CRE8LEARN INSTITUTE

Anatomy & Physiology for Health Information Management

Supplementary study guide: Nervous, Musculoskeletal, Senses and Endocrine systems

Extra-class tutor: Teboho Mpholo (Mr.), Cre8Learn Institute
Supports: Botho University Health Information Management programme
Reference text: Tortora & Derrickson, 14th Edition

About this guide. An independent supplement for extra classes. It is not official Botho University material and does not replace your lecturer's notes, set texts or assessment briefs. Where this guide and your lecturer differ, follow your lecturer.

Welcome, HIM students. You are training to be a guardian of the medical record, not a doctor or nurse. You will translate clinical documentation into standardised codes (such as ICD-10) for billing, research and patient safety. Study anatomy through pathology and medical terminology: how the body is built, what happens when it breaks, and how to spell it.

One rule runs through every section. A coder codes what the provider has documented. You do not diagnose from symptoms or test results. When documentation is unclear or incomplete, you query the provider.

Which coding system? Laterality, combination codes and initial/subsequent encounters are ICD-10-CM features, and WHO ICD-10 differs in places. Confirm with your lecturer which your course uses.

Contents

1. Medical terminology primer
2. The nervous system
3. The musculoskeletal system
4. The senses (eye and ear)
5. The endocrine system
6. Review quiz
7. Abbreviations quick reference

1. Medical Terminology Primer

Almost every medical term is built from a prefix (start), a root (core meaning) and a suffix (end). Learn the parts and you can decode words you have never seen.

Prefixes	Roots	Suffixes
a-/an- without brady- slow tachy- fast hyper- above, excess hypo- below, deficient dys- difficult, abnormal poly- many peri- around endo- within hemi- half	neur(o) nerve encephal(o) brain cerebr(o) cerebrum oste(o) bone arthr(o) joint my(o) muscle ophthalm(o), ocul(o) eye ot(o) ear thyr(o) thyroid gluc(o), glyc(o) sugar	-itis inflammation -pathy disease -algia pain -emia blood condition -osis abnormal condition -penia deficiency -plegia paralysis -paresis weakness -ectomy removal -otomy cutting into -plasty surgical repair -scopy viewing

TRY IT

Decode hemiplegia, polyneuropathy and arthroplasty.

Answer: hemiplegia = half + paralysis (paralysis of one side of the body); polyneuropathy = many + nerve + disease (disease affecting many nerves); arthroplasty = joint + surgical repair.

2. The Nervous System (Tortora Ch. 12–15)

The body's electrical wiring, divided into the Central Nervous System (CNS) (brain and spinal cord) and the Peripheral Nervous System (PNS) (nerves branching out, including 12 pairs of cranial nerves and 31 pairs of spinal nerves).

Structure and function

Structure	Main role
Cerebrum	Thought, memory, voluntary movement, sensation. Lobes: frontal, parietal, temporal, occipital
Cerebellum	Coordination, balance, smooth movement
Brainstem	Breathing, heart rate, consciousness
Hypothalamus	Body temperature, hunger, thirst; controls the pituitary gland
Spinal cord	Carries signals between brain and body; reflex arcs
Meninges	Three protective membranes (dura mater, arachnoid mater, pia mater) around brain and cord
Neuron	Dendrites receive signals; the axon sends them; the myelin sheath speeds conduction
Autonomic system	Involuntary control. Sympathetic is fight or flight; parasympathetic is rest and digest

HIM FOCUS: PATHOLOGIES & TERMINOLOGY

Cerebrovascular accident (CVA): A stroke. Note the site (e.g. middle cerebral artery) and type: blockage (ischaemic) or bleed (haemorrhagic).
Transient ischaemic attack (TIA): A "mini-stroke" with brief blockage and resolving symptoms. A critical warning sign.
Neuropathy: Disease of the nerves, often a diabetic complication.
Meningitis: Inflammation of the meninges. Usually bacterial or viral; fungal causes also occur.
Epilepsy: A seizure disorder. Focal (formerly partial) seizures start in one area; generalised seizures involve both sides. You will meet both terms.
Multiple sclerosis (MS): Autoimmune attack on the myelin sheath of CNS nerves.
Parkinson's disease: Loss of dopamine-producing neurons. Tremor, rigidity, slow movement.
Dementia / Alzheimer's disease: Dementia is the syndrome of cognitive decline; Alzheimer's is its most common cause. Charts may specify type and stage.
Concussion: A mild traumatic brain injury. Look for documented loss of consciousness and its duration.
Bell's palsy: Sudden weakness of the facial nerve (cranial nerve VII), usually one side of the face.

CHECKPOINT

Scenario: "Meningitis due to Streptococcus pneumoniae." Which structure is inflamed, and why does the organism matter?

Answer: The meninges. ICD-10 classifies bacterial meningitis by cause, so the organism determines the code and supports accurate statistics.

3. The Musculoskeletal System (Tortora Ch. 6–11)

Structure, support and movement. The adult skeleton has 206 bones: the axial skeleton (skull, spine, ribs, sternum) and the appendicular skeleton (limbs, shoulder and pelvic girdles).

Structure and function

Structure	Main role
Osteoblasts / osteoclasts	Osteoblasts build bone; osteoclasts break it down. They must stay in balance
Fibrous joints	Immovable (skull sutures)
Cartilaginous joints	Slightly movable (between vertebrae)
Synovial joints	Freely movable (knee, shoulder, hip)
Skeletal muscle	Voluntary, striated; moves bones via tendons
Cardiac muscle	Involuntary, striated; found only in the heart
Smooth muscle	Involuntary, non-striated; walls of organs and vessels
Ligament / tendon	Ligaments join bone to bone; tendons join muscle to bone

HIM FOCUS: PATHOLOGIES & TERMINOLOGY

Fractures: Pay attention to:
- Type: closed/simple (skin intact) versus open/compound (bone through skin). Under ICD-10-CM conventions a fracture not documented as open or closed is classified as closed.
- Pattern: comminuted (three or more pieces), spiral, greenstick (incomplete, common in children).
- Laterality: left or right.
- Encounter: initial (active treatment) or subsequent (routine healing or follow-up).
Osteoarthritis (OA): Mainly degenerative cartilage loss, commonly in knees, hips and hands.
Rheumatoid arthritis (RA): Autoimmune attack on the joint lining; systemic. Never confuse with OA.
Osteoporosis: "Porous bone": broken down faster than rebuilt, so brittle and fracture-prone.
Gout: Uric acid crystals in a joint, causing sudden painful inflammation, classically the big toe.
Scoliosis: Abnormal sideways curvature of the spine.
Sprain versus strain: A sprain is a ligament injury; a strain is a muscle or tendon injury.
Dislocation: Bone ends displaced from their normal joint position.

CHECKPOINT

Scenario: "Fell off a ladder. Right femur is broken and protruding through the skin." What three details do you extract, and what else do you confirm?

Answer: The bone (femur), laterality (right) and fracture type (open, because it protrudes through skin). Confirm the encounter type (initial or subsequent). If anything is missing, query.

4. The Senses (Tortora Ch. 16 & 17)

Structure and function

Structure	Main role
Cornea, lens	Focus light onto the retina (the cornea does most of the focusing)
Iris, pupil	Control how much light enters
Retina	Rods (dim light, black and white) and cones (colour); signals leave via the optic nerve
Outer ear	Collects sound and channels it to the eardrum
Middle ear	Eardrum and three tiny bones (ossicles) pass vibrations inward
Inner ear	Cochlea for hearing; semicircular canals and vestibule for balance
Taste, smell, touch	Taste buds and olfactory receptors detect chemicals; skin receptors detect touch, pressure, temperature and pain

HIM FOCUS: PATHOLOGIES & TERMINOLOGY

Myopia: Short-sightedness. Hyperopia: Long-sightedness. Presbyopia: Age-related loss of near focusing as the lens stiffens (not the same as hyperopia).
Cataract: Clouding of the lens. Common in older patients; treated by surgical lens replacement.
Glaucoma: Optic nerve damage, often (not always) with raised intraocular pressure. The "silent thief of sight."
Ocular hypertension: Raised pressure without optic nerve damage. A different diagnosis from glaucoma.
Age-related macular degeneration: Damage to the central retina, causing loss of central vision.
Retinal detachment: The retina separates from the back of the eye. An emergency.
Conjunctivitis: Inflammation of the conjunctiva ("pink eye"); viral, bacterial or allergic.
Otitis media: Middle ear infection; a leading reason children are given antibiotics.
Hearing loss: Conductive (blocked in outer or middle ear) or sensorineural (cochlea or nerve). Presbycusis is age-related sensorineural loss.
Ménière's disease: Inner ear disorder with vertigo, tinnitus and fluctuating hearing loss.
Tinnitus: Ringing or buzzing in the ears. Vertigo: A false sensation of spinning.

CHECKPOINT 1

Scenario: "Difficulty hearing high-pitched sounds, likely due to ageing." What must the provider document before you assign a type of hearing loss, and what if it is missing?

Answer: The type and cause (e.g. sensorineural hearing loss due to presbycusis). You cannot work it out from symptoms, so you query. Note also the word "likely": uncertain terms are treated differently in inpatient and outpatient coding.

CHECKPOINT 2

Scenario: One chart says "clouding of the lens"; another says "elevated intraocular pressure." What does each point to, and what do you do for the second?

Answer: The first is a cataract. The second is a finding, not a diagnosis (ocular hypertension or glaucoma). Code what the provider documents and query if no diagnosis is stated.

5. The Endocrine System (Tortora Ch. 18)

Hormones and glands. Chemical messengers regulate metabolism, growth, reproduction and mood, largely through negative feedback: when a hormone level rises too high, the body signals the gland to reduce output.

Glands and hormones

Gland	Key hormones and roles
Hypothalamus	Links nervous and endocrine systems; controls the pituitary
Pituitary	The "master gland": growth hormone, ADH, TSH and others
Thyroid	T3 and T4 set metabolic rate
Parathyroids	Parathyroid hormone raises blood calcium
Adrenals	Cortisol (stress, glucose), aldosterone (salt and water), adrenaline
Pancreas	Insulin lowers blood glucose; glucagon raises it
Gonads	Oestrogen and progesterone (ovaries); testosterone (testes)
Pineal	Melatonin, sleep-wake rhythm

HIM FOCUS: PATHOLOGIES & TERMINOLOGY

Diabetes mellitus:
- Type 1: little or no insulin (autoimmune destruction of insulin-producing cells).
- Type 2: cells resist insulin, often with falling production over time.
- HIM alert: ICD-10-CM uses combination codes (e.g. type 2 diabetes with diabetic neuropathy), but only when the provider documents the complication. Watch for retinopathy, nephropathy and neuropathy.
Diabetic ketoacidosis (DKA): Dangerous acid build-up when the body lacks insulin; most associated with type 1. Hypoglycaemia: Low blood glucose.
Hyperthyroidism: Overactive thyroid (weight loss, fast heart rate, heat intolerance); Graves' disease is a common autoimmune cause.
Hypothyroidism: Underactive thyroid (weight gain, fatigue, cold intolerance); Hashimoto's thyroiditis is a common autoimmune cause.
Goitre: Enlargement of the thyroid gland.
Cushing's syndrome: Excess cortisol. Addison's disease: Adrenal insufficiency (too little cortisol, often aldosterone too).

CHECKPOINT

Scenario: "Type 2 diabetes mellitus. Patient reports numbness and tingling in both feet." Can you code diabetic neuropathy?

Answer: No. Numbness and tingling are symptoms, not a diagnosis. Query the physician. Once "diabetic neuropathy" is documented, the combination code applies.

6. Review Quiz

TERMINOLOGY

1. Break down osteoarthritis, and say whether it is mainly inflammatory.

Osteo (bone) + arthr (joint) + itis (inflammation). Despite the suffix, OA is mainly degenerative, unlike RA.

2. What does hypothyroidism mean from its parts?

Hypo (below, deficient) + thyroid + ism (condition): an underactive thyroid.

3. What is the difference between a ligament and a tendon?

Ligaments join bone to bone; tendons join muscle to bone.

ANATOMY AND PHYSIOLOGY

4. Which part of the brain coordinates balance and smooth movement?

The cerebellum.

5. What is the difference between osteoblasts and osteoclasts?

Osteoblasts build bone; osteoclasts break it down. Osteoporosis results when breakdown outpaces building.

6. Which hormone raises blood glucose, and which lowers it?

Glucagon raises it; insulin lowers it.

CODING AND QUERIES

7. A chart says "haemorrhagic CVA." What is happening?

A blood vessel has ruptured and bleeding occurs in or around the brain, unlike an ischaemic CVA, where a blockage cuts off blood flow.

8. Why must you not assign glaucoma from "elevated intraocular pressure"?

Raised pressure is a finding, not a diagnosis. It may be ocular hypertension or glaucoma (which can even occur with normal pressure). The provider must document it; otherwise you query.

9. A fracture is not documented as open or closed. How is it classified in ICD-10-CM?

As closed, by convention. If the wording seems incomplete, check the full record.

10. A chart says "suspected multiple sclerosis" on an outpatient visit. Can you code MS?

Generally no. Outpatient guidelines say not to code uncertain diagnoses such as "suspected" or "probable"; code the documented signs and symptoms instead. Inpatient rules differ, so check your guidelines.

7. Abbreviations Quick Reference

Abbreviation	Meaning	Abbreviation	Meaning
CNS / PNS	Central / peripheral nervous system	DM	Diabetes mellitus
CVA	Cerebrovascular accident	DKA	Diabetic ketoacidosis
TIA	Transient ischaemic attack	T1DM / T2DM	Type 1 / type 2 diabetes
MS	Multiple sclerosis	TSH	Thyroid-stimulating hormone
OA / RA	Osteoarthritis / rheumatoid arthritis	ADH	Antidiuretic hormone
ORIF	Open reduction, internal fixation	IOP	Intraocular pressure
AMD	Age-related macular degeneration	ICD-10-CM	Diagnosis classification (clinical modification)

A final note. You will not perform surgery or prescribe medication. You will read an operative report and extract the exact anatomical location and pathology to assign a code. Master the terminology, know the difference between similar-sounding conditions, and know when to query.