proportion being 1:9. See also: Prothrombin time (PT): Collection of Specimen.


  1. Sample handling is very sensitive, false and raised values are obtained if the ratio of blood and anticoagulant is not correct.
  2. Plasma is stable for one hour if kept at 4º C.
  3. Plasma can be preserved for 28 days if frozen.


Activated Partial Thromboplastin Time (APTT)

Plasma is incubated with an activator (which initiates intrinsic pathway of coagulation by contact activation). Phospholipid (also called as partial thromboplastin) and calcium are then added and clotting time is measured.

Partial Thromboplastin Time (PTT)

It is one stage test. It distinguishes the functionality of the clotting factors I, II, V, VIII, X, XI, and XII. Both Activated Partial Thromboplastin Time (APTT) and Partial Thromboplastin Time (PTT) have the same clinical significance but Activated Partial Thromboplastin Time (APTT) is more reliable as compare to Partial Thromboplastin Time (PTT) due to its sensitivity.

Prothrombin Time (PT)

Tissue thromboplastin and calcium are added to plasma and clotting time is determined. The test determines the overall efficiency of extrinsic and common pathways.

International Sensitivity Index (ISI) and International Normalized Ratio (INR)

International Sensitivity Index (ISI) of a particular tissue thromboplastin is derived (by its manufacturer) by comparing it with a reference thromboplastin of known ISI. For standardization and to obtain comparable results, it is recommended to report PT (in persons on oral anticoagulants) in the form of an International Normalized Ratio (INR).

International Normalized Ratio (INR) is calculated by the following formula.

INR = PT of Patient ISI
          PT of Control

Purpose of INR: The INR is calculated to evaluate the following conditions.

  1. Atrial fibrillation
  2. Thrombophilia
  3. Cardiomyopathy
  4. Prosthesis (Replacement of heart valve)
  5. Venous thromboembolism
  6. Antiphospholipid syndrome

Normal Values

Technique of APTT, PTT, and PT is different in different laboratories therefore normal values varies with the lab to lab. A normal control is always run with the patient's sample. In general, normal values are below.

  • APTT: 30-40 seconds
  • PTT: 60-70 seconds
  • PT: 11-16 seconds
  • INR: 1-1.5
Table 882.1 Required value of INR in various diseases
Disease Required INR Value
Deep vein thrombosis prophylaxis 1.5 to 2.0
Deep vein thrombosis 2.0 to 3.0
Atrial fibrillation 2.0 to 3.0
Orthopedic surgery 2.0 to 3.0
Pulmonary embolism 2.5 to 3.5
Prosthetic valve prophylaxis 3.0 to 4.0

Critical Values

  • APTT: > 70 seconds (Usually it is considered as panic value. If APTT is greater then 100 seconds, spontaneous bleeding may occur.)
  • INR: > 5.0 (In Deep Vein Thrombosis (DVT) patient on warfarin treatment, an expected value of INR is between 2.0 to 3.0.)

Reasons for the high results

  1. Disseminated intravascular coagulopathy (DIC )
  2. Factor XII deficiency
  3. Cirrhosis
  4. Hemophilia A and B
  5. Von Willebrand’s disease
  6. Hypofibrinogenemia
  7. Vitamin K deficiency
  8. Malabsorption
  9. Leukemia
  10. Fibrin breakdown products
  11. All congenital deficiencies of Intrinsic system coagulation factors
  12. Drugs

The significance of APTT, PTT, PT, and INR test for the layman

  • Patients, taking medication for blood thinning or on heparin treatment, are advised for these laboratory investigations.

Why is this test performed?

  1. This hormone test is evaluated in different conditions, such as Adrenal insufficiency, in Acromegaly and Cushing Syndrome.
  2. In Addison's disease, the level of Adrenocorticotropic hormone (ACTH) is noted more than 1000 pg/ml.
  3. In Adrenal carcinoma, Adenoma, and Adrenocortical insufficiency, the level of Adrenocorticotropic hormone (ACTH) decreases.

Collection of Sample

For the estimation of Adrenocorticotropic hormone (ACTH), patient’s plasma is needed. Blood is collected in a chilled plastic test tube containing EDTA or heparin and blood is placed in cold ice-water.

The sample is centrifuged at 4º C, plasma is separated and stored at -20º C immediately within 15 minutes of the blood collection.

See: Uses of anticoagulants for hematological investigations

Note: For the diagnosis of Cushing Syndrome, the blood sample is collected in between 6 PM to 11 PM.

See: Procedures for the collection of blood for hematological investigations


  1. Collect the blood sample in a chilled plastic test tube containing EDTA or heparin.
  2. Avoid high carbohydrates diet, take the low-carb diet.
  3. Avoid physical activity for 12 hours before the collection of the blood sample.
  4. Stop medication such as corticosteroids, 48 hours before the collection of blood sample.
  5. An anxious collection of the blood sample may increase the level of Adrenocorticotropic hormone (ACTH).

Normal Values

  • 6 to 8 AM: < 80 pg/ml or < 18 pmol/L (SI units)
    6 to 11 MP: < 50 pg/ml or < 11 pmol/L (SI units)
    or less than 120 pg/ml
  • According to another references:
    8 AM:  < 120 pg/mL
    4 to 8 PM: < 85 pg/mL
    Cord blood: 50 to 570 pg/mL
    Newborn: 10 to 185 pg/mL
Table 881.1 ACTH and Cortisol values in various conditions and  diseases.
Disease ACTH Value Cortisol Value
Cushing syndrome Increased/low Increased
Adrenal cancer Low Raised
Adrenal adenoma Low Raised
Ectopic ACTH (Lung cancer) Raised Raised
ACTH- producing Pituitary tumor Raised Raised
Adrenal gland failure ( Infarction, Haemorrhage) Raised Low
Hypopituitarism Low Low
Congenital adrenal hyperplasia Raised Low
Addison's disease

Reasons for the increased level of ACTH

  1. Cushing syndrome
  2. Addison's disease
  3. Stress
  4. Ectopic ACTH syndrome

Reasons for the decreased level of ACTH

  1. Secondary adrenal insufficiency
  2. Exogenous steroid administration
  3. Hypopituitarism
  4. Adrenal adenoma or carcinoma

The significance of Adrenocorticotropic hormone (ACTH) test for the layman

  1. This test is advised in abnormal metabolism of lipids.
  2. This test is advised to the patients of Diabetes Mellitus (DM).
  3. This test is performed for the diagnosis of Cushing syndrome.
  4. This test is advised if there are truncal obesity and thin extremity.
truncal obesity
Figure 881.1 Example of Truncal Obesity

Why is this test performed?

  1. The test is performed for the diagnosis of prostatic carcinoma by the estimation of total acid phosphatase (TAP) and the prostatic component.
  2. The test is also performed for the examination for the presence of semen in medicolegal cases by a vaginal swab. Due to the high level of acid phosphatase in semen, its presence indicates recent sexual intercourse. Level of ≥50 U/sample is considered as positive evidence of semen.

Collection of Sample

For the test of total acid phosphatase (TAP) and the prostatic acid phosphatase (PAP), morning sample is preferred. About 3 to 5 ml blood is collected in a vacutainer and blood is allowed to clot. Then blood is centrifuged for 10 minutes at 4500 rpm in order to get the clear serum. The test is performed immediately. However, the sample can be preserved for 24 hours if kept at 2-8º C.

See: Procedures for the collection of blood for hematological investigations


  1. The sample has very poor stability in the whole blood, therefore serum is separated immediately and the test is performed within an hour.
  2. The sample is unstable for the test of ACP if the pH is more then 7.0.
  3. The sample is unstable for the test of ACP at room temperature (> 37º C).
  4. Hemolyzed serum causes the false-positive result. Increased values can be observed in hemolyzed serum.

Normal Values

  • Total acid phosphatase (TAP)
    2.5 to 3.7 ng /mL
    or < 3.0 mg /L
  • Prostatic acid phosphatase (PAP)
    < 2.5 ng/mL (0 to 0.6 U/L)
  • Other references
    Adult: 0.13 to 0.63 units/L at 37° C or 2.2 to 10.5 units/L (SI units)
    Child: 8.6 to 12.0 units/mL at 30° C
    Newborn:10.4 to 16.4 units /mL at 30°C

Reasons for the increased level

  1. Prostatic carcinoma
  2. Prostatitis
  3. Benign prostatic hyperplasia
  4. Metastatic carcinoma of the prostate
  5. Metastases to the bones

Moderately raised level seen in, other than prostatic carcinoma

  1. Hyperparathyroidism
  2. Niemann-Pick disease
  3. Sickle cell anemia
  4. Prostatitis and Benign prostatic hyperplasia ( BPH )
  5. Any cancer that has given metastasis to the bones.
  6. Urinary retention
  7. Multiple myelomas
  8. Myeloid Leukemia
  9. Paget disease
  10. Liver diseases like cirrhosis
  11. Renal diseases
  12. Thrombocytosis
  13. Gaucher’s disease

The significance of acid phosphatase test in medicolegal cases

Due to the high level of acid phosphatase in semen, its measurement is very important in rape cases. For the collection of a sample from the victim's body, following methods are applied.

  1. Direct aspiration or saline lavage
  2. Vaginal swab is obtained from the victim's vagina, and the sample is placed in 2.5% broth and can preserve at 4° C.

The significance of acid phosphatase test for the layman

  1. The test is performed for the diagnosis of prostatic carcinoma.
  2. This is carried out in cases of alleged rape or sexual assault.

Purpose of the test

The test is performed to assess the adrenal cortex function, and evaluate and monitor the adrenal tumors and hyperplasia.

How to collect the urine sample for the 17-ketosteroids test?

  1. For the test of 17-ketosteroids in urine, 24 hours urine sample is required. Urine is collected in a container, containing one gram boric acid or 6 ml hydrochloric acid (HCl).
  2. The first urine sample is discarded and then collected the all urine sample for 24 hours.
  3. The 24 hours urine sample is transferred to the pathology laboratory for laboratory findings.

Why is boric acid used for the collection of the urine sample?

Boric acid converts the urine into a bacteriostatic medium, which inhibits the growth of bacteria in urine and preserves the urine for its bacteriological examination.


Some medicines like aspirin, diuretics, antibiotics, birth control medication and hormones therapy (e.g. Estrogen) may interfere with laboratory findings, so avoid such types of medicine before preparing yourself for the laboratory test.

Normal Values

  • Males: 8-20 mg/24-hour
  • Females: 6-15 mg/24-hour
  • Elderly males > 70 years: 3-12 mg/24-hour
  • Elderly females > 70 years: 3-13 mg/24-hour
  • Infants: < 1 mg/24-hour
  • 1 to 5 years: < 5 mg/24-hour

Reasons for the increased level of 17-ketosteroids in the 24-hour urine sample

  • Pregnancy
  • Stein-Leventhal syndrome
  • Hyperpituitarism
  • Ectopic ACTH-secreting tumors
  • Administration of ACTH
  • Cushing’s syndrome
  • Congenital adrenal hyperplasia 
  • Testosterone secreting or androgen-secreting tumors of:
    (1) Ectopic ACTH-secreting tumors
    (2) Ovaries
    (3) Testes

Reasons for the decreased level of 17-ketosteroids in the 24-hour urine sample

  • Hypopituitarism
  • Severe infections 
  • Klinefelter's syndrome
  • Addison’s disease
  • Severe stress
  • Nephrosis
  • Debilitating diseases
  • Chronic diseases
  • Castration
  • Myxedema
  • Drugs that can decrease the level of 17-ketosteroids include:
    (a) Probenecid
    (b) Estrogens
    (c) Reserpine
    (d) Thiazide diuretics
    (e) Salicylates (prolonged use)
    (f) Birth control pills

The significance of 17-ketosteroids for the layman

  1. The test is advised if the females has hairs on her face.
  2. The test is performed to elaborate any abnormality or disorders of the adrenal gland.

Anal sex refers to the activity in which penis is inserted into the anus. Some people found anal sex more joyful, but the fact is that the practice has the downside and it contains so many health risks.

It is prohibited in various cultures especially with regard to religious prohibition. It is a criminal offense in some countries and punishable by corporal or capital punishments. By disparity, people regard it a valid and natural form of sexual activity.

Is Anal Sex Safe?

There are so many health risks associated with the anal sex and anal intercourse, for both partners. Some of the health risks which may affect both homosexual and heterosexual couples are listed below.

Risk of bacterial infection: E. coli is a Gram-negative, facultative anaerobic bacteria, that is commonly found in the lower intestine. Anal sex increases the risk of transmission of E. coli bacteria from anal to your penis, which may cause a severe type of urinary tract infection.

E. coli may cause many bacterial infections, including, urinary tract infection (UTI), meningitis, cholecystitis, cholangitis, bacteremia, and pneumonia.

Hepatitis A Virus (HAV): Hepatitis A Virus can transmit by the oral sex (anal licking). HAV causes jaundice. It is usually not a life-threatening virus but may cause illness.

Hepatitis C Virus (HCV): It may be transmitted through the anal intercourse. Hepatitis C Virus is the cause of fetal liver chronic disease. It is a life-threatening virus and may lead to death.

Human Papilloma Virus (HPV): It may be transmitted through the anal intercourse and may cause to the anal wart. A research showed that some of the strain of HPV have carcinogenic potential. Some strains of HPV cause cancer of the cervix in women and also cause cancer of the throat.

Human immunodeficiency virus (HIV): There is a greater risk of transmission of HIV through anal intercourse. It is a life-threatening virus and leads to death.

Weakening of the anal sphincter: The anal anus is enclosed by the ring-like muscle, called the anal sphincter. The main function of anal sphincter is to hold the feces until you get to the toilet. After the excretion of feces, it tightens. Penetration of something like a penis inside the anal can be difficult and painful. Anal intercourse may lead to the weakening of the sphincter muscles, and make it hard to hold the feces.

Lack of natural lubrication: Naturally, the anal is not made for sex. The anal has lack of lubricant as vagina have, which makes the penetration harder and painful. Penetration can tear the tissues inside the anal and cause the wound, allowing viruses and bacteria to easily enter the bloodstream. Somehow, usage of oil or other lubricants can help in preventing the tearing of tissues inside the anal but doesn't completely.

A research showed that risk of transmission of HIV and HPV is much higher in anal sex and compared to the vaginal sex.

How to Prevent Anal Sex Problems

There is no way to completely eliminate the risk factors of anal sex until you avoid the anal sex. However, you can reduce the risk by the following tips.

  1. Always use a condom during anal sex.
  2. Do not enter penis into the mouth after inserting it into the anal.
  3. Use a sufficient amount of lubricants when penetrating into the anal to reduce the risk of tissue tear. Always use water-based lubricants with condoms.
  4. Do not lick the anal as it may cause the transmission of bacteria and viruses.
  5. Take a warm bath before anal sex.
  6. Lying on your stomach will make the insertion easier.
  7. Stop if you feel so much pain during anal sex.
  8. Stop if you experience bleeding or discharge coming from it, go to the hospital as soon as possible.

The Middle East respiratory syndrome (MERS) caused by coronavirus which has a large family of virus. This viral disease first identified in September 2012 in Saudi Arabia. This virus can cause disease ranging from common cold to Severe Acute Respiratory Disease (SARS).

Yellow fever refers to jaundice that presents in a patient infected with the virus by getting a bite from a mosquito carrying the virus. The virus is arbovirus of the flavivirus genus. And the species of the mosquito is Aedes and Hemogogus.

The medical term for an infection in the vagina is vaginitis. The infection caused by any pathogenic organism such as streptococcus, staphylococcus, Trichomonasvaginalis or maybe Candida. It can happen in a child of age one to five years old, adults and old women.

Menopause is a phase when you stop getting your period. It marks the end of your menstrual cycles. You stop getting your period for at least six months or one year and confirm with your gynecologist. Woman between 40s to 50s is the age of getting menopause, but in the United States, the average age is 51 years old.

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