KAPLAN USMLE Step1 Lecture Notes‘Author and Executive Editor David Seiden, Ph.D. Profesor of Newroscence and Cel Biology Asociate Dean for Admissions and Student Airs UMDNJ-Robert Wood fonson Medical Schoo Pistaway NT Contributors Executive Director of Curriculum James A. Colgan, Ph.D. Richard Friedland, M.D, ising Letre an Course Coordinator ‘Human Gross Anatomy Director of Publishing and Media Division of Biomedical Scenes Michele Cone nies of Cara ‘iver, CA “s Medical Mtustrators Ronald Dudek, Ph.D. Rich LaRocco Profesor CuitneSchaae Depart of nator an Cl Biology ry Sc of eine Managing Editor ast Cartna Universi Gronile o Kathlyn MeGreeey James White, Ph.D. Production Editor Adjunct stant Profesor of Neuroscience and Cl Bio Wiis Ng Robert Wood Jonson Medic School Now Brunswick Piscataway, NJ Adjunct ascie Profesor of Cel Bilgy Production Artist Univers of Malice and Dettyof New Fey Mich Wot Newark. NJ Adjunct Assistans Profesor of Cal an Developmental logy Cover Design Univesity of Ponsyvania chal of Medicine Joanna Milo Philadel, PA Jack Wilson, Ph.D. ont At Distinguished Alun Profesor of Antony and Neurobiology isin Shas University of Tennessee Heath Center ‘Memphis, TNPreface Section I: Histology and Cytology ‘Chapter 1: Cel Components. ‘Chapter 2: Nervous Tissue «. Chapter 3: Muscle Tissue (Chapter 4 ymphoid Organs (Chapter 5 tegument Chapter 6: Respiratory System Chapter 7: Gastintestnal System ‘Chapter @: Renal/Urinary System Chapter 8: Male Rerodcve System ‘Chapter 10: Female Reproductive System Section II: Early Embryology Chapter 1: Gonad Development ........-.-+++ Chapter 2: Week 1: Beginning of Development Chapter 3: Week 2: Formation of the Bilaminar Embryo (Chapter 4: Embryonic Period (Weeks 3-8) .. oil 35 3 a AS 48 6 n 93 101 103 medicalSection Ill: Gross Anatomy and Organogenesis Chapter 1: Back and Nervous System .. Chapter 2: Thorax Chapter 3: Abdomen, Peis, and Perineum Chapter 4: Upper Limb . Chapter 5: Lower Limb . ‘Chapter 6: Head and Neck Neuroscience ‘Chapter 1: Peripheral Nerous System ‘Chapter 2: Central Nervous System ..... 0.0655 ‘Chapter 3: The Venter System ‘Chapter 4: The Spinal Cord Chapter 5: The Brain Stem ‘Chapter 6: The Cerebellum . hate 7 Vl Patsy hater 8: Dienepaon hap 9: sl Cangla haptr1: certra Carex ‘Ghapter 11: The Limbic System idtical mM ms 167 235 253 269 38 33 31 35 363 407 a7 29 35 a3 465SECTION I Histology and CytologyCell Components NUCLEUS “The nucleus (Figore -1-1) is te ste of deoxyribonucleic acid (DNA) replication and tran- scription of DNA into precursor ribonucleic acid (RNA) molecules. It contains all of the ‘enzymes required for eepiation and repair of newly synthesized DNA, as well as for transrip~ tion and processing of precursor RNA molecules. It is enclosed by the nuclear envelope and contains the nuclear lamina, nucleolus, and chromatin. Euehromatin Heterochromatin Nucleolus Figure b4-1, Nucleus Nuclear Envelope ‘he nuclear envelope is a double membrane containing pores that are approximately 90 nm in diameter. The outer nuclear membrane is continuous with the endoplasmic reticulum, Nuclear Lamina “The moclear lamina ea atclike network of proteins that include lamins Lamins attach chro matin tothe inner membrane of the nuclear envelope and participate in the breakdown and. feformation of the nuclear envelope during the cell eyle. Phosphorylation of the lamina (by lamin kinase) during prophase of mitosis initiates nuclear disassembly into small vesicle.USMLE Step 1: Anatomy Nucleolus “The nucleolus is responsile for ribosomal RNA (2RNA) synthesis and ribosome assembly, I contains three morphologically distinct zones + Granular zone—found atthe periphery; contains ribosomal precursor particles in various tages of asembly, + Fibrillar zone—centrally located; contains eibonuclear protein fib, + Fibrillarcenter—contains DNA thats not being transcribed ‘Chromatin (Chromatin is a complex of DNA, histone proteins, and nonhistone proteins. + DNA—a double-stranded hetical molecule that caries the genetic information ofthe call It exists in three conformations: B DNA, Z DNA, and A DNA, + Histone proteins —posiively charged proteins enriched with lysine and arginine residues. They are important informing two types of structures in chromatin: nulee- somes and solenoid fibers. The nucleosomes are the base repeating units ofthe aromatin fiber, having a diameter of approximately 10 nm + Noaistone proteins—include enzymes involved in nuclear funetions such as replica ‘ion, transcription, DNA repair, and regulation of chromatin function. They ar acidic ‘or neutral proteins Forms of chromatin + Heterechromatio—highly condensed (30-nm solenoid fibers or higher states of con- ‘densation) and transcrptionally inactive In a typical eukaryotic cell approximately 10% of the chromatin is heterochromatin, Almost the entre inactive X chromosome (Barr bods) in each somatic celina woman is condense into heterochromatin, + Enchromatin—a more extn form of DNA, which is potentially transcriptionally active. in a pial cll, euchromatin accounts for approximately 90% ofthe total ‘aroma, akbough only about 10% is being atively tanscribed ia the 10-nm Ser of mmckeosomes.Proxicomes, endoplasmic reteulum (FER) laments Figure bt-2 CYTOPLASM Ribosomes Ribosomes are composed of FRNA and protein. They consis of larg tunis, Ribosomes ae assembled in the maclus and transported to the cytoplasm through the nuclear poces. The large ribosomal subunits are symthesized in the nucleolus, whereas the small ‘subuis ae syhesized in the nucleus. + Polysomes—Ribosomes often form polysomes, which consist ofa single messenger RNA (tRNA) thats being translated by several ribosomes a the same time. The ribosomes move on the mBNA from the 5’ end toward the 3 end. The two riboso. ‘mal subunits associate on the mRNA, with the small subunit binding first. Forms of ribosomes Ribosomes exist in two forms: + Froe polysomes are the site of synthesis for proteins destined for the nucleus, peroxi= somes, ox mitochondria, + Membrane-assciated polysomes are th site of synthesis of secretory proteins, mem- brane proteins, nd lysosomal enzymes Cell ComponentsUSMLE Step 1: Anatom 6 fiédical 5 Endoplasmic Reticulum “The endoplasmic reticulum exist in two forms, rough endoplasmic reticulum (RER) and smooth endoplasmic reticulum (SER). Rough endoplasmic reticulum RRER isa single lipid bilayer continuous withthe outer nuclear membrane Is organized into stacks of large fattened sacs called cisternae that are studded with ribosomes onthe cytoplas- imi side (Figure -1-) RRER synthesizes proteins that are destined forthe Gol apparatus, secretion, the plasma mem brane, and iysosomes. RER is very prominent n el that are specialized inthe synths of ro- teins destined for secretion (eg. pancreatic acinar cll). Capone 200 Ga Suncor same, ns AV een Figure 11-3. Rough Endoplasmic Reticulum ‘Smooth endoplasmic reticulum ‘SER sa network of membranous sacs, vesicles, and tobules continuous with the RER, but lack ing ribosomes (Figure [1-4 SER contain enzymes involved inthe biosynthesis of phospholipid, riglycerdes, and sterolsfrgecoyot 164 Lepncot Wome & Wiens Used ne pemeson Figure -1-4, Human Corpus Luteum of Pregnaney Functions of SER Detoxification Reactions “These are reactions that make compounds water soluble so that they canbe excreted Tv types of rections that increase solubility at + Steroid synthesis + Hydroxylation eactions-—by way of hydronylaxe complexes containing eytochrome PASO, fvoprotein, anda nonheme iron protein + Conjugation ractions—the transfer of polar groups (ie, glucuronic acd) from the ‘active cariet UDPglucuronc acid tothe toxic water-insoluble molecule ‘lycogen Degradation and Gluconeogenesis Removal of the phosphate group frm glucose-6-phosphate bythe enzyme glucose-6 phos [hates an integral membrane protein of the SER. This controls the formation of fre glucose from glycogen and via ghiconengencss Metabolism ns inthe SER with the elease of a fatty acid from triglyceride. The SER i also the site where lipoprotein particles are assembled Sequestration and Release of Calcium lons In striated muscle the SER is known a the sarcoplasmic reticulum (SR). The sequestration end release of calcium fons takes place in the SR. Cell ComponentsUSMLE Step 1: Anatomy Col De tree apparatus with the Golgi ten ose eer soya being te CaCl aso prec tn Nils Che sce pees beng tame nf Cos she san nove ta be yea! igre Secret erin prose, be bao Clg Gieaecmmelon thewotet patel be (algal he ‘peel nw Ch mat Golgi Apparatus ‘The Gly apparatus conto ic shaped smh citerna tat ar asembled in sac (ic tyme aving «diameter ofapprosimatly | yim and anoclated with numerous anal membrane-bound aces (Figure 1-3). Mitochondria Figure 4-5. Cytoplasm “The Golgi apparatus has two disint faces: + Thee (forming) face is associated with the RER, + The trans (maturing) fee i often oriented toward the plasma membrane. The trans mos regio isa network of tubular stractores known a the trane-Golgi network (IGN) (Figure 1-6).Figure 11-6. Golgi Apparatus Functions ofthe golgl apparatus Proteins and Lipids “The Gol apparsts isthe ste of postransatonal modification and sorting of neal synthe sized proteins and lps. Glycoproteins Further modification of the carbohydeate moisty of glycoproteins produces complex and hybrid oligosaccharide chains. This determines which protein remain inthe Golgi apparatus ‘of leave the Golgi apparatus to Decome secretory proteins, lysosomal proteins, or pat of the plasma membrane. Two diseases are caused by a breakdown in this process T-cell disease and hyperproinulinemia (se Clinical Correlates) Cell Components Glincal Correlate Hyperpecinslinemia is charaeried by elevated level of prin in the serum sulting fom the falure of peptidase to deave roisuin t insuin and C peptide inthe Col appara The dial manifestations are ilar to tose seen in patents wth noni ependent dab. inédical 9LUSMLE Step 1: Anatomy nical Coreeate | r Fell Disease Phosphorylation of mannose in lycopatis targets protest sasomes. Phosphate i aed in a twat sequence of reactions that ae cated by ceylucsaine phosphotoserse and act lunsaminidses. | | define in Macehylucesanine phosphotrnstease rutin Kel dase (neces 1, nih a bole fray of enzymes is sen to he wrong destination i caraceredby huge inchs odes in cls ase by the acclaton of undead eoconugtes mn hsoomes | msn tbe doles tat realy degrade these macomolecles. Te mising enzymes are fund | inthe pasa ander body fis where they he normal levels f acy Te absence of the | mannse phosphate onthe hydelaes sul in the secretion rte than ther incorporation it yosomes The dss resin shell abnamates, cae fees resided int movements and psychomotor ears. Sploms ae general ced at bith, ad tee pan sles than 10 on | Ase s sevee form of the disease wth late: ost and poten sural int dtd is | cated prea te soph. ‘There sno trestment for ether disease, but prenatal agnosis avalable lysosomes lysosomes ae spherical membran-endoscd orgs tht are approimaty 05 yum in lamer and consi enzynes required for inacellr digestion Cre et) ysosomes consist of two forms + Primary lysosomes have not yet acquired the materials tobe digested, They are formed by budding fom the trans side ofthe Goi apparatus -ysosomes ae formed by the fusion ofthe primary lysosome with the sub ‘rate to be degraded and have contents that are ia various stages of degradation, {ysosomes contain approximately 60 Indrolti enzymes These include nucleases for degrading DNA and RNA, lipases for degrading lpi, ghcosdases for degrading gycoconiugate (ico proteins, proteoglycans, and ghcolipids), proteases and peptidase for degrading proteins, and a ‘riety of phosphatases, + Alllsosomal enzymes sce acid hydrolases, with optimal activity at a pH of mately 5.0 + The synthesis of the lysosomal hydrolases occurs in the RER; the hydrolases are trans ferred tothe Golgi apparatus, where they ae mosifed and packaged into lysosomes. prac 10 iedicalCell Components ipo 200 Gas anced ted, he A roar Figure -.Lysosomes Peroxisomes Peroxisomes area heterogeneous group of smal spherical organelles with a single membrane and a diameter that ranges from approximately 0.15 to 0.5 um (Figure 1-1-8) Peronisomes contain a number of enzymes that transfer hydrogen atoms from organi sub- strates (urate, -amino acids an very lng chan fay acids) to molecular anygen withthe for- ‘mation of hydrogen peroxide, Catalase, the major peroxisomal protein, degrade the hydrogen Petonideto water and oxygen Peroxisomal enzymes are synthesized on fre polysomes. After translation, the enzymes are ‘incorporated directly into peroxisomes, Peroxsomes have several fntions + Synthesis and degradation of hydrogen peroxide + B-Oxidaton of very long chain fatty acids (>C24) start inthe peroxisome and proceeds ‘inti the carbon chai has been reduced to a length of approximately 10 carbons. ‘Oxidation ofthe residual 10 cazbons i completed in the mitochondria + Phospholipid exchange perosisomes contain enzymes that convert phosphatdyser ine and phosphatidylethanolamine + Bile acid synthesis Clinical Correlate Peroxisome Delcency Sera geetic diseases ate ‘zsnited wt the impairment or absence of perenisomes These pals falto oxidize very long chain fay ads and accumulate ble acid pressor. The four ost common disorders ae + elweger (cerebrobepatrenal) syndiome + Neonatal sdrenolekodstropy “Iai Rlsum ease + FyperipecoateiaUSMLE Step 1: Anatomy tochonatia Peroxisome Copy 200 Ga Sard anes he ANG ened Figure 1-8. The Peroxisome Mitochondria Mitochondria have two membranes. They ate about 0.5 jm in width and vary in length from to 10 um (Figure 1-1-9). They synthesize adenosine triphosphate (ATP), contain their own, double-stranded circular DNA, and make some of ther own proteins, Mitochondria have sev- cra compartments, Outer membrane ‘The outer membrane is smooth, continuous, and highly permeable. I contains an abundance of porin, an integral membrane protein tha forms channels inthe outer membrane through which molecules of es than 10 KD can pas. {nner membrane ‘The inner membrane is impermeable to most small ons (Na*, K*, H') and small molecules (ATR, adenosine diphosphate, pyruvate) The impermeabiity is likely related tothe hi tent ofthe lipid cardiolipin, *+ The inner membrane has numerous infldings, called cristae. The cristae greatly Increase the total surface area. They contain the enzymes for electron transport and oxidative phosphorylation. +The number of mitochondria and the numberof cristae per mitochondrion are pro- Portional tothe metabolic activity ofthe cells in which they reside, Intermembrane compartment ‘Theintermemirane compartment isthe space berween the inner and outer membranes Itcon= tains enzymes that use ATP to phosphorylate other nucleotides (creatine phosphokinase and adenylate kina). 12 Hiedicalcell Components Matrix ‘The mati is enclosed by the inner membrane and contains + Dehydrogenasesoxidire many ofthe substrates inthe cll (pyruvate, amin acids, faty acids), generating reduced nicotinamide adenine dinucleotide (NADH) and reduced flavin adenine dinucleotide (FADH,) for use by the electron transport chain and energy generation, + A double-stranded circular DNA genome—encodes afew of the mitochondrial pro- ‘eins. Mitochondria DNA i always iherited fom the mother, resulting the mater- nal transmission of diseases of energy metabolism. + RNA, proteins, and ribosomes—although there is some protein synthesis, most mito- chondrial proteins are synthesized in the eytoplasm and arc transferred int the mitochondria. + Intramitochondrial granules—contai calcium end magnesium. Thelt function is not known, but i is believed that they may represent a storage st for ealeinm, Chistae ‘Conyrgh 200 Ge Saas asada he Arg ese Figure --8. Mitochondria Cytoskeleton The cytoskeleton provides a supportive network of tubules an filaments inthe eytoplasm of eukaryote cell. tis composed of microtubules, intermediate filaments, and microfilaments. Microtubules ‘Microtubules are polymers of tubulin that undergo rapid assembly and disassembly. They are found inthe cytoplasmic matrix ofall eukaryote cell Hiédical 13USMLE Step 1: Anatomy Glnical Correlate ‘Chéiak-igashi syndrome is araderied by a deectin _mrtubule polymerization, This leads to des in ctopasmicanues inducing: + Debed son of Phagosomes wth hsosomes sn evkocys hus preventing peaootosis ot beta “toaessed ison of rmeanosomes in maanacts, leading 0 abrism. + Granular dele in natural ile els and ples. Glinical Correlate -Actinbinding devgs (eg, ‘ytochalsin 8) can interfere wth the pohmeriaton- epoymerzaton cde of miami Processes such 2 endocytss phagooyos ‘kines and cytoplasmic and amoeboid overnent re al inibted by cpectlsn 8. ‘Tubulin ‘The major component of microtubules is tubulin, protein dimer composed of two diffrent polypeptides «tubulin and tubulin. Polymerization of tubulin to form microtubules i accomplished by microtubule organizing can ters and two types of accessory proteins, tu proteins and microtubule associated proteins “Mirotubls grow from the organirng centers Calcium fons can block or reverse polymerization ‘Microtubules play a role in: + Chromosomal movement during meiosis and mitosis, Microtubule assembly isan {important event in spindle formation. + tracellular vesicle and organelle transport. Two specific microtubule-éependent ATPases, kinesin and dynein, re involved in gencrating the force that deves trans ort, with the microtbular stzucture playing a more pasive role in intracellular transport + Cliny and flagellar movement. Intermediate filaments Intermediate filaments are intermediate in thickness (10-nm diameter) between microtubules and microfilaments. They function primarily a structural oles nd contin several types of te suc-spciic proteins: + Cytokeratins—found in epithelial tissue + Desmin—found in smooth muscle 7: disks of skeletal and cardiac muscle + Vimentin—found in cel of mesenchymal origin (endothelial cells, fibroblasts, chon- roblass, yaseular smooth muscle) + Neurofilaments—found in neurons + Glia billy acidic protein (GFA)—found in astrocytes ‘Microfilaments “Microfilaments have a diameter of 6 nm and ate composed of actin. Each actin filament (F-actin) consists of two strands of actin twisted into a helical pattern with 13.5 molecules of globular actin (G-actin) per turn ofthe helix ‘wo types of movement are associated with merolaments: + Local movement takes advantage of the polymerization and depolymerization proper- ties of microfilaments + Sling lament mavernent is generated by the interaction of atin flaments with myosin filaments.CELL SURFACE Basement Membrane The basement membrane isa shestlikestcture that underlies virtually al epithelia. Icons ofthe following: + Basal lamina—composed of type IV collagen elycoprotens (eg. laminin), and pro teoglveans (eg. heparan sulfate) (Figure -1-10}. Reticular lamina—composed of delicate reticular Hibers. ‘Baca Lamina Figure 4-10. Basal Lamina inédical 15USMLE Step 1: Anatomy Lateral Surface Specializations ‘The lateral surface specializations are ilustrated in Figure [- Figure F111. Surface Spocializtions Found on Simple ‘Columnar Epithelial Celis Tight junction (zona occludens) “The tight junction i formed by the fasion of opposed cll membranes (Figure [-1-11). These ides of fusion present as “scaling strands" scen in frcere-factue replicas (Figure [-1-12) It «extends completely around the apical el borders o seal the underlying intercallar clefts from ‘contact with the outside environment. [constitutes the anatomic component of many barriers inthe body.cell Components ‘seating ‘Stancs nage copy 198 Lanta hn Used min persian, Figure 1-12. Freaze-Fracture Replica ofa Tight Junction Zonula adherens ‘A zonula adherens (adherent junction) often lie basal tothe omula oceludens (Figure 1-1-1), Iie bandlike junction that serves in the attachment of adjacent epithelial cells Desmasome The desmosome (macula adherens) is formed by the juxtaposition of two disk-shaped plaques contained within the eytoplasm of each adjacent cell (gute I-13) + Intermediate filaments (tonoflaments) radiate away from the plagues (not seen in Figure 1-12) These intermediate filament ate anchored by desmoplakins (plagues) that alo bind to transmembrane linker proteins, linking adjacent cells + Desmosomes ate most common in Bining membranes, are subject to wear and tar, and ate considered spot welds that hold cells together. HSuical 17LUSMLE Step 1: Anatomy —_ Intermediate Density (opyioh 200 Cd Sant ine, AL see Figure 11-13. Desmosome Gap junction ‘The yap junction isan area of communication between adjacent cell that allows the passage of ‘very small particles end ions across a smal intercellular gap within the junction (Figure I--14) The gap junction consists ofa hexagonal latice of tubular protein subunits called connexons, which form hydcophilic channels connecting the cytoplasm of adjacent cells (Figure I-15) ‘This permits the direc passage of ions and srvall molecules between cells to conduct electri cal impulses.cell Components ge po 184 poco Haskin Und wi ean, Figure 11-14, Freeze-Fracture Replica ofa Gap (Communicating) Junction (CJ)USMLE Step 1: Anatomy Figure L1-15, Gap Junetion Note Apical Free) Surface Specializations Microvili Microvllar pial ell sueice evaginations of cll membranes that faneton to increase the cell miso found the apies : eae surface ateasvilable for absorption (Figure I-1-16) A thik plyeocalyx coat covers them. The ofa ring the epddyms, Core of each microvillus contains actin microfilaments Is anchored in the apical el cytoplasm lcs deferens and har cst gh erminal web, which itself s anchored to the zona adherens of the cll membrane ofthe ine x, where they playa role in audtry sersaon, Serena ar elongated Note aga we ogee bathe hese eee es Gouetieeee sree sng asin pres cy Figure 11-16. Apieal Cel Surace/Cell Junctionsa Cell Components cia Cilia are apical cll surface projections of cell membrane that contain microtubules (Figures 1-17 and I-18) They are inserted on centriole-lke basal bodies present below the mem- brane surface atthe apical pole ita contain to central microtubules surrounded by « circle of nine peripheral micro tubule doublets. The peripheral doublets are fused s0 that they share a common tubule wall and form two subtubules, A and B. Adjacent doublets are connected to one another by nexin links (Figure 1-1-1), Figure H1-17. ciaLUSMLE Step Conta singlet Structure of the Axoneme of a Cilum Movement of Cia A pair of dynein arm is attached to each A subtubule. The arms bind to ATP and rearrange themseles so that «binding ste fr the B subtubule in the tp of the arm is exposed. The B tubule interacts with the binding site, causing the arm to snap back and movement to ou. Each oyce of single dynein arm slides adjacent doubles 10 nm past eachother. Cilia move back and forth to propel fluid and particles in one direction. They are important in clearing macas from the resptatory tact. Glinical Correlate artagener Syndrome ‘Ase ot aera dynein ars are found inthe oli and age of individuals suing fom Kartagener sycome (a subse fmol syndome), Such nda often hae nic sins and Drones, 5 vel as ntrty and, some aes Sts ivesCell Components [ (Chapter Summary | Geongoene nce eras cropem oferty eel are | The Nucess | omc os ance tp nt nc dr | Fosphoration of he lamina dng prophase of mitsinines nce seb isa vesies | Thenudeolsasebles boone nd sts asomal RNA The meshes ar ever cris ontarsbed OWA " Ghromainis complexe ON, toe ad onion pts. DNA ess in tee os BONA ZLDKA and ANA sone prt ae poste charged and compe wth ONAYo fm desomes and sli ers Nontistne pros renewal and pero dese uncon uch 2 D4 rep epaton,tascpon, nd eqdaton of ona uncon. Thre Wo fos of bro’ eudvona, ich tanscitondy ai, and trod, wich s tensa ae Ten peret of romain nthe mo heecratn The Bar body Arai X romeo) ecco Te Ctolasm “The etplasm cans rbnsanes,endplasic eum, Gl appara, hsosames, eoesones ntochonai and ati bosomes re composed A and pc, Large rBsomal ns ae steed inthe rues, eras sal nes a sytested in te rules. osomes ae formed fom rbsomes asscating wth singe NA stan, There ae two kindof poomes: re and membrane bound The fome shee pts destined rhe nes, peossomes, of manconda. The ter fom sect potes, sasonlewynes and menrane rts Endoplesnicetilum exis i to fas srcth nd ough. Smooth endoplasnic ecu (68) bd bosames. 8h in detonation reactions, va cere 450, od conugtn. ors gcse fam ghcogn vie menbrnebound eye gucose-$ phosplae and poss by eleing tty acd tom eerie. Othe routs made hr indude hostoiids bop, and tos. ERin sted msde noun as scoplasmic ecm. Calum ions ae sequstered and eee here. Rough endplesnic eum (ER) contains rosomes tha shez rts th ae dered 0 Gol appara sos, ard pasa mmenbrane lysosomes cased spray osezoday. The terre foe by son of the foe ith ete phagesomes rll oganees soars contin approx 6 yea eres a cf whch ate acidic They dead DNA RNA, ips, reopens, pets nd phosphatases. eroxisomes a ganesh stesze and degrade eouen pre, inst ston of verylong chan at assez le and exchange of psp Macon ecg bounded by to meréranes-a ote and ier membre Tener membrane cotains exes for eon tarsport and nde phosphono. (Coronet) medical 23USMLE Step 1: Anatomy Mitochondrial matrix contains dehydrogenases ad mitochondrial DNA, which sas inher ‘tom the math Ths, tansmsson of dseasesof energy metabolism rm the mote. Iramitochondia granules conn au and magresum and ae probably sted ere. The ‘eftoskeletn is supportive netork tha conan mirtubules termed laments and rmicolament. Assembly of mictubules is importar for pnd formation. Inet fame “conan tsue spec reins Micoflament are composed of ain cet urtace Important cel sutace modcatons indude the basal and rescaling ight jncions, esmsomes gap uncon, iowa cia 4 iMiédicalNervous Tissue NEURONS. ‘Neurons are composed of thee basic parts the cell body (soma or petikaryon; the dendrites, ‘which receive information from other neurons; and a single axon, which conducts electrical Smpulses vey from the cll body (Figure 1-2-1) Cell Body The cl body contains lag vesicular nudes withing prominent nudes, mitochon {nd ober npn tb sudant RER, ecg high tes of tein sya, Ate ight ‘nicowcopi ee he RER tains intensely with bai yes and i rred os Nil ubtance. Microtubules and neurofilaments contribute tothe neuronal cytoskeleton and play important oles in suonal transport. Pigment granules suchas lipofuscin (“wear and tear” pigment) and ‘melanin (found in some catecholamine-containing neurons) may be seen inthe cytoplasm Dendrites Dendrites are neurons! proceses that receive information and transmit it to the call body Extensive dendrite branching serves to increase the receptive area ofthe neuron. ‘Axons sons ae thin, cylindrical processes typically arising from the perikaryon (or from a proximal ‘dendrite through a short pyramidalshaped region called the axon hillock. The cll membrane ofthe axon is called the axolemma, and the eytoplasm of the axon i called the axoplasm. ‘Axonal transport "Axons contain abundant microtubules and nearoSlaments. Axon ist tansport uses micr- tobules proces in both anterograde and retrograde directions Anterograde transports ‘powered by kinesins, whereas eeograde raspor is pviered by dyneln ‘Synaptic boutons Axons terminate in specialized endings known as synaptic boutons, which contain synaptic ‘sil fll of neurotransmitter.26 HigtticalMyelin Axons may be unmyelinated or myelinated, depending on the type of covering provided by their supporting cell, Unmyelinated Axons ‘Unmyelnated axons in peripheral nerves are surrounded by the cytoplasm of Schwann cells ‘These axons have sll dlameter anda reaively low conduction velocity A single Schwann cll may ensheath several axons Myelinated Axons ‘Myelinaed axons are larger in diameter and are ensheathed in myelin (Figure -2-2. Schwann cells are the myelin-forming cells of the peripheral nervous system (PNS) ‘Myelintiom inthe PNS begins during the fourth month of development. One Schwann cell will rnyelinate only one axon in peripheral nerves. Oligodendrocytes are the myelin-forming cells of the central nervous system (CNS). n the Clinical Correlate CNS, myelination begins during the fourth month of development and continues into the sc ond decade of life, An individual oligodendrocyte sable to myelinate many axons. The degeneration of | oligodendrocytes rests in Node of Ranier may of the so-alled | Atthe junction between two myelin-producing cls theresa dscontinityin the myelin. This Genlinatng Gordes, such creates a “collar of naked axon, called anode of Ranvier, which is exposed to the extracellular Sui sera spoce (Figure I-2-1), The action potential skips from node to node ina proces called salta- tory conduction. Myelinsted axons conduct action potentials rapidly Composition ‘Because myelin i of membrane origi itis ies in phospholipids and cholesterol MyelinLUSMLE Step 1: Anatomy Classification of Neurons by Neuronal Processes Unipolar neurons Unipolar neurons have one axon and no dendsites and probly occur only during development Pseudounipolar neurons ‘seudounipolar neurons (Fgute 1-2-3) have a single process close to the peikaryon, wiich vides into two branches. One branch extend tos peripheral ending, ad theater extends to the CNS. PreuJounipolar neurons ae found in dorsal root ganglia and most cranial ganglia, Conta process 2 etgncen NS Figure -2-2. Peeudounipolar Neurone Bipolar neurons Bipolar neurons have one axon and one dendrite. Bipolar neurons are foundin the cochlear and vestibule ganglia as well as in the retina and olfictory mucosa, Multipolar neurons. “Maltipolar neurons have one axon and mliple dendrites. Most neurons inthe body re mul- ‘pola (eg, ventral horn neurons in the spinal cor) Classification of Neurons by Functional Role ‘Motor neurons Motor neurons control effector organs and muscle fibers. Sensory neurons ‘Sensory neurons receive sensory stimuli from the internal or exteral environment and relay ‘hem tothe CNS. Synapses Snape ar specialized membrane junctions designed forthe uniirectonal communion ‘tween acuns or betwen neurons an eestor cl (Fgue 124). The pe and pony ‘apc membrane are seperated by on 20 nm thi space incall the amps ct[Nervous Tissue Location ‘Synapses are ether between an axon and a dendrite (axodendritic: Figure 1-2-8) or between an ‘axon and a ell body (axosomati). Synapses between dendrites (dendrodendriic) and between, snons (axeaxonie) also occu Presynoptic cet Posisymoptic Synaptic wesiies Figure 2-4. Synapse (apt 00 lt Sar strc Alig sane Figure -2-8. Axedendniie Synapse medical 29USMLE Step 1: Anatomy Synaptic vesicles Syapses contain synaptic vesicles. They consist of 30: to 50-4 spherical or ovoid structures in the axoplasn that contain neurotransmitter (6, acetylcholine [ACh])- Neurotransmiter is released into the synaptic clef atthe synapse when synaptic vesicles fuse with the presynaptic membrane. + Neurotransmitters may either excite (depolarize) or inhibit (hyperpolarize) the postsy- naptic membrane, depending onthe type of receptor to which it binds + Certain neurotransmitters are inactivated in the synaptic cleft by enzymatic degrada- tion (eg. ACH is broken down by aceticholinesterase [ACHE]}, wheres others are taken up by the presynaptic ell eg norepinephrine) ina proces called reuptake. Neuromuscular Junction Tae neuromuscular junction occurs a the motor end plate. It isthe synapse between neurons and muscle cells (Figure 2-6) ‘tthe neuromuscula junction, the axon forms numberof smal branches that it into grooves ‘on the muscle where the postsynaptic membrane is convoluted into numerous folds called the subneutal des, ‘ACh released from the axon depolries the sarcolemma via the aceyicholine nicotinic receptors. ‘Axon ternal i itochondria Basal lamina ‘Sarcolemma Muscle fee Figure 12.6. Portion of a Motor End Plate Along a Skeletal Muscle Fiber 30 medical(liical Correlate Myasthenia gravis disease characterized by weakness and easy Sige of msc. kan bee threatening naling ee bet is feted [eis caused by an aucune response to the Ah recep, Neal ok recep are constnty removed by endocytosis and ranspared to and degraded by the hsosomes. These ae replaced by new receptors, which are manvfadured by the Gol apparatus and then inetd inc the juncional feds, Te norma al eof ees about 10 days. a yashesia avs the abies educed to about 2 das, resting na marie decease nthe number of aable receptors. /Amitaion of ACKEnhibers has bah agnostic nd therapestic alu. slong the rate of ‘AC dearadation, they increase the binding time of ACh o the reraning recep. The usual spore prompt proven in muscle powe. An rial nal dagress of myasheie gas becomes questionable shoud no improvement be observed. NEUROGLIA essroglia (nerve lu) serve asthe connective tissue ells ofthe nervous system. Although they not gencrate or transmit neural impulses, they pay an important eo in the normal func: tioning ofthe nervous system. They form the myelin sheaths of axons and provide metabolic support to neurons, Neuroglia ofthe CNS include microglia, astrocytes, oligodendrocytes, and pendymal cl In the PNS,neuroglia cll consist of Schwann eal Astrocytes Astroeytes are the largest ofthe ncurogil el They have centrally located nuce and numer~ ‘ous long processes with expanded vascular end-fet, or pedicels, which attach tothe walls of ood capil. Astrocytes are important in contoling the microenvironment of nerve cll and participate in he maimenance ofthe blood-brain bari. Oligodendrocytes Oligodendrocytes have small nucle and contin abundant mitochon, ribosomes and snirotbales Oligodendrocytes myeinate axons inthe CNS. Microglia Microglia are small, dense, elongated call with clongated nucle. They originate from the meso- erm, unlike other neurogil cells, which originate fom the neuroectoderm, Microglia are phagocytic and are part ofthe mononuclear phagocyte system, Nervous TissueLUSMLE Step 1: Anatomy Ependymal Cells Ependymal cls Hine the ventricular cavits ofthe brain and the central canal of the spinal cond ‘They are capable of mitosis and can develop long process that deeply penetrate the neural issue. (ila on the ependymal calls help move cerchrospinl fluid through the ventricles. ‘Schwann Cells ‘Schwann cells contain elongated nuclei that lie paral othe axons of peripheral neurons. Schweann cells myetnate peripheral axons Chapter Summary "Neurons ae compsed of cel body, dvds, nd n axon. They contain piers such os mani ad ptscn. The el Body Goraorpertayon conan a rude cher cellar components, and rough endoplasmic reticulum, Micoubues and neurofizmert om he Se ey ue eT tine | the cel body Axons ase rm the pekajon o prxinel dnd. They contain mohbules and | reuriaments Rapid awl arsport wives migcubues Kinesis promot arerogadetarspd, | | wheres rin poms reograde anspor Myelin the covering of axons ands composed of phosphlpids ard chester. Aaons may be myelinated or ronmyelnated. Swann cls myeinate a sine peripheral neous stem an, They may ao aoc With severl ars (unmyelrte) who fring myelin. Oligodendrocytes form myeinin the central nervous tem. One cgadencoyte myintes many axons The nade of Ravers a cor of raked ron between a prosimal and da bund of myelin that hs myelinated thea. puse to low psig rsport by kping am one nade the et, has avon wel trough the ene a. Thisproesis ced altar conduction.GENERAL FEATURES Muscle Tissue “Moscle is clasifed as skeletal cardiac, or smooth. Some general features of all three types of ‘muscle are suramarized in Table 1-3-1 Table -3-1. General Cytologic Features of the Three Types of Muscle Skeletal Gardine Smooth ‘Swiated, unbranched | Striated, branched fibers | Nonstriated fusiform bers fibers ultinclear ‘Single nucleus Single naceus Strong. quick ‘Strong, quick, continuous, | Weak, slow, involuntary ‘mutnicate with the nasal cavities. They contin a thin respiratory epithelium over a lamina pro- ra containing numerous goblet el, which produce mucus that drains into the nastl passages. NASOPHARYNX ‘The nasopharynx is lined by a respiratory epithelium. The cilia bet toward the oropharynx, which is composed ofa stratified, squamous, nonkeratinized epithelium.Pharyngeal Tonsil Located on the posterior wal ofthe nasopharya,sbjaen to the eihelium isthe pharyn- teal tons an aggre of nodular and ioe lpaphate tie. Respiratory System Glinical Correlate Adenoids yparuopy of the pharyngeal tonslas area of onic iflarmaton rests na LARYNX ‘onder krona See Gros Anatomy section aes TRACHEA The trachea lade tothe terminal bronchioles The major hsoogle changes ocuring in the pase fom the trachea tthe Bronte ar summarized in Table 61 “able 641. Histologic Feature of Trachea, Bronchi and Broncos e ~ ~ “Trachea ‘Bronchi Bronchioles ticle | Peeudosraiied cited PCC osaple columnar] Gliated, ome gobi lls | columnar (PCC) cel, | eas (Gara clin terminal | goblet cells bronchioles Caniage 16-20 C-shaped Tregular ples Nene cartilaginous ings ‘Gand ‘Seromucous glands Fever eons Tone ands Smooth mle Tew open nds of Prominent Tighe proportion of Chap cariage sevooth muscle inthe | bronchial re ("Baste fers Present ‘Roandant ‘Abundant RESPIRATORY BRONCHIOLES Respiratory bronchioles contain alveoli and branch to form two to three alveolar ducts, which are long sinuous tubes that often terminate in alveolar sacs. Alveolar stcs are spaoes formed by two or more conjoined alveoli. They ae lined bythe simple squamous aheolar epithelium, ALVEOLI Acoli are the terminal, thin-walled sacs of the respiratory tee thet are responsible for gas cachange, There are approximately 309 milion alveoli per fang, cach one 200 co 300 am in a> ster (Figure -6-2). The alveolar epithelium contain two cll types. medical 51USMILE Step 1: Anatomy Type | Cells {ype cells cover almost all ofthe abot luminal sue and provide a thin suri or gas exchange. This simple quamous epithelium so thin -25 an) thats deta ar beyond the resolution of the ight microscope Type cals constitute one component of the blood-air interface ‘+ Onygen in the alveoli is separated from the red blo cell of the slveoa capillaries by the type tcl, + sbasal laminas often conjoined with the basal lamina ofthe capillary and the capil lary endothelial cl, + The total thiknes ofall chese layers canbe es then 05 mm. Type i Cells Type I als ar abide ie ces hat ston the basal ina of th epitiam and onan membrane bound fantes of phoyphaipid and protein (mela bots). The contents of thee tye ods are secreted no tv aot surat to provide a coaing of surfactant tha rede solr suas tension Type teal Endothotal cot Red blood oa Type cat Figure 1-2. Alveolus and Blood-Alr Barrer‘ALVEOLAR MACROPHAGES. Aeolar macrophages (dus ell) ae found onthe surface ofthe alveoli. They are derived from monocytes that extravasate from alveolar capillaries; alveolar macrophages are part of the mononuclear phagocyte ster, Chapter Summary The nasal otis have to major aes: respon and okay | The espa areais ned by peste lites lara eitheum Gobkt es ae reser 2s wel. The afar resin he psteesper area and coins ipa reves | Otacry nent are const plished, Paransal suse ar latin the ort, malay | eho nd spenaclbaes. They communicate wth the nasal cites. Te nasophays composed of staid squirted piel. The pharyngeal toss an agtegate trol nd dfse pha se win the pst wal therapy | | | solo oes ofthe wach, ron nd Boch ae destin ble. Resptory | branes conan aol a branch a om ak is, hich trie in abe ssn | | ene by squrees aver epielun Aho ae emi, sled sa the spay tee | espe fr peusexcange They oan we nf els Tye eels rode in srace | orien exces eres peels roi suacant Aker macopheges (4s els) | arlene secs and win the tae connect They ate deed | [fommenognes Respiratory System medical 55Gastrointestinal System GENERAL FEATURES ‘The gastrointestinal (GI) system consists ofthe digestive tract and is associated glands DIGESTIVE TRACT “The major regional characteristics and ell types ofthe digestive tract ate summaried in Table ‘Table -7-1, Digestive Tract—Regional Comparisons “Mucosal Cell of Se Region MajorCharceristics | Typer at Surftce Muconal Call Taophags Nonkeratied Seite squamovs ptelioms ‘Sekt mae n nsclai externa (uper 13) Sinoth muscle ower iomach bly and fundus | Rogse: shallow pits Macros elle Tecate Form | dsp glands peeselerain | $id Tight junctions Beoween theses | probably contibursto | theacidbarereethe | - eric Chek cas Secret pepanonen and | lipase precursor. | Paria el Secrte HCl and intinsc | factor. | treoentone( teats | Seca eyo pie hormones [ Soma: pros esp ptssallow Nacoas ele Same sso | Ianched nds | ariel els Same a shove | EE celle High concentration of | ee _ een | (Continued) medical 55“Table 1-7-1 Digestive Tract—Regional Comparisons (continued) ‘Mucosal Cell Function of Surface | | Region ‘Major Characteristics “Types at Surface Mucosal Cells | Son SE Sa Han ad pe] Chandar seSIE | Coin reas | ee [Scotitagay | cence | reer acing | ae |mum gu73) | basen is | ct Se erm | | parse ieee Srpwermcrane | | | nec Contains rust | | | ee ty | | ee | | eet | | ret Vieheonanion ate | eee ace | jum vatwet-dpai, | samecttopesntod | Some se | oe Pen ae | team Rapeoiomofynph | Melaoundwer | Eadogtseand wae | ure 7-9 pods called Peyer Iymphatc modules and | antigen ftom the lamen | ne rc oa — Teicatiatcype | kaipmuestaceing | tampon ne ce) Set | ea sot ‘serosa £ > Musoulrs externa -Submucoea LE cosa vA Epithelium Lain roa sare mucosa Figure 17-1. Layers of the Digestive TractGastrointestinal System Sires boraor Caplary (how with red Bio cot) Lymphatic ae facto — Gobet cls: Myotoroia Entorocytes Paneth cols Lamina an Propria muscle Figure L7-2 Structure of Small Intestine Villus and Crypts Fi } Muscular mucosa Submucosa, Myentorc | Muscle Layer Plows brunet Snes Figure 17.2, Duodenum iedical 57USMLE Step 1: Anatomy va yor Patones Figure 7-4 teu 58 iméilicalASSOCIATED GLANDS Salivary Glands ‘Table 1-7-2. Comparison of the Major Salivary Glands _ ‘Acinar Cal Type Gland (Histotogle Appearance) | Innervation Parotid Serous (high amylase | Glossopharyngeal (1X) activity) Submandibular Serous and mucous; Facial (VI) mainly serous Sublingual ‘Macous and serous; Facil (VID) sainly macous Pancreas Tae exocrine portion ofthe pancreas consists of parenchymal cll arranged in the form of sci and a sytem of branching ducts that drain into the humen of the small intestine, Aci _Acni are composed of pyramidal serous-type cells, each of which produces membrane-bound ‘granules of mised enzytes for secretion. Pancreatic enzymes cleave proteins (eg, trypsin chy- ‘motrypsin, carboxypeptidase, elastase), carbobyrats (e.g, amylase), fats (eg lipase, lecthi- nase) and nucleic acids (eg ibonucease, deoxyribonucease). Duct cells Dict cells secrete water, clectrolytes, and bicarbonate (HCO3), which dilute enzyme secretions nnd neutralize aciie hye. Liver ‘The liver is the largest gland ofthe body. It has multiple and complex functions, including cxocrine secretion (via bile ducts into the duodenal lumen) and maintenance of optimal con- entation of various components of blood, which it receives va the portal vein from the diges- ‘ie tract and spleen, Liver parenchyma ‘The liver parenchyma is divided Figure 7-5). + Each elder is composed of plates of celle arranged radially acound a central vein Berween the plats are radial blood sinus + atthe periphery ofthe lobules, branches ofthe portal ven, hepatic artery, bile ducts, and lymphatics course together Yo many small lobule shaped like polygonal cylinders Gastrointestinal SystemUSMLE Step 1: Anatomy Hepatocytes Hepatocytes are 20- to s0-mm poled cll (Figure 17-5). Liver regeneration can occur rapidly under some circumstances. As mach as 99% canbe eeplaced in about 2 weeks + Theirscor more surfaces may either contact another cll form gp junctions and bile canaicul or forma fe sofce with ncrvill exposed to the perinucodal space of Dis Abundant glycogen in these cll takes the form of elestro-eme granules hat are clustered nae the + There ae several hundred mitochondsi per liver el + The hepatocyte produces proteins for export (eg, abuin, prothrombin, fibrinogen, secrets ie, totes lipids and eatbobydrats,coavers pds and amino aid into cose via the enzymatic proces of gluconeogenesis, and detoifis and inactivates rugs by oxidation, methyaion, and cosogatin. Sinusoids ‘The lver contains sinusoids (Figure 7-5) that are lined wit fenestrated endothelial cells and scattered phagocytic Kuper cells, which are part ofthe mononuclear phagocyte system + Kupffer eels phagocyte red blood cells and particles and contain cyteplasmie resi ‘al bodies of ion and pigments, + Lipocytes also lie in the perisinusoidal space Biliary system The liver contains a biliary system consisting of + Bile canaliculi—tubular spaces limit by the plasma membrane of several hepato- cytes (Figure -7-5) These ducts empty into Hering canals, which are small ducts composed of cuboidal ells. + Hepatic duets—receve Hering canal and eventually form the right and let hepatic «ducts, which jon form the eommion hepatie duct. ‘Common bile duet—receives the common hepatic and cyte duct Gallbladder ‘The gallbladder is lined by a surface epithelium composed of simple, tal colomnar els They bear izegular microvll with a glycoprotein surface cost. ‘The gallbladder concentrates bile by active transport of Net, Cry, and water (especially of Na") from the cytoplasm tothe intercellular space. Fom there, the water moves into blood vessels, and the bile i concentrated ‘Contraction ofthe muscle lever (muscularis externa ofthe gallbladder i induced by the hor- ‘mone cholecystokinin, which i produced inthe mucosa ofthe small intestine.Gastrointestinal System Figure 7-8. Organization of Liver Lobule Chapter Summary “The gastrointestinal system includes te digestive tract and is asst glands. The regional | comparsons ofthe digestive tral are gen in Tbe 7-1 | the esse lands ae salivary, pancreas ie, andthe gallbladder. The slvary glands are comnpaed in Tale 172. The pancreas hasan exci pation 2d an endocrine potion. Te extne porn is composed of cand ccf. Ai secrete enyres that dave pots, cabohytates, and nude 2s Duct cells secrete wate, declan bicarbonate, “Thelveristhe ae nd inthe bd Te percnaa is made up of hepa ranged in corésnitin lobules, Hepes pode pts, sere ble sored and colts and come iis an ino acs eto dace. They dont rs by oxida, methystion oc Congo, ad ey ae capable ol regenerate. iret Susoids, ound between epticcors | | Soe wih endothe! els and catered Kuper ells, hich phagocytosed lod es | their system is compoted bea hepa ts he as de, andthe common ile | uct The gal ladder is ined by simple al clay ces and has a ycoproensutace coat | concentrates be by emovng water though atv varepot of sum and cre ios (especialy | the tormes. all adder contacin is medisted va choleystolrin, a hormone produced by erteroendoctin cls inthe mucosa ofthe smal intesine— Renal/Urinary System KIDNEY ‘The kidaey is divided into three major regions: the hilum, cortex, and medulla (Figure 8-1), Hilum_ The hilum is Jocated medially and serves as the point of entrance snd ext for the renal artery, renal vein,and urete + The real pelvis, the expanded! upper portion ofthe ureter, divides into two or three naj calyces upon entrance into the kidney. These, in tur divide into eight minor caljces + Branches of the renal artery, ven, and nerve supply each part of the idney. Cortex ‘The cortex forms the outer sone ofthe Kidney os well as several renal columns, which penetrate the entre depth ofthe kidney. Medulla The medulla appears asa series of medllary pyramids. "The apex ofeach pyramid directs the urinary stream into a minor aly. Minor cays Major cay Hun Figure 8-1. Organization ofthe KidneyUSMLE Step 1: Anatomy 64 inédical URINIFEROUS TUBULES The uriniferous tubules consist of tro functionally related portions called the nephron and the collecting tubule, Nephron ‘The nephron consists ofa renal corpuscle, proximal convoluted tubule, oop of Henle, and dis- tal convoluted tubule (Figure -8-2). Bowman erent capsule arteriole ar) Collecting uct of ele Meee Figure 18-2. Nephron Diagram Renal corpuscle The renal corpuscle consists of a tuft of capillaries, or glomerulus, surrounded by a double walled epithelial capsule called Bowman capsule (Figure I-€-3)Renal/Urinary System Glomerulus ‘The glomerulus is composed of several anastomotic capillary loops interposed between an afferent and an efferent arteriole, The endothelium ofthe glomerulus is thin and fenestrated Plasma filtration (ultrafiltration) occurs in the glomerais. Bowman Capsule “The Rowman capsule consists ofan inner visceral layer and an outer pric layer (Figute I-63). “The space between these layers, the urinary’ spac, is continuous wth the renal tubule. + "The visceral layer is composed of podocytes resting ona basal lamina, whichis fused ‘with the basal lamina ofthe caplary endothelium (Figures 1-8-4, 1-8-5, and [-8-6). + The parietal layer is composed ofa simple squamous epithelium thats continuous with the proximal convoted tubule epithelial lining. ‘Arent arteriole Figure 18-3, Bowman Capsule Diagram ur, 6(re 20 Go San anda ne A Figure 8-8, Scanning Electron Micrograph Demonstrating Podocytes: ‘ith Their Processes (arowe) Urinary (eowman) ‘Space Feat Processes Podocyte Capitary endothe REC Figure --8.Transmission Electron Micrograph Demonstrating PodocylesFigure 8-6 Eleotron Mlerograph Demonstrating Relationship Betwoen Basel Lamina, Pococyte, and Endothelial Cel Proximal convoluted tubule ‘The proximal convoluted tubule is the longest and most convoluted segment ofthe nephron. Its cells posses an apeal bruth border that proves a much greater sutface area for reabsorp~ tion and secretion, Most ofthe components ofthe glomerular fate are reabsorbed in the proximal tubule. Loop of Henle “The lop of Henle is a hairpin loop ofthe nephron that extends into the medulla and consists ‘of thick and thin segments. Distal convoluted tubule ‘The distal convoluted tubule is lined by cuboidal cells that reabsorb sodium and chloride from the tubular irate Collecting Tubules Colecing tubules consist of arched and straight segments made wp of cls that range from “Sheil to columnar In vespons t rsopresn {also known a antguretc hormone, ot ‘ADHD secreted by the neuaypophyss caleting tables Become pemesble o Water and, ‘hus important in the Kidney oe in water conservation and urine concentration. Renal/Urinary SystemLUSMLE Step 1: Anatomy VASCULAR SUPPLY Renal artery —m——_Imterlobar arteries, © pe Arcunte arteries, = ee Interiobular arteries Alert arterioles > Glomerul —S Berent arterioles = Peritubular plexos Vasa recta Vasa Recta ‘The arteriole rectae andthe corresponding venae rectae with theie respective capillary net ‘works comprise the vasa recta, which supplies the medulla “The endothelium of the venae rete is fenestrated and plays an important role in maintaining the osmotie gradient required for concentrating urine in the kidney tabu. JUXTAGLOMERULAR APPARATUS ‘The justaglomerular apparatus consist of justaglomerular cells polkssen cells and the mac la densa (Figure I-67), Glomeruar basement membrane CGlomeruae epithet ~Baserent membrane of Bowman Capaule Epitobum of ‘Bowman CapsuleJuxtaglomerular Cells “The justaglomeralar cells are myoepithelial cell in the aferent arteriole. They secrete an Zozyine ealed renin, which enters the Bloodstream and convers the citculating polypeptide “ngiotensinogen into angiotensin L Angiotensin is converted to angiotensin I, «potent vasoconstrictor that stimulates aldosterone ‘scaton fom the adrenal cortex. Aldosterone increases sodium and water reabsorption in the Esl portion ofthe nephron. Polkissen Cells Bolkssen ells are located hetween the afferent and efferent arterioles tthe vascular poe of the ‘Somerulus adjacent tothe macula densa, Thee function is unknown. Macula Densa lls of the distal tubule near the ferent arteriole are taller and more slender than elsewhere nthe distal tubule, They constitute the macula densa. The macula densa is thought to sense ‘dium concentration in the tubular fd Chapter Summary ] ‘Tees ce ear eee an co dada etiam ste oreo | | crtrance and ext or the eal vessels and ureter. The uper expanded potion fhe ureter scaled the renal pes, and dies int no or tre major cays and several minor cays, The cortex as ever eal cols that penetate the ene dep othe kdney The medulla fom a sis of | rami that det he unary seam into a minor Cl ‘The urriferous tubule is composed ofthe nephron and calling tubule. The nephron contains ‘he glomerulus (atu of capil interposed between an afleent and erent arteriole), Pasa Fraen occurs ete, The Bowman's capsule hasan ine scar and outs patel yes The space eten the urinary space. The visceral ayers composed of podocytes res ona bas lina, _ahich is aed with te coir ent, The parietal layers composed of simple squamous «pitheum tat coninuaus wth the posal ubule eh tring The proximal convoated tubules the longest and ost convclutedsegent of the sepron. Most of the gomerur ia s reabsorbed here. Te loop of Henle extends tothe med and has thick ad thin segment. haps to reate an osmetic radi important for concenrion of he tuba at. The distal ‘convoluted tubule absorbs sadam and chi rom the tubular late he collecting tubules have a ange of els rom cbeial to columra Wate eral and une concentration oc here wt the ep ofthe aria hormone, The blood supply is va rena ater and en “he asa recae supply the medula They pla an impo ole in maining the osm gradient The jutaglomerular apparatus (GA) ' composed fjuntaglomersar cel, which are myoethek cel inthe aflerent esol. They sett renin. The IGA ako contains Plkisen calls (union | ukoon), cated between aferet a eferent rele andthe macla densa Maca densa | cel are cated inthe wal of the dal tubve located ner the afleen atele. They sense sodium cooceeratn nub Renal/Urinary System medical 69Male Reproductive System GENERAL FEATURES “The male reproductive system consists ofthe primary reproductive organs, the estes, and the se ondary organs including a complex series of genital ducts, the accessory glands, and the penis. TESTES “The testes are composed of many seminiferous tubules and connective testicular stroma (Figure E55 ‘Seminiferous Tubules The seminiferous tubules are the ste of spermatogenesis. The epithelium is composed of sup- porting Sertoli clls and spermatogenic cells, Sertoli cells, Sertol els ae irregular coluranar cells that extend ftom the basal lamina to the lumen and provide structural organization othe tubule + They synthesize testicular androgen-binding protein, which helps to maintain the high androgen levels within the seminiferous tubule. The androgen is necessary for spormetogenesis. + They provide the blaod-testis barrier. Tight junctions between adjacent Sertoli calls divide the seminiferous tubules ino a basal compartment (containing spermatogonia) land en adhuminsl compartment (containing spermatocytes and spermatic) Spermatogenic cells Spermatogenie cells ae the germ cells located betwoun the Sertoli els They consist of sper- rmatogonia, primary and secondary spermatocytes, spermatids, and spermatozoa (see Embryology section) Spermatozoa There are approximately 60,000 spermatozoa per cubic millimeter of seminal ful, of 200 to 600 million ina single ejaculation (Figures 18-2 and 1-9-3) ‘The mature spermatovon consist of ahead and a til + The head ofthe spermatozoon is pear-shaped, and chromatin is enclosed within the nacear envelope. Covering the apex ofthe nucleus isthe acrosome. +The tal ofthe speematozoon consists primarily of microtubules for the Daglium and mitochondria for energy. nUSMLE Step 1: Figure 19-1. Seminiferous Tubule DiagramAcrosome Nucleus Mitochondria Microtoues Flageiom Male Reproductive System medicalUSMLE Step 1: Anatomy _ Nucleus Figure 19-3, Electron Micrograph of a Spermatozoan Interstitial Cells of Leydig hese ar lated between the seminiferous tubules inthe intra connective sue (Figure rsh + They snthesn ond socrete testosterone and 0% ofthe male estrogen + They have abundant SER, mitochondria with tuba critae, and merous pid droplet containing cholesterol eters + They depend onthe production of unrng hormone (1) by the anterior pntry sland for avin GENITAL DUCTS. + Tubul ecti—connect the seminiferous tubules with the ot tests. Continuous pro- duction of testicular uid by Sertoli cells helps to move the gametes out of the semi niferoustubales. + Rete testie—consists ofan anastomoing labyrinth of channcs within the medi- sstinum that converge toward the efferent ductules + Efferent ductules—ned by a pseudostatifie, ciliated epithelium + Ductus epididymis—a single, elongated tortuous duct that may be 6 m or more in lengtt Its ined bys pseudostratified epithelium containing stereciia ‘Wishere tat sperm undergo maturation and develop increased motility and fertilizing capacity. + Ductus deferens (vas deferens)—contains a thick muscular coat, which dates distally into an ampulla. The ampulla gradually narrows to form the ejaculatory duct, which penetrates the prostate gland and empties into the urethra‘Male Reproductive System Urethra + The male urethra extends from the blade to the end ofthe penis. + The prosaic portion is composed of tanstional epithelium. + The penile distal portion is composed of stratified epithelium, Sperm Storage Sperm storage occur inthe efferent ductlsepidiymis and proximal ductus deferens ACCESSORY GLANDS AND PENIS ‘Seminal Vesicles ‘The seminal vesicles secrete a slighty alkaline, viscous uid into the semen thats rch in Srv tose and serves as an energy source for the sperm, “They ae nota storage organ for sperm Prostate Gland ‘The prostate gland produces a secrotion rch in citric acd lipids, zine, and aid phosphatase sxtivity Itoften contains concretions composed of protein and carbohydrate. Figure 19-4, Male Reproductive System76 medical Bulbourethral (Cowper) Gland ‘The bulbourethral gland secretes visoous mucous Mu tha hindgut and pelvic viscera 4 Lumber Proverb spiancnic gang uy nervos + “Cutaneous organs $ ‘eat glands, recor pil Sympatnais muscle, vascular smooth ‘muscle. chain l Cl Figure l--7. Overview of Sympathetic Outflow 18 MedicalBack and Nervous System Sympathetic ‘gangion Figure l-18. Cross-Section of Spinal Cord Showing Sympathetic OutiowUSMLE Step I:Amatomy Parasympathetic System Parasympathetic = Craniosacral outflow (Figure LI-1-9) oregut and midge n= Figure --9. Overview of Parasympathetic Outflow{ “Gupte Summary ‘The verbal cokinn i composed oa series of cena thro, lumbar sacra and cacy vertebrae connec by intervertebral dss and games. Te dks const fan outer ore of ‘orca, the ancl boss, and an ines prt-the mucus pulposs, which developed rom | the ntochrd. Heriton ofthe meus pulposus s usualy postercltarl where can compressa spinal nerve atthe intervertebral fora, | The spinal neve este verbal column atthe terval foramen, The foramen s bound superar intel bythe peace ofthe vertebrae, anterionyby te verbal bodies and intervertebral dks, and posterity by the zyppophysal ji | the spinal cords covered bythe pote layer of meninges: dura mater, rach and pia rates, The dura and duel sc terminate infra the second soa wtb, andthe pina cord terminates at the second mbar vertebra. The cud egana isthe lower pat ofthe dual sac and Conti the flu ternal and the ental and dosal root ofthe lumbar and sacl spinal ners. Between the eraenaid and pai the subarachnoid space hat contains cetebrospina fic, and beeen the dura mater and he verbs the epidural space which contains at and apes of | es, Spinal tps ae performed a the lel of the La verre (acted atthe horizontal veo the lia est vod puncing the spina rd. ‘Autonomic Nerous System The autonomic neous system (ANS) provides vice! motor nara to smeath mus, adic ruse, nd glands The ANS sided into wo disons: ympathac (horecaumba) and presse (cranicraa), The peripheral disbuton ofthese two disions consis of wo | | | | neurons (the preganghonic neuron (cl bes in the CNS) and 2 the postgangloic neuron (el bodies in moar ganglia in PN). Sympathetic preganglionic cl bodies are found inthe lateral horn ofthe gray mate of spina cord Segments T-12. These saps wih pasganginic el bodies located in eer chain (paravertebral) ging o cola (prevereba) ganglia Sjmpathets to the body wal hes, and thoracic cera | synapse inthe ein gang. Sympathetic to the foregut and midgut (horace splanchnic reves: 115-T) and othe hindgut and pic vere (umbar splanchnic nerves I-12) synapse in cele gngia. nition of pathetic inerain to the heed resus in islet Homes | syndrome | Porasympathetic preganglionic neucon cel bodes ar located inthe bran tem nucle of cranial | nerves Vl 1X, and X or inthe gray mater ofthe spinal cord segments S2-S4 (pec splanchnic). The pregangionc neurons synapse wih postgangicnic neurons in terminal ganglia scattered ‘trouphout the boy. Paresympathts othe head gate in canal nes Vi and; thse Ue kon! mg enn nam roe al ee Beg pvc | atmo be Seder Back and Nervous System medical 121USMLE Step 1: Anatomy Review Questions 1 Which of the following procedures is correcily matched tothe last layer that needle will traverse in the proper performance of that procedure! (A) Lumbar puncturelarichnoid mater (8) Pericardiocentesstfibrous pericardium (©) Thoracocentessvsceral pleura (D) Culdoscopyiposterioe fornix (&) Pudendal blockidura mater You are performing a spinal tap slighty off the midline benseen the L3 and LA vertebrae. What sractare wil the needle passthrough during proper performance of this procedure? (A) Posterior longitudinal ligament (B) Ligamentum flavum (©) Anterior longitudinal tigament (D) Dentculate ligament () Filum terminale ‘Which nerves increase peristalsis and glandular secretion in the gestroiestinal tract? (A) Greater splanchnic nerves (B) Lesser splanchnic nerves (©) Pelvic splanchnic nerves (D) Vagus nerves (2B) Lumbar splanchnic nerves Yous patent has a dey eye and reduced nasal secretions. The location of lesion might be inthe (A) otic ganglion (B)_pterygopaatine ganglion (©) clay ganglion (D) superior cervical ganglion (2) submandibular ganglion ‘Your patient has a herniated nucleus pulposus ofthe intervertebral dsc between the Lt andiL5 vertebrae. Which ithe most likely condition that your patent would present with? (A) Altered sensation in the 13 dermatome (B) Weakness of muscles innervated by the LS spinal cord segment (©) Inability to contract the Bladder (D) Fecal incontinence (2) Weakness in the ability to extend the leg atthe knee6 During pregnancy, amniocentesis reveals levated level of alpha-fetoprotcn, and ultra sound imaging indicates the presence of a est in the dorsal midline in the lower lumbar ‘region. Corrective postnatal surgery reveals thatthe est contains cerebrospinal uid but ‘no neural tissue, What is your evaluation ofthe est? (A) Ieis seen i infunts with spina bifida occulta, (8) Iewas a meningocele (©) leas an Arnold Chiat formation, (D) Ie results fom the rostral neuropore filing to close. (2) Tewas a cystocele Answers and Explanations 1 “Answer: A. In lumbar puncture, which i used to sample CSE, the needle must enter the subarachnoid space by last crossing the arachnoid mater. Peicardiocentesis is performed after the needle crosses the patel ayer of serous pericardium, which i dep to fibrous pericardium. Thoracocentess is performed after the needle traverses the parietal pleura CCaldoscopy is performed afer an endoscope traverses the parietal peritoneum lining the rectouterine pouch of Douglas. A pudendal bloc anestheties the padendal nerve afer it has emerged from the greater sciatic foramen, Answer: B, The ligamentum fava unite the laminae of adjacent vertebrae and would be pierced in an off midline lumbar puncture, The posterior and longitudinal ligaments ae found on the corresponding side of the bodies and dsc of vertebrae and are outside the ‘dural sac. The denticulate ligament and the flum terminal are pial extensions that help stabilize che spinal cord. Neither would have tobe pierced ina lumbar puncture. Answer: D. Branches ofthe vagus nerves provide preganglionic parasympathetic innerva- tion to terminal ganglia in the midgut. Pelvic splanchnic nerves increase peristalsis and flandular secretion in the hindgut. The other choices provide sympathetic innervation to ‘gu structures, which inhibits peristalsis and glandular secretion, Answer: B. The pterygopaatine ganglion provides postganglionic parasympathetic inne ‘ation tothe lacrimal gland and to mucous glands ofthe orl and nasal cavities. The otic {ganglion innervates the parotid gland, the cary ganglion innervates the iery nd con strictorpupilae muscles, the superior cervical ganglion provides sympathetic innervation twthe face scalp and orbit, and axons fom the submandibular ganglion innervate the sub- ‘mandibular and sublingual salivary glands. “Answer: B. Th spinal nerves afeced by lumbar disc herniation between TA and 15 might be theLS and! spinal nerves The L spinal nerve exits between L4 and but ispared because it pases through the intervertebral foramen superior to the sit ofthe herniation. The blad= Kidney Coacal membrane Mesonephric sins Mesonepires Urorctal . 4 eee Yr Mepret Ureter dct Reciim UB ygtanephic Trogéetal Aa Rectum Dastema membrane membrane End of Week 5 End of Wook Figure i-3-20. Development ofthe Urinary System 198 inédicalEMBRYOLOGY OF BLADDER AND URETHRA “The urorectal septum divides the cloaca into the anorectal canal and the urogenital sinus by week’. +The upper and largest part ofthe urogenital snus becomes the urinary bladder, which {sinitally continuous with the allantois. As the lumen of the allantois becomes oblit- ‘erated, fibrous cord, the urachus, connects the apex ofthe bladder to the umbilicus, In the adult this structure becomes the median umbilical ligament. +The mucoss of the trigone ofthe bladder is formed by the incorporation ofthe caudal rmesonephric ducts into the dorsal bladder wall. This mesodermal tissue is eventually replaced by endodermal epithelium so thatthe entice lining ofthe bladder i of endo- dermal origin +The smoath muscle ofthe bladder is derived ffom splanchnic mesoderm. ‘The male ure spongy (penile). + The prostatic urethra, membranous urethra, and proximsl penile urethra develop from the narrow portion ofthe urogenital sinus below the urinary bladder. +The distal spongy urethra is derived fom the ectodermal cells of the lans penis is anatomically divided into three portions: prosaic, membranous, and The female urethra is derived from two sources. The upper two thirds develop ffom the mesonephric ducts, and th lower portion is derived from the urogenital sinus Congenital Abnormalities Renal agenesis Failure of one or both kidneys to develop because of early degeneration of the ureteric bud. ‘Agenesis is fay common inthe unilateral form but lads to death shortly after birth inthe balteral form. Renal cysts “The formation of thin-walled, uid- filed cyt Grom blind tubules, pehaps arising from improper Hinkage between the collecting ducts and distal convoluted tubules. Pelvic and horseshoe kidney Pelvic kidney is caved by fue of one kidney to ascend, Horseshoe kidney sa foson ofboth [kidneys at their ends and failure ofthe fased kidney to ascend, Double ureter Caused by the earl splitting ofthe ureteric bud or the development of two separate buds. Patent urachus Failure ofthe allantois to be obliterated It causes urachl sul or sinuses, Remnants ofthe allantoic tlk may give rset urachal cysts. In male children with congenital valvular obstuc= tion ofthe prostatic urethra or in older men with enlarged prostates, patent urachus may cause drainage of urine through the umbilicus ‘Abdomen, Pelvis, and Perineum Medical 195