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ChiroEssentials Part 1 3rd Perfect Bound Edition
ChiroEssentials Part 1 3rd Perfect Bound Edition
Boards Review
Part 1
3rd edition
J.R. La Rose
1
2
Chiro Essentials
Boards Review
Part 1
J.R. La Rose
DISCLAIMER
Care has been taken by the authors to confirm the accuracy of the information
presented. However, the authors and the publishers are not responsible for
errors of omission or for any consequences from application of the information in
this book and make no warranty, expressed or implied, with respect to the
completeness or accuracy of the content of the publication. The application of the
information contained in this book in a particular situation remains the sole
responsibility of the reader.
ISBN: 978-0-615-28610-5
3
Preface to the 3rd edition
This is the third edition of ChiroEssentials Boards Review part 1. Errors have
been corrected and there are additional drawings and new information. Public
Health has been deleted from the Microbiology section in keeping with the recent
NBCE® change in the scope of the subject. This review for NBCE® Part 1 has
been prepared with the sole purpose of helping chiropractic students to be better
prepared for the NBCE® Part 1. The information contained in this book highlights
the major facts and concepts commonly covered in the NBCE® Part 1. Although it
is recommended that you use this book as early as possible in conjunction with
your basic science courses, it is not intended to replace any lectures, lecturers or
the recommended textbooks. The material is organized in a systemic manner in
which relevant topics in General Anatomy, Spinal Anatomy, Physiology,
Pathology, Microbiology and Chemistry are covered. The information in this book
has been gleaned from a variety of sources including the basic medical science
textbooks such as Moore’s Clinically Oriented Anatomy, Guyton and Hall’s
Textbook of Physiology, Robbins and Cotran’s Pathological Basis of Disease, the
Lippincott Williams & Wilkins Board Review Series, the Elsevier Mosby Crash
Course series and Mosby’s Review Questions for the NBCE® examinations Parts
I and II. The material is presented in bullet format to facilitate easy learning and
rapid recall. Key words are highlighted to trigger recall. It is recommended that
you look up unfamiliar words and concepts. The use of the recommended
textbooks is highly encouraged to supplement this book if you need a more
detailed explanation of unfamiliar concepts. Where there are differences of
opinion on certain issues, I have used the recommended NBCE® textbooks and
have indicated the source with an asterix. The Rapid Review session added to
the 3rd edition had very favorable comments from many students and has been
expanded to cover many of the important areas. The author would also like to
express thanks to Jessie Tapia who did most of the drawings. Like the previous
edition, this is still a work in progress and will be revised on an annual basis.
Should you find errors or omissions, please do not hesitate to email me at
chiroessentials@gmail.com with a reference and the necessary amendments
will be made. As soon as possible after you take the examination, it is
recommended that you review the book to help us create an even better fourth
edition. Let me know what information should be revised, included or removed.
4
Table of Contents
1. General Anatomy
a. Introduction 9
b. Anatomical Triangles 11
c. Anatomical Spaces 14
d. Cardiovascular 19
e. Endocrine 27
f. Gastrointestinal 29
g. Musculoskeletal 35
h. Reproductive 46
i. Respiratory 50
j. Reticuloendothelial 54
k. Skin 58
l. Thoracic cage 59
m. Urinary 63
2. Spinal Anatomy
a. Vertebral Column 69
b. Spinal Joints 73
c. Back Muscles 75
d. Spinal Cord 76
e. Central Nervous System 80
f. Skull, Scalp and Face 92
g. Peripheral Nervous System 96
h. Autonomic Nervous System 100
3. Physiology
a. Cardiovascular 105
b. Endocrine 108
c. Gastrointestinal 112
d. Hematological 115
e. Immunological 117
f. Musculoskeletal 119
g. Neurophysiology 122
h. Renal 124
i. Reproductive 128
j. Respiratory 130
4. Pathology
a. General principles 135
b. Genetic disorders 137
c. Neoplasia 139
d. Cardiovascular 141
e. Endocrine 144
f. Gastrointestinal 147
5
g. Musculoskeletal 149
h. Nervous system 153
i. Nutritional 157
j. Renal 159
k. Respiratory 161
l. Sexually Transmitted Diseases 164
m. Skin diseases 166
5. Microbiology
a. History of Microbiology 169
b. General principles 170
c. Viral 172
d. Bacterial 175
e. Fungal 183
f. Parasitic 185
g. Tests for micro-organisms 189
h. Specificity and Sensitivity 191
i. Infection control 192
j. Epidemiological terms 192
6. Chemistry
a. General principles 195
b. Carbohydrate metabolism 197
c. Glycolysis 199
d. Gluconeogenesis 201
e. Krebs cycle 203
f. Oxidative Phosphorylation 206
g. Cori cycle 208
h. Pentose Phosphate Pathway 209
i. Glycogen metabolism 210
j. Fat metabolism 212
k. Protein metabolism 215
l. Purine metabolism 217
m. Vitamins and minerals 218
n. Pathways summary 221
8. INDEX 235
6
GENERAL ANATOMY
7
8
INTRODUCTION
Surfaces of limbs
dorsal [back] or posterior
ventral [front] or anterior
Coronal plane
Sagittal plane
Horizontal plane
9
Anatomical terms related to movements
flexion-bent towards the trunk
extension-stretched out away from trunk
adduction-brought towards midline
abduction-moved away from midline
supination-turned upwards
pronation-turned downwards
medial rotation-turned inwards
lateral rotation-turned outwards
ulnar deviation-bent towards ulnar side
radial deviation-bent towards radial side
Histology introduction
Cells may be classified into the following groups:
o epithelial
o muscle-smooth, skeletal and cardiac
o nervous
o bone
o blood
o connective tissue
All of the above cell type can reproduce except cardiac and skeletal muscle and nervous tissue.
There are several types of epithelia:
squamous
o simple: lining lymphatic and blood vessels, pleura and peritoneum
o stratified: skin, esophagus, lower half of the anal canal
cuboidal
o Bowman’s capsule, convoluted tubules of the kidney, thyroid follicles
columnar
o simple: lining of the gastrointestinal tract
o stratified: uterine tube
o pseudostratified: respiratory tract
transitional
o ureter, urinary bladder and most of the urethra
Embryology introduction
nd
The body develops from an embryo which at the end of the 2 week has two layers [bilaminar] and at the
rd
end of the 3 week [Day 21] of gestation has three germinal layers [trilaminar]:
the endoderm lies on the inside and gives rise to the following:
o epithelium of the respiratory, gastrointestinal and genitourinary tract
the ectoderm lies on the outside and gives rise to the following:
o epidermis including hair
o retina and lens
o Central Nervous System, Peripheral Nervous System, pia and arachnoid mater
o adrenal medulla
the mesoderm lies in the middle between the two and gives rise to the following:
o bones and muscles of the trunk and extremities
o cardiovascular system and most of the genitourinary system
o cartilage and muscle of the respiratory system
o adrenal cortex, dermis of the skin and dura mater of the spinal cord
10
ANATOMICAL TRIANGLES
Suboccipital Triangle
Boundaries: rectus capitis posterior major, obliquus capitis superior, obliquus capitis inferior
Roof: deep fascia covered by semispinalis capitis
Floor: posterior arch of C1 and posterior atlanto-occipital membrane
rd
Contents: 3 part of vertebral artery, suboccipital nerve [CI] and suboccipital veins
All of the muscles forming its boundaries are supplied by the dorsal ramus of C1
11
Submental Triangle [aka suprahyoid triangle]
Boundaries: anterior bellies of both digastric and hyoid bone
Roof: skin, subcutaneous fascia
Floor: mylohyoid muscles
Contents: submental lymph nodes and submental veins
Muscular Triangle
Boundaries: sternocleidomastoid, superior belly of omohyoid and anterior midline of neck
Roof: skin and superficial fascia
Contents: sternohyoid, sternothyroid and thyrohyoid muscles, thyroid, trachea and larynx
Triangle of Auscultation
Boundaries: trapezius, latissimus dorsi and medial border of scapula
Roof: skin and superficial fascia
Floor: rhomboid major
Contents: none
Trapezius
Triangle of Scapula
Auscultation
Latissimus dorsi
External oblique
Lumbar triangle
Iliac crest
12
Inguinal Triangle [of Hesselbach]
Boundaries: rectus abdominis, inferior epigastric vessels and inguinal ligament
o Inguinal ligament is the infolding of the lower end of the aponeurosis of External oblique
and extends from the Anterior Superior Iliac Spine to the pubic tubercle
Roof: skin and external oblique aponeurosis
Floor: transversalis fascia
Direct hernias pass through Hesselbach’s triangle
Indirect hernias pass through the deep inguinal ring which is a defect in the transversalis fascia
Rectus abdominis
Inguinal ligament
Iliopsoas
Adductor longus
Sartorius
13
ANATOMICAL SPACES
Brachial plexus
st T1
1 rib Subclavian artery
Manubrium
Axilla
Boundaries: pectoralis major and minor [anterior], subscapularis, teres major and latissimus dorsi
[posterior], upper 4 ribs and serratus anterior [medial] and bicipital groove of the humerus [lateral]
Roof:
o triangular interval bounded by:
clavicle [anterior]
st
1 rib [medial]
scapula [posterior]
Floor:
o skin
o superficial fascia
Contents: axillary artery and branches, axillary vein and tributaries, cords of the brachial plexus and
six groups of lymph nodes:
o Anterior [pectoral]
o Posterior [subscapular]
o Infraclavicular
o Central
o Apical
o Lateral [along the axillary vein]
Quadrangular Space
Boundaries:
o teres minor [superior]
o teres major [inferior]
long head of triceps [medial]
o humerus [lateral]
Contents:
o axillary nerve
o posterior circumflex humeral artery and vein
Roof: none
Floor: none
14
Triangular Space
Boundaries: teres minor [superior], teres major [inferior], long head of triceps [lateral]
Contents: circumflex scapular branch of the subscapular artery
Roof: none
Floor: none
Quadrangular space
Triangular space
Teres minor
Teres major
Long head of triceps
Cubital Fossa
Boundaries: pronator teres [medial], brachioradialis [lateral], imaginary line between humeral
epicondyles [superior]
Roof: skin, superficial fascia containing median cubital vein, deep fascia and the bicipital
aponeurosis
Floor:
o brachialis [medial]
o supinator muscle [lateral]
Contents from lateral to medial: radial nerve, tendon of biceps brachii, brachial artery [and its
terminal branches-radial and ulnar] and the median nerve
Brachialis
Brachial artery
Median nerve
Biceps tendon Imaginary line
Radial Nerve
Bicipital aponeurosis
Pronator teres
Brachioradialis
15
Anatomical Snuffbox
Boundaries: tendons of abductor pollicis longus and extensor pollicis brevis [anterior] and tendon of
extensor pollicis longus [posterior]
Roof: skin, superficial fascia with cephalic vein and superficial branch of the radial nerve
Floor:
o styloid process of radius
o scaphoid
o trapezium
st
o base of the 1 metacarpus
Contents: radial artery and tendons of extensor carpi radialis longus and brevis
Carpal Tunnel
Roof: flexor retinaculum-1” fibrous square attached to the following carpal bones:
o Scaphoid, Trapezium, Os hamate and Pisiform bones [STOP]
Floor: carpal bones [trapezium, trapezoid, capitate and hamate]
Contents: the median nerve, tendons of Flexor digitorum superficialis and profundus and tendon of
Flexor pollicis longus [Flexor carpi radialis lies in a separate compartment]
NB: the superficial palmar branch of the median nerve passes over the retinaculum and therefore is
not compressed allowing for the sensation of the palm to be intact in carpal tunnel syndrome
Flexor digitorum
superficialis and
Flexor pollicis longus tendon profundus tendons
16
Inguinal Canal [of 2’s]
Boundaries: external oblique aponeurosis and internal oblique [anterior] with the conjoint tendon
and transversalis fascia [posterior]
Roof: arching fibers of internal oblique and transversus abdominis
Floor: inguinal ligament and lacunar ligament medially
Extent: between the deep and superficial inguinal rings
Contents:
o ilioinguinal nerve
o spermatic cord in males
o round ligament of uterus in females
Extent: from the deep ring [above a point midway between the ASIS and pubic tubercle] to the
superficial ring [medial to the pubic tubercle and above the pubic crest]
External Oblique
Internal Oblique
Spermatic cord
Transversus abdominis
Inguinal ligament
Femoral Canal
Boundaries: lacunar ligament [medial], inguinal ligament [anterior], femoral vein [lateral] and
pectineus and pectineal ligament [posteriorly]
Roof: connective tissue
Contents: lymph node [Cloquet or Rosenmuller], lymphatics and connective tissue
17
Vastus medialis
Sartorius
Adductor longus
Adductor magnus
Popliteal Fossa
Boundaries: biceps femoris [superolateral], semitendinosus and semimembranosus [superomedial],
lateral and medial heads of gastrocnemius [inferolateral and inferomedial]
Roof: skin, superficial fascia with short saphenous vein and deep fascia
Floor: lower end of femur, posterior aspect of knee joint, popliteus muscle and fascia
Contents:
o tibial nerve
o popliteal vein and artery
o common peroneal [fibular] nerve
o nodes
o fat
o the artery is deepest, the tibial nerve is most superficial and the vein is in between
Gracilis
Semitendinosus
18
Tarsal Tunnel
it lies behind the medial malleolus and under the flexor retinaculum
Contents:
o Tibialis posterior tendon
o Flexor Digitorum longus tendon
o posterior tibial Artery, vein and Nerve
o Flexor Hallucis longus tendon
o [Tom, Dick ANd Harry] in that order from anterior to posterior
19
CARDIOVASCULAR ANATOMY
Embryology
the heart develops in the mesoderm in the cephalic region of the developing fetus at the third
week
angioblastic tissue coalesce to form the right and left endocardial tubes which fuse to form the
primitive heart tube
the primitive heart tube folds on itself and develops three dilations-atrial, ventricular and the
bulbus cordis
the proximal end of the heart tube is formed by the sinus venosus
the distal end is formed by the truncus arteriosus
Sinus venosus
Atrium
Truncus arteriosus
Endocardial tubes
Bulbus cordis
Ventricle
Truncus arteriosus
th
the atrial dilation is divided by a septum [septum primum] in the 5 week
a hole appears in the upper part of the septum primum-ostium secundum
another septum appear to the right of the septum primum called the septum secundum
o this septum is incomplete inferiorly remaining as the limbus of the fossa ovalis
the ventricular dilation is divided by a septum which goes upwards towards the endocardial
cushions
Interventricular septum
20
th th
the truncus arteriosus is divided into two separate tubes-aortic and pulmonary in the 7 and 8
weeks
the two tubes twist on each other to allow the pulmonary artery to lie anterior to the aorta initially
and then posterior
there is a connection called the ductus arteriosus in the fetus that allows oxygenated blood to be
shunted from the left pulmonary artery to the arch of the aorta
this ductus closes shortly after birth to form the ligamentum arteriosum
the following congenital anomalies may occur:
o Ventricular Septal Defect: most common congenital heart disease]
o Atrial Septal Defect: most common is an ostium secundum defect
o Fallot’s tetralogy: most common congenital cyanotic heart disease
o Patent Foramen Ovale
o Persistent Ductus Arteriosus
Fallot’s tetralogy:
o Pulmonary stenosis
o Ventricular Septal Defect
o Right Ventricular Hypertrophy
o Over-riding [dextroposition] of the aorta
cyanosis is due to the mixing of arterial blood with deoxygenated blood and occurs in right to left
shunts
the acyanotic congenital heart diseases include Atrial Septal Defect, Ventricular Septal Defect and
a Persistent Ductus Arteriosus and are all left to right shunts
Persistent Ductus Arteriosus results from failure of the ductus arteriosus to close after birth
Cardiac Chambers
Right heart border is made up of the right atrium
Inferior heart border is made up of the right ventricle
Left heart border is made of the left ventricle and left auricle of left atrium
Right atrium
it has two origins-from the sinus venosus and from the true atrium
the rough part is derived from the true atrium
o the rough part of the atrium has the pectinate muscle bundles
the smooth part is derived from the sinus venosus embryologically
they are separated by a ridge called the crista terminalis
21
the openings of the Superior Vena Cava [SVC] and Inferior Vena Cava [IVC] are located in the
superior and inferior aspects of the right atrium
there is an oval depression [fossa ovale] on the interatrial septum
this represents the location of the fetal foramen ovalis-the septum primum
above the depression is a ridge called the limbus of the fossa ovalis
this is the remnant of the septum secundum
just above the opening of the tricuspid valve lies the orifice of the coronary sinus
60-70% of myocardial venous blood drains into the heart via the coronary sinus
Left atrium
it has the openings of the 4 pulmonary veins carrying oxygenated blood from the lungs
like the right atrium, it has both rough and smooth parts reflecting its dual embryological origins
Right ventricle
it has several large fleshy trabeculae carneae and papillary muscles
there is a large fleshy piece called the septomarginal branch [aka moderator band] which carries
a major part of the right bundle branch
the infundibulum is a smooth funnel-shaped inlet to the opening of the pulmonary valves
Left ventricle
it has a thick muscular wall [three times that of the right ventricle] with trabeculae carneae
the left ventricle is separated from the right ventricle by the interventricular septum
o the septum has a thin upper membranous part and a thicker lower muscular part
A P
M
N
Heart Valves
There are 4 heart valves which allow blood flow from the following:
from right atrium to right ventricle -Tricuspid [with anterior, posterior and septal leaflets]
from right ventricle to pulmonary trunk -Pulmonary [with anterior, right and left posterior
semilunar valves-PAP]
from left atrium to left ventricle -Mitral [with anterior and posterior leaflets]
from left ventricle to ascending aorta -Aortic [with posterior, right/left anterior semilunar
valves-APA]
The valve leaflets are attached to papillary muscles by fibrous cords called the chorda tendinae.
22
Coronary Blood Supply
the heart is supplied by two branches that arise from the ascending part of the aorta
o right coronary artery
o left coronary artery
Circumflex artery
Posterior Interventricular
artery
Right marginal artery
23
Coronary Sinus
AV node
Bundle of His
Purkinje fibers
Right bundle branch Left bundle branch
Cardiac Plexuses
divided into two parts-deep and superficial
o the superficial plexus lies below the arch
o the deep lies behind the arch of the aorta
superficial part receives fibers from:
o superior cervical sympathetic ganglion
o inferior cardiac branch of the vagus
deep plexus receives contributions from the superior, middle and inferior cervical sympathetic
ganglia, the superior and inferior cardiac branches of the vagus and branches from the
recurrent laryngeal nerves from the vagus nerve
24
Branches of the thoracic aorta
right and left coronary arteries [from the ascending aorta]
brachiocephalic trunk [from the arch of aorta]
left common carotid [from the arch of aorta]
left subclavian artery [from the arch of aorta]
rd th
3 to 11 posterior intercostals [from the descending part of thoracic aorta]
bronchial [from the descending part of thoracic aorta]
esophageal [from the descending part of thoracic aorta]
25
External Iliac artery
Popliteal artery
26
Subclavian Artery
the left subclavian artery comes off of the arch of the aorta
the right subclavian artery comes off of the brachiocephalic trunk
st
both pass over the 1 rib behind the Scalenus anterior muscle
branches of the subclavian artery include:
o internal thoracic
o vertebral
o thyrocervical trunk with the following branches [SIT]:
Suprascapular
Inferior thyroid
Transverse cervical
o costocervical trunk with the flowing branches:
superior intercostal
deep cervical
st
beyond the outer border of 1 rib, the subclavian artery becomes the axillary artery which is
divided into three parts by pectoralis minor
branches of the axillary artery include:
st
o 1 part [proximal to pectoralis minor]-superior thoracic artery
nd
o 2 part [beneath pectoralis minor]-thoraco-acromial and lateral thoracic arteries
rd
o 3 part [distal to pectoralis minor]-subscapular, posterior and anterior circumflex humeral
arteries
27
the radial and ulnar arteries form two arches in the palm:
o the superficial palmar arch is the continuation of the ulnar artery
lies between the palmar aponeurosis and the digital flexor tendons
it is completed by the superficial palmar branch of the radial artery
o the deep palmar arch is the continuation of the radial artery
lies between the palmar interossei and the deep digital flexor tendons
it lies proximal to the superficial palmar arch
the common palmar digital arteries are derived from the arches and supply the fingers
Brachial artery
Ulnar artery
28
ENDOCRINE ANATOMY
Pituitary gland
this gland is considered the master endocrine gland
it has two parts [anterior and posterior] and two embryological origins [Rathke’s pouch and a
down growth of the hypothalamus respectively]
it lies in the sella turcica found within the sphenoid bone below the optic chiasma
it is covered by a fold of dura called the diaphragm sellae
the anterior lobe is from Rathke’s pouch [stomodeal ectoderm] and produces Follicle Stimulating
Hormone [FSH], Luteinizing Hormone [LH], Adrenocorticotropin Hormone [ACTH], Thyroid
Stimulating Hormone [TSH], Prolactin [PRL] and Growth Hormone [GH]
the above hormones are influenced by releasing factors from the hypothalamus [except
Prolactin which is influenced by Prolactin Inhibiting Factor-which is dopamine]
the posterior lobe stores [does not produce] Oxytocin and Anti-Diuretic Hormone [ADH or
vasopressin], which are produced by the paraventricular and supraoptic nuclei of the
hypothalamus respectively
supplied by the superior and inferior hypophyseal arteries from the Internal Carotid Artery
Thyroid gland
this H-shaped endocrine gland is formed by two pear-shaped lobes linked by an isthmus
it is derived from a down growth from the foramen cecum in the tongue
it weighs 25 grams and lies in the anterior cervical triangle under the cover of SCM and the
infrahyoid muscles
the thyroid is enclosed in a true fibrous capsule and an outer false capsule derived from the
pre-tracheal layer of deep cervical fascia
nd th
the lobes lie under the lower end of SCM, the isthmus lie over the 2 to 4 tracheal rings
it is supplied by the following arteries:
o superior thyroid artery from External Carotid Artery
o inferior thyroid artery from the thyrocervical trunk
o thyroidea ima which occurs in 3-10%
its venous drainage is via the superior, middle and inferior thyroid veins [note that the middle
thyroid vein accompanies the inferior thyroid artery]
the superior thyroid artery is accompanied by the external laryngeal branch of the superior
laryngeal nerve which innervates the cricothyroid muscle, the only muscle that tenses the vocal
cords
the inferior thyroid artery is closely related to the recurrent laryngeal nerve which supplies the
rest of the intrinsic laryngeal muscles
consists of cuboidal cell-lined follicles secrete thyroxin from which T3 is developed
parafollicular cells are found in between the follicles
o these cells secrete calcitonin
Hyoid bone
Thyrohyoid membrane
Thyroid cartilage
Cricothyroid membrane
Cricoid cartilage
Pyramidal lobe
Trachea
29
Parathyroid glands
there are usually two pairs of parathyroid glands
th
the superior pair is derived from mesoderm in the 4 pharyngeal pouch
rd
the inferior pair is derived from the 3 pharyngeal pouch
supplied by the inferior thyroid artery
each gland contains two types of cells-chief cells and oxyphils
PTH is secreted by the chief cells in the parathyroid glands
PTH takes calcium out of the bone and into the bloodstream
Pancreas
the pancreas is both an endocrine and exocrine gland
it is derived from ventral and dorsal endodermal buds from the foregut
its endocrine secretions from the islets of Langerhans:
o beta cells [75%] -insulin
o alpha cells [20%] -glucagon
o delta cells [5%] -somatostatin
the islets of Langerhans are embedded in between the pancreatic acini
the pancreas weighs approximately 90 grams
it has a large head, small uncinate process, a short neck, a wide body and a long tail
it lies in the bed of the stomach with its head is in the C-shaped curve of the duodenum, its body
is draped across the IVC, aorta and the left kidney and its tail end lies in the hilum of the spleen
its main pancreatic duct [of Wirsung] carries the exocrine juices from the tail, body and neck of
the pancreas
the main pancreatic duct joins with the common bile duct to open into the ampulla of Vater in
the main duodenal papilla into the duodenum
the opening of the main duct is guarded by a smooth muscle sphincter [of Oddi]
the accessory pancreatic duct [of Santorini] drains the head and opens approximately 2 cm
above the main duodenal papilla via the minor duodenal papilla
the difference in the drainage is due to the fact that the head is derived from the ventral
pancreatic bud and the rest of the pancreas comes from the dorsal pancreatic bud
blood supply:
o superior pacreaticodudodenal artery [from the gastoduodenal artery of the celiac trunk]
o inferior pacreaticoduodenal artery [from the superior mesenteric artery]
o great pancreatic artery [from the splenic artery]
Adrenal Gland
these are paired endocrine glands
the adrenal gland is derived from two separate embryological origins:
o outer layer [cortex] from mesoderm
o inner layer [medulla] from the neuroectoderm [neural crest cells]
the right one is triangular and smaller
the left one is semilunar and larger
its cortex has three structural zones with different hormones:
o zona Glomerulosa – Mineralocorticoids – Aldosterone [under Renin control]-Salt
o zona Fasciculata – Glucocorticoids [under ATCH control]-Sweet
o zone Reticularis – Sex hormones-Sex
o the deeper you go the sweeter the sex gets
the medulla secretes norepinephrine under sympathetic control
the adrenal medulla behaves like a sympathetic ganglion
3 arteries supply the adrenal gland:
o superior adrenal artery from inferior phrenic artery
o middle adrenal artery from the abdominal aorta
o inferior adrenal artery from the renal artery
the gland is drained by a single vein
the left adrenal vein drains into the left renal vein
the right adrenal vein drains into the Inferior Vena Cava
30
GASTRO-INTESTINAL ANATOMY
Embryology
derived from endoderm
3 parts:
o foregut [supplied by the celiac trunk]
gives rises to the following:
esophagus
stomach
proximal half of the duodenum-up to major duodenal papilla
o midgut [supplied by the superior mesenteric artery]
gives rise to the following:
distal half of duodenum
small intestine
proximal half of large intestine up to the proximal two thirds of
transverse colon
o hindgut [supplied by the inferior mesenteric artery]
gives rise to the rest of the large intestine from the distal third of the transverse
colon to the proximal half of the anal canal
Foregut
Midgut
Hindgut
Meckel’s diverticulum:
o this is an uncommon congenital anomaly
o it occurs in 2% of the population
o it is 2 inches long
o it is located 2 feet proximal to the ileocecal junction
o it may contain 2 types of ectopic tissue-gastric and pancreatic tissue
o it is found 2 times more common in males
31
the dermatomes and underlying parietal peritoneum are innervated by the lower 6 thoracic and
st
the 1 lumbar spinal nerves:
o T7-xiphoid level
o T10-umbilical level
o L1-inguinal region
Rectus sheath
The rectus sheath is formed in the following ways:
o above the arcuate line:
the anterior layer consists of the external oblique aponeurosis and the anterior
layer of the internal oblique aponeurosis
the posterior layer is made up of the posterior layer of the aponeurosis of the
internal oblique and the aponeurosis of transversus abdominis
o below the arcuate line:
the anterior layer consists of the aponeurosis of the external oblique, internal
oblique and transversus abdominis
the posterior layer below the arcuate line is deficient and is covered only by
transversalis fascia
o the arcuate line is located posterior to the rectus muscle midway between the
umbilicus and the symphysis
Contents of the rectus sheath
o rectus abdominis muscle
o pyramidalis muscle [absent in 15% of the population]
o superior and inferior epigastric arteries and veins which lie below the rectus muscle
Peritoneum
the peritoneum is the inner lining of the abdominal cavity
it has two parts: parietal and visceral
o the parietal layer is sensitive to pain and is innervated by the lower intercostal and
subcostal nerves like the anterior abdominal wall
o the visceral layer is not sensitive to pain but sensitive to distension
the abdominal cavity is divided into two compartments: greater and lesser sacs
32
the lesser sac lies behind the stomach and opens into the greater sac via the epiploeic
foramen of Winslow
most of the intra-abdominal organs are covered completely by peritoneum
those that are only covered anteriorly by peritoneum are referred to as retroperitoneal
retroperitoneal structures [AC DC PARK AID]: ascending colon, descending colon, pancreas,
nd th
adrenals, rectum [lower 2/3], kidneys, aorta, IVC, duodenum [2 to 4 parts]
Stomach
J-shaped sac lined by columnar epithelium and covered by three layers of smooth muscle-outer
longitudinal, inner circular and innermost oblique
the stomach has 2 notches-cardiac and angular
there are 2 curvatures-lesser and greater
there are 2 attached omenta-greater and lesser
it is guarded by 2 sphincters-lower esophageal and pyloric
it contains 2 main types of cells-chief cells producing pepsinogen and parietal [oxyntic] cells
which produce hydrochloric acid and Intrinsic Factor
it is supplied by the following direct or indirect braches of the celiac trunk:
o left gastric [from the celiac trunk]
o right gastric [from the common hepatic or from the proper hepatic artery]
o left gastro-epiploic and short gastric [from the splenic artery]
o right gastro-epiploic [from the gastro-duodenal branch of the common hepatic artery]
Cardia
Short gastric arteries
Gastroduodenal artery
Left gastro-
epiploic
artery
Pylorus Anrtrum
Right gastric artery
Duodenum
10-inch C-shaped tube surrounding the head of the pancreas
it has 4 parts:
st
o 1 [2” long] – superior part
nd
o 2 [3” long] – descending part
rd
o 3 [4” long] – horizontal part
th
o 4 [1” long] – ascending part
the upper half [above the major duodenal papilla] is supplied by superior pancreatico-duodenal
artery [from gastro-duodenal branch of the common hepatic artery from celiac trunk]
the lower half by the inferior pancreatico-duodenal artery [the first branch of the superior
mesenteric artery]
the common bile duct of the biliary tree opens into the second part of the duodenum
the superior mesenteric vein and artery pass over the third part of the duodenum
the fourth part is continuous with the jejunum at the duodeno-jejunal junction
this junction is fixed and is held in place by the suspensory ligament [of Treitz] which is attached
to the right crus of the diaphragm
the first inch of the first part of the duodenum is intraperitoneal
the rest of the duodenum is retroperitoneal
33
Aorta
Spleen
Right kidney
Left kidney
Duodenum
IVC Stomach
Pancreas
34
Small intestine
the small intestine lies between the duodenum and the large intestine
it is subdivided into proximal and distal parts:
o proximal part of the small intestine-jejunum [8’ long] occupies the upper left part of the
abdomen, is thicker, wider and more vascular
o the distal part of the small intestine-ileum [12’ long] occupies the lower right part of the
abdomen and is thinner, narrower and less vascular
the mesentery of the jejunum has large translucent [less fat] windows with few large vascular
arcades with longer and fewer vasa recta
the mesentery of the ileum has small opaque [more fat] windows, numerous smaller arcades
and numerous short vasa recta
the ileum has numerous lymphoid aggregates called Peyer’s patches [Gut Associated
Lymphoid Tissue]
the Superior Mesenteric Artery supplies all of the small intestine and the large intestine up to
the proximal two thirds of the transverse colon
Colon
subdivided into the cecum [3” long], ascending [5” long], transverse [20” long], descending [10”
long] and sigmoid [15” long]
the appendix is an approximately 4” long out-pouching from the posteromedial aspect of the
cecum where the teniae coli meet and it is suspended by the mesoappendix
it is located in the following areas:
o behind cecum [65%]
o in pelvis [30%]
o either retro-ileal or pre-ileal [5%]
it is supplied by the appendicular artery [branch of the ileocecal branch of the SMA]
its base is located at McBurney’s point-2/3 along a line from the umbilicus to the ASIS
Retro-ileal
Pre-ileal
Retrocecal [65%]
Pelvic [30%]
the large intestine is derived from both the midgut and the hindgut and therefore is supplied by both
the Superior Mesenteric and Inferior Mesenteric arteries
there is a watershed area at the junction of the proximal two thirds and distal third transverse
colon due to the end of the mid gut and the beginning of the hind gut
a watershed area is where the blood supply may be compromised during hypovolemic shock
lymphatics of the colon drain first to pericolic, then to paracolic to mesenteric to para-aortic
nodes which lie close to the aorta
the sigmoid continues as the rectum
35
Transverse colon
Descending colon
Ascending colon
Cecum
Sigmoid colon
Anal Canal
it is approximately 1½ inches long
it is derived from two embryological origins-endoderm and ectoderm
the junction between the two embryological origins is the pectineal line
the columns of Morgagni are longitudinal folds in the anal mucosa above the pectineal line
the columns are connected inferiorly by mucosal folds called the valves of Ball
the anal glands open behind these valves
the anal canal is directed posteriorly and inferiorly
it is guarded by two sphincters:
o internal circular sphincter which is made up of smooth muscle
o external sphincter [skeletal muscle] which has three parts
deep
superficial
submucosal
the external sphincter is supplied by the inferior rectal branch of the pudendal nerve
Pectineal line
the pectinate line is an important line separating the upper anal half from the lower half:
the upper half is derived from the hind gut [endoderm] and is insensitive to pain
the blood supply to the upper half is from the inferior mesenteric artery
the lymphatics from the upper half drain into the inferior mesenteric nodes
the lower half is derived from ectoderm and sensitive to pain
the blood supply to the lower half is from the inferior rectal branch of the internal pudendal
artery which is a branch of the anterior division of the internal iliac artery
the lymphatics from the lower half drain into the lateral group of superficial inguinal nodes in
the groin
36
MUSCULOSKELETAL ANATOMY
Classification of Bones
Bones may be classified according to their shape or method of ossification.
long -femur, phalanges
short -carpals and tarsals
flat -ribs, frontal, parietal and temporal skull bones
irregular -vertebra
sesamoid -intratendinous [pisiform and patella]
intra-cartilaginous ossification -all long bones EXCEPT the clavicle
intra-membranous ossification -clavicle, flat skull bones and axial skeleton
st
NB. The clavicle is the 1 bone to begin ossification and the last to completely ossify
Classification of Joints
Joints may be classified according to their movements, axes of movement or structure
Movement:
Synarthrosis [Immobile] Fibrous joint
Amphiarthrosis [Slightly mobile] Cartilaginous joint
Diarthrosis [Mobile] Synovial joint
Periosteum
Fibrocartilage
disc
Synchondrosis
37
Synovial:
Synovial [diarthrosis] interphalangeal joints
Synovial membrane
Fibrous capsule
Hyaline cartilage
Joint cavity
Remember all midline joints are secondary cartilaginous joints EXCEPT the following:
the median atlanto-axial [atlantodental] joint which is a trochoid synovial joint
Innervation of joints
This follows Hilton’s law:
the nerve which innervates a muscle that acts on a joint, will supply the joint and an area of skin
over the joint
Bone histology
Bone is made up of:
o central Haversian canals
o concentric lamella
o bone matrix
38
central Haversian canals with blood vessels
o the canals are connect by Volkmann’s canals
supplying nutrients and removing waste
concentric lamellae surround the Haversian canals
o the lamellae are comprised of lacunae which the osteocytes
o the lacunae are connected by canaliculi which contain thin cytoplasmic strands
allowing the osteocytes to communicate with each other
bone matrix-calcified intercellular material comprised of
o osteoblasts synthesize the matrix [build bone] and later become osteocytes
o osteoclasts reabsorb and remodel bone tissue [clears bone away]
Cartilage Histology
cartilage has an outer layer called the perichondrium in which are found the chondroblasts and
blood vessels
mainly comprised of [95%] extracellular matrix of gylcosaminoglycans and proteogylcans and few
chondrocytes [5%] in lacunae
chondrocytes arise from chrondroblasts cells
cartilage has no blood vessels or nerves
o damaged cartilage shows very limited ability to regenerate
there are 3 types of cartilage:
o Hyaline: most abundant, consisting mainly of Type II collagen fibers covers joint
o Elastic: contains Type II collagen fibers and elastin; found in the larynx
o Fibrocartilage: dense compact Type I collagen fibers; found in intra-articular discs
Classification of muscle
muscle consists mainly of contractile fibers
muscle can be classified according to the histological types:
o smooth
no cross striation [hence smooth]
spindle-shaped cell
central nucleus
involuntary
o skeletal
cross striations
elongated peripheral nucleus
voluntary control
o cardiac
cross striations
branches
intercalated discs
central nucleus
involuntary control
individual muscle fibers are surrounded by delicate connective tissue called the endomysium
a bundle [fascicle] of fibers is in turn surrounded by more connective tissue called the perimysium
the epimysium is the dense connective tissue surrounds the entire muscle which is made up of
several bundles or fascicles
skeletal muscle may be further classified according to the shape into the following groups:
o fusiform
thick in the middle and tapered at each end: biceps brachii, gastrocnemius
o parallel
uniform width with parallel fascicles: rectus abdominis and sartorius
o triangular
fan-shaped with a broad origin and narrow insertion: pectoralis major
o pennate
feather-shaped
unipennate: palmar interossei
bipennate: rectus femoris and dorsal interossei
multipennate: deltoid
o circular
forms rings around certain body openings: orbicularis oculi and anal sphincter
39
SPECIFIC JOINT ANATOMY
Temporomandibular Joint
Type Atypical synovial
Classification Compound hinge and gliding joint [articular surfaces are covered by fibrocartilage
instead of hyaline like most other synovial joints]
fibrocartilage is more resistant to damage and can regenerate
Intra-articular disc separates an upper [above the disc] from a lower [below the
disc] compartment
Protraction and retraction [gliding] occurs in the upper compartment
Elevation and depression [hinge] occurs in the lower compartment
Bones involved Condyle of the mandible, mandibular fossa and articular eminence of the
temporal bone
Range of motion Elevation, depression, protraction, retraction and side to side
Muscles acting Elevation-temporalis, masseter, medial pterygoid
Depression [5 cm]-gravity, mylohyoid, digastric, lateral pterygoid
Protraction [1 cm]-lateral pterygoid, anterior part of temporalis, superficial fibers
of masseter
Retraction-posterior part of temporalis and deep part of masseter
Side to Side [1 cm]-pterygoids acting alternately
The superior part of the lateral pterygoid muscle is partially inserted into the
anterior portion of the intra-articular disc
Innervation Auriculotemporal, deep temporal and masseteric branches of CN V3
Intra-articular disc
Condyle of mandible
40
Sternoclavicular Joint
Type Synovial with an intra-articular disc
Classification Saddle [sellar] type but behaves as a ball and socket [articular surfaces are
covered with fibrocartilage unlike other synovial joints which are covered by
hyaline cartilage]
Bones involved Manubrium of sternum and the medial head of the clavicle
Range of motion Elevation, depression, protraction, retraction and circumduction
Muscles acting Elevation-sternocleidomastoid and trapezius
Depression-pectoralis minor, subclavius
Protraction-pectoralis minor
Retraction-trapezius
Circumduction-combination of the above
Innervation Medial branch of the supraclavicular nerves [C3]
Elbow Joint
Type Synovial
Classification Hinge [ginglymus]
Bones involved Lower end of humerus and the head of the radius and trochlea of the ulna
Range of motion Flexion and extension
Muscles acting Flexion-biceps brachii, brachialis, brachioradialis
Extension-triceps and anconeus
Innervation Radial and musculocutaneous nerves
Wrist Joint
Type Synovial
Classification Condyloid [ellipsoid]
Bones involved Distal end of radius, scaphoid and lunate bones
Range of motion Flexion, extension, adduction, abduction and circumduction
Muscles acting Flexion-flexor carpi radialis and ulnaris, flexors of fingers
Extension-extensor radialis longus and brevis, extensor ulnaris, extensors of the
fingers
Adduction [ulnar deviation]-flexor and extensor carpi ulnaris
Abduction [radial deviation]-flexor and extensor carpi radialis
Innervation Radial, median and ulnar nerves
Triquetrum
Scaphoid
Lunate
Radius Ulna
41
st
1 Carpometacarpal Joint
Type Synovial
Classification Saddle [sellar]
st
Bones involved Trapezium and 1 metacarpal bones
Range of motion Flexion and extension
Abduction and adduction
Opposition [approximating the tips of the thumb and the little finger]
Muscles acting Flexion-flexor pollicis longus and brevis
Extension-extensor pollicis longus and brevis
Abduction-abductor pollicis longus and brevis
Adduction-adductor pollicis
Opposition-Opponens pollicis
Innervation Radial and median nerves
Metacarpophalangeal Joint
Type Synovial
Classification Condyloid [ellipsoid]
Bones involved Head of metacarpal and base of proximal phalanx
Range of motion Flexion and extension
Adduction and abduction
Circumduction
Muscles acting Flexion-flexor digitorum superficialis and profundus and lumbricals
Extension-extensor digitorum
Adduction-palmar interossei [PAd]
Abduction-dorsal interossei [DAb]
Circumduction-combination of the above
Innervation Median, ulnar and radial nerves
Interphalangeal Joint
Type Synovial
Classification Hinge [ginglymus]
Bones involved Proximal and middle, and between the middle and distal phalanges
Range of motion Flexion and extension
Muscles acting Flexion-flexor digitorum superficialis and profundus
Extension-extensor digitorum, lumbricals and interossei
Innervation Median, ulnar and radial nerves
Hip Joint
Type Synovial
Classification Ball and socket [spheroidal]
Bones involved Acetabulum of os coxae [hip bone] and the head of the femur
Range of motion Flexion and extension
Adduction and abduction
Internal and external rotation
Rotation
Circumduction
Muscles acting Flexion-iliopsoas, rectus femoris and sartorius
Extension-gluteus maximus, semimembranosus, semitendinosus and hamstring
part of adductor magnus
Abduction-gluteus medius, minimus and tensor fasciae latae
Adduction-adductor longus, brevis and adductor part of adductor magnus,
gracilis, pectineus and lower part of gluteus maximus
Internal Rotation-gluteus medius and minimus
External Rotation-gluteus maximus, psoas, piriformis, the gemelli, obturator
interns and externus, quadratus femoris
Circumduction-a combination of the above
Innervation Femoral, obturator and nerve to quadratus femoris
42
Head of femur
Acetabular fossa
Joint capsule
Knee Joint
Type Synovial
Classification Modified hinge [ginglymus]
Bones involved Lower end of the femur and the upper end of the tibia
Range of motion Flexion, extension and rotation
Muscles acting Flexion-biceps femoris, semitendinosus, semimembranosus, gastrocnemius,
sartorius, gracilis
Extension-quadriceps femoris
Medial rotation-popliteus
Innervation Femoral, tibial and common peroneal nerves
Medial meniscus
Anterior cruciate ligament
43
there are two intra-articular ligaments:
o anterior cruciate ligament
originates from the anterior part of the intercondylar ridge
inserted into the posterior side of the medial aspect of the lateral condyle of
the femur; prevents anterior movement of tibia on the femur
o posterior cruciate ligament
originates from the posterior part of the intercondylar ridge
inserted into the anterior part of the lateral aspect of the medial condyle of
the femur; prevents posterior movement of tibia on the femur
there are two extra-articular ligaments:
o medial collateral
thick broad ligament from femur to tibia
attached to the medial meniscus; prevents abduction stress
o lateral collateral
thin narrow ligament from femur to head of fibula; prevents adduction stress
there are two intra-articular discs:
o medial meniscus
semilunar fibrocartilaginous disc attached to the medial collateral ligament
and to the intercondylar ridge
o lateral meniscus
nearly circular
attached to the intercondylar ridge
not attached to the lateral collateral ligament
Medial meniscus
Lateral meniscus
Ankle Joint
Type Synovial
Classification Hinge [ginglymus]
Bones involved Lower end of the tibia and fibula and the talus
Range of motion Flexion [dorsiflexion] and extension [plantar flexion]
Muscles acting Flexion-tibialis anterior, extensor hallucis longus and extensor digitorum
longus
Extension-gastrocnemius, soleus, plantaris and tibialis posterior
Inversion and eversion do not occur at the ankle [tibiotalar] joint but in the
subtalar joint
Innervation Tibial and deep peroneal nerves
44
IMPORTANT MUSCLES
Sternocleidomastoid
Origin Mastoid process and lateral third of superior nuchal line
Insertion Manubrium of sternum and medial third of the clavicle
Innervation Spinal part of CN XI [motor] and ventral rami of C2, C3 [proprioception]
Action Tilts the head towards the shoulder on the same side and rotates the head to the
opposite side
Trapezius
Origin Medial third of superior nuchal line, external occipital protuberance, ligamentum
nuchae, spinous processes of C7 and all thoracic vertebrae
Insertion Lateral third of clavicle, acromion and spine of scapula
Innervation Spinal part of CN XI [motor] and branches of C3 and C4 [proprioception]
Action Shrugs the shoulder, retracts and rotates the scapula
Latissimus dorsi
Origin Thoracolumbar fascia, spinous processes of the lower thoracic and lumbar
vertebrae
Insertion Floor of the bicipital groove
Innervation Thoracodorsal nerve [C6, 7, 8]
Action Adducts, extends and medially rotates the arm
Levator scapulae
Origin Transverse processes of C1 and C2
Posterior tubercles of the transverse processes of C3 and C4
Insertion From the superior angle to the root of the spine of the scapula
Innervation Dorsal scapular nerve [C5]
Action Elevates the scapula
Scalenus anterior
Origin Anterior tubercles of the transverse processes of C3, 4, 5 and 6
Insertion Scalene tubercle on the upper inner aspect of the first rib
Innervation Anterior rami of C4, 5 and 6
Action Ipsilateral lateral flexion of the neck
Scalenus medius
Origin Posterior tubercles of the transverse processes of C2 to C6
st
Insertion Upper aspect of the 1 rib between groove for the subclavian artery and the tubercle
Innervation Anterior rami of C3 to C7
Action Ipsilateral lateral flexion of the neck
Serratus anterior
Origin Lateral aspects of the upper 8 ribs
Insertion Along the medial aspect of the inferior surface of the scapula
Innervation Long Thoracic Nerve [C5, 6 and 7]
Action Draws the scapula forwards and rotates the scapula
Deltoid
Origin Lateral third of clavicle, acromion and spine of the scapula
Insertion Deltoid tubercle of the humerus
Innervation Axillary nerve [C5 and C6]
o o
Action Abducts the arm [15 to 90 ], anterior fibers flex and medially rotates the arm
Posterior fibers extend and laterally rotate arm
Pectoralis major
Origin Sternum, upper 6 costal cartilages and medial half of clavicle
Insertion Lateral lip of the bicipital groove
Innervation Medial and lateral pectoral nerves [C5, 6, 7 and C8, T1]
Action Adducts, flex and medially rotates the arm; it also extends the flexed arm
45
Supraspinatus
Origin Supraspinous fossa of the scapula
Insertion Superior facet of the greater tuberosity of the humerus
Innervation Suprascapular nerve [C5 and C6]
o
Action Initiates abduction [0-15 ] of the arm
Infraspinatus
Origin Infraspinous fossa of the scapula
Insertion Middle facet of greater tuberosity of the humerus [just below supraspinatus insertion]
Innervation Suprascapular nerve [C5 and C6]
Action Externally rotates the humerus
Teres major
Origin Oval depression on the lateral aspect of the dorsum of the scapula above the inferior
angle
Insertion Medial lip of the bicipital groove
Innervation Lower subscapular nerve [C5 and 6]
Action Extends, adducts and medially rotates the arm
Teres minor
Origin Middle third of the lateral border of scapula
Insertion Inferior facet of greater tuberosity of humerus [just below infraspinatus insertion]
Innervation Axillary nerve [C5 and C6]
Action Externally rotates the arm
Subscapularis
Origin medial two-thirds of the ventral aspect of the scapula
Insertion Lesser tuberosity of the humerus
Innervation Upper and lower subscapular nerves [C5 and C6]
Action Internally rotates and adducts the arm
Biceps brachii
Origin Coracoid process [short head] and the supraglenoid tubercle [long head]
Insertion Posterior border of the radial tuberosity of the radius
Innervation Musculocutaneous nerve [C5, 6, 7]
Action Flexes and supinates the elbow
Triceps
Origin Infraglenoid tubercle [long head], lateral upper and medial lower parts of the humerus
Insertion Olecranon of the ulna
Innervation Radial nerve [C7 and C8]
Action Extends the forearm and adducts the arm
Brachioradialis
Origin Upper two-thirds of the lateral supracondylar ridge of humerus
Insertion Base of the styloid process of the radius
Innervation Radial nerve [C6 and C7]
Action Flexes the forearm
Pronator teres
Origin Medial epicondyle of the humerus and medial border of the coronoid process of ulna
Insertion Upper part of the radius
Innervation Median nerve [C6 and 7] which passes between the humeral and ulnar heads
Action Pronates the forearm and flexes the elbow
Psoas major
Origin Bodies, intervertebral discs and transverse processes of L1-5
Insertion Lesser trochanter of the femur
Innervation L2, 3 and 4 from the lumbar plexus
Action Flexes the thigh and trunk
46
Gluteus maximus
Origin Ilium, sacrum, coccyx and sacrotuberous ligament
Insertion Gluteal tuberosity of the femur [25%] and iliotibial band [75%]
Innervation Inferior Gluteal nerve [L5, S1 and S2]
Action Extends and externally rotates the thigh
Piriformis
Origin Pelvic [anterior] surface of sacrum
Insertion Medial aspect of the superior border of the greater trochanter of the femur
Innervation S1 and S2 from the sacral plexus
Action Externally rotates the thigh
Quadriceps femoris
Origin AIIS [straight head of rectus femoris], superior rim of acetabulum [reflected head of
rectus femoris] femur [vastus medialis, intermedius and lateralis]
Insertion Tibial tuberosity via the patellar tendon which encloses the patella
Innervation Femoral nerve [posterior divisions of L2, 3 and 4]
Action Extends the knee, stabilizes the patella and flexes the thigh [through the action of rectus
femoris]
Tibialis anterior
Origin Upper half of the lateral aspect of the tibial shaft and interosseous membrane
st
Insertion Inferomedial aspect of the medial cuneiform and base of 1 metatarsal bone
Innervation Deep Peroneal nerve [L4 and L5]
Action Dorsiflexes and inverts the foot
Peroneus longus
Origin Lateral tibial condyle, head and upper lateral aspect of fibula
st
Insertion Inferolateral aspect of the medial cuneiform and base of 1 metatarsal bone
Innervation Superficial Peroneal nerve [L5 and S1]
Action Plantar flexes and everts the foot
Gastrocnemius
Origin Posterior aspects of the medial and lateral femoral condyles
Insertion Posterior aspect of the calcaneus via the calcaneal tendon [Achilles]
Innervation Tibial nerve [S1 and S2]
Action Plantar flexes the ankle
Soleus
Origin Soleal line, middle third of the tibia and upper third of the fibula
Insertion Calcaneal tendon to the posterior surface of the calcaneus
Innervation Tibial nerve [S1 and 2]
Action Plantar flexes the ankle and aids in the venous return from the leg
Tibialis posterior
Origin Interosseous membrane and the upper parts of the tibia and fibula
nd th
Insertion Navicular, the three cuneiform bones and the bases of the 2 to 4 metatarsal
bones
Innervation Tibial nerve [L5 and S1]
Action Plantar flexes and inverts the foot; supports the medial longitudinal arch of the foot
47
REPRODUCTIVE ANATOMY
Embryology
The reproductive system is derived from the mesoderm
the Seminal vesicle, Epididymis, Ejaculatory duct and the Ductus deferens arise from the
mesonephric [Wolffian] duct
the primitive testis develops from mesoderm lying on top of the kidney
the uterus and upper third of the vagina are developed from the paramesonephric [Mullerian]
duct which runs parallel to the mesonephric duct
the primitive ovary or testis develops from mesoderm on top of the kidney
Primitive gonad
Paramesonephric duct
Mesonephric duct
Male Genitalia-testis
spermatozoa are produced in the seminiferous tubules of the testis
under the influence of testosterone
testosterone is secreted by the interstitial cells of Leydig which are under the influence of
Luteinizing hormone
testosterone is attached to Sertoli cells found in the tubules of the testis
0
the testis lies in the scrotum so that it is at a temperature 1 C less than the rest of the body
the testis is a 1½ by 1 by ½ inch oval-shaped gonad weighing approximately ½ ounce
it is suspended by the spermatic cord in the lower part of the scrotum
the testis is enclosed in a thick fibrous capsule called the tunica albuginea
it is divided by septa into 300 lobules each containing 1-4 seminiferous tubules
the seminiferous tubules empty into 25 straight tubules which join to form the rete testis which
empty into the epididymis via 15-20 efferent ductules
the testis is covered by the following seven layers from outside in:
o skin
o dartos muscle within Colles fascia [dartos muscle is under sympathetic control]
o external spermatic fascia from the external oblique aponeurosis
o cremasteric muscle and fascia from the internal oblique muscle
o internal spermatic fascia from transversalis fascia
o parietal and visceral layers of tunica vaginalis from the peritoneum
sperm travel through the rete testes into the epididymis where they mature
the epididymis continues as the ductus deferens where the sperm are stored
on ejaculation, the sperm travel up the 18” long ductus deferens
the ductus deferens is joined at its terminal end by the seminal duct forming the ejaculatory duct
the ejaculatory duct opens into the posterior part of the prostatic urethra from where sperm
travel through the rest of the urethra to be deposited into the posterior vaginal fornix on ejaculation
48
Spermatic cord
lies in the inguinal canal and is made up of 3 coverings, 3 arteries, 3 nerves and 3 other structures
3 coverings: external spermatic fascia, cremasteric muscle and fascia and internal spermatic
fascia
3 arteries: testicular, artery to the ductus deferens and cremasteric artery
3 nerves: testicular nerves, genital branch of the genitofemoral nerve and ilioinguinal nerve [which
actually lies outside of the spermatic cord]
3 other structures: ductus deferens, pampiniform plexus of veins and testicular lymphatics [drains
to the para-aortic lymph nodes]
Genital branch Testicular artery, pampiniform veins and
of the lymphatics
genitofemoral
nerve
Ductus deferens,
artery to the
ductus deferens
and testicular Internal spermatic fascia
nerves
External spermatic fascia
Cremasteric fascia
Cremasteric
artery and
vein . Ilioinguinal nerve
Female Genitalia
mons pubis is the hair bearing fat pad covering the symphysis pubis
labia majora are two longitudinal folds of skin extending posteriorly from the mons pubis
outer aspect of this fold is pigmented and hairy
inner aspect of the labia majora is pink and hairless
labia minora are two smaller folds between the labia majora and are divided into lateral and
medial parts
lateral parts of the labia minora are fused above the clitoris forming the prepuce
medial parts of the labia minora are fused below the clitoris forming the frenulum
clitoris consists of erectile tissue:
o it is made up of two crura and a glans
o the clitoris is the female homologue of the penis in the male
the vestibule is the space found between the labia minora with the urethral and vaginal orifices
Vagina
develops mainly from the urogenital sinus
highly distensible fibromuscular canal which extends from the vestibule to the cervix
lower part of the cervix protrudes into the upper part of the vagina forming the anterior,
posterior and lateral fornices
the urethra lies anterior and the rectum lies posterior to the vagina
49
Uterus
pear-shaped fibromuscular organ weighing 30 to 40 grams with a fundus, body and cervix
the cervix lies partly in the upper vagina
the uterus measures 3” x 2” x1” and has a triangular cavity whose base is superior
the normal uterus is anteverted [angled forwards to the vagina] and anteflexed [body is bent
forwards to cervix]
the uterus is attached to the ovary by the ligament of the ovary and to the labia majora by the
round ligament of the uterus and to the broad ligament
uterus and upper vagina are supplied by named branches of the anterior division of the internal iliac
artery
fallopian [uterine] tubes are 4-inch long muscular tubes lined by ciliated columnar epithelium
with four parts:
o the fimbriated end is funnel-shaped [infundibulum]
o the large ampulla where fertilization occurs
o a long narrow isthmus
o a short intramural part which pass through the cornu [lateral horn] of the uterine cavity
Uterine tube
Ovary
Uterus
Bladder
Vagina
Ovary
1½ x ¾ x ½ inch oval female homologue of the testis
lies in the ovarian fossa between the external and internal iliac arteries
it is attached to:
o posterior aspect of the broad ligament by the mesovarium
o suspensory ligament of the ovary to the pelvic wall; contains ovarian blood vessels
o ligament of the ovary to the uterus
supplied by the ovarian artery, a branch of the abdominal aorta at L2 level
the right ovarian vein drains into the inferior vena cava
the left ovarian vein drains into the left renal vein
Broad Ligament
this is a double layer of peritoneum
it covers the uterus [mesometrium] and the uterine tubes like a sheet
it also contains two additional structures:
o ligament of the ovary
o round ligament of the uterus
the round ligament of the uterus is the female equivalent of the gubernaculums testes in the male
the ovary is attached to the mesovarium which is the posterior part of the broad ligament but it is
not enclosed in the broad ligament
the part of the broad ligament between the mesovarium and the uterine tube is the mesosalpinx
50
Ligament of the ovary Uterine tube
Fundus of the uterus
Ovary
Suspensory ligament
Round of the ovary
ligament of
the uterus
Ilium
Acetabulum
Greater sciatic notch
the male pelvis is different from the female pelvis in the following ways:
o heavier with more prominent muscular markings
o smaller heart-shaped pelvic inlet
0 0
o subpubic angle is narrow [45 in the male compared to 85 in the female]
o inverted ischial spines
o sacrum is more curved
51
RESPIRATORY ANATOMY
Embryology
developed as a respiratory diverticulum from the upper end of the foregut
from this two lung buds develop
lung buds become the primary bronchi of each lung
the primary bronchi subdivide into secondary [lobar] bronchi
secondary bronchi divide into tertiary [segmental] bronchi
the tertiary bronchi continue to divide and divide until the terminal bronchioles are formed
terminal bronchioles give rise to respiratory bronchiole
the alveoli develop later from the respiratory bronchioles in the third trimester
an uncommon congenital defect is esophageal atresia with tracheo-esophageal fistula
o the upper end of the esophagus is blind-ending [atresia]
o the lower end is connected to the lower end of the trachea by a fistula
Tracheobronchial Tree
the trachea begins at the lower border of the cricoid cartilage [C6]
it is a rigid fibrocartilage tube lined by pseudo-stratified ciliated columnar epithelium
the trachea is held open by 15-20 U-shaped rings
it is 5 inches long and 1 inch in diameter
each ring is incomplete posteriorly [linked by the trachealis muscle]
it ends at the sternal angle [of Louis] T4/5 by bifurcating into the right and left bronchi
there is a V-shaped cartilage that marks the bifurcation of the trachea called the carina
the esophagus lies behind the trachea
nd th
2 to 4 tracheal rings are crossed anteriorly by the isthmus of the thyroid gland
the right bronchus is shorter, wider and is more vertical than the left
the left bronchus is longer, narrower and lies more horizontal
aspirated foreign bodies are more likely to go into the middle lobe of the right primary bronchus
the right main bronchus divides into three secondary bronchi while the left divides into two
each lobar bronchus divides within each lobe into segmental bronchi
each segmental bronchus feeds a bronchopulmonary segment
the segmental bronchus continues to subdivide until it reaches the terminal bronchiole
from here the terminal bronchioles lead to the respiratory bronchioles which bear a number of
alveolar sacs
Trachea
Carina
52
Lungs
2
provides a surface area for gaseous exchange over 40m per lung
each lung has an apex [cervical], a base [diaphragmatic], a lateral [costovertebral] and a medial
[mediastinal] surface
right lung is bigger, wider and longer than the left
the left lung is smaller, narrower and shorter than the right
each lung is made up of several bronchopulmonary [functional units] segments
each bronchopulmonary segment is pyramidal in shape with its apex directed towards the hilum
there are 10 segments in the right lung:
o upper lobe-apical, posterior and anterior
o middle lobe-lateral and medial
o lower lobe-superior, lateral, anterior, medial and posterior basal
the left lung may have 8 or 9 segments:
o upper lobe-apicoposterior, anterior, superior and inferior lingual
o lower lobe-superior, anterior, lateral and posterior basal
inter-segmental veins drain each segment and empty into either the azygos venous system or into
the pulmonary veins
segmental arteries are derived from the bronchial branches of the aorta
In the root of the lungs, the bronchus lies behind, the veins lie below
the pulmonary artery lies in the Right lung root Anterior to the bronchus
on the Left pulmonary artery lies Superior to the bronchus [RALeS]
Left Bronchus
Horizontal
Oblique fissure fissure
Bronchus
LEFT RIGHT
Lingula
Pleura
2 layers of pleura: outer and inner layers which are continuous at the root of the lung
the outer [parietal] layer lies against the inner aspect of the thoracic cage
the inner [visceral] layer lies against the lungs
the outer layer is sensitive to pain and is supplied by intercostal and phrenic nerves
the inner layer is insensitive [has autonomic innervation mainly from the vagus]
the pulmonary ligament is a sleeve of pleura at the root of the lung and functions as an
anatomical dead space allowing for expansion of the pulmonary veins
the pleura have the following parts: costal, mediastinal, diaphragmatic and cervical
st
the cervical pleura [cupola] extends above the 1 rib
53
the extension of the lung into the neck is limited by the suprapleural membrane [Sibson’s fascia]
th
o this is a fibrous structure that extends from the tip of the transverse process of the 7
st
cervical vertebra to the inner border of the 1 rib
the pleura are supplied by branches of the anterior and posterior intercostal arteries
the upper 6 anterior intercostal arteries are derived from the internal thoracic artery, a branch
st
of the 1 part of the subclavian artery
the lower 5 are derived from the musculophrenic branch of the internal thoracic artery
st nd
1 and 2 posterior intercostal arteries are from the costal branch of the costocervical trunk of
the subclavian artery
rd th
3 to the 11 posterior intercostal arteries are derived from the descending part of the thoracic
aorta
venous drainage is via the azygos venous system
lymphatics of the lung drain from the periphery of the lungs to:
o pulmonary nodes found in the lung parenchyma
o then to bronchopulmonary nodes located in the hilum of the lung
o then to tracheobronchial nodes located at the bifurcation of the trachea
o into para-tracheal nodes found on either side of the trachea
o finally into the mediastinal lymphatic trunks
Azygos vein
Thoracic duct
Hemi-azygos vein
54
Diaphragm
it is a fibromuscular septum that separates the thoracic cavity from the abdominal cavity
embryology of the diaphragm:
o developed from four origins:
rd
central tendon comes from the septum transversum which arises from the 3 ,
th th
4 and 5 cervical somites
peripheral rim of the body wall
pleuroperitoneal membranes
dorsal mesentery of the esophagus
its muscle fibers originates from four areas:
o the right crus from the bodies of L1-3
o the left crus from the bodies of L1 and L2
o the lower 6 ribs
o the sternum [posterior aspect of the xiphoid process]
the muscular fibers are inserted into the central tendon
there are three major openings in the diaphragm at T8, T10 and T12 respectively
o T8-IVC, the right phrenic nerve and pericardiacophrenic vessels
o T10-esophagus and the vagus nerves
o T12-aorta, thoracic duct and azygos vein
o the inferior vena cava passes through the central tendon
o the esophagus passes through the right crus
o the aorta passes between and behind the right and left crura
the diaphragm is innervated by the phrenic nerve which is derived from C3, 4 and 5 [keeps the
diaphragm alive]
it is covered by pleura on the superior aspect and peritoneum on the inferior aspect
the peritoneum and pleura in the center of the diaphragm is innervated by the phrenic nerve
the peritoneum and pleura in the periphery of the diaphragm are supplied by the lower six
intercostal nerves
condensation of fascia over the psoas muscle is called the medial arcuate ligament
the lateral arcuate ligament is the condensation of fascia over quadratus lumborum
the median arcuate ligament connects the right and left crura and arches over the aorta
IVC
Central tendon
Esophagus
Medial
Lateral arcuate
arcuate ligament
ligament
Aorta
Median
Arcuate
Ligament
Left crus
Right crus
55
RETICULO-ENDOTHELIAL ANATOMY
Lymph node
small bean-shaped encapsulated lymphatic draining structure with a cortex and a medulla
enclosed within a thin fibrous capsule
directly under the thin fibrous capsule is a space called the subcapsular sinus
the cortex is further subdivided into outer and inner layers:
o outer cortex consists of mature B cells organized into the follicles
o these follicles have germinal centers containing activated B [plasma] cells
o inner cortex has mature T cells mainly
the medulla contains lymphocytes, plasma cells and macrophages
lymph flows from nearby afferent vessels towards the cortex to pass through the subcapsular
sinuses and into cortical sinuses
eventually lymph drains through the medullary sinuses then to the efferent lymphatic vessels
that exit at the hilum
the sinuses contain macrophages and reticular fibers arranged in a crisscross fashion which act
like a filter
activated lymphocytes leave the lymph node via the hilum
Afferent lymphatic vessel
Cortex
Fibrous capsule
Medulla
Efferent lymphatic vessel
Artery Vein
Spleen
largest aggregation of lymphoid tissue
develops from mesoderm within the dorsal mesentery of the stomach
lies under the left dome of the diaphragm close to the lower ribs
measures 1” thick x 3” wide x 5” long; weighs 7 ounces
th th
lies between the 9 and 11 ribs in the left midaxillary line
made up of red and white pulp enclosed in a thin fibrous capsule
old red blood cells are destroyed in the red pulp
the white pulp is involved in the immune system
the spleen is attached by two ligaments:
o gastrosplenic ligament which contains the short gastric and left gastroepiploic
arteries and veins
o splenorenal ligament which contains the terminal part of the splenic artery
visceral aspect of the spleen is related to the following structures:
o tail of the pancreas [hilum]
o stomach [anterior to the hilum]
o left kidney [posterior to the hilum]
o splenic flexure of the colon [below the hilum]
56
Liver
considered as part of the reticulo-endothelial system as it has many Kupffer cells which filter
out bacteria
largest internal organ in the body weighing 3 lbs [the skin is really the largest organ of the body
as an organ is defined as a body structure made up of several tissues contributing to many
functions]
developed from a ventral outgrowth of the distal end of the foregut along with the biliary tree
surrounded by a fibrous capsule and is suspended by the coronary ligament to the undersurface
of the diaphragm
the coronary ligament is a continuation of the falciform ligament which extends
from the umbilicus to the liver and contains the round ligament of the liver [remnant
of the left umbilical vein in the fetus]
covered almost completely by visceral peritoneum except in the region bounded by the
coronary ligament-the bare area and the part through which the inferior vena cava passes
divided into four anatomical and two functional lobes
4 anatomical lobes and 2 functional lobes:
right right
left left
quadrate left
caudate right half belongs to the right and the other half to the left
right functional lobe is supplied by the right hepatic artery, a branch of the proper hepatic artery
left functional lobe is supplied by the left hepatic artery
Coronary ligament
Diaphragm
Left
triangular
ligament
Right
triangular
ligament
Left lobe
Right lobe
the liver is made up of functional units of sinusoids lined by hepatocytes and Kupffer cells
sinusoids are fed by branches of the hepatic artery and tributaries of the portal vein
the proper hepatic artery is a branch of the common hepatic artery from the celiac trunk
the portal vein provides the liver with 70% of its blood supply and contains nutrients from the gut
the portal vein is formed by the joining of splenic and the superior mesenteric veins behind the
head of the pancreas
the inferior mesenteric vein drains into the splenic vein
venous blood from the sinusoids drains into the central veins and from here to three hepatic
veins which open into the Inferior Vena Cava, ultimately draining in the right atrium
the right and left hepatic ducts drain bile from the liver and are located in the porta hepatis
which lies between the caudate and quadrate lobes of the liver
the porta hepatis also contains the right and left hepatic arteries, right and left tributaries of
the portal vein, autonomic nerves and lymphatic vessels
the right and left hepatic ducts join to form the common hepatic duct
the common hepatic duct joins up with the cystic duct from the gallbladder to form the common
bile duct
57
the common bile duct joins the main pancreatic duct [of Wirsung] within the head of the
pancreas to open via the ampulla of Vater into the duodenum
the ampulla of Vater is guarded by a smooth muscle sphincter [of Oddi] under the influence of
cholecystokinin [CCK] which is secreted by the small intestine in response to the presence of fat
in the duodenum
Quadrate lobe
Round ligament of the liver
Gallbladder in the falciform ligament
Right lobe
Left lobe
Porta hepatis
Caudate lobe
Inferior Vena Cava
Fig 53: Visceral Aspect of Liver
Thymus
rd
the thymus is derived from the 3 pharyngeal pouch along with the inferior parathyroid glands
it is a bi-lobed gland which is located in the anterior portion of the superior mediastinum
it may extend into the upper part of the anterior mediastinum
it is supplied by branches from the anterior intercostal and internal thoracic arteries
its venous drainage is to nearby veins
it is involved in T cell production
it is almost completely atrophic in the adult
macroscopically, it has a highly cellular cortex and a less cellular central medulla enclosed in a
loose connective tissue capsule
cortex is comprised of immature and maturing T cells
medulla has lymphocytes and a particular feature found only in the thymus-Hassall’s corpuscles
Hassal’s corpuscles are oval bodies made up of a central area of degenerated cells surrounded
by concentrically arranged flattened keratinized epithelial cells
Thoracic duct
it is an 18 inch-long multi-valve tube that begins at the cisterna chyli [L1]
it passes through the diaphragm at T12 to the right of the aorta
it lies in the posterior mediastinum and crosses over from right to left at T4/5
it ascends into the left neck to empty into the junction of the left internal jugular and subclavian
veins
it drains lymph from the following areas:
o lower half of the body
o left half of head and neck
o left half of the chest
lymph from the right side of the head and neck, the right upper limb and right side of the
chest drain into the right lymphatic trunk
other lymphoid collections include:
o tonsils in the pharynx:
palatine tonsils
tubal tonsils
lingual tonsils
o Peyer’s patches in the small intestine
o the appendix
58
SKIN ANATOMY
The skin is the largest organ in the body and has the following functions:
mechanical protection
body temperature regulation
Vitamin D synthesis
salt excretion
non-specific immune defense
tactile sensation
Skin histology
the skin is made up of the following three layers:
o epidermis
o dermis
o hypodermis
the epidermis is made up of stratified keratinized squamous epithelium
it is further subdivided into the following distinct layers from outside in [Californians Like Girls
in String Bikinis]:
o stratum Corneum
o stratum Lucidum [only found in thick skin e.g. palms and soles]
o stratum Granulosum
o stratum Spinosum produces keratin
o stratus Basale [aka stratum germinativum]
the epidermis also contains melanocytes [pigment producing cells], Langerhan’s cells [cells
involved in immune identification], Merkel cells [mechanoreceptors] and naked nerve
endings [nociceptors and heat receptors]
the epidermis is thickest in the soles and palms
the dermis lies immediately underneath the epidermis which is anchored on to it
it is made up of two indistinct layers:
o papillary layer which is made up of loose connective tissue containing fibroblasts
and collagen fibers
this layer also contains Meissner’s corpuscles which are specialized
pressure sensitive structures along with Krause corpuscles which are
thought to be sensitive to cold
o reticular layer lies deeper and is made up mainly of collagen and elastic fibers
the hypodermis is the deepest layer of the skin
it is also known as the subcutaneous layer
the hypodermis contains the Pacinian corpuscles which are sensitive to vibration
along with Ruffini sensory corpuscles are sensitive to joint position sense
the skin has the following appendages from which tumors may arise:
o hair follicles
o sweat glands [two types]:
eccrine which are found all over the body
these are innervated by cholinergic nerves
eccrine glands produce water and salts which are excreted
through tiny tubules
involved in thermoregulation
apocrine glands are specialized glands found in the axilla, mons pubis
and around the anus
these are innervated by adrenergic nerves
apocrine glands are outgrowths of the upper portions of hair
follicles and secrete an oily mixture
involved in body scent
o sebaceous glands which produce an oily secretion called sebum
these occur everywhere EXCEPT where there is thick skin in the palms
and soles
they are abundant in the scalp and face
they are holocrine glands because their secretions are produced within the
cell followed by the rupture of the plasma membrane which releases the
cellular contents into the lumen
59
THORACIC ANATOMY
Manubrium
Body of Sternum
Xiphoid process
Ribs
Classification of Ribs
Ribs may be classified as:
o true [vertebrosternal]
o false [vertebrochondral]
o floating [vertebral]
ribs 1-7 are classified as true ribs because they are articulate with the sternum
ribs 8, 9 and usually 10 are called false ribs because their cartilaginous ends are articulate with
the cartilage of the rib above them
ribs 11 and 12 are known as floating ribs as their anterior ends are not connected
Typical Ribs
rd th
3 through to 9 ribs are described as typical ribs because of the following common features:
o a head with two articular demi-facets:
the upper demi-facet articulates with the vertebra above
the lower demi-facet articulates with the corresponding vertebra
o there is a neck between head and tubercle
o the upper border of neck has a crest for attachment of the superior costotransverse
ligament
o there is a tubercle with 2 areas:
smooth oval facet for articulation with the transverse process of corresponding
vertebra
rough part for attachment of the lateral costotransverse ligament
o the angle lies between tubercle and the shaft
o the shaft has external/internal surfaces and superior/inferior borders
60
o the upper border is smooth and rounded
o the lower border is sharp and shelters the costal groove
o the costal groove passes along the inferior border of the internal surface
o the costal cartilage is the unossified anterior end of the rib
o the costal ends articulate with the sternum via synovial joints [2-7]
st
o all of the costosternal joints are synovial joints except the 1 which is primary
cartilaginous
Shaft
Head
Neck
Articular facet on tubercle
Costal groove
Costal end
Intercostal Space
the intercostal space lies between two adjacent ribs which are connected by three intercostal
muscles:
o external with its fibers running downwards and medially [hands-in-the-pocket fashion]
o internal with its fibers running upwards and medially [downwards and backwards]
o innermost with its fibers running upwards and medially [downwards and backwards]
the neurovascular bundle runs between the internal and innermost intercostal muscles in the
following order from top to bottom in the costal groove:
o intercostal Vein which drains into the azygos venous system
o intercostal Artery from the internal thoracic artery and the thoracic aorta
o intercostal Nerve which is the ventral ramus of the thoracic spinal nerve
it is covered by skin externally and by parietal pleura internally
61
Breast
the female breast is variable in size and location
it is a modified apocrine sweat gland located in the superficial fascia except for its tail [of
Spence] which is located under the deep fascia in the axilla
nd th
usually lying over the anterior chest between 2 and 6 ribs
there are 15-20 radially arranged lobules of acinar glandular tissue embedded in fat and fibrous
tissue
glandular tissue is attached to the skin above and the pectoral fascia below by the suspensory
ligaments [of Cooper] of the breast
glandular tissue opens on to the lactiferous ducts which are dilated towards the end as the
lactiferous sinuses before opening on to the nipple
the nipple lies in the center of the areola which is the darkened area of skin on the breast
supplied by the following arteries:
o lateral thoracic artery
o internal thoracic artery
nd th
o 2 to 4 anterior intercostal arteries
lymphatic drainage:
o 75% of the breast drains to the anterior [pectoral] group of axillary nodes
o then to central group of axillary nodes and the apical group of axillary nodes
o most of the rest drains to nodes along the internal thoracic artery
o a small amount drains to the opposite side and downwards to the anterior abdominal wall
Posterior group
Areola
Mediastinum
this is the space between the lungs
a horizontal line passing through the manubriosternal joint [angle of Louis] and the
intervertebral disc of T4 and T5 separates the superior from the inferior mediastinum
in addition this horizontal line marks the following events:
o the manubriosternal joint between the manubrium and body of the sternum
o the articulation of the second rib with the sternum
o the bifurcation of the trachea
o the bifurcation of the pulmonary trunk
o the arch of the aorta begins
o the arch of the aorta ends
o the thoracic duct crosses from right to left
o the left recurrent laryngeal nerve passes under the aortic arch
62
the superior division contains the following structures [TVPASTER]:
o Trachea
o Vagus nerves
o Phrenic nerves
o Arch of the aorta and its branches
o Superior Vena Cava
o Thoracic duct
o Esophagus
o Remnant of the thymus gland
the inferior mediastinum is further subdivided into three compartments:
o middle compartment
o anterior compartment lies between the sternum and the heart
o posterior compartment lies between the heart and the thoracic vertebra
the anterior compartment contains:
o connective tissue
o lymph nodes
o remnants of the thymus
the middle compartment contains:
o heart
o pericardium
o roots of the great vessels
o phrenic nerves
the posterior compartment contains the following structures [VS DATES]:
o Vagus nerves
o Splanchnic nerves
o Descending thoracic aorta and its branches:
posterior intercostal arteries
esophageal branches
bronchial arteries
o Azygos venous system
o Thoracic duct
o Esophagus
o Sympathetic trunks
Esophagus
10” long muscular tube lined by stratified squanous epithelium
it begins at the inferior border of the cricoid cartilage at C6
it passes behind the trachea in the lover part of the neck and in the superior mediastinum
it lies behind the left atrium of the heart in the posterior mediastinum
it passes through the diagphragm at the level of T10
it ends at T11 by joining the stomach
it has three layers:
o inner layer-stratified non-keratinized squamous epithelium
o middle layer-submucosa with esophageal glands
o outer layer-two layers of muscle, outer longitudinal and inner circular
the esophagus may be divided into three thirds
the upper third is surrounded by skeletal muscle
the lower third is surrounded by smooth muscle
the middle third is surrounded by a mixture of both
the upper third is supplied by branches of the inferior thyroid artery
the middle third is supplied by branches of the thoracic aorta
the lower third is supplied by branches of the left gastric artery
the venous drainage is via the inferior thyroid, esophageal and left gastric veins
the upper third drains into lower deep cervical lymph nodes
the middle third drains into mediastinal lymph nodes
the lower third drains into left gastric lymph nodes
there are three areas of narrowing in the esophagus:
o at C6 where it begins
o at T5 where it is crossed by the left bronchus
o at T10 where it passes through the diaphragm
63
URINARY ANATOMY
Embryology
the kidney and ureter have a different embryological origin from the bladder
the kidney develops in the mesoderm from three successive systems:
o pronephros-this disappears early
o mesonephros-this also disappears early leaving the mesonephric [Wolffian] duct
o finally from the metanephros which remains to develop into the secretory part of the
kidney
the ureteric bud of the mesonephric duct develops into the collecting system and the ureter
the bladder arises from the urogenital sinus [endoderm]
Pronephros
Mesonephros
Mesonephric duct
Ureteric bud
Metanephros
Kidney
bean-shaped retroperitoneal organ measuring 4” long by 2” wide by 1” thick
right kidney lies ½” lower than the left because of the larger right lobe of the liver
hilum is located in the medial indentation of the kidney and has the following structures situated
from anterior to posterior:
o renal vein
o renal artery
o ureter
covered by three coverings:
o thin fibrous capsule
o peri-renal fat enclosed in a layer called the renal fascia
o surrounded by another layer of fat called extraperitoneal or para-renal fat
posterior relations of the kidney include 4 muscles, 3 nerves, 2 vessels and 1 bone:
o 4 muscles-diaphragm, quadratus lumborum, psoas major and transversus abdominis
o 3 nerves-subcostal, iliohypogastric and ilioinguinal nerves
o 2 vessels-subcostal vein and artery
th th
o 1 bone-12 rib [add the 11 rib on the left side]
supplied by the renal artery
o the renal artery is a branch of the abdominal aorta at L1 level
o each renal artery has five segmental branches from which the interlobar, then arcuate,
then interlobular arteries, afferent arterioles, glomerulus and efferent arterioles arise
renal veins drain into the inferior vena cava
o right renal vein is shorter and has no tributaries
o left renal vein is longer and receives the following tributaries:
left adrenal vein
left gonadal vein
64
Aorta
IVC
Renal vein
Renal artery
Ureter
Hilum of kidney
Ureter
Bladder
highly distensible receptacle for urine with a capacity of 300 cc
its triangular base lies posteriorly
the bladder lies superior to the prostate in the male
the bladder lies inferior to the uterus in the female
the bladder is made up of smooth [detrusor] muscle lined by transitional epithelium
65
there are two bladder sphincters: internal and external
o internal sphincter is comprised of smooth muscle which is relaxed by the pelvic
splanchnic nerves [S2, 3 and 4] and is contracted by the sympathetic fibers
o external sphincter is skeletal and is controlled by the pudendal nerve [S2, 3, 4]
Prostate
an unpaired fibromuscular gland found only in males
it is pyramidal in shape with its apex pointing inferiorly and lies on the urogenital diaphragm
st
it surrounds the 1 part of the urethra
made up of 5 lobes: anterior, posterior, right and left lateral with the median lobe lying between and
above the ejaculatory ducts
it is made up of 3 distinct zones-peripheral [70%], central [25%] and transitional [5%]
it is covered by 2 capsules: true thin fibrous capsule and a false capsule which is a
condensation of endopelvic fascia
the prostatic venous plexus lies in between the two capsules
prostatic venous plexus communicates with the external and then internal vertebral venous
plexuses which have no valves [Batson] allowing for easy spread of prostatic cancer to lumbar
vertebrae via the basivertebral veins
the prostate lies below the bladder, above the urogenital diaphragm, in front of the rectum
and behind the pubic bone
Ureter
Ductus deferens
Seminal vesicle
Prostate
Urethra
Fig 61: Prostate
Urethra
approximately 8 inches long in the male and 1¾ inches in the female
male urethra is divided into prostatic, membranous and penile parts
membranous part is the shortest part measuring ½ to ¾ inch
penile part passes through the corpus spongiosum and opens at the urethral orifice which is
located in the undersurface of the glans of the penis
bulbourethral glands [of Cowper] in the male lie within the urogenital diaphragm and drain into
the penile part of the urethra
shorter female urethra lies anterior to the vagina and its opening lies between the clitoris
anteriorly and the vaginal orifice posteriorly
Ductus deferens
Prostate
Spongy urethra
Epididymis
Testis
66
SPINAL ANATOMY
67
68
VERTEBRAL COLUMN
Vertebral Embryology
develops in the mesoderm
the notochord guides the development of the vertebral column and spinal cord
the notochord gives rise to the nucleus pulposus of the intervertebral disc
the notochord persists as the nucleus pulposus
condensations of mesoderm around the notochord called somites are formed
from the somites develop the following:
o sclerotomes from which the vertebrae develop:
3 primary ossification centers:
centrum [for the body]
right and left halves of the neural arch
5 secondary ossification centers:
spinous process
right and left transverse process
upper and lower vertebral endplates
o myotomes from which muscle develops:
somatic skeletal muscles
splanchnic smooth muscles
epimere extensor muscles
hypomere flexor muscles
o dermatomes from which the peripheral nerves develop
chondrification-mesoderm is replaced by cartilage
ossification-cartilage is replaced by bone:
o intramembranous-bone is formed within a membrane
o intracartilaginous-bone is formed within cartilage
Typical Vertebra
large weight bearing body anteriorly
2 pedicles posterolaterally
2 transverse processes laterally
2 laminae forming the neural arch
1 spinous process posteriorly
superior articular process with its facet facing backwards
inferior articular process with its facet facing forwards
pars interarticularis between the superior and inferior articular processes
vertebral canal behind the body
Pedicle
Vertebral foramen
Body
Inferior articular process
Spinous process
69
Regional Vertebral Characteristics
cervical-rectangular body, bifid spinous process, transverse foramina in the transverse
process which possess anterior and posterior tubercles
thoracic-heart-shaped body, sloping spinous process, costal facets on body and transverse
process
lumbar-kidney-shape body, quadrangular spinous process, mammillary and accessory
processes
atypical cervical vertebra:
C1 [atlas]
no body
large lateral masses
anterior arch and an posterior arch with a groove for vertebral artery
C2 [axis or epistropheus]
dens or odontoid process is present
C7 [vertebra prominens]
long non-bifid spinous process
regional orientation of the superior articular facets differ also:
cervical facets face backwards, upwards and medially [BUM] in the horizontal
plane
thoracic facets face backwards, upwards and laterally [BUL] in the coronal plane
lumbar facets face backwards and medially [BM] in the sagittal plane
the inferior articular facets face in the opposite direction
Vertebral Ligaments
anterior longitudinal ligament:
extends from the sacrum to the basal part of the occiput
thicker and stronger than the posterior longitudinal ligament
prevents hyperextension of the spine
posterior longitudinal ligament
extends from C2 to the sacrum
thin and weak, prevents hyperflexion of the spine
this ligament continues as the tectorial membrane upwards and beyond C2
supraspinous ligament:
connects the tips of the spinous processes
prevents hyperflexion
this continues as the nuchal ligament upwards and beyond C7
interspinous ligament:
runs in between the spinous processes of adjacent vertebrae
prevents posterior translation and limits flexion
ligamentum flavum:
extends between the laminae of adjacent vertebral
contains lots of elastic tissue which limits flexion and prevents buckling in extension
intertransverse ligament:
runs between the transverse processes of adjacent vertebrae
limits lateral bending
alar ligament [aka check ligament]:
o originates from the posterior and lateral aspects of the dens
o inserts into the medial aspect of the condyle of the occiput
o limits axial rotation
apical ligament:
arises from the apex of the dens
inserts into the anterior aspect of the foramen magnum
limits flexion and extension of C2
cruciate ligament:
shaped like a cross
transverse ligament extends from a small medial tubercle [colliculus atlantis] on the
lateral mass of the atlas to the same tubercle on the other side
superior longitudinal ligament extends from the middle of the transverse ligament to the
anterior lip of the foramen magnum between tectorial membrane and the apical ligament
inferior longitudinal ligament extends from middle of transverse ligament to body of C2
limits lateral translation
70
Posterior longitudinal ligament Supraspinous ligament
Interspinous ligament
Anterior longitudinal ligament
Intervertebral Disc
fibrocartilaginous sandwich with outer Type I and inner Type II collagen fibers
the outer part is the anulus fibrosus which has 15-20 concentric laminae
0
its fibers at 40-70 to the vertical
0
the fibers of the next lamina run in the opposite direction at 120-130 to the vertical
the inner aspect is called the nucleus pulposus
it has a gelatinous consistency and is located posterocentrally in the lumbar region
lies between two adjacent vertebral endplates which are considered as part of the disc
thickest in the lumbar region and thinnest in the thoracic region
only the outer third of the anulus fibrosus is innervated:
the sinuvertebral [recurrent meningeal] nerve posteriorly
sensory nerves which run in the gray sympathetic rami communicantes laterally
the disc is not well-vascularized as it is nourished by diffusion from the vertebral endplates
the diffusion [imbibition] is facilitated by movement of the spine
there are 23 intervertebral discs as there is none between C1 and C2
Nucleus pulposus
Anulus fibrosus
71
Inferior vertebral notch
Transforaminal ligaments
Spinal nerve
Intervertebral disc
Spinous process
Extra-dural space
Neural arch
Dura
Arachnoid
Spinal nerve
Pia
72
SPINAL JOINTS
Atlanto-Occipital Joint
Type Synovial
Classification Condylar
Bones involved Condyle of occipital bone and superior articular facet of C1
Range of motion Flexion, extension and a little lateral bending and rotation
Muscles acting Flexion-longus capitis and rectus anterior
Extension-SCM, semispinalis, splenius
Lateral bending-rectus lateralis, SCM and trapezius
Innervation C1
73
Sacroiliac Joint
Type Compound made up of an anterior synovial joint and posterior syndesmosis
Classification Reciprocal interlocking planar which allows minimal gliding
Bones involved Articular surface of the ilium and the auricular aspect of the sacrum
Range of motion Nutation and counternutation around an axis passing through S2
Nutation-forward movement of the base of the sacrum [like nodding]
Counternutation-backward movement of the base of sacrum
Muscles acting All muscles acting on the lower spine and hip:
mainly erector spinae and psoas major
Innervation Superior gluteal nerve and branches from S1 and S2
Costovertebral Joint
Type Synovial
Classification Planar
Bones involved Body of the vertebra and the head of the corresponding rib
Range of motion Upper 6 joints-pump handle action; lower 6 joints-bucket handle action
Muscles acting Intercostals and diaphragm
Innervation Segmental spinal nerve
Costotransverse Joint
Type Synovial
Classification Planar
Bones involved Tubercle of the rib and the transverse process of the corresponding
vertebra
Range of motion Upper six costotransverse joints allow rotation and the lower six joints allow for
gliding
Muscles acting Intercostal and diaphragm
Innervation Segmental spinal nerve
Costochondral joint
Type Primary cartilaginous
Classification Synchondrosis
Structures Distal end of the rib and cartilage
Range of motion None
Muscles acting Intercostal and diaphragm
Innervation Segmental spinal nerve
Sternochondral joint
st nd th
Type 1 is a primary cartilaginous and 2 to 7 are synovial
st
Classification Synchondrosis for the 1 and planar for the others
Structures Cartilage and sternum
Range of motion Pump handle during respiration
Muscles acting Intercostal
Innervation Segmental spinal nerve
Manubriosternal joint
Type Secondary cartilaginous
Classification Symphysis
Bones involved Manubrium and body of sternum
Range of motion Slight increase and decrease angulation during respiration
Muscles acting Intercostal
Innervation Segmental spinal nerve
Xiphisternal joint
Type Secondary cartilaginous
th
Classification Symphysis, becomes an synostosis after the 40 year
Bones involved Body of sternum and xiphoid process
Range of motion very little
Muscles acting Intercostals, diaphragm and rectus abdominis
Innervation Segmental spinal nerve
74
BACK MUSCLES
Erector spinae
arranged in three parallel groups from lateral to medial: iliocostalis, longissimus and spinalis
each of these groups is further subdivided into subgroups: iliocostalis lumborum, thoracic and
cervicis, longissimus thoracic, cervicis and capitis and spinalis thoracis, cervicis and capitis
there are architectural and functional differences in the thoracic and lumbar portions of these
muscles
Bogduk et al recommended further partitioning of the lumbar and thoracic portions of longissimus
thoracis and iliocostalis lumborum into the following:
o longissimus thoracis pars lumborum
o longissimus thoracic pars thoracis
o iliocostalis lumborum pars lumborum
o iliocostalis lumborum pars thoracis
the lumbar component of these muscles function differently that their thoracic counterparts
o their line of action is not parallel to the compressive axis of the spine but rather in a
posterior caudal obliquity causing a posterior shear force together with an extensor
movement of the superior vertebrae
the thoracic portion of these two muscles is parallel to the compressive axis of the spine and results
a greater extension with minimal compression
the erector spinae muscles are supplied by branches of the dorsal rami of the segmental spinal
nerves
Multifidus
the multifidus [many splits] muscles are the most medial of the lumbar back muscles
work differently from the more lateral extensors especially in the lumbar region where they slop
upwards from the laminae and mammillary processes to the spinous process of vertebrae 2 or 3
over their level of origin commencing at the upper part of the sacrum and ending at C2
affect local areas of the spine and producing extension, lateral bending and contralateral rotation
these muscles are loaded with mechanoreceptors
acting more in providing information in initiation and correction of movement at the specific spinal
motor unit level and less in actual overall movement of the spine as a whole
75
SPINAL CORD REVIEW
Spinal Cord
18-inch-long structure begins at the foramen magnum and ends at L1/2 in an adult
2 regional enlargements-cervical [largest at C6] and lumbosacral regions for the brachial
and lumbosacral plexuses respectively
the dilated end of the spinal cord is called the conus medullaris [medullary cone]
the nerves that leave the end of the spinal cord are known as the cauda equina
the spinal cord is covered by three coverings or meninges:
o outermost is the tough dura mater [single layer compared to cranial dura]
o thin web-like arachnoid mater with subarachnoid space beneath with CSF
o thinner pia mater with filum terminale and two dentate ligaments [each with 21 teeth]
which anchor the spinal cord to the spinal dura
the dural sac ends at S2
the filum terminale is 20 cm long and is divided into two parts:
o filum terminale interna [15 cm long] extends from the conus medulla to the end of the
dural sac at S2
o filum terminale externa [5 cm long] fuses with the dura and extends to the coccyx
the spinal cord lies within the spinal canal
the spinal cord is subdivided longitudinally into 31 segments
each segment of the spinal cord has a pair of ventral and dorsal roots that come together to
form the spinal nerves
the dura and arachnoid extend along the spinal nerves as they pass through the IVF
76
the descending tracts carry axons that control skeletal motor function, smooth muscles and
secretory glands
all descending tracts are motor EXCEPT the raphespinal tract which modulates nociception
Fasciculus gracilis
Posteromedian sulcus Fasciculus cuneatus
Rubrospinal
Tract
Ventral
Ventral
Spinocerebellar Tract
Corticospinal
Anterolateral System Tract
Fig 68: Spinal Cord Cross Section
Ascending 1st Order Neuron 2nd Order Neuron Decussation 3rd Order Neuron
Dorsal column Mechanoreceptors Nuclei gracilis and Medulla VPL nucleus of the
Vibration cuneatus thalamus
Fine touch
Spinothalamic Nociceptors, Lamina I and II in Spinal cord VPL nucleus of the
[Anterolateral thermoreceptors the dorsal horn of thalamus
System] and light touch the grey matter
receptors
Dorsal Unconscious Clarke’s nucleus Does not cross Cerebellum via
Spinocerebellar proprioception [dorsal nucleus] Remains inferior cerebellar
from the lower found in the ipsilateral peduncle
limb thoracic region
Ventral Unconscious Lamina VII Twicefirst at the Cerebellum via
Spinocerebellar proprioception spinal cord and superior cerebellar
from both lower again in the pons peduncle
and upper limb It remains
ipsilateral
Table 1: Ascending Tracts
st
Descending 1 Order Neuron Decussation 2nd Order Neuron
Rubrospinal Red nucleus Midbrain Laminae VVIII
Tectospinal Tectum of midbrain Midbrain Laminae VI and VIII
Lateral Corticospinal* Precentral gyrus Medulla Laminae IVIX
Ventral Corticospinal Precentral gyrus Spinal cord at level of exit Laminae VIIX
Reticulospinal Reticular Formation Various levels Laminae VIII
Vestibulospinal Vestibular nuclei Uncrossed Laminae VI and VIII
Raphespinal Raphe nucleus Uncrossed Laminae I, II and V
*aka known as the PYRAMIDAL TRACT as its primary neurons are the pyramindal cells in the cerebral cortex
Table 2: Descending Tracts
Descending Function
Lateral Corticospinal Voluntary control of the muscles in the limbs
Ventral Corticospinal Voluntary control of the muscles in the head, neck and trunk
Rubrospinal Excites proximal flexors and inhibits extensors mainly in the upper limb
Reticulospinal Restricts voluntary movements through the gamma motor neurons
Tectospinal Head and eye turning in response to light and sound
Vestibulospinal Involved in postural reflexesneck muscles, extensors of back and limbs
Raphespinal Inhibits nociception by releasing serotonin and acts on the C fibers
77
Post-central gyrus
Brodmann’s areas 3,1,2 Pre-central gyrus
Brodmann’s area 4
CEREBRAL CORTEX
THALAMUS
Posterior limb of
the Internal capsule
MIDBRAIN
Nucleus cuneatus
Nucleus gracilis
MEDULLA
Fig 69: Pain, Temperature, Vibration and Proprioception Fig 70: Voluntary Motor Control
78
o Laminae III and IV as jointly referred to the nucleus proprius
their main input is from fibers that carry mechanoreception and light touch
o Lamina V contains neurons that respond to both noxious and visceral afferent stimuli
o Lamina VI is the deepest layer of the dorsal horn and receives mechanical signals from
the skin and joints
o Lamina VII contains the dorsal nucleus [Clarke’s column] and the intermediolateral
horn or nucleus
the intermediolateral horn is seen in the T1-L2 spinal cord segments and
contains the cell bodies of the preganglionic sympathetic neurons
axons from Clarke’s nucleus ascend the spinal cord and carry unconscious
proprioception
o Laminae VIII and IX represents motor neuron groups in the ventral horn
o Lamina X is the small area of gray matter surrounding the central canal of the spinal cord
and is known as the grey commissure
Posterior spinal artery
Dura mater
Subarachnoid space
I
II
III
IV
V Intermediolateral
VI
VII
horn
X
IX
VIII
79
CNS ANATOMY REVIEW
CNS embryology
derived from the rostral [cranial] end of the neural tube
development is guided by the underlying notochord
it begins with 3 primary dilatations called vesicles
st
1 vesicle is known as the prosencephalon [forebrain]:
o this further develops into secondary vesicles from which develop:
the telencephalon from which the cerebral hemispheres and the lateral
ventricles ultimately develop
the diencephalon which gives rise to the thalamus, epithalamus and
subthalamic nuclei
nd
2 vesicle is the mesencephalon [midbrain]:
o this becomes the mid brain
rd
3 vesicle is the rhombencephalon [hindbrain]:
o this vesicle further develops into:
the metencephalon
this develops into the pons and the cerebellum
the myelencephalon
th
this becomes the medulla and the 4 ventricle
Cerebral
Hemispheres
Telencephalon
Prosencephalon
Diencephalon Thalamus
Metencephalon Pons
Rhombencephalon
Myelencephalon Medulla
80
Lobes in the brain
Frontal [thinking and motor function] lies in front of the central sulcus
Parietal [sensory] lies between the central sulcus and the parieto-occipital fissure
Occipital [visual] lies behind a line connecting the parieto-occipital fissure and preoccipital notch
Temporal [hearing, smell and memory] lies onferior to he lateral fissure
Precentral gyrus [motor] Postcentral gyrus [sensory]
Parietal lobe
Frontal lobe
Occipital lobe
Lateral fissure
Preoccipital notch
Superior Ttemporal gyrius
Temporal lobe
Fig 73: Lobes of the Brain
Types of white fibers
commissural [right to left cerebral hemisphere or right and left halves of the spinal cord]:
o anterior and posterior commissures, and corpus callosum in the brain
o white commissural fibers in the spinal cord for tracts that decussate
association [from one part to another part on the same hemisphere]:
o visual and auditory association fibers
projection [from brain to spinal cord and vice versa]: corticospinal tract
Anterior
Communicating
Artery Anterior Cerebral Artery
Internal Carotid Artery
Posterior
Communicating
artery Posterior
Cerebral
Artery Superior Cerebellar artery
Basilar artery
Labyrinthine artery
Posterior Inferior Cerebellar artery
Vertebral artery Anterior spinal artery
81
Distribution of blood supply
Anterior Cerebral Artery
o medial aspect of the cerebral hemisphere up to the parieto-occipital fissure
Middle Cerebral Artery
o rest of the cerebral hemisphere up to the parietal-occipital fissure
o upper part of the temporal lobe
Posterior Cerebral Artery
o occipital lobe, inferior portion of the temporal lobe
o midbrain and thalamus
Superior Cerebellar Artery
o superior part of cerebellum
Anterior Inferior Cerebellar Artery
o anterior Inferior part of cerebellum
Posterior Inferior Cerebellar Artery
o posterior Inferior part of cerebellum
Basilar Artery
o pons which contains the nuclei for CN V, VI, VII and VIII
Vertebral Artery
o medulla which contains the nuclei of the last 4 cranial nerves: CN IX, X, XI and XII
The blood supply of the brain is regulated by the levels of CO2
o High levels of carbon dioxide causes vasodilation
4 312
Middle Cerebral
Artery
45 44 22 17
17
Mnemonic: Some Say Marry Money But My Brother Says Bigger Brains Matter Most
82
Olfactory bulb of CN I
Olfactory tract of CN I
CN II
CN III
CN IV
CN V
CN VII CN VI
CN VIII
CN IX
CN X
CN XII
CN I
Olfactory nerves
The specialized sensory bipolar neurons are located in the olfactory mucosa which is found in
the roof of the nasal cavity
Axons from these bipolar neurons pass through the cribriform plate of the ethmoid bone
Unlike other neurons, these neurons have the unique ability to regenerate after they are
destroyed like following the common cold
The axons of these receptor cells synapse with the mitral cells in the olfactory bulb
Most of the fibers from the mitral cells pass backwards in the olfactory tract
These fibers end in the primary olfactory cortex which is located in the temporal lobe
The olfactory cortex has connections with other parts of the brain including the hippocampus
linking smell with memory
It is also linked with:
o hypothalamus-linking smell with the autonomic nervous system
o limbic system-linking smell with emotions
It is the only cranial nerve that is not linked initially to the thalamus before its fibers terminate in
the primary olfactory cortex in the temporal cortex
83
CN II
Optic nerve
Specialized sensory neurons [rods and cones] are in the retina at the back of the eyeball
Visual impulses are sent to the optic nerve via axons of the ganglion cells of the retina
The optic nerves meet at the optic chiasm which lies above the pituitary fossa
Impulses from the nasal retina [temporal field of vision] cross over at the chiasm
Damage at the optic chiasm will present with bitemporal hemianopia
Fibers from the optic nerve synapse in the lateral geniculate body of the thalamus
Fibers from the thalamus continue as the optic radiation [geniculocalcarine tract] to the primary
visual cortex
Damage to the optic radiation will present with homonymous hemianopia
Primary visual cortex is located in the occipital lobe on either side of the calcarine fissure
[Brodmann’s Area 17]
Damage to this area will result in homonymous hemianopia with macular sparing
Temporal visual field
Optic nerve
Bitemporal hemianopia
Pituitary stalk
Optic tract
Lateral
Geniculate
Body
Homonymous hemianopia
Optic radiation
Homonymous hemianopia
with macular sparing
Primary Visual Cortex Area 17
Fig 77: Visual Pathways and effects of damage
84
CN V
Largest mixed cranial nerve
The trigeminal nerve has two roots:
o large sensory
o small motor
The motor nucleus of CN V is located in the pons and supplies the muscles of mastication:
Temporalis, Internal [medial] pterygoid, Masseter, External [lateral] pterygoid muscles plus the
mylohyoid, tensor tympani, tensor veli palatini and the anterior belly of the digastric muscle
There are three parts of the sensory trigeminal nucleus:
o mesencephalic [carrying proprioception] is located in the midbrain
o main sensory [carrying touch] is located in the pons
o spinal [carrying pain and temperature] is located in the medulla and extends into the
upper cervical segments of the spinal cord
CN V has three divisions which come off of the Gasserian ganglion:
o ophthalmic
o maxillary
o mandibular
The ophthalmic division:
o gives the following branches [LEFT] which pass through the superior orbital foramen:
Lacrimal
Ethmoidal
Frontal
Trochlear
The maxillary division:
o divides into the following branches [PINZ] after exiting through the foramen rotundum:
Pharyngeal
Infraorbital
Nasopalatine
Zygomatic
The mandibular division:
o divides into anterior and posterior divisions after exiting the skull via the foramen
ovale
o before it divides, the trunk gives off one branch: the nerve to medial pterygoid
o the anterior division has the following terminal branches [3 motor and 1 sensory nerves]:
deep temporal nerves [motor]
nerve to the lateral pterygoid [motor]
nerve to masseter [motor]
buccal nerve [sensory]
o the posterior division has the following branches [3 sensory and 1 motor branches]:
auriculotemporal [sensory]
inferior alveolar [sensory]
lingual [sensory]
nerve to mylohyoid [motor]
the ciliary ganglion is attached to the ophthalmic division of CN V [nasociliary nerve]
o this receives parasympathetic fibers from the Edinger-Westphal nucleus via CN III
the pterygopalatine ganglion is attached to the maxillary division of CN V
o this receives parasympathetic fibers from the Superior Salivary nucleus via CN VII
the otic ganglion is attached to the auriculotemporal branch of the mandibular division of CN V
o this receives parasympathetic fibers from the Inferior Salivary nucleus via CN IX
the submandibular ganglion is attached to the lingual branch of the anterior division of the
mandibular division
o this receives parasympathetic fibers from the Superior Salivary nucleus via CN VII
CN VII
very mixed nerve with four different nuclei:
o motor [motor nucleus in the pons]
o ordinary sensation [sensory nucleus of the trigeminal nerve]
o parasympathetic [superior salivary nucleus]
o taste [solitary tract nucleus]
its motor nucleus is located in the pons
it leaves the brain stem at the pontomedullary angle
85
it enters the skull via the internal acoustic meatus located in the temporal bone
it leaves the skull via the stylomastoid foramen located in the temporal bone
it carries motor fibers to the muscles of facial expression via the following branches:
o Temporal
o Zygomatic
o Buccal
o Marginal mandibular
o Cervical
o Ten Zebras Broke My Car is the mnemonic for the 5 branches
it also innervates the stapedius muscle in the middle ear plus the muscles of the ear and the
posterior belly of digastric
it conveys taste from the anterior two thirds of the tongue to the nucleus solitarius
it also carries parasympathetic innervation from the Superior Salivary nucleus to the
submandibular and sublingual salivary glands via the submandibular ganglion of CN V3
the taste and parasympathetic fibers are carried by the chorda tympani which connects the
facial nerve to the lingual branch of CN V3
taste sensation from the tongue:
o sweet and sour [sides of the tongue-CN VII]
o salt [tip of the tongue-CN VII]
o bitter [root of the tongue which is supplied by CN IX]
the facial nerve also carries a few general sensory afferent fibers from the skin of the external
ear canal via the auricular branch of CN X
these sensory fibers end in the trigeminal sensory nucleus before crossing over to the opposite
to synapse in the Ventral Posterior Medial nucleus of the thalamus
CN VIII
sensory nerve [with a very very small motor component]
it has two distinct parts:
o cochlear [hearing]
o vestibular [balance]
the cochlear fibers arise from the central portions of the bipolar spiral ganglion cells of the
cochlea from the organs of Corti found in the inner ear
o these fibers traverse the internal auditory meatus to reach the lateral aspect of the
medulla
o these fibers terminate in the dorsal and ventral cochlear nuclei in the medulla
o the majority of the efferent fibers from these nuclei cross to the opposite side ending in
the nuclei in the trapezoid body
o from here fibers ascend through the inferior colliculus
o from here fibers go into the medial geniculate body in the thalamus
o from here fibers finally sweep laterally to the primary auditory cortex which is located in
the middle portion of the superior temporal gyrus [Brodmann’s area 22]
the vestibular fibers on the other hand, arise from the semicircular canals [head turning-angular
acceleration], utricle and saccule [gravity-linear acceleration] in the inner ear
o these fibers enter the medulla just medial to the cochlear division of CN VIII
th
o the fibers end in the vestibular nuclei located in the floor of the 4 ventricle
o many of the efferent fibers from the vestibular nuclei pass to the cerebellum through the
inferior cerebellar peduncle
there are a small number of efferent [motor] fibers which end up on the outer hair cells in the
organ of Corti in the inner ear
o they modulate the stiffness of the outer hair cells and attenuate loud sounds
CN IX
mixed nerve
it contains motor fibers from the nucleus ambiguus to one muscle-Stylopharyngeus
sensation from the posterior third of tongue and pharynx to the sensory nucleus of CN V
it carries taste from the posterior third of the tongue to the nucleus solitarius in the medulla
it also carries parasympathetic innervation to the parotid gland via the otic ganglion of CN V3
from the inferior salivary nucleus in the medulla
it leaves the skull via the jugular foramen
its carotid branch runs down on the internal carotid artery to supply the carotid body
[chemoreceptors] and the carotid sinus [baroreceptors]
86
CN X
mixed nerve: motor, sensory and parasympathetic
the General Somatic Efferent component is derived from the nucleus ambiguus [skeletal motor]
the General Visceral Efferent component from the dorsal motor nucleus of CN X [visceromotor]
the General Somatic Afferent component is related to the spinal nucleus of CN V [sensory]
the General Visceral Afferent fibers arise from the solitary nucleus [sensory]
the Special Visceral Afferent fibers from the base of the tongue go to the solitary nucleus [taste]
CN X leaves the brain stem in the groove between the olive and the cerebellum
It passes through the jugular foramen after which it gives off its tympanic branch
the tympanic branch enters the middle ear cavity to form the tympanic plexus
below the jugular foramen, CN X passes between the superior and middle constrictors
breaks up into its terminal branches to supply the root of the tongue, tonsils and muscles and
mucosa of the pharynx
the vagus nerve passes through the neck and thorax and ends in the abdomen
it carries parasympathetic innervation to the thorax and abdomen as far as the transverse
colon
it also carries sensory fibers from the thorax and abdomen
in fact the ratio of afferent [sensory] to efferent [motor] fibers in the vagus is 10:1
CN XI
motor nerve
there are two parts of the nerve:
o cranial [from the nucleus ambiguus] accessory
o spinal [from spinal nuclei in the C1-C5 spinal cord segments] accessory
the cranial part:
o contains fibers of the cranial root emerge from the medulla as rootlets posterior to the
olive
o these rootlets unite to form a single nerve which is joined by the spinal part before
passing through the jugular foramen
o on leaving the skull, the cranial part leaves the nerve and joins the vagus nerve to
supply the muscles of the palate, pharynx and larynx
the spinal part:
o arises from rootlets from the upper five cervical segments of the spinal cord
o they join together and pass upwards through the foramen magnum to join with the cranial
part of the cranial nerve
o on exiting the skull, it pierces and supplies the sternocleidomastoid muscle
o it passes through the posterior cervical triangle
o and ends up piercing and supplying the trapezius muscle
CN XII
motor nerve
all of the intrinsic and extrinsic muscles of the tongue are supplied by the hypoglossal nerve
EXCEPT:
o palatoglossus which is innervated by the pharyngeal plexus of the vagus
the nerve begins as rootlets found in the groove between the pyramid and the olive in the medulla
it exits the skull via the hypoglossal foramen located in the occipital bone
it descends passing between the internal carotid artery and the internal jugular vein
it then loops upwards and forwards crossing the hyoglossus muscle to enter the tongue from
below
87
SVE
o Special Visceral Efferents
o Motor to:
Muscles from the branchial [pharyngeal] arches
Arch 1 CN V muscles of mastication
Arch 2 CN VII muscles of facial expression
Arch 3 CN IX stylopharyngeus
Arch 4 CN X muscles of the pharynx and larynx
GSA
o General Somatic Afferents
o Ordinary sensation-pain, temperature, touch, vibration and proprioception
GVA
o General Visceral Afferents
o Sensory from gut: distension and stretch
SSA
o Special Somatic Afferents
o Special senses: vision, hearing and balance
SVA
o Special Visceral Afferents
o Special Senses to do with the gut:
taste
smell
88
Caudate nucleus
Thalamus
Thalamus
Major transit area for all sensory input on the way to the cortex EXCEPT from the olfactory nerves
4 major thalamic nuclei to remember:
VentroPosteroLateral: input from the neck and below
VentroPosteroMedial: input from the head
Lateral geniculate body: visual input [Light] connects with the Superior Colliculus
Medial geniculate body: auditory input [Music] connects with the Inferior Colliculus
Basal Ganglia
These collections of interconnected neurons exert influence on the motor activity of the brain through
inhibition or facilitation. The ganglia or nuclei that make up the basal ganglia are:
caudate nucleus
lentiform nucleus which is made up of the putamen, globus pallidus externa and interna
o the corpus striatum is made up of the caudate nucleus and the putamen
o the anterior limb of the internal capsule separates the caudate from the putamen
substantia nigra which has two parts:
o pars compacta
o pars reticulata
Cerebellum
3 lobes:
o anterior [spinocerebellum]-balance of the arms and legs
o posterior [cerebrocerebellum]-receives information from the cortex
o flocculonodular [vestibulocerebellum]-balance of the trunk
3 peduncles:
o superior [mainly output to the cerebral cortex]
o middle [mainly input from the cortex carrying the cortico-ponto-cerebellar fibers]
o inferior [minor input from the body via the dorsal spinocerebellar tract ]
3 main nuclei [Flowers Grow Every Day-from medial to lateral]:
o Fastigial nucleus which is related to the spine
o Interpositus which is made up of:
Globose nucleus which is related to proximal joints e.g. Glenohumeral
Emboliform nucleus which is related to middle joints e.g. Elbow joint
o Dentate nucleus which is related to distal joints e.g. Digital joints
3 cerebellar arteries:
o superior cerebellar artery from the basilar artery
o anterior inferior artery from the basilar artery
o posterior inferior artery from the vertebral artery
89
Blood Brain Barrier
this barrier is formed by three structures:
o tight junctions between non-fenestrated capillary endothelial cells
o basement membrane
o the processes of astrocytes
glucose and amino acids cross the Blood Brain Barrier by carrier-mediated transport
lipid-soluble substances cross more readily than water soluble ones
few specialized regions in the brain where there are fenestrated capillaries and no blood brain
barrier, namely the area postrema which facilitates vomiting in response to poisons and the
neurohypophysis [posterior pituitary lobe] for secretion of hormones
Vertebral Artery
o derived from the subclavian artery and has four parts
st
o Part 1 lies between its origin from 1 part of the subclavian artery to transverse foramen of C6
o passes between longus coli and scalenus anterior
o passes behind the carotid tubercle [anterior tubercle of C6 transverse process]
o Part 2 lies within the transverse foramina of C6 through to C1
o it is relatively fixed at C2 and C1
o it is accompanied by the vertebral veins and sympathetic nerves
o Part 3 extends from C1 to the foramen magnum
o this part of the vertebral artery is most prone to dissection
o passes posteriorly behind the lateral mass of CI to lie on the posterior arch of C1
o then it passes beneath the posterior atlanto-occipital membrane
o turns upwards to pass through the foramen magnum
o Part 4 is the section of the artery lying above the foramen magnum
o passes forwards to lie anterior to the medulla
o it ends at the lower pons by joining with its counterpart to form the basilar artery
th
4 part
rd
3 part
nd
2 part
st
1 part
Subclavian artery
90
PICA [aka Wallenberg or lateral medullary] syndrome
o occlusion of the vertebral or posterior inferior cerebellar artery
o dysphagia, ataxia, ipsilateral Horner’s syndrome, loss of sensation in the face, loss of
light touch and position sense in the limb on the same side and contralateral loss of
pain and temperature
Medial medullary syndrome
o occlusion of the vertebral artery
o contralateral spastic hemiplegia, loss of touch, vibration and pressure
Clause’s syndrome
o occlusion of the blood supply to the dorsal midbrain
o ipsilateral CN III palsy and contralateral ataxia and tremor
Weber [aka medial midbrain] syndrome
o occlusion of the perforating branches of the posterior cerebral artery
o contralateral spastic paralysis with ipsilateral CN III weakness
CSF circulation
CSF is produced mainly by the choroid plexus in the lateral ventricles
CSF flows into the third ventricle through the interventricular foramina of Monro
From the third ventricle to the fourth ventricle via the cerebral aqueduct of Sylvius
CSF leaves the fourth ventricle via the lateral foramina of Luschka and the median foramen of
Magendie
It circulates in the subarachnoid space and collects in large spaces called cisterna:
cisterna magna [between the medulla and cerebellum-largest collection]
pontine cistern [below the pons]
interpeduncular cistern [between the cerebral peduncles]
chiasmatic cistern [below the optic chiasm]
CSF drains via arachnoid granulation which open into the superior sagittal sinus
Transverse sinus
Sigmoid sinus
Internal Jugular Vein
91
SKULL, SCALP AND FACE
PARIETAL
Pterion
Asterion
Bregma FRONTAL
PARIETAL
FRONTAL BONE Asterion
Sphenoid
Nasion Lambda
TEMPORAL
OCCIPITAL
Asterion
Fig 81 Skull
Important points on the skull
Asterion: this is the point where the temporal, occipital and parietal bones meet
Bregma: this is the meeting point of the frontal and parietal bones [anterior fontanelle]
o the anterior fontanelle should be closed by the first 18 months of life
Glabella: this is the transverse ridge connecting the supraorbital ridges
Inion: this is the highest point on the External Occipital Protuberance
Lambda: this is the meeting point of the occipital and parietal bones [posterior fontanelle]
o the posterior fontanelle is closed by the first 2-3 months of life
Nasion: this is the center of the frontonasal suture between the frontal and nasal bones
Pterion: where frontal, sphenoid, parietal and temporal bones meet
Vertex: highest point on the skull in the sagittal plane
Basion: middle of the posterior aspect of the foramen magnum
92
Cranial foramina, related bone and contents
Foramen cecum [frontal/ethmoid] Nasal emissary vein
Anterior/posterior ethmoidal [ethmoid] Anterior and posterior ethmoidal n/a/vs
Cribriform foramina [ethmoid] Olfactory nerves [CN I]
Optic canal [sphenoid] Optic nerve [CN II] and ophthalmic artery
Superior Orbital Fissure [sphenoid] CN III, CN IV, CN V1, CN VI, ophthalmic veins
Foramen rotundum [sphenoid] CN V2
Foramen ovale [sphenoid] CN V3, accessory meningeal artery and vein
Foramen spinosum [sphenoid] Recurrent meningeal branch of CN V3, middle
meningeal artery and vein
Foramen lacerum [sphenoid/ Internal Carotid Artery, venous plexus, sympathetic
temporal] nerves passing horizontally rather than vertically
Internal acoustic meatus [temporal] CN VII, CN VIII, nervus intermedius and the
labyrinthine artery
Jugular foramen [temporal/ CN IX, X and XI, inferior petrosal sinus, sigmoid sinus
occipital] and the posterior meningeal artery
Hypoglossal foramen [occipital] CN XII
Foramen magnum [occipital] Medulla, vertebral, spinal arteries, spinal part of CN XI
FORAMINA BONE
Foramen cecum
Ethmoid bone
Anterior ethmoidal foramen
Cribriform foramina
Foramen rotundum
Optic canal
Foramen ovale Sphenoid bone
Foramen spinosum
Temporal bone
Foramen lacerum Clivus
Jugular foramen
Hypoglossal foramen
Occipital Bone
Foramen magnum
93
Muscles of facial expression
around the eye:
o orbicularis oculi [closes the eye] and corrugator supercilii [furrows the brow]
around the nose:
o dilator nares, compressor nares and procerus
around the mouth:
o orbicularis oris, zygomaticus major and minor, depressor angularis oris, levator labii
superioris, depressor labii inferioris, rizorius, buccinator and platysma
nd
all muscles of facial expression are derived from the mesoderm of the 2 branchial or pharyngeal
arch
they are innervated by the following branches of CN VII [Ten Zebras Broke My Car]:
o Temporal
o Zygomatic
o Buccal
o Marginal mandibular
o Cervical
Levator palpebrae superioris is not a muscle of expression and is supplied by CN III
the frontalis muscle has a dual innervation meaning that each muscle is separately innervated by
branches of the facial nerves that arise from both sides of the brain
this allows the differentiation of an upper motor neuron lesion from a lower motor neuron lesion
th
of the 7 cranial nerve to be made
th
in an upper motor neuron lesion of the 7 cranial nerve [caused by a stroke] the patient is able
to raise the eyebrow on the affected side
o this is because the frontalis muscle is bilaterally innervated
th
in a lower motor neuron lesion of the 7 cranial nerve [as seen in Bell’s palsy] the patient will
not be able to raise the eyebrow on the affected side
o the muscles of the face on the affected side will be paralyzed resulting in the inability of
the patient to:
o close the eyelids [orbicularis oculi]
o smile [rizorius]
o whistle [buccinator and orbicularis oris]
o blink the eye reflexively
Frontalis
Orbicularis oculi
Compressor naris
Rizorius
Depressor angularis Orbicularis oris
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Derivatives of the branchial [pharyngeal] arches
Paranasal sinuses
frontal sinus
lies in the frontal bone above and between the orbits
drains into the hiatus semilunaris in the middle meatus of the nasal cavity
ethmoid sinuses
lies between the orbits: posterior, middle and anterior
drains into the superior [posterior] and middle [middle and anterior] meatus
maxillary sinus
lies in the maxilla below each orbit
drains into the hiatus semilunaris of the middle meatus
sphenoid sinus
lies in the sphenoid bone below the pituitary fossa
drains into the sphenoethmoidal recess which lies above the superior concha
95
PERIPHERAL NERVOUS SYSTEM ANATOMY REVIEW
Cervical Plexus
derived from the ventral rami of C1, 2, 3, 4 and 5 forming the following:
o C1 supplies geniohyoid and thyrohyoid
o Ansa cervicalis [C1, 2 and 3] supplies all the other infrahyoid muscles:
sternothyroid, sternohyoid and the superior and inferior bellies of omohyoid
o Lesser occipital [C2, perhaps C3] supplies the back of the head up to the vertex
o Great auricular [C2 and 3] supplies most of the ear
o Transverse cervical [C2 and 3] supplies skin over the anterior cervical triangle
o Supraclavicular [C3 and 4] supply skin over the clavicle
o Phrenic [C3, 4 and 5 keeps the diaphragm alive] innervates the diaphragm
o Note that the greater occipital nerve is derived from the dorsal ramus of C2
o Most of the above branches lie in the anterior cervical triangle
CN XII
C4
C5
Phrenic nerve Supraclavicular nerve
96
Roots C5
C6
Trunks
Divisions C7
Cords
C8
T1
Axillary nerve
Median nerve
Ulnar nerve
Musculocutaneous
nerve Axillary artery
Radial nerve
Fig 85: Brachial Plexus
other branches include:
o branches from the roots:
dorsal scapular [C5] supplies levator scapulae, rhomboid major and minor
long thoracic [C5, 6 and 7] which supplies serratus anterior [damage of this
nerve results in a winged scapula]
o branches from the trunks:
suprascapular nerve [C5 and 6] supplies supraspinatus and infraspinatus
nerve to subclavius nerve [C5 and 6] supplies subclavius
o branches from the cords:
posterior cord:
upper and lower subscapular nerves supply the subscapularis
thoracodorsal nerve [C6, 7 and 8] nerve supplies latissimus dorsi
medial cord:
medial pectoral nerve supplies pectoralis minor and major
medial brachial cutaneous nerve supplies the medial arm
medial antebrachial cutaneous nerve supplies the medial forearm
lateral cord:
lateral pectoral nerve supplies pectoralis major
damage to C5 and 6 roots results in Erb-Duchenne palsy with the waiter accepting a tip
appearance [elbow extended, forearm pronated and fingers flexed]
damage to C8 and T1 roots results in Klumpke’s palsy and presents with a claw hand
Lumbar plexus
derived from the ventral rami of L1-4
the plexus is formed within the psoas major
all of its nerves leave the lateral aspect of the psoas major muscle except the following:
o genito-femoral nerve which exits the psoas major anteriorly
o obturator nerve which exits the psoas muscle medially
branches include:
o iliohypogastric nerve [L1] innervates lower abdomen above the inguinal region
o ilioinguinal nerve [L1] supplies the inguinal region
o genitofemoral nerve [L1,2] -medial upper thigh and anterior part of genitalia
o lateral femoral cutaneous [L2,3] supplies the anterolateral aspect of the thigh
o femoral nerve [L2,3,4 posterior divisions] supplies the extensor thigh compartment
o obturator nerve [L2,3,4 anterior divisions] supplies the adductor thigh compartment
o contributes to the formation of the lumbosacral trunk [L4,5]
97
T12
L1
L2
Iliohypogastric nerve
Ilioinguinal nerve L3
Genitofemoral nerve
Lateral femoral cutaneous nerve L4
L4
L5
S3
Sciatic nerve
S4
Pudendal nerve
98
o tibial nerve [L4, 5, S1, 2 and 3] supplies all of the following:
all of the muscles in the posterior compartment of the leg
all of the muscles in the plantar aspect of the foot
divides into the medial and lateral plantar branches after it passed behind the
medial malleolus at the ankle
also supplies all of the skin over the posterior aspect of the leg and the
plantar aspect of the foot
the medial plantar nerve corresponds to the median nerve in the hand and
supplies the flexor digitorum brevis, flexor hallucis brevis, adductor hallucis and
the first lumbrical in the sole of the foot
the lateral plantar nerve corresponds to the ulnar nerve in the hand and
supplies the rest of the muscles in the sole of the foot
o common peroneal nerve [L4, 5, S1 and 2] supplies the anterior and lateral
compartments of the leg:
winds around the neck of the fibula and then divides into superficial and deep
peroneal nerves:
superficial peroneal nerve supplies the muscles in the lateral compartment of
the leg:
peroneus longus
peroneus brevis
also supplies the skin of most of the dorsum of the foot except the
web space between the first and second toes
deep peroneal nerve passes through the peroneus longus [however it does not
supply it] and then enters the anterior compartment of the leg to supply the
following muscles:
tibialis anterior
extensor hallucis longus
extensor digitorum longus
peroneus tertius
also supplies the skin of the web space between the first and second
toes
99
AUTONOMIC NERVOUS SYSTEM REVIEW
Divisions
there are two major divisions:
o sympathetic aka the thoracolumbar outflow [Fight or Flight]
o parasympathetic aka the craniosacral outflow [Rest and Digest]
Sympathetic division
originates in the posterior nuclei in the hypothalamus
preganglionic fibers are derived from the intermediolateral horn of the spinal cord fromT1-12 and
L1-L4
associated ganglia are located near the vertebral column [paravertebral]
connected to the thoracic spinal nerves by white and grey rami communicantes
preganglionic fibers are short and myelinated input [hence white] fibers
postganglionic fibers are long and unmyelinated output [hence grey] fibers
some of the fibers leave the sympathetic ganglia without synapsing in the ganglia
these long preganglionic fibers pass on to other ganglia in the periphery where they synapse-the
splanchnic nerves synapse in the celiac, superior mesenteric and aortico-renal ganglia in the
abdomen before going to the gut, aorta and kidneys:
cardiac plexuses from T1-T4 ganglia
greater splanchnic nerves are derived from T5-T9 ganglia [ to the celiac ganglion]
lesser splanchnic nerves are from T10 and T11 [to the superior mesenteric ganglion]
least splanchnic nerves are from T12 [to the aortico-renal ganglion]
Inferior hypogastric nerves are from L1 and L2
some of the preganglionic fibers in T1 and T2 ganglia ascending in the trunk to synapse in the
inferior, middle and superior cervical sympathetic ganglia which are not connected to the
cervical spinal nerves
sympathetic fibers are distributed to smooth muscle in blood vessels, bronchi, gut and the
arector pili and to sweat glands in the skin
the main end organ neurotransmitter in the sympathetic system is norepinephrine
EXCEPT for the sweat glands in which acetylcholine is the transmitter
the neurotransmitter in the sympathetic ganglia is acetylcholine [nicotinic receptor]
Intermediolateral horn
100
Parasympathetic division
originates in the anterior nuclei in the hypothalamus
carried by CN III, VII, IX and X and S2, 3 and 4 nerves
its ganglia are closer to the end organs
it has long preganglionic fibers and short postganglionic fibers
Acetylcholine is the neurotransmitter in both the ganglia and end organs
Neurotransmitters
There are two types of neurotransmitters in the autonomic nervous system:
cholinergic [acetylcholine]
adrenergic [norepinephrine]
all acetylcholine receptors are nicotinic
including the ACH receptor in the neuromuscular junction which is also nicotinic in nature
EXCEPT the postganglionic receptors which are muscarinic including the sweat gland receptors
Not all tissues have both sympathetic and parasympathetic innervation, namely:
o Blood vessels [only sympathetic innervation]
o Arector pili muscle [only sympathetic innervation]
o Bronchial glands [only parasympathetic innervation]
o Adrenal medulla [only preganglionic sympathetic innervation]
o Sweat glands [only sympathetic innervation]
101
Adrenergic receptors
there are two types of adrenergic receptors: α and β
All α adrenergic receptor type cause contraction of smooth muscle including the dilator
[radially-arranged fibers] pupillae muscle in the eye
All β adrenergic receptors are β2 type EXCEPT those that are found in the heart which are β1
The β1 receptors in the heart cause an increase in the heart rate and force of contraction
All β2 receptors cause relaxation of smooth muscle EXCEPT the receptors to the arector pili
which causes contraction
Enteric Brain
found within the wall of the intestine and it contains as many neurons as the spinal cord
two major interconnected intramural plexuses:
o myenteric plexus of Auerbach:
found between the inner circular and outer longitudinal smooth muscle
layers of the muscularis externa and regulates contraction of these muscles
o submucosal plexus of Meissner:
o lies under the mucosa and regulates the secretion of intestinal glands
Auerbach plexus lies on the Autside and Meissner plexus lies on the inside
these two plexuses contain both sympathetic and parasympathetic fibers
the enteric brain contains many more neurotransmitters besides norepinephrine and acetylcholine
it controls the gastrointestinal tract
nociception from the esophagus to the splenic flexure is carried by fibers passing along the
sympathetic fibers
afferent parasympathetic fibers carry nociception from the splenic flexure to the rectum and
from the bladder and prostate
the enteric brain is also involved in autonomic mediated reflexes
Auerbach plexus
Meissner’s plexus
Mucosa
Submucosa Serosa
Circular muscle layer
Longitudinal muscle layer
102
PHYSIOLOGY
103
104
CARDIOVASCULAR REVIEW
Functions
1. muscular pump for blood circulation-5 to 6 liters per minute in a 70 kg man
2. endocrine:
ANP [Atrial Natriuretic Peptide] in response to increased atrial pressure
BNP [B-type Natriuretic Peptide] in response to overstretched ventricles
Cardiac muscle
o involuntary muscle with cross striations
o the individual cells are connected by intercalated discs with gap junctions
o the gaps junctions allow for the passage of ions between the myocytes
o these allow the action potentials to spread between the cardiac myocytes
o the intercalated discs allow the heart to contraction in synchrony as one unit [syncytium]
+20 Phase 2
0 mV
-20
-40 Phase 3
-60
Phase O
-80 Phase 4
-100
Refractory periods:
i. absolute-no action potential can be initiated regardless of the stimulus strength
because the Na channels are closed as in Phase 1 and 2
ii. relative-an action potential can be elicited, however a greater stimulus is
needed-extends between the middle of Phase 3 to the start of Phase 4
iii. cardiac musce is incapable of sustained contration [tetany] as in skeletal muscle
because of the refractory period
Digoxin acts by increasing the influx of calcium thus increasing the force of the contraction
Frank-Starling law: cardiac output is directly proportional to the venous return
i. force of contraction of a myocardial fiber is proportional to the length of the
myocardial fiber
ii. the greater the amount of blood entering the heart during diastole [venous
return], the greater is the stretching of the cardiac myocytes
iii. greater stretch results in a greater force of contraction resulting in an increase
in the cardiac output
iv. Cardiac output is the volume of ejected blood from the heart per minute
Cardiac cycle
st
1 heart sound due to the closure of the tricuspid and mitral valves [LUB]
nd
2 heart sound due to the closure of the pulmonary and aortic valves [DUB]
rd nd
3 heart sound occurs after the 2 heart sound-congestive heart failure [DUBup]
th st
4 heart sound is heard just before 1 heart sound-hypertrophic ventricles [beLUB]
systole [contraction] occurs between heart sounds 1 and 2
diastole [relaxation] occurs between heart sounds 2 and 1
105
Pressure in the aorta [80/120 mm Hg]
Electrocardiogram
This is a reflection of the electrical activity in the heart as the impulse generated in the SA node
is propagated to the rest of the heart
The initial impulse is generated by the SA node which has its own intrinsic rhythmicity of around
80-100 beats per minute
The impulse is spread throughout the atria via intra-atrial bundles to cause both atria to contract
simultaneously
The atria are separated from the ventricles by the 8-shaped annulus fibrosus
The impulse is spread to the ventricles from the SA node to the AV node which has its own
intrinsic rhythmicity of around 40-60 beats per minute
When the SA nodal rhythm is superimposed upon the AV nodal rhythm, the heart beats at 70 beats
per minute
The impulse from the AV node is passed down through the Bundle of His into the right and left
bundle branches which are located in the muscular part of the interventricular septum
The conduction velocity is slowest in the AV node and fastest in the Purkinje fibers
These are the following parts in the ECG:
o P wave represents atrial depolarization
o PR interval-extends from the P wave to the start of the Q wave [,200 milliseconds]
o QRS complex-represents ventricular depolarization [<120 milliseconds]
o QT interval-extends from the beginning of the Q wave to the end of the T wave
o ST segment-extends from the end of the S wave to the start of the T wave
o T wave-ventricular repolarization
o Atrial repolarization is not seen on the ECG because it is buried by the QRS complex
o In some people there may be a U wave after the T wave
o The U wave may represent repolarization of the Purkinje fibers or the papillary muscles
P T
Q
PR ST
S
QT interval
Blood Pressure
systemic arterial blood pressure is 120/80 mm Hg
120 mm Hg is the systolic pressure and 80 mm Hg is the diastolic pressure
Blood pressure is the product of the Cardiac Output multiplied by the Peripheral Resistance
Cardiac output is the product of the Stroke Volume multiplied by the Heart Rate
70 ml x 70 beats per minute = approximately 5 liters per minute
Peripheral Resistance
Poiseuille’s law: Peripheral resistance [PR] is directly proportional to the viscosity of blood and
th
to the length of the vessel and inversely proportional to the radius of the vessel to the 4 power
If the blood vessel radius decreases by a factor of 2, then the resistance increases by a factor of 16
Blood Flow
blood flow through a tubular structure is governed by La Place’s law which states that pressure
within a blood vessel is related to the tension, size and shape of the vessel
blood flow is inversely proportional to the diameter of the blood vessel
blood flow in a normal blood vessel is smooth and laminar
as the diameter of the vessel becomes smaller, the resistance to flow is increased
60% of the total blood volume is contained in the venous system at any one time while 20% is in
the arteries and arterioles, 15% lies within the pulmonary system and 5% in the capillaries
blood flow is greatest in the arteries and veins and least the capillaries
Capillary pressures
intracapillary hydrostatic pressure which tends to force fluids out into the interstitial space [+]
intracapillary oncotic [protein-related] pressure which tends to pull fluids into the capillary [-]
interstitial hydrostatic pressure which forces fluids into the capillary [-]
interstitial oncotic pressure which pulls fluid out of the capillary [+]
imbalance in these forces may cause edema which is due to excess fluid in the interstitial space
107
ENDOCRINE REVIEW
Prolactin
LH
Oxytocin
FSH
ADH
TSH ACTH
Somatotropin
108
o Prolactin [affected by Prolactin Inhibiting Factor and TRH]
promotes breast development and milk production
however it does not cause milk ejection from the breast
posterior pituitary lobe
o aka neurohypophysis
o two hormones stored [but not secreted] in the posterior lobe
o Oxytocin is secreted by the paraventricular nucleus in the hypothalamus:
it stimulates contraction of uterine muscle [labor] and the myoepithelial cells
in the breast [milk ejection]
its released is stimulated by nipple stimulation
it also plays a role in maternal bonding
o ADH is secreted mainly by the supraoptic nucleus of the hypothalamus:
it acts on the collecting ducts in the kidney
released in response to water deprivation
prevents water from being excreted in the urine [diuresis]
decreased ADH leads to diabetes insipidus-polyuria and polydypsia
pars intermedia
o this lies between the anterior and posterior pituitary lobes
o it secretes Melanin Stimulating Hormone
stimulates the production of melanin by the melanocytes in the skin
109
cortisol is a glucocorticoid [sweet] which regulates the metabolism of the following:
o fat [increases lipogenesis]
o carbohydrates [increases glycogenesis]
o proteins [increases gluconeogenesis at the expense of protein]
o maintains blood pressure by upregulating alpha-1 receptors in arterioles
o decreased bone formation
o suppresses inflammation [anti-inflammatory effect]
estrogen, progesterone and testosterone are derived from androsteinone [sex] secreted by the
zona reticularis
destruction of the adrenal cortex results in Addison’s disease
o it affects all three layers of the cortex
o it causes weight loss, low blood pressure and bronzing of the skin
all of the adrenal cortex hormones are produced from cholesterol
the adrenal medulla:
o secretes epinephrine [80%] and nor-epinephrine [20%]
o it behaves more like a sympathetic ganglion as it is supplied by preganglionic fibers
o nor-epinephrine is produced from tyrosine which is derived from phenylalanine
o epinephrine is produced from nor-epinephrine
these two hormones are neurotransmitters in the sympathetic nervous system and are responsible
for the flight or fight response to stress:
o increase heart rate
o dilate coronary vessels
o dilate arteries to skeletal muscle
o dilate the bronchi and the pupil
o decrease gut motility
o constrict the bladder and bowel sphincters
o contract the erector pili muscles in the skin
o decrease salivary secretion
o increase sweat production
increased secretion of nor-epinephrine is seen in pheochromocytoma
o results in 4 Ps: perspiration, heart palpitations, paroxysms of hypertension and
pressure headaches
Pancreas
the endocrine cells in the pancreas are found in the islets of Langerhans
Insulin is secreted by the beta type of islet cells
o moves glucose from in the blood to inside the cells
there are several tissue specific transporters that carry glucose:
GLUT 1 erythrocytes and brain
GLUT 2 liver and beta islet cells
GLUT 3 neurons
GLUT 4 skeletal muscle and adipose tissue
o promotes synthesis of fat, glycogen and protein and cellular uptake of potassium
o inhibits gluconeogenesis, lipolysis and protein degradation
o anabolic hormone released when blood glucose levels are high
o insulin secretion is also stimulated by the amino acids alanine and leucine
o excess insulin is seen in insulin secreting tumors [insulinoma]
produces low blood sugar levels
o decrease insulin secretion or function results in diabetes mellitus
produces polyuria, polydypsia, polyphagia and pruritus
Glucagon is secreted by the alpha cells
o causes the liver to convert glycogen to glucose [promotes glycogenolysis]
o released when blood glucose levels are low
Somatostatin is secreted by delta cells of the pancreas
o it is also secreted by the D cells in the stomach and by the hypothalamus
o also known as Growth Hormone Inhibitory Hormone as it inhibits the following:
Renin
Insulin
Growth hormone
Gastrin
Glucagon
110
GASTROINTESTINAL REVIEW
Functions
GI tract has several functions:
o digestion
o absorption
o excretion
o endocrine
function of the GI tract is best understood by looking at what happens in the various parts of the
gastrointestinal tract and in addition to what happens with the various food types as they pass
through the alimentary tract
Mouth
mastication [chewing] breaks down food
in addition salivary amylase [ptyalin] assists in the chemical breakdown of carbohydrates and
starches into maltose
there is also lingual lipase which is secreted by lingual glands in the mouth
Stomach
food on entering the stomach is mixed with secretions from the gastric glands
gastric glands contain 3 types of cells:
o mucosal [neck] cells:
secrete mucus and gastrin
G cells produce gastrin which stimulates gastric secretions
o chief cells:
produce pepsinogen
in the presence of hydrochloric acid, pepsinogen is activated to form pepsin
pepsin is necessary for protein digestion
o parietal cells:
secrete hydrochloric acid and intrinsic factor
HCl is needed for the activation of pepsinogen
HCl will destroy many bacteria
Intrinsic factor is necessary for the absorption of Vitamin B12 in the terminal
ileum
the mixture of food and gastric secretions is called chyme
Small Intestine
chyme is propelled through the small intestine by peristaltic waves
the presence of chyme in the small intestine stimulates the release of secretin from the S-cells
found in the duodenum:
o secretin stimulates pancreatic acinar cells to release bicarbonate and water
o bicarbonate is also secreted by Brunner’s glands in the duodenum, neutralizes the
gastric acid and makes the pH alkaline
it also protects the duodenal wall from digestion by the highly acidic gastric juice
being emptied into the duodenum
o in addition secretin decreases gastric motility
the presence of fat in the duodenum stimulates the release of cholecystokinin [CCK]
o cholecystokinin is released by the I-cells in the duodenum
o it causes the gallbladder to contract
o CCK causes the sphincter of Oddi to relax
o this causes bile to be excreted into the duodenum
o it also stimulates the pancreas to secrete enzymes which aid in the digestion of fat,
starches and protein
o pancreatic amylase completes the breakdown of starch into maltose
further digestion is assisted by secretion of others enzymes from enterocytes in the small intestine:
o maltase which breaks down maltose into two molecules of glucose
o lactase which breaks down lactose into glucose and galactose
o sucrase which breaks down sucrose into glucose and fructose
o lactase, sucrase and maltase are found in the brush border of the enterocytes
o there is also a small amount of intestinal lipase that is secreted which digests fat
111
o some digested fat is absorbed into the central lacteals which drain into the thoracic duct
o intestinal peptidases digest the polypeptides released by the action of the proteolytic
pancreatic enzymes [trypsin, chymotrypsin, carboxypolypeptidase and proelastase] to
produce amino acids
the final breakdown products of fat, starch and protein digestion are produced in the small intestine:
o fat to fatty acids and glycerol
o starch, sucrose and lactose to glucose, fructose and galactose
o proteins to amino acids
these breakdown products are absorbed by the small intestine and transported to the liver
except some fat which is absorbed by the central lacteals which drain into the thoracic duct
Pancreas
there are both exocrine and endocrine cells in the pancreas:
o exocrine cells make up the bulk of the pancreas and are arranged in acini to secrete:
trypsinogen
trypsinogen is activated to trypsin by enterokinase
enterokinase is released by enterocytes in the small intestine
chymotrypsin, carboxypolypeptidase and proelastase
pancreatic amylase
aids in the digestion of starch to produce maltose
lipase
breaks down fat into fatty acids and glycerol
o endocrine cells are located in the islets of Langerhans which secrete:
Glucagon [alpha cells]
Insulin [beta cells]
Somatostatin [delta cells]
Large Intestine
most of the water in food is absorbed in the large intestine
undigested food is propelled down the large intestine and out through the anal canal as feces
bacteria found in the large intestine produce Vitamin K
the colon has numerous goblet cells which secrete mucus to aid in the passage of feces
112
Bilirubin metabolism
bilirubin is a byproduct of red blood cell breakdown in the spleen
old red blood cells [> 120 days] are broken down to release heme and globin
the heme is further broken down into bilirverdin and iron
bilirverdin is converted into bilirubin which is carried in the blood attached to albumin
in this form, it is soluble in lipids but insoluble in water
it is transported to the liver where it is conjugated with a glucuronide by glucuronyl transferase
conjugation renders the previous water-insoluble [indirect] bilirubin into a water-soluble state
conjugated [direct] bilirubin is secreted into the biliary tract and into the gallbladder
when it is excreted by the gallbladder, the bile [bilirubin plus bile salts] saponifies [making it like
soap] fat rendering it more easily digested by pancreatic lipase
the bilirubin in the gut is converted by bacteria to urobilinogen
some of the urobilinogen is absorbed into the blood stream
this is excreted in the urine where it is converted to urobilin which gives the urine its color
the rest of the urobilinogen in the gut is converted to stercobilinogen
stercobilinogen is oxidized to stercobilin which gives the characteristic color of the stool
95% of the bile salts are reabsorbed and sent back to the liver [enterohepatic circulation]
113
HEMATOLOGY REVIEW
Function of Blood
gas transport
immunity
clotting
transport of nutrients
transport of waste
Composition of Blood
total blood volume is 5 liters in the average 70 kg man
cells [45%] [equivalent to the hematocrit] made up of the following:
o red blood cells [4.5 to 6 million per milliliter of peripheral blood]
o white blood cells [5,000 to 10,000 WBCs per milliliter of peripheral blood]
o platelets [150,000 to 300,00 platelets per milliliter of peripheral blood]
plasma [55%] which contains electrolytes, glucose, urea and protein
Phagocytosis
this is the process by which white blood cells ingest offending agents in the tissue
mainly done by neutrophils and macrophages
macrophages are monocytes that have migrated from the blood into the surrounding tissue
114
phagocytes [neutrophils and migrated monocytes] must be selective of the material they ingest
most natural structures in the tissues have smooth surfaces which resist phagocytosis
most natural substances have protective protein coats which repel phagocytes
dead tissue and foreign particles have no protective coats which makes them more susceptible
to phagocytosis
both neutrophils and macrophages have lysosomes filled with proteolytic enzymes
after phagocytosis, the lysosomes come in contact with the ingested material and dump their
enzymes into the phagocytic vesicle and digestion begins
in addition, both neutrophils and macrophages produce bactericidal agents which kill most
bacteria
macrophages are found in the skin, subcutaneous tissue, lungs, lymph nodes, liver [Kupffer
cells], spleen and bone marrow
Blood clotting
when tissue is damaged, some blood vessels may be torn and bleeding occurs
in order to limit blood loss, the body initiates a clotting process
two pathways-Intrinsic and Extrinsic connected to a common pathway
Vascular damage activates the intrinsic pathway [XII,XI, IX, VIII and X]
o Factor XII is activated by chemical derived by damaged tissue
o Activated Factor XII activates Factor XI
o Activated Factor XI activates Factor IX
o Activated Factors IX and VIII activates Factor X
Tissue damage activates the extrinsic pathway [VII and X]
o Factor VII is activated by chemical released by vascular damage
o Activated Factor VII activates Factor X
Activated Factor X converts prothrombin [Factor II] to thrombin [activated Factor II]
Thrombin [activated Factor II] converts fibrinogen [Factor I] to fibrin
Fibrin forms the clot
Factor XII Activated Factor XII Activated Factor VII Factor VII
Factor VIIIa
Blood Groups
The common blood groups are ABO and Rh types based on the presence of A, B or Rh antigens on the
surface of the red blood cells.
Group O [no A or B antigens] blood can be safely given to patients with all blood types and is known as the
universal donor.
People with blood group AB can receive all blood types and is known as the universal recipient.
When incompatible blood is given to a patient [e.g. A, B or AB blood to a Group O patient], then the
antibodies to the A or B antigens will cause the transfused red blood cells to agglutinate and clump together.
115
IMMUNITY REVIEW
Divisions
2 major subdivisions:
o nonspecific [innate]
o specific [acquired-after initial exposure]
Differentiation of T cells
T cell precursors in the bone marrow go to the thymus where they differentiate into CD8 or CD4 T
cells
The CD8 T cells become Cytotoxic T cells which kill virus-infected, neoplastic and donor graft cells
The CD4 T cells further differentiate into Helper T cells which develop into Th1 and Th2 cells
o Th1 cells activate macrophages
o Th2 cells help B cells to make antibodies.
116
Humoral Immunity
antibodies belong to a class of proteins called immunoglobulins [Ig] in the shape of a Y
the Fc [tail of the Y] region determine the type of immunoglobulin [IgM, IgD etc]
o IgG-most abundant, promotes phagocytosis and cell lysis, confers passive immunity
o IgA-present in saliva, tears and breast milk
o IgM- secreted early on, promotes agglutination, phagocytosis and cell lysis
o IgD-surface antibody on B lymphocytes, role unclear
o IgE-important in parasitic infections and some allergic responses
the Fab [arms of the Y] is responsible for the antigen binding specificity
antibodies bind to antigens, thus promoting their destruction:
o directly by Precipitating soluble antigens, Lysis of membranes, Agglutination [clumping
together], and Neutralization of toxins or inactivation of some viruses
o indirectly activating the complement system
Table 8: Immunoglobulins
Cell-mediated Immunity
relies on activated T lymphocytes
important in combating viral and fungal infections as well as against potential cancer cells
T cells are activated by exposure to foreign antigens which are bound by specific surface receptors
three types of T lymphocytes with different functions:
o cytotoxic [killer] T lymphocytes:
lyse cells carrying the antigens to which they are sensitive
o helper T lymphocytes [most numerous]
activated by macrophage-processed antigens
once stimulated, lymphokines are released: Interleukin 2-6 and Interferon
o suppressor T lymphocytes:
inhibit lymphocytic function
cell-mediated responses persist longer than antibody responses
117
MUSCULOSKELETAL REVIEW
Function of Joints
main function of joints is to allow movement
o for joints to function, one needs an intact spinal cord, nerves and muscles
Skeletal Muscle
muscle fibers are made up myofibrils which are organized in sarcomeres surrounded by a cell
membrane called the sarcolemma
these units are connected by T tubules which allow calcium to be released and carry the Action
Potential into the sarcomeres
the sarcomere is the functional unit of a muscle:
o it lies between two Z lines which bisects the I band
o the dark band is the A [anisotropic] band which has both actin and myosin
o H band bisects the A band and has only myosin [thick filaments]
o the light band is the I [isotropic] band and has only actin [thin filaments]
o the A band always remain the same length during contraction
o the HIZ bands shorten during contraction
two types of myofibrils-thick and thin:
o the thick filaments contain myosin
o the thin filaments contain actin, troponin and tropomyosin
o there are three types of Troponin: C, T and I
Troponin C binds to calcium ions
Troponin T binds to tropomyosin
Troponin I binds to actin and inhibits the interaction between actin and myosin
Troponin is the calcium-binding protein in skeletal and cardiac muscle
o Actin and Myosin at a 2:1 ratio
Sarcomere
H band
Z line Z line
A band I band
Fig 95: Sarcomere
Neuromuscular junction
the neuromuscular junction is a specialized region where the ends of the axons of the α-motor
neurons are connected to motor end plates of a specific group of muscle fibrils
each NMJ has a nerve bouton that is filled with vesicles that release Acetylcholine when the
nerve is stimulated and calcium flows into the bouton
released Acetylcholine passes through the presynaptic membrane and into the synaptic cleft
the post-synaptic membrane [motor end plate] on the muscle contains nicotinic ACh receptors
when acetylcholine binds with these receptors, an end plate potential is generated and this spreads
to cause the skeletal muscle to contract
the enzyme acetylcholinesterase is found in the synaptic cleft
118
it hydrolyzes [breaks down] Acetylcholine into acetate and choline
choline is reabsorbed and combined with Acetyl CoA in the presynaptic vesicles
Bouton
Slow Twitch [ 1 Small Slow Red Ox] Fast Twitch [2 Fast Skinny White Chickens]
Type I Type II
Red fibers White fibers
Found more in long-distance runners More common in sprinters
Smaller fiber size Large fiber size for greater contraction
Uses less glycogen Large amounts of glycogen for quick energy release
Many mitochondria-increase oxidative metabolism Few mitochondria for increased anaerobic glycolysis
More myoglobin Less myoglobin
Types of contraction
o isometric muscle fibers do not change length, e.g. pushing against a wall
o isotonic load remains same, e.g. keeping the elbow flexed with a weight in hand
o isokinetic speed of contraction remains the same throughout the contraction
o concentric muscle shortens during contraction, e.g. flexing elbow with a weight in hand
o eccentric muscle lengthens during contraction, e.g. extending the elbow slowly with a
weight in the hand
119
Smooth muscle types
multi-unit-behaves as separate motor units, found in the iris, ciliary body and ductus deferens
single unit-permits coordinated contraction, present in the uterus, bladder, ureter and gut
mixed-found in the walls of blood vessels
Motor reflexes
There are three main types of motor reflexes: flexor withdrawal, crossed extensor and deep tendon or
stretch reflexes.
120
NEUROPHYSIOLOGY REVIEW
Nerve conduction
depends on the diameter of the nerve axon and the degree of myelination
myelin is produced by Schwann cells in the PNS and by oligodendrocytes in the CNS
electrical events are caused by the movement of ions across cell membranes
potential difference exists across the membranes of all cells-membrane potential
+
In the resting state, there are more K ions inside the cell than outside
+
in these cells, there are more K channels that are open
when an action potential is generated, the Resting Membrane Potential [RMP] becomes positive
[depolarization] for 1 millisecond
after this the membrane potential is restored [repolarization] to its original negativity in a further 1-
2 milliseconds
Synaptic conduction
two basic types of synapses-electrical and chemical [more common]
the electrical or gap-junction type has cytoplasmic connections between the pre- and post
synaptic elements which allow direct conduction of electrical current between cells and is bi-
directional
the chemical type has a small space of cleft between the pre- and post-synaptic elements which
allow for the neurotransmitter to diffuse between the cells and is unidirectional
when an action potential is generated [following depolarization of the presynaptic terminal], it opens
++
voltage-gated Ca channels in the synaptic end of the neuron
the calcium influx activates calmodulin which causes the synaptic vesicles to fuse with the
presynaptic membrane
this allows constant amounts or quanta of the neurotransmitter to be released
the specific neurotransmitter diffuses into the synaptic cleft where it will activate receptors on the
post-synaptic membrane which leads to excitation or inhibition depending on the tissue
121
Neurotransmitter classification
CNS
o All are Excitatory [Glutamine, Serotonin, Acetylcholine, Norepinephrine and Dopamine]
EXCEPT Glycine and GABA [Gamma Amino Butyric Acid which are Inhibitory
o Glycine is found mainly in the spinal cord
PNS
o Neuromuscular junction
Acetylcholine
o Autonomic Nervous System
Acetylcholine
Norepinephrine
Nociceptor classification
1. specific: mechanical, cold thermal, heat thermal
a. fast conduction [A fibers] producing well-localized, sharp, pricking pain
2. silent: present in healthy tissue, not activated by noxious stimuli
a. only begin to fire when tissue becomes increasingly inflamed
3. polymodal: mostly group IV [C type] fibers, found in somatic and visceral tissue
a. may be activated by chemical, thermal or mechanical stimuli that may or may not be
noxious
b. have receptors for bradykinin, prostaglandin E2, serotonin, histamine, interleukin and TNF
c. slow conduction, poorly localized burning, dull aching pain
122
RENAL REVIEW
Function
an excretory organ with endocrine function with two parts-cortex and medulla
the main functions are:
o waste excretion
o electrolyte balance
o blood pressure control
o acid base balance
functional unit of the kidney is the nephron:
o nearly 1 million nephrons [incapable of regeneration] in each kidney
o two types of nephrons-cortical [80%] and juxta-medullary [20%]
o each nephron has the following parts:
a glomerulus enveloped in a double-layered Bowman’s capsule
two convoluted tubules-proximal and distal
two parts of the loop of Henle-thin descending and ascending thin and thick
two hormones that are secreted by the kidney-erythropoietin and renin
additional hormones that act on the kidney- ADH, aldosterone, ANP, 1,25
dihydroxycholecalciferol and parathormone
Glomerular Filtration
glomerulus and Bowman’s capsule allow an ultrafiltrate to pass into the proximal convoluted
tubule
influenced by opposing forces:
o hydrostatic [+60 mm Hg] pushes water out of the capillary
o oncotic pressure [-32 mm Hg] pulls water back into the capillary
o Bowman’s capsule pressure [-18 mm Hg] pushes water back into the capillary
o resulting in a positive net pressure of 10 mm Hg
this causes filtration through the glomerulus at a rate of 120 ml/minute
pores [fenestrations] in the capillary membrane, slits between the pedicles of the podocytes in
Bowman’s capsule and the specialized negatively-charged basement membrane sandwiched in
between allow free passage of small molecules and the repulsion of negatively charged proteins
the size of the openings does NOT allow red blood cells to be filtered
+ + + ++
Na , K , H , Ca and urea are filtered passively through the glomerulus and reabsorbed
actively according to the needs of the body
glucose is filtered passively by the glomerulus
o glucose is reabsorbed actively by the Proximal Convoluted Tubule once the threshold is
exceeded [renal threshold for glucose is 180 mg/dL]
Loop of Henle
two structurally and functionally different parts of the loop of Henle-thin and thick
the thin descending part is permeable to H2O and impermeable to urea
o purpose is to concentrate the urine as it moves from descending into ascending parts by
+ -
trapping Na and Cl
o water moves out of the descending limb and the urine becomes concentrated
the thick ascending part is impermeable to H2O and is the diluting segment of the loop
123
Distal Convoluted Tubule
+ - ++
it is involved in Na , Cl , H2O and Ca reabsorption
+
Aldosterone acts mainly on the distal convoluted tubules to facilitate Na resorption [in
+ +
exchange for H ] and K secretion
in addition, Parathormone converts 25 hydroxycholecalciferol to 1, 25 dihydroxycholecalciferol
which is the active form of Vitamin D
o Vitamin D produced by the skin is converted to 25 hydroxycholecalciferol in the liver
++
1, 25 dihydroxycholecalciferol acts on the DCT to facilitate Ca resorption and PO4 secretion
Collecting duct
Anti-Diuretic Hormone acts mainly on receptors in the cells of the collecting ducts and increase
water permeability which allows more water to be reabsorbed
Efferent arteriole
Collecting duct Distal Convoluted Tubule
Afferent arteriole
Bowman’s capsule
Glomerulus
Endocrine function
the kidney produces the following hormones:
o Erythropoietin [produced by interstitial cells in the cortex] in response to hypoxia
acts on myeloid tissue in the bone marrow
increases the production of red blood cells
o Renin is produced by cells in the juxtaglomerular apparatus in response to a drop in BP
o Renin-Angiotensin-Aldosterone mechanism:
drop in renal blood flow results in a decrease NaCl delivery to the macula
densa
the macula densa is located in the distal convoluted tubule near the afferent
and efferent arterioles of the glomerulus
it is sensitive to salt [NaCl] concentration
this triggers the secretion of renin from cells of the juxtaglomerular apparatus
the juxtaglomerular apparatus is made up of a segment of the distal
convoluted tubule in close relation with the afferent and efferent arterioles of
the glomerulus
renin is released from the juxtaglomerular cells located in the walls of the
afferent arteriole immediately proximal to the glomerulus
renin is a proteolytic enzyme which causes angiotensinogen secreted by the
liver to be converted into angiotensin I
angiotensin 1 is converted to angiotensin II by Angiotensin Converting
Enzyme which is found in the lung
124
angiotensin II is a powerful vasoconstrictor which will cause an elevation of
the blood pressure
in addition, angiotensin II stimulates the release of aldosterone
aldosterone causes NaCl reabsorption and thus water
the increased water causes an increase in the blood volume
this in turn causes an increase in venous return
increased venous return increases the cardiac output which in turn raises the
blood pressure
Macula densa
DCT
Afferent arteriole
Efferent arteriole
Juxtaglomerular cells
Bowman’s capsule
Glomerulus
additional hormones act on the kidney on the cells in the DCT or collecting ducts:
o Anti-Diuretic Hormone [aka vasopressin]
secreted by the supra-optic nucleus in the hypothalamus
due to stimulation of osmoreceptors in the hypothalamus
acts mainly on the principal cells in the collecting ducts of the kidney
increases water permeability
causes reabsorption of water
o Atrial Natriuretic Peptide
peptide hormone produced by stretched atrial myocardial fibers
causes decreased Na reabsorption resulting in increased urine production
also causes relaxation of vascular smooth muscle causing decrease peripheral
resistance
o 1,25 dihydroxycholecalciferol acts on the distal convoluted tubule increasing Ca++
absorption
o Aldosterone acts mainly on the distal convoluted tubule increasing NaCl reabsorption
125
+
the excess hydrogen ions are excreted as ammonium [NH4 ] in the kidneys
the lungs are also involved in maintaining the balance between acids and bases
If the body produces too much non-volatile acids [metabolic acidosis]:
o the lungs will compensate by blowing off H2O and CO2 through hyperventilation
If the lungs are under-functioning, volatile acid CO2 will be retained causing respiratory
acidosis
+ -
o the kidneys will compensate by excreting excess H or increasing HCO3 reabsorption
If excess hydrogen ions are lost [through vomiting or with diuretics] metabolic alkalosis results
o the lungs will compensate by decreasing the excretion of CO2 through hypoventilation
If too much CO2 is blown off by the lungs by hyperventilation, this results in respiratory
alkalosis
-
o the kidneys will compensate by decreasing H+ excretion and HCO3 reabsorption
it is easy to tell whether a patient has a respiratory or metabolic alkalosis or acidosis by first
-
checking the blood pH and then looking at the PCO2 and HCO3 levels
Respiratory opposite:
o acidosis [decreased pH and raised CO2]
o alkalosis [increased pH and decreased CO2]
Metabolic equals:
_
o acidosis [decreased pH and decreased HCO3 ]
_
o alkalosis [increased pH and increased HCO3 ]
Check arterial pH
Check PCO2
126
REPRODUCTIVE REVIEW
Sperm development
spermatozoa are produced in the seminiferous tubules of the testis under the influence of
testosterone secreted by the interstitial cells of Leydig
the Interstitial cells of Leydig are under the influence of Luteinizing Hormone
testosterone is attached to receptors on the Sertoli cells
Sertoli cells are found in the seminiferous tubules of the testis
the sustentacular cells of Sertoli are under the influence of Follicle Stimulating Hormone
0
the testis is housed in the scrotum so that it lies at a temperature 1 Centigrade lower than body
temperature
higher temperatures decrease spermatogenesis
sperm produced in the tubules mature in the epididymis
200-600 million sperms are released during each ejaculation
Each sperm has a head with an acrosome, a middle piece with mitochondria and a tail
The sperm feeds on fructose produced by the seminal vesicles
the sperm released from the testis during ejaculation are not capable of fertilizing the egg
Capacitation
this is the process of transforming sperm so that they have the capacity to penetrate the corona
radiata which surrounds the ovum
with the aid of a sperm membrane protein with hyaluronidase activity found in the acrosome of
the sperm
capacitation occurs in the female genital tract
it is aided by the low pH which is maintained by the production of acid by the numerous
lactobacilli that inhabit the vagina
Ovum development
there are > 2 million primary oocytes present at birth
only 400-500 become secondary oocytes waiting to be expelled at ovulation during the
reproductive period under the stimulation of FSH
o via a negative feedback loop involving estrogen: high estrogen leads to low FSH
several follicles develop during each menstrual cycle
o only one matures and releases the ovum
the empty follicle changes into the corpus luteum after ovulation
the development of the corpus luteum is under the influence of LH via a negative feedback loop
involving progesterone and LH
the ovum lives for 24 hours while the sperm lives 48 hours in the female
127
Fertilization
if the woman has ovulated and sperm are in the neighborhood, then fertilization could occur in the
ampulla [largest part which has ample room] of the uterine tube
hyaluronic acid in the acrosome on the head of the sperm assists in penetrating the corona
radiata and zona pellucida which surrounds the ovum
the zona pellucida changes its configuration after fertilization preventing other sperm from entering
the fertilized egg [zygote] travels down the uterine tube and develops into the morula at Day 3 and
into the blastocyst at Day 5
Implantation
implantation occurs around Day 7 after fertilization, when the blastocyst makes contact with the
endometrial lining of the uterine cavity
after implantation the blastocyst develops into the embryoblast
the embryoblast develops into an inner cell mass and an outer cell mass
the inner cell mass becomes the embryo and further differentiates into two layers:
o the outer layer is known as the epiblast
the epiblast becomes the ectoderm
o the inner layer is known as the hypoblast
the hypoblast becomes the endoderm
o later a third layer develops between these two layers and this becomes the mesoderm
the outer cell mass becomes the trophoblast which later becomes part of the placenta
Placentation
the trophoblast on implantation develops into outer and inner layers
o the outer layer of the outer cell mass becomes the syncytiotrophoblast and secretes
βHCG
βHCG maintains the hormonal activity of the corpus luteum during the early
stages of pregnancy
the syncytiotrophoblast erodes endometrial cells allowing maternal blood to seep
in and out of vascular lacunae forming the uteroplacental circulation
o the inner layer of the outer cell mass becomes the cytotrophoblast
the cells in the cytotrophoblast proliferate and grow into the syncytiotrophoblast
these cellular projections form the chorionic villi which later develop into the
placenta
the placenta produces a number of hormones:
o Estrogen which contributes to uterine growth, increased uterine vascularity,
proliferation of the ducts in the mammary gland
o Progesterone which prepares the endometrium for implantation, inhibits uterine
contraction, inhibits T lymphocyte-mediated activity [preventing immunological
rejection of the fetus by the mother] and prepares the breast acini for lactation
o Relaxin which relaxes the pelvic ligaments and softens the cervix at the time of delivery
o Human Chorionic Somatomammotropin which causes partial development of the
breast in early pregnancy, decreases insulin sensitivity and promotes the growth of protein
tissue in the same way that growth hormone does
Lactation
estrogen causes proliferation of the mammary ducts
progesterone prepares the acini for milk synthesis
milk synthesis is dependent on high levels of prolactin in association with cortisol and insulin
prolactin secretion is high during pregnancy
but it has no effect during pregnancy as its action is inhibited by the high levels of estrogen
the sudden drop in estrogen levels after delivery removes this inhibition
milk is produced by the breast acini and accumulates in the glandular tissue
oxytocin is released from the posterior pituitary lobe by stimulation of the nipple by suckling
oxytocin causes the myoepithelial cells around the glandular tissue in the breast to contract
causing the milk let-down reflex
continued lactation is dependent on the removal of milk at regular intervals
failure to empty the breast regularly will cause lactation to cease within a week
128
RESPIRATORY REVIEW
Functions
two main functions:
o gaseous exchange
o acid base balance
Gaseous Exchange
Gaseous exchange is dependant on:
1. Ventilation
2. Perfusion
3. Diffusion
Ventilation deals with the amount of gas delivered by the lungs
Boyle’s law: when the temperature is constant, the volume of a fixed amount of gas is
inversely proportional to its pressure
Charles’ law: when the pressure is constant, the volume of a fixed amount of gas is
directly proportional to the absolute temperature
Perfusion deals with the amount of blood delivered by the heart to the lungs
Diffusion deals with the amount of gas that passes through the air-blood barrier
The air-blood barrier is made up of the capillary endothelium, basement membrane
and Type I pneumocytes [90% of the cell types in the alveolus]
Type II pneumocytes produce surfactant [dipalmitoyl phosphatidylcholine], which
reduces the surface tension in the alveoli
Rate of diffusion is governed by Fick’s law
diffusion through a tissue membrane is inversely proportional to the tissue thickness
Ventilation/perfusion ratio:
VA/Q where VA is 4 L/min and pulmonary blood flow is 5L/minute [4L/5l = 0.8]
VA/Q is highest in the apex [3], lowest in the base [0.6] and closer to the ideal in the midzone
Ventilation is highest in the apex
Perfusion is greatest in the base
PaO2
Oxygen saturation
129
o carbaminohemoglobin [23%]
o dissolved in plasma [7%] least
o Haldane effect-binding of O2 to Hemoglobin tends to displace CO2
o High O2 levels in the lungs displaces CO2 and low O2 levels in the tissues binds more CO2
Control of Respiration
rate and depth of breathing are regulated so that arterial PCO2 = 40 mm Hg
under normal circumstances the concentration of CO2 in blood is the major determinant of
breathing
breathing is controlled by centers in the brain stem:
o pneumotaxic center in the upper pons turns off or inhibits the inspiratory center [-]
causing a decrease in the depth of inspiration which results in an increase in the
respiratory rate
o apneustic center in the lower pons prevents turning off of the inspiratory center [+]
o dorsal [inspiratory] and ventral [expiratory] centers in the medulla [DIVE]
o higher centers in the cerebral cortex act on the medullary centers
Pneumotaxic center
Apneustic center
Inspiratory center
Pons Expiratory center
Medulla
CO2 freely crosses the blood brain barrier and enters the CSF
+ -
in the CSF, CO2 combines with H2O to form H2CO3, which dissociates to form H and HCO3
+
the medulla senses levels of H in the CSF directly and CO2 in the blood indirectly
the medullary receptors are not sensitive to O2
chemoreceptors in the carotid body and adjacent to the aorta are peripheral chemoreceptors
that are stimulated by first by raised PaCO2, then by decreased arterial pH [acidosis] and
finally by decreased PaO2 [<60 mm Hg]
Cheyne-Stokes breathing is characterized by periods of rapid breathing with increasing then
decreasing tidal volume followed by a period of apnea as seen in Congestive Heart Failure
Kussmaul breathing is characterized by deep rapid regular breathing [aka air hunger]
o this is seen in diabetic ketoacidosis
Biot’s respiration is characterized bouts of irregularly irregular breathing and apnea
o this is seen in brain stem compression
Hering-Breuer reflex-limits over-inflation of the lungs
o this reflex is mediated by stretch receptors found in the smooth muscle in the airways
with afferents via the vagus nerve and efferents via the phrenic nerve
Lung Compliance
This is a measure of the distensibility of the lungs and chest wall
It is the change in lung volume caused by a given change in the respiratory pressure [C= V/P]
It is related to the elastic fibers, water content, surfactant in the lungs
It is inversely related to the amount of elastic tissue and proportional to force needed to
expand chest
The elasticity of the lungs tends to collapse the lung
Surfactant helps to counter this tendency to collapse
Emphysema increases the compliance allowing the lungs to over-expand
Pulmonary fibrosis and pulmonary edema decrease lung compliance
Ankylosing spondylitis decreases the ability to the chest wall to expand
Kyphoscoliosis will cause a decrease in the chest wall’s ability to expand
130
Lung Volumes
Total Lung Capacity [total volume held in the lungs] 5800 ml
Vital Capacity [volume expired after maximal inspiration] 4600 ml
Inspiratory Reserve Volume [volume inspired above tidal volume] 3000 ml
Tidal Volume [volume of a normal breath] 500 ml
Expiratory Reserve Volume [volume expired after normal breath] 1100 ml
Residual Volume [lung volume left after maximal expiration] 1200 ml
Functional Residual Capacity [air left in lungs after normal expiration] 3300 ml
Forced Expiratory Volume1 [volume expired after 1 second/FVC] 80%
6000 ml
5000 ml
Total
Lung 3000 ml
Capacity
Tidal Volume
2000 ml
Expiratory Reserve Volume
1000 ml
Residual Volume
131
132
PATHOLOGY
133
134
GENERAL PRINCIPLES
The body is in a dynamic state of balance [homeostasis] and responds to changes in its environment.
When excessive stress is placed on tissues, the cells respond by either adapting, developing reversible
injury or may suffer from irreversible damage and die. Inflammation is the body’s innate response to
injury.
The 5 Cardinal Signs of inflammation are rubor, dolor, calor, tumor and functio laesa:
rubor or redness due to vasodilation caused by histamine
dolor or pain due to kallikrein and bradykinin
calor or heat due to the increased vascularity due to histamine and serotonin
tumor or swelling due to increased vascular permeability-histamine and serotonin
functio laesa or loss of function due to decreased cell functioning
When tissues are injured or inflamed, there is a sequence of events involving cellular response and
hemodynamic [vascular] changes:
cellular response:
o margination is the process of the WBCs move to the periphery of the blood vessel by
chemotaxis
o chemotaxis is due to inflammatory chemical compounds which attract WBCs
o pavementation refers to WBCs sticking to the endothelium
o emigration is the passage of WBCs through blood vessels [diapedesis or
transmigration] by chemotaxis
o phagocytosis is the process of ingestion of bacteria by macrophages which are
derived from monocytes from the blood
hemodynamic changes:
o initial transient vasoconstriction lasting less than a few seconds
o followed by massive vasodilation mediated by:
histamine [released by basophils]
bradykinin and kallikrenin [responsible for nociception]
prostaglandins [responsible for further inflammation]
o increased vascular permeability due to endothelial cell contraction which increases
the size of the pores [fenestrations] between the endothelial cells
o blood stasis due to increased viscosity which allows the white blood cells to
marginate and the blood to clot
Acute inflammation is an immediate response to injury. It is a short lived process which may end in
complete healing, abscess, ulcer, fistula, scarring or it could progress to become chronic:
abscess is a pus-filled cavity
ulcer results when there is loss of surface epithelium
fistula is an abnormal communication between two epithelial surfaces
sinus is a blind-ending track connected to one epithelial surface
scar occurs when tissue healing characterized by fibrous tissue
keloid is a tumorous overgrowth of fibrous tissue in a scar
135
anaplasia is the term used to describe the disorganized, uncontrolled growth with lack of
differentiation
neoplasia is the term used to describe new growth of cells and is synonymous with a tumor
When tissues are deprived of a blood supply, the following might occur:
agenesis refers to the complete absence of an organ
aplasia is due to the failure of an organ or tissue to develop normally; a small remnant is left
hypoplasia refers to the underdevelopment of an organ or tissue resulting in decrease in the
number of cells
When the damage is too much for the cell to handle, cell death or necrosis will occur. There are several
types of necrosis:
coagulative necrosis in infarctions in the heart and is due to protein denaturation
liquefactive necrosis as seen in infarctions in the brain
caseous necrosis as seen in tuberculosis
enzymatic necrosis as seen in acute pancreatitis
fatty necrosis as seen in liver damage and injury to fatty tissue
There is a special type of cell death which is programmed. This is known as Apoptosis and is regulated by
nitric oxide and requires ATP. Apoptosis is characterized by the following:
no inflammatory response in the surrounding tissue
unlike necrosis which is accompanied by an inflammatory response in the surrounding tissue
When a cell is injured, the nucleus undergoes specific changes in order of progression:
pyknosis-reversible nuclear chromatin condensation or clumping [pH changes]
karyorrhexis-irreversible chromatin fragmentation [Ca++ influx]
karyolysis-enzymatic breakdown of DNA after cell death
o complete disappearance of stainable nuclear material
Immune deficiencies
The body’s ability to defend itself and respond by inflammation may be compromised by specific genetic
diseases which affect the immune system like:
Bruton’s agammaglobulinemia
o X-linked tyrosine kinase defect blocks B cell maturation; seen in Boys
DiGeorge syndrome
rd th
o Thymic and parathyroid aplasia due to failure of 3 and 4 pharyngeal arch development
Severe Combined Immune Deficiency
o Often X-linked with defective B and T cell activation
Wiskott-Aldrich syndrome
o X-linked defect with progressive depletion of B and T cells
Chediak-Higaski syndrome
o Autosomal recessive defect in phagocytosis
136
GENETIC DISORDERS
Genetic disorders are caused by mutations which are permanent alternation in DNA. The mutations may
affect an entire chromosome or may affect specific base pairs in the DNA sequencing of specific genes. The
mode of inheritance of genetic disorders could be autosomal or sex-linked and are either dominant or
recessive:
autosome
o any chromosome other than the X or Y chromosomes
sex-linked
o linked to one sex; e.g. Duchenne’s muscular dystrophy and hemophilia in males
autosomal dominant
o having a 50% chance of inheritance if the gene is present in one parent
o e.g. Sickle Cell trait
autosomal recessive
o having a 25% chance of inheritance if the gene is present in both parents
o e.g. Sickle Cell Disease
137
Amino acid disorders:
o Phenylketonuria
accumulation of phenylalanine due to lack of PA hydroxylase; mental
retardation
restrict dietary phenylalanine if the Guthrie test for PKA is positive
o Alkaptonuria
deficiency in homogentisic acid
urine turns black on standing
dark damaged cartilage-ochronosis
Metabolic
o Cystic fibrosis
Autosomal recessive condition causing defective chloride transport
impaired mucociliary action and thick vicid secretions
recurrent infections in lung and sinuses
salty sweat
Hemopoietic:
o Sickle Cell Disease
recessive gene
valine replaces glutamine at position 6 of the beta chain in hemoglobin
common in African-Americans [2% has the disease]
causes microvascular occlusion triggered by hypoxia, acidosis, fever
painful bones with anemia, jaundice and fatigue
hepatosplenomegaly in children
priapism [prolonged erections]
increased risk of salmonella osteomyelitis and pneumococcal pneumonia
protects from Plasmodium falciparum type of malaria
o Sickle Cell Trait
autosomal dominant present in 8% of African-Americans
asymptomatic unless severely stressed
o Thalassemia
More common in Americans of Mediterranean descent [β Thalassemia]
defect in either the α or β globin chains of hemoglobin A
α Thalassemia is more common in South East Asia and West Africa
β Thalassemia is more common in Americans of Greek or Italian descent
results in sub-optimal hemoglobin synthesis
presents with varying degrees of anemia and fatigue
Thalassemia persons are also resistant to the malaria parasite
138
NEOPLASIA
Neoplasia is the term used to describe new cell growth and is synonymous with a tumor. It could be
benign or malignant. The term tumor is synonymous with neoplasia. Tumors may be classified according to
the following:
behavior
tissue of origin
degree of differentiation
Behavior
Benign tumors are slow growing, encapsulated masses of orderly cells
Malignant tumors are caused by genetic mutations that allow for uncontrolled growth
Oncogenes are mutated genes whose products are associated with neoplastic transformation
Malignant tumors are not well encapsulated, fast growing and invasive with the ability to
metastasize
Only malignant tumors metastasize [seed] elsewhere
Tissue origin
Specific neoplasia
Burkitt’s lymphoma is characterized by a starry-sky appearance
o it is caused by the Epstein Barr virus and is more common in children
Hodgkin’s lymphoma is common in adults
o it is characterized by Reed-Sternberg cells
Pheochromocytoma is an adrenal medulla tumor which secretes excess nor-epinephrine
o it is characterized by paroxysms of palpitations, perspiration and pressure headaches
Wilms’ tumor is a mixed [mesenchymal, stromal and epithelial cells] tumor of the kidney
o it is the most common renal tumor in children
Multiple myeloma is the most common primary bone cancer in adults:
o characterized by malignant plasma cells in the bone marrow
o M spike [due to elevated IgG]
o Bence Jones protein in urine
o nocturnal bone pain
o recurrent infections due to improperly formed immunoglobulins
Osteosarcoma is the most common primary bone cancer in children
o it commonly affects the bones around the knee joint-lower femur and upper tibia
Ewing’s sarcoma is a malignant bone tumor which mimics osteomyelitis
139
Uterine leiomyoma [fibroid] is the most common benign smooth muscle tumor in the uterus in
females
Leukemia is a blood malignancy characterized by numerous immature WBCs
There are 4 main types of leukemia:
o Acute Lymphoblastic Leukemia [ALL]-commonest leukemia in children under 5 years
o Acute Myelogenous Leukemia [AML]-80% of acute leukemias in adults, Auer rods+
o Chronic Myelogenous Leukemia [CML]-30 to 60 years; Philadelphia chromosome,
anemia, bleeding and infection
o Chronic Lymphocytic Leukemia [CLL]- >60 year-old men; lymphadenopathy is
common
Cancer etiology
Oncogenes
o Genetic mutations which are associated with many cancers
• BCR-abl on the Philadelphia chromosome in Chronic Myelogenous Leukemia
• N-MYC in neuroblastoma
• L-MYC in lung cancer
• BRCA 1 in breast cancer
• p16 in melanoma
Carcinogens
o Chemical
• Nitrosamine esophageal cancer
• Asbestos mesothelioma
• Benzene leukemia
• Aflatoxin hepatocellular carcinoma
o Radiation
• UV light melanoma
• X-ray thyroid cancer
• Uranium lung cancer
o Microbiological
• HPV infection 16, 18 cervical cancer
• HHV 8 Kaposi sarcoma
• Epstein-Barr virus Burkitt’s lymphoma
• Hepatitis B/C hepatocellular carcinoma
Acanthosis nigricans
symmetric velvety hyperpigmented plaques in the axilla, groin, neck
may be associated with:
o lung, breast and stomach cancer
o it is also seen in insulin-resistant states such as obesity and diabetes
Cancer Epidemiology
Males: prostate [32%], lung [16%] then colon and rectum [12%
Females: breast [32%], lung [13%] then colon and rectum [12%]
140
CARDIOVASCULAR PATHOLOGY
Diseases of the cardiovascular system may be classified according to the structure affected such as heart,
artery or vein or by the type of underlying pathology such as trauma, infectious, degenerative or neoplastic.
Congenital
It may be either cyanotic or acyanotic:
o Cyanotic Heart Disease is due to a right to left shunt in the heart
o Acyanotic Heart Disease is seen in left to right shunt as in VSD, ASD and PDA
Fallot’s tetralogy is the most common cyanotic congenital heart disease and consists of:
o pulmonary stenosis
o ventricular septal defect
o right ventricular hypertrophy
o overriding [dextro-position] aorta
Patent Ductus Arteriosus is caused by failure of the ductus arteriosus to close shortly after birth
ASD is due to a defect in the atrial septum: failure of the ostium secundum to close
VSD is due to a defect of ventricular septum: most common congenital heart disease [30%]
Transposition of the Great Vessels is an uncommon cause of congenital cyanotic heart disease
in which the aorta is connected to the right ventricle and the pulmonary trunk to the left ventricle
Coarctation of the aorta is due to narrowing of the arch near the ligamentum arteriosum
Infections
Rheumatic fever is due to a post-strep infection
o it is characterized by Aschoff bodies [granulomas with giant cells], Anitschkow cells and
MacCallum’s patches
MacCallum’s patches are found in the left atrium
o Jones major criteria in diagnosing rheumatic fever include:
Sydenham’s chorea
Polyarthritis
Erythema marginatum
Carditis
Subcutaneous nodules
Endocarditis is the inflammation of endocardium [affecting the valves] and may be caused by
Streptococcus pyogenes, Streptococcus viridans or Staphylococcus aureus
o Subacute Bacterial Endocarditis-infection of previously damaged valves
seen more commonly as a sequel of rheumatic fever [S. viridans]
fever, new murmur, splinter hemorrhages, Olser’s nodes and Janeway nodules
o Acute Bacterial Endocarditis-infection of previously health valves
seen more commonly in intravenous drugs users [Staph. aureus]
o Libman Sacks Endocarditis is the sterile [non-infective] endocarditis of pulmonary and
tricuspid valves seen in SLE
Syphilitic aortitis often affect the arch of the aorta
o Treponema pallidum infection leading to aortic aneurysm, aortic stenosis and angina
pectoris
Vascular
Thrombus is a clot formed within an atherosclerotic vessel with lines of Zahn
Embolism is a dislodged mass of undissolved material in blood vessel travelling in the blood
o arterial embolism: painful, pale, pulseless, perishingly cold limb
Arteriosclerosis refers to the thickening of the arteries with loss of elasticity and contractility
due to infiltration of the tunica intima by collagen and smooth muscle fibers
Atherosclerosis is commonly caused by lipid/calcium deposits in tunica intima:
o risk factors include cigarette smoking, fatty diet, obesity, hypertension, diabetes and
homocysteinemia and bad cholesterol [Lethal LDL cholesterol]
o pathology includes subendothelial fatty streaks, fibrosis, atheroma and rupture with
eventual occlusion or embolus formation
Ischemic Heart Disease is caused by coronary atherosclerosis and leads to angina,
myocardial infraction or Congestive Heart Failure
Angina pectoris is caused by reversible inadequately perfused myocardium and the pain
relieved by rest
141
Prinzmetal [variant] angina is angina that occurs at rest and is caused by coronary artery
spasm
Myocardial Infarction is related to ischemic necrosis of myocardium due to blocked coronary
artery, mainly the Left Anterior Descending artery; the pain is NOT relived by rest
o results in the release of cardiac enzymes such as Troponin and Creatine Kinase-MB
[myocardial band] and Lactic Dehydrogenase
Degenerative
Aneurysm is the localized dilation of an artery; congenital or acquired
Atherosclerotic aneurysms are most often affect the abdominal aorta-AAA
o Abdominal aortic aneurysm is due to atherosclerosis and presents with pulsatile
abdominal mass with a bruit and low back pain
Dissecting aneurysm results from a longitudinal intraluminal tearing of the ascending thoracic
aorta and is seen in Marfan’s and Ehlers-Danlos syndromesand longstanding hypertension
Syphilitis aneurysm results from tertiary syphilis and mainly affects the arch of the aorta
rd
Berry aneurysms are congenital weaknesses that only present in the 3 decade and onwards
o may be associated with adult polycystic disease of the kidney
o commonly in the anterior part of the circle of Willis in the brain
o may cause subarachnoid hemorrhage in young adults
o may present with severe sudden headache, neck stiffness and loss of consciousness
Miscellaneous
Hypertension is defined as the elevation of BP >140/90 on 3 or more occasions
o Hypertension is classified as essential or secondary:
o Essential hypertension is unknown [95%]:
risk factors include:
family history
high salt intake
stress
obesity
o Secondary hypertension [5%]:
unilateral renal artery stenosis
hyperthyroidism
Cushing’s
pheochromocytoma
o Malignant hypertension is rapidly progressing with severe vascular damage
may lead to an early death from a stroke or heart failure
Congestive Heart Failure is caused by coronary artery disease, hypertension, valvular heart
disease, congenital heart disease or cardiomyopathy
Cardiomyopathy is diseased myocardium
o caused by:
alcohol
pregnancy
viral infections
o there are three types:
dilated [most common]
hypertrophic
restrictive [rare]
Cor pulmonale is right heart failure due to:
o COPD
o pulmonary embolism
Cardiac tamponade occurs when the heart is compressed due to excess fluid in pericardial
sac
o it is characterized by Beck’s triad:
Hypotension
Heart sounds are distant
High venous pressure
Peripheral Vascular Disease is caused by:
o atherosclerotic narrowing of large arteries
o presents with intermittent claudication
pain in the calves on walking and relieved by rest
142
Deep Vein Thrombosis is related to Virchow’s triad:
o Viscosity-increased clotting which may be related to the contraceptive pill
o Stasis in the veins from prolonged immobilization
o Damage to vessel wall due to trauma
o may present with a painful swollen leg
Pulmonary Embolism
o related to deep vein thrombosis-leg or pelvis
o a piece of the clot breaks off [embolus]
o the embolus travels up into the inferior vena cava and into the heart
o from the heart the clot travels up the pulmonary trunk
o occludes one of the pulmonary arteries or a smaller branch
o causes a ventilation/perfusion mismatch
o presents with a triad of shortness of breath, pleuritic chest pain and hemoptysis
Varicose veins
o tortuous dilated superficial veins
o may lead to thrombophlebitis
Thrombophlebitis
o inflammation of the vein wall and may lead to thrombosis
o presents with a swollen tender superficial cord under the skin
Raynaud’s disease
o Decreased blood flow triggered by cold and emotion and is characterized by:
vasospasm [white]
cyanosis [blue]
vasodilation [red]
often in young females with no known cause
Raynaud’s phenomenon
o secondary to:
SLE
Atherosclerosis
Scleroderma
o may be part of the CREST syndrome:
Calcinosis cutis
Raynaud’s phenomenon
Esophageal dysfunction
Scleroderma
Telangiectasia
Polyarteritis nodosa
o Inflammation due to a Type III hypersensitivity reaction
o affects medium size arteries, 30% are seropositive for Hepatitis B
o may present with fever, joint, abdominal pains and palpable purpura
Thromboangitis obliterans [aka Buerger’s disease]
o due to idiopathic segmental inflammation of medium size arteries and veins
o seen in male smokers between 20 and 40 years
o intermittent claudication and weakened distal pulses
Temporal arteritis is the localized giant cell inflammation in small arteries
o associated with a raised ESR
o in the elderly mainly
o may affect other small arteries like branches of the ICA and vertebral arteries
o may cause blindness if not treated promptly
Takayasu’s arteritis [pulseless disease]
o due to inflammation of the aorta; possible autoimmune
o more common in Asian females < 40 years
o presents with absent pulses, mainly in the upper limbs
Neoplastic
Hemangioma is a benign blood vessel tumor
Kaposi sarcoma may be caused by HHV type 8 in HIV/AIDS
Atrial myxoma is a benign myxomatous tumor in the region of the fossa ovalis
143
ENDOCRINE PATHOLOGY
Diseases of the endocrine may be classified according to the structure affected such as pituitary, thyroid,
parathyroid, adrenal or gastrointestinal or by the type of underlying pathology such as trauma, infection or
neoplasm.
Pituitary disorders
Gigantism
o due to excess Growth Hormone before 18 years
o may be associated with a functioning pituitary adenoma and presents with:
overgrowth of tissues in the entire body-large hands and protruding jaw
headache
visual disturbance
Acromegaly
o due to excess GH after growth plate has closed
o functioning pituitary adenoma presenting with:
protruding jaw, large spatulate hands and large feet
headache
visual disturbance
Cushing’s disease
o caused by excess ACTH from a functioning pituitary adenoma
o this causes excess cortisol production by the adrenal cortex resulting in:
moon-face, buffalo hump, truncal obesity and hypertension
purple striae on the abdomen and hyperpigmented skin creases
muscle wasting in the extremities, recurrent infections
Pituitary dwarfism
o GH deficiency in children
o may be related to a non-functioning pituitary tumor presenting with:
growth retardation
Sheehan’s syndrome
o ischemic necrosis of anterior pituitary lobe
o following a severe postpartum hemorrhage
o afterwards there is no secretions from the anterior lobe resulting in:
amenorrhea
cessation of lactation
loss of axillary and pubic hair
Hyperprolactinemia
o secreting prolactin pituitary adenoma presenting with:
galactorrhea
milky discharge from a non-lactating breast
amenorrhea
absent menstruation
prolactin inhibits GnRH release from the hypothalamus
infertility
inability to conceive in spite of unprotected sex for a year
Diabetes insipidus
o ADH deficiency
o caused by head injury, pituitary tumors, kidney disease and sarcoidosis presenting
with:
polyuria-frequent passage of copious diluted and colorless urine
polydypsia-excessive water consumption
constant specific gravity of urine < 1.006 in spite of dehydration
Thyroid disorders
Hypothyroidism [myxedema in adults and cretinism in infants]
o thyroxin deficiency may be:
primary or secondary
o Primary hypothyroidism
low T3, T4 and high TSH
fatigue, constipation, brittle hair, slow to relax reflexes, weight gain
144
o Secondary hypothyroidism
low T3, T4 and low TSH: pituitary hypofunctioning
o Hashimoto’s thyroiditis
anti-thyroglobulin antibodies, goiter and hypothyroidism
o Riedel’s thyroiditis
lymphocytic fibrotic thyroid disease leading to hypothyroidism
Hyperthyroidism
o Primary hyperthyroidism
elevated T3, T4 with low TSH
Graves disease [most common form of hyperthyroidism]:
autoimmune disorder-IgG antibodies bind to TSH receptors
exophthalmos, goiter, fine tremors of the hands, nervousness, diarrhea,
weight loss despite increased appetite, HLA B8 predisposition
exophthalmos-bilateral bulging eyes
goiter-diffuse enlarged thyroid gland
Plummer’s disease: toxic multinodular goiter and no exophthalmos
o Secondary hyperthyroidism
elevated T3, T4 with high TSH: TSH-secreting pituitary tumor
Parathyroid disorders
Hyperparathyroidism
o functioning parathyroid adenoma
o hypercalcemia
o fatigue
o brown bone cysts due to decomposed blood and hemosiderin pigment
Hypoparathyroidism
o incidental removal of the parathyroids in total thyroidectomy
o causes hypocalcemia
o presents with tetany and muscle twitching
o Chvostek test may be positive:
tapping the facial nerve in front of the ear causing facial twitching
Adrenal disorders
Addison’s disease
o chronic underfunctioning of the adrenal cortex
o may be an autoimmune disorder or associated with tuberculosis infection
o low glucocorticoids and aldosterone
o hyperpigmented skin creases and bronze skin
o low Na, low BP, high K and high ACTH
Waterhouse-Friderichsen syndrome
o acute adrenal bleeding secondary to Neisseria meningitidis septicemia
o results in shock and hemorrhagic rash
Conn’s disease
o overfunctioning of the zona glomerulosa layer of the adrenal cortex
o due to an adrenal adenoma which produces excess mineralocorticoids
o low potassium, low renin, metabolic alkalosis and high BP
Cushing’s syndrome
o may be due to exogenous steroids or a tumor of the adrenal cortex
o truncal obesity, moon face and buffalo hump, hypertension, hyperglycemia
o poor wound healing purple abdominal striae but no hyperpigmentation
Neuroblastoma
o Most common adrenal medulla tumor in children, associated with the N-myc oncogene
Pheochromocytoma
o adrenal medulla tumor which presents with:
palpitations, perspiration, pressure headaches and periodic hypertension
vanilyl mandelic acid is found in excess in the urine
known as the 10% tumor:
10% are bilateral
10% are malignant
10% occur outside of the adrenal gland
10% are familial
145
Gastrointestinal disorders
Diabetes mellitus Type 1
o Insulin Dependent DM
o due to insulin deficiency
o caused by beta cell destruction
o associated antibodies to beta cells of the pancreas
weight loss
more prone to Diabetic KetoAcidosis
common in children and teens
o HLA DR3 or 4 genetic predisposition
Diabetes mellitus type 2
o insulin insensitivity
o Non-Insulin Dependent DM
o insulin levels may be even elevated
o common in obese adults
o many have a family history of diabetes
o presents with:
polyuria
polydypsia
polyphagia
prone to HyperOsmolar Non-Ketotic coma
o some complications may be due to accumulation of Advanced Glycated End products
o causing narrowing of small and medium-size vessels
o premature cataracts and retinopathy may be related to accumulation of sorbitol
MODY type
o Mature Onset Diabetes in the Young
o not dependent on Insulin, no antibodies and not obese
o under 25 years of age
Gestational diabetes
o occurs in 4% of all pregnancies
o usually resolves with the end of the pregnancy
o some may progress to type 2 DM
Carcinoid syndrome
o tumors of neuroendocrine cells in the gut
o results in recurrent diarrhea, cutaneous flushing and bronchial wheezing
o 1/3 metastasize
o 1/3 are multiple
Insulinoma
o pancreatic beta-islet cell tumor
hypoglycemia relieved by food
Gastrinoma
o excess gastrin from GI tumor
recurrent peptic ulcer disease
aka Zollinger-Ellison syndrome
may be part of MEN type 1
146
GASTROINTESTINAL PATHOLOGY
Diseases of the gastrointestinal tract may be classified according to the structure affected such as
esophagus, stomach, intestinal, liver or gallbladder or by the type of underlying pathology such as trauma,
infection or neoplasm.
Esophageal disorders
Achalasia
o failure of Lower Esophageal Sphincter to relax; dysphagia for fluids not solids
Hiatal hernia
o protrusion of stomach into the chest through the diaphragm
Esophageal varices
o dilated veins in the lower esophagus seen in portal hypertension
GERD
o chronic inflammation of lower esophagus due to acid regurgitation
Barrett’s esophagus
o premalignant metaplastic change of lower esophagus due to GERD
Esophageal cancer
o squamous cell carcinoma
o excess nitrosamines in the diet and smoking
o adenocarcinoma; Barrett’s esophagus
Mallory-Weiss syndrome
o linear tear in lower esophagus due to protracted vomiting and retching
Gastric disorders
Peptic Ulcer Disease
o H. pylori infection, ulcer along lesser curvature of stomach [70%] or duodenum [95%]
o Epigastric pain is greater with meals in gastric ulcers and decreases with duodenal ones
Congenital Pyloric Stenosis
o young male infants > 6 weeks, projectile vomiting, hypertrophic pylorus
Atrophic Gastritis
o H. pylori infection; predisposition to pernicious anemia and cancer
Gastric Carcinoma
o H. pylori infection, high nitrosamines in diet; smoked meats
o Unexplained weight loss and Troisier’s node
Troisier’s sign: Virchow’s node in left supraclavicular fossa
metastatic spread from intra-abdominal cancer
147
Hirschsprung’s disease
o arrested neural crest cell migration, congenital aganglionosis of the colon
o presents with chronic constipation in a child
Ulcerative colitis
o chronic ulcerative inflammation mainly confined to the rectum
o presents with bloody diarrhea, toxic megacolon and an increased risk of colon cancer
Carcinoma of the colon
o third most common cancer in both sexes
o unexplained weight loss and change of bowel habits in the older population
Volvulus
o twisting of part of the bowel on itself; more common in sigmoid colon and in blacks
o presents with intestinal obstruction and abdominal pain
Peutz-Jegher syndrome
o oral pigmentation and multiple intestinal polyps
Irritable Bowel Syndrome [IBS]
o spastic colon of unknown cause
o presents with pain relieved by defecation, bloating, diarrhea and/or constipation
Liver disorders
Hepatitis: inflammation of liver caused by viral infections, alcohol or drugs
o Hepatitis A: fecal/oral transmission; water borne infection
o Hepatitis B: intravenous drug use and sexually transmitted; chronic carrier state
o Hepatitis C: used to be the most common cause of post-transfusion hepatitis
Nutmeg liver: chronic passive venous congestion
o seen in congestive heart failure
Cirrhosis [Laennec’s]
o chronic liver condition with damage, fibrosis and regeneration nodules:
presents with portal hypertension
o portal hypertension:
obstruction to portal blood flow to the liver due to liver fibrosis
causes ascites which is the accumulation of excess fluid in the abdomen
may also be due to decrease protein and increased aldosterone levels
o caput medusae:
dilated varicose veins radiating from umbilicus due to portal hypertension
Reye’s syndrome
o rare cause of childhood hepatoencephalopathy caused by the use of aspirin in children
with some febrile illnesses-chickenpox and influenza
Hepatocellular carcinoma [aka malignant hepatoma]
o liver cancer associated with Hepatitis B and C cirrhois, raised α-fetoprotein
o may be associated with fungal [aspergillus] aflatoxins
o may present with painful hepatomegaly, anorexia, fatigue andweight loss
Gallbladder disorders
Cholecystitis: inflammation of gallbladder
o fair, fat, fertile, flatulent females over forty with right upper quadrant pain
o 95% is caused by gallstones [cholelithiasis]:
cholesterol, pigment or mixed stones
70 to 80% of people with gallstones are asymptomatic
Pancreatic disorders
Pancreatitis: inflammation of the pancreas
o caused by alcohol, gallstones, trauma, steroids, mumps and hypercalcemia
o swollen pancreas with leakage of pancreatic enzymes into the abdominal cavity
o severe abdominal pain, bluish discoloration [Cullen’s sign] around umbilicus or in the
flanks [Grey Turner’s sign]
severe epigastric pain radiating through to the back
nausea and vomiting
Pancreatic cancer: malignancy arise from the pancreatic ducts [adenocarcinoma]
o painless jaundice
o clay-colored stool if the cancer is in the head of the pancreas
o weight loss due to malabsorption and anorexia; very poor prognosis
148
MUSCULOSKELETAL PATHOLOGY
Musculoskeletal diseases may be classified according to the tissue of origin such as bone, joint, muscle or
neuromuscular junction or according to the type of pathology such as traumatic, infectious, metabolic or
neoplastic.
149
Malignant bone disorders
Multiple myeloma
0
o most common 1 bone cancer in adults
o more common after 50 years
nocturnal bone or back pain
recurrent infections
hypercalcemia: stones, bones, moans and abdominal groans
o punched-out lesions on x-ray
o raised IgG causing an M [myeloma] spike on serum electrophoresis
o Bence Jones proteins [light chain Ig] in urine
Osteosarcoma [aka osteogenic sarcoma]
0
o second most common malignant bone tumor; most common 1 bone cancer in teenagers
o may be seen in patients with Paget’s disease
o Codman’s triangle of periosteal elevation on x-ray
Chondrosarcoma
o third most common malignant bone tumor; men aged 30-60 years
Ewing’s sarcoma
o malignant tumor mimicking osteomyelitis
o onion skin appearance on x-ray
Arthritides
Seropositive arthritis
o Rheumatoid Factor is positive: RA and SLE
Rheumatoid arthritis
o autoimmune bilateral small joint disease in HLA-DR4 positive patients
o Rheumatoid factor [IgG antibody] in 70-80% of patients
o Joint inflammation characterized by pannus formation:
inflamed granulation tissue in the joint space destroying articular surface
o joint deformities
swan neck
ulnar deviation
boutonnière
Haygarth’s nodes-metacarpophalangeal joint swelling
Bouchard’s nodes-proximal interphalangeal joints [also seen in OA]
Still’s disease
o Juvenile Rheumatoid Arthritis
affects small and medium-size joint pains mainly wrist and knee
lymphadenopathy and splenomegaly in children and teenagers
Felty’s syndrome
o splenomegaly
o neutropenia
o seen in patients with RA
Systemic Lupus Erythematosus
o unknown cause
o autoimmune disorder: AntiNuclear Antibodies, anti ds-DNA antibodies
o more common in younger females
o more severe in young black females
o affects multiple organ systems
joints: polyarthritis-small and large joint
skin: butterfly [malar] rash and photosensitivity
kidney: nephrotic syndrome
heart: Libman-Sack’s endocarditis
Sjðgren’s syndrome
o dry eyes [xerophthalmia], dry mouth [xerostomia] and arthritis
o may be seen in both RA and scleroderma
o more common in women between 40 and 60 years
o antibodies to ribonucleoproteins [SS-A and SS-B]
Seronegative arthritis
o Rheumatoid Factor is negative
o HLA-B27 is positive
o Reiter’s syndrome, Psoriatic arthritis, Ankylosing Spondylitis
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HLA-B27+ arthritis [PAIR]
o Psoriatic arthritis, Ankylosing Spondylitis, Reiter’s syndrome
Psoriatic Arthritis:
polyarthritis with silvery-scales over extensor aspects
autoimmune disorder causing rapid turnover of skin
pitted nails and dactylitis [sausage fingers]
Ankylosing Spondylitis [aka Marie Strumpell’s disease]:
Sacroiliitis and low back pain
bamboo spine and a positive HLA B27 genetic marker
Inflammatory Bowel Disease like Ulcerative Colitis
some patients with ulcerative colitis present with joint pains
Reiter’s syndrome: [can’t pee, can’t see and can’t dance with me]
Urethritis
Arthritis-joint or heel pain
Conjunctivitis
may be caused by Chlamydia or Shigella infection
Osteoarthritis
o degenerative disease affecting weight-bearing joints:
hips
knees
spine
o causes subchondral sclerosis, osteophytes, Heberden’s and Bouchard’s nodes
o Heberden’s nodes
primary osteoarthritis in distal interphalangeal joints of the fingers
in females mainly
o Bouchard’s nodes
swelling of the proximal interphalangeal joints seen in OA and RA
Gout
o aka podagra [when it affects the foot] or gonagra [when it affects the knee]
o due to hyperuricemia [raised uric acid]
o more common in males
o may be associated alcohol and purine-rich foods
o alcohol metabolites compete for the same excretion site in the kidney as uric acid
st
o acute gout: sudden onset of severe 1 metatarsophalangeal joint pain
o chronic gout is characterized by tophi:
accumulation of uric acid crystals in the ear and skin over joints
o uric acid crystals are needle-shaped and negatively birefringent with polarized light
[yellow with parallel light]
Periarticular disorders
Lyme disease
o named after the town of Lyme, Connecticut where a number of case were seen in 1975
o caused by Borrelia burgdorferi
o transmitted by deer tick: Ixodes scapularis
o polyarthritis with bulls-eye lesion [erythema chronicum migrans]
Neuromuscular disorders
Myasthenia gravis
o acetylcholine receptor antibodies
o major peak incidence in 30+ year-old females; second peak in 60+ year-old males
o diplopia, ptosis, problems chewing, fatigue with repetitive muscle use
o Tensilon [injection of edrophonium chloride] test is positive
o 80% of female myasthenic patients have thymic pathology:
65% have thymic hyperplasia
15% have a thymic tumor [thymoma]
Lambert-Eaton syndrome
o auto-antibodies to the pre-synaptic voltage-gated calcium channels in the
neuromuscular junction
o prevents acetylcholine from being released by the vesicles
o seen in small [oat] cell lung cancers
o older male population-60+ years
o weakness improves with repetitive use
o Tensilon test is usually negative
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Myopathies
Dermatomyositis
o Unknown cause
o Autoimmune disorder
o More common in females
o Causes a heliotrope rash [reddish purple eyelids and papules on the knuckles of the
hands [Gottron’s papules]
o Produces antinuclear antibodies and anti-Jo-1 antibodies
o 10% associated with underlying malignancies of the lung, breast, gut or ovary
Duchenne’s muscular dystrophy
o sex-linked recessive
o absence of Dystrophin
o males predominantly
o pseudohypertrophic calves
muscle infiltrated by fat and connective tissue
although the muscle appears to be big and strong, it is actually weak
o death from cardiorespiratory failure before age 20 years
Becker’s muscular dystrophy
o sex-linked recessive
o inadequate dystrophin levels
o not as severe as Duchenne’s muscular dystrophy; tend to live beyond 40 years
Neuropathies
Charcot-Marie-Tooth disease
o progressive hereditary nerve damage
o peroneal muscular wasting
o inability to evert the foot
Miscellaneous conditions
Legg-Calvé-Perthes Disease
o ischemia and subsequent avascular necrosis of the head of the femur
o unknown cause
o more common in young boys
Slipped Capital Femoral Epiphysis
o displacement of the epiphysis of the head of the femur
o more common in overweight children and teens
o possible traumatic Salter-Harris type 1 epiphyseal fracture
Polymyalgia rheumatica
o unknown cause
o older females > 50 years
o pain and stiffness in the shoulder and hips
o malaise and fever
o associated with temporal arteritis
o may lead to blindness
o highly elevated ESR with normal creatine kinase
152
NERVOUS SYSTEM DISORDERS
Diseases of the nervous system may be divided into the following categories:
Central Nervous System
Peripheral Nervous System
Autonomic Nervous System
Congenital disorders may result from failure of the neural tube to form properly:
Spina bifida is a neural tube defect due to folic acid deficiency in the first trimester
o Spina bifida occulta present with failure of the neural arch to close and with a tuft of hair
over a dimple in the region of the lumbar spine
o Spina bifida vera is a more severe form with failure of neural arch to close with meninges
herniation under skin
o associated with elevated levels of alpha-fetoprotein
Meningocele refers to the protrusion of meninges through defect in the spinal column
Myelomeningocele is when there is protrusion of meninges & spinal cord through spinal column
defect
Anencephaly is the failure of the brain and cranial vault to develop
Sometimes the defect may affect the ventricles and the flow of CSF:
Hydrocephalus is the accumulation of excessive CSF in the ventricles
Obstructive hydrocephalus is caused by obstruction to the flow of CSF: non-communicating type
Normal pressure hydrocephalus: dilated ventricles in the elderly
o reversible cause of dementia
o presents with incontinence, ataxia and dementia [wet, wobbly and wacky]
Arnold-Chiari deformity is characterized by a small posterior fossa with cerebellar herniation
into foramen magnum
o Arnold-Chiari type 1 herniation of cerebellar tonsils into foramen magnum
o Arnold-Chiari type 2 herniation of cerebellar vermis and medulla into the
foramen magnum
Dandy-Walker syndrome is characterized by:
o a large posterior fossa
th
o with cystic dilation of the 4 ventricle
Some brain damage may be due to brain anoxia at the time of birth:
Cerebral palsy is the non-progressive motor disorder due to prenatal brain anoxia
o scissors gait is the upper motor neuron gait seen in cerebral palsy
153
Vascular supply interruption will cause brain damage:
Cerebrovascular Accident [stroke] is the sudden contralateral motor/sensory loss due to
interrupted blood supply to brain
Transient Ischemic Attacks [mini stroke] are similar but brief episodes of neurological dysfunction
caused by small emboli lasting less than 24 hours
Thrombosis refers to a clot formed within an atherosclerotic blood vessel
Embolism is a mass of undissolved material in blood vessel brought by the blood
Intracerebral hemorrhage refers to the accumulation blood inside the brain:
The most commonly affected are the lenticulostriate branches of the middle cerebral artery
154
Von Recklinghausen’s disease is characterized by multiple neurofibromas in skin, spinal cord
and brain with café au lait skin lesions
Von Recklinghausen’s disease is Type 1 [peripheral] neurofibromatosis and may be associated
with pheochromocytoma
Type II neurofibromatosis is the central variety and is characterized by bilateral acoustic
neuromas
The causes of some CNS diseases are unknown [idiopathic] and include:
epilepsy is characterized by seizures of unknown origin: grand mal or petite mal
Friedreich’s ataxia is characterized by progressive spinocerebellar tract damage, ataxia,
scoliosis, speech and heart problems
syringomyelia is the dilation of central spinal canal; results in a cape-like pattern of loss of
pain and temperature but intact proprioception and vibration
Trauma
Erb-Duchene’s palsy is due to C5, 6 roots damage during delivery or sports injury
o results in elbow extended, internal shoulder rotation and pronation of the forearm
Klumpke’s palsy is due to C8 and T1 root damage during breech delivery or sports injury
o results in claw hand deformity
Compression neuropathies
Carpal Tunnel Syndrome is caused by the median nerve compression at wrist: Phalen’s, Tinel’s
and wrist compression tests may be positive-pain or numbness in the lateral 3½ digits
Elbow Tunnel Syndrome is caused by compression of the ulnar nerve at the elbow-pain or
numbness along the ulnar aspect of the forearm and medial 1½ digits
Cheiralgia paresthetica is caused by compression of the superficial radial nerve near the wrist
and presents with pain over the lateral aspect of the distal forearm
Piriformis syndrome refers to the compression of the sciatic nerve when it or a part of the nerve
passes through the piriformis muscle-pain radiates into the back of the thigh and leg
Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve-
numbness in the anterolateral aspect of the thigh
Gonalgia paresthetica is caused by compression of the saphenous nerve at the knee in obese
patients-medial knee and medial leg pain
Tarsal Tunnel Syndrome is due to compression of the posterior tibial nerve and results in pain
in the plantar surface of the foot
Poisoning
Lead poisoning
aka plumbism
due to lead paint ingestion or lead paint inhalation
155
presents with:
o Anorexia and anemia
o Belly pain and Burton’s blue gum line
o Clumsiness or Constipation
o Developmental delays or Dementia or Drop wrist
o Emesis [vomiting]
o Fatigue due to a microcytic hypochromic anemia
Minamato disease is due to mercury poisoning
o excessive mercury in tuna fish in Japan
o characterized by peripheral neuropathy
o with numbness and hypotonia
Metabolic disorders
Diabetes mellitus causes a peripheral neuropathy
o due to damage to vasa nervora and presents with glove and stocking paresthesia
o this is caused by the accumulation of Advanced Glycated End products
Leprosy
o caused by Mycobacterium leprae
o bacterium loves cool areas: skin and peripheral nerves
o causes peripheral neuropathy
o claw hand
o loss of outer third of eyebrow
o anesthetic hypopigmented skin lesions
Herpes zoster
o caused by HHV type 3 infection
o presents with a dermatomal rash on one side
o following a prodrome of pain and hypersensitivity over the same area
Guillain-Barré syndrome
o infectious ascending demyelinating polyneuropathy
o due to possible viral infection or immunizations
o presenting with progressive motor loss starting in the legs
o may affect the diaphragm causing respiratory problems
156
NUTRITIONAL PATHOLOGY
Vitamin deficiencies
Vitamin B1 [thiamine] deficiency
o Beriberi
o seen in alcoholics, dietary deficiency, anorexia, bulimia and hyperemesis gravidarum
o Dry Beriberi
B1 deficiency with peripheral neuropathy
Causes numbness and foot drop
o Wet Beriberi
B1 deficiency with heart failure
Causes swollen ankles, tachycardia
o Wernicke-Korsakoff syndrome
B1 deficiency affecting the brain
Causes confusion, confabulation [telling lies], coma in chronic alcoholics
Vitamin B2 deficiency
o hyporiboflavinosis
cheilosis [cracked lips]
glossitis [sore tongue]
seborrheic dermatitis [itchy scaly scalp]
B3 [niacin] deficiency
o Pellagra
Diarrhea
Casal’s necklace may be present:
o V-shaped dermatitis seen in sun-exposed part of chest
Dermatitis
Dementia
Death
B9 [folic acid] deficiency
o neural tube defect in the newborn: spina bifida
o megaloblastic anemia [large red blood cells] in adults: fatigue and beef-red tongue
B12 deficiency
o pernicious anemia
due to lack of Intrinsic Factor secreted by the parietal cells of the stomach
o other causes include:
deficient in diet
poor absorption due to disease in the terminal ileum
o causes a macrocytic [megaloblastic] anemia and spinal cord degeneration
o fatigue, ataxia, upper motor neuron signs, urinary and fecal incontinence
Vitamin C deficiency
o inability to hydroxylate proline and lysine residues in collagen
o this weakens the capillaries
o results in scurvy
tissue hemorrhage with bleeding swollen gums and loose teeth
poor wound healing
impaired bone formation [in children]
Vitamin A deficiency
o nyctalopia, xerophthalmia and keratomalacia
nyctalopia [night blindness] seen in Vitamin A deficiency
xerophthalmia [dry eyes]
keratomalacia [soft cornea]
157
Vitamin D deficiency
o rickets in children
soft bones with bowed legs
rachitic rosary
swollen costochondral junctions in rickets
pectus carinatum
pigeon chest seen in rickets
o osteomalacia in adults
Looser’s zones [pseudofracture]
Vitamin E deficiency
o causes hemolytic anemia
destruction of red blood cells leading to low red blood cell count and low Hb
fatigue
Vitamin K deficiency
o hemorrhagic disease of newborns
abnormal bleeding from the umbilicus
o easily preventable by giving the newborn an injection of Vitamin K
Mineral disorders
Iodine deficiency
o myxedema and goiter in adults
o cretinism in infants
o severe hypothyroidism in an infant
o usually caused by failure of the thyroid gland to develop
mental retardation
hoarse cry
thick scrotal tongue [macroglossia]
umbilical hernia
Iron deficiency
o microcytic, hypochromic anemia
o anemia = low hemoglobin and decreased red blood cell count
o red blood cells are small [microcytic] and pale [hypochromic]
o diet deficient in iron rich foods such as meat and dark green leafy vegetables
o excess blood loss as seen in bleeding peptic ulcer or heavy menstruation
severe anemia may be accompanied by pale mucosa and nails
the tongue is also pale and smooth-glossitis
koilonychia [spoon-shaped nails] may also be present
when iron-deficiency anemia, glossitis with dysphagia occur in a post-
menopausal woman it is known as Plummer-Vinson syndrome
Excessive Iron absorption
o Hemochromatosis
o affects the liver, heart and endocrine glands including the pancreas and gonads
o may be genetic [autosomal recessive] or acquired [excessive dietary iron]
o presents with the following:
Arthritis
Bronze skin
Cirrhosis
Diabetes mellitus
Erection problems due to testicular failure
Excessive copper absorption
o Wilson’s disease
o aka hepatolenticular disease
o autosomal recessive disease
o lack of ceruloplasmin-major copper-carrying protein in the blood
o results in excessive copper deposition in brain and liver
o may present with damage to the liver, brain and eyes:
Asterixis [coarse flapping tremor of the wrist when it Is extended]
Basal ganglia degeneration [Parkinson-like tremors]
Cirrhosis, corneal deposits [Kayser-Fleisher rings] due to copper accumulation
Dementia
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RENAL DISEASES
Diseases of the urinary tract may be classified according to the structure affected such as kidney, ureter or
bladder or by the type of underlying pathology such as trauma, infection or neoplasm.
Nephritic syndrome
o Glomerulonephritis
o most commonly associated with post-streptococcal infections
o antigen-antibody complex damage to the glomeruli
o activation of the complement system causes inflammation
o causes leakage of RBCs [hematuria] and protein in the urine [proteinuria]
o red blood cells casts are present in the urine
o inflammation of the glomerulus results in renal ischemia
o the ensuing renal ischemia results in hypertension by the activation of the renin-
angiotensin system
o the resulting renal damage causes edema
edema is the accumulation of fluid in the interstitial tissue
due to raised hydrostatic pressure
Nephrotic syndrome
o idiopathic in many cases
o may be caused by diabetes, SLE or drugs
o minimal change damage to the basement membrane
o large holes appear in the basement membrane allowing for loss of protein in the urine
o causes massive proteinuria more than 3.5 grams/24 hour period
o results in hypoproteinemia and hypoalbuminemia in the blood
o as a result of the low protein content in the blood, there is edema
due to a decrease in the oncotic pressure
there may be ascites or pleural effusions if severe
o there is also hyperlipidemia
related to the hypoproteinemia and increased lipoprotein synthesis
Pyelonephritis
o ascending E. coli infection from cystitis usually
o inflamed collecting tubules and renal pelvis
o causes white blood cell casts to be present in the urine
o presents with chills, fever, nausea, vomiting and costovertebral angle tenderness
o chronic pyelonephritis will result in a shrunken kidney and hypertension
Diabetic nephropathy
o causes nephrotic syndrome:
massive proteinuria > 3.5 grams of protein per 24 hours
hyperlipidemia
recurrent infections
o may also cause Kimmelstiel-Wilson disease
kidney damage which is characterized by nodular sclerosis of the glomeruli
Urinary Tract Infection
o ascending infection with enteric organisms
o most commonly due to E. coli
o causes dysuria, increased urinary frequency and nocturia
o WBCs, bacteria and nitrites are found in the urine
o many bacteria possess a reductase which reduces urinary nitrates to nitrites
Interstitial cystitis
o uncommon bladder inflammation
o caused by leakage of urine beneath the bladder epithelium
o unknown etiology resulting in damage to the mucus lining the bladder mucosa
o causes superficial cracks and Hunner’s ulcers of the bladder mucosa
o seen more commonly in females
o presents increased frequency and nocturia
o urinalysis shows white blood cells but no bacteria or nitrites
Wilms tumor
o aka nephroblastoma or mixed tumor
o most common malignant kidney tumor in children
o presents with a mass in the flank and hematuria
159
Renal Cell Carcinoma
o most common type of adult renal cancer
o aka Grawitz tumor
o presents with painless hematuria
o mass in the flank
Adult Polycystic Disease of the Kidney
o autosomal dominant disorder
o presents with bilateral kidney enlargement and hypertension
o increased incidence of berry aneurysms of the circle of Willis in the brain
Goodpasture’s syndrome
o affects the parenchyma of the kidney and lung
o antibodies against Type IV collagen fibers
o presents with hemoptysis and hematuria
Renal Calculi
o stone formation in the ureter and pelvis of the kidney
o calcium oxalate is the most common urinary stone
o 85% of renal stones are radiopaque
o other types [which are radiolucent] include:
cystine
uric acid
phosphate
o presents with:
severe colicky loin [flank] to groin pain
hematuria
160
RESPIRATORY PATHOLOGY
Diseases of the respiratory tract may be classified according to the structure affected such as
tracheobronchial tree, lung or pleura or by the type of underlying pathology such as trauma, infection or
neoplasm.
Tracheobronchial tree
Asthma
o reversible bronchospasm due to hypersensitivity of the bronchi
o extrinsic: allergens, eczema and hay fever; intrinsic: exercise
o bronchial mucosa inflammation and constriction of bronchial smooth muscle
o Curschmann spirals and Charcot-Leyden crystals may also be found in the sputum
o presents with paroxysms of shortness of breath and wheezing worse at nights
Bronchiectasis
o chronic dilation of bronchi
o due to bronchial obstruction by mucous plugs
o may be associated with cystic fibrosis
o copious foul smelling mucopurulant sputum early in the morning
Kartagener’s syndrome
o immotile cilia which present with a clinical triad consisting of:
chronic sinusitis
bronchiectasis
situs inversus
Lung
Atelectasis
o collapse of or incomplete expansion of alveoli
o compression atelectasis
collapse due to external pressure like:
pleural effusion
pneumothorax
o resorption atelectasis
collapse distal to an obstructed bronchus by:
foreign body
tumor
o contraction atelectasis
collapse due to interstitial fibrosis and loss of elastic recoil
commonly seen in pulmonary tuberculosis
COPD [Chronic Obstructive Pulmonary Disease]
o Emphysema
Pink puffers who tend to thin
alveolar wall destroyed, loss of elastic recoil, good oxygenation
centriacinar type of emphysema:
smoking related, affects respiratory bronchioles, barrel-chest
panacinar type of emphysema:
α1-antitrypsin deficiency
affects all pulmonary acini
destruction of elastic tissue in alveolar wall, younger patients
o Chronic Bronchitis
Blue Bloaters who tend to be overweight
chronic cough >3 months for at least 2 consecutive years
bronchial gland hyperplasia due to infection
cyanosis [blue]
right-sided heart failure [bloater]
Pneumonia
o inflammation of lung tissue
o lobar pneumonia:
inflammation of a lobe with red then grey hepatization
Streptococcus pneumoniae
o bronchopneumonia
patchy inflammation of both lungs usually in the bases
161
o interstitial pneumonia
involved both lungs
caused by Mycoplasma or Chlamydia pneumoniae
o pneumocystis jiroveci pneumonia [PJP]
opportunistic infection by Pneumocystis jiroveci [carinii]-AIDS
causes ground glass appearance on chest x-ray
Lung abscess
o pus-filled cavity in the lung
o Staph aureus and Klebsiella pneumoniae are common causes
o seen more often in alcoholics and epileptics
Pneumoconiosis
o occupational lung disease
o caused by inhalation of inorganic industrial particles
anthracosis
lung disease caused by coal dust in coal miners
silicosis
lung disease caused by silica dust in quarry workers: quartz and sand
asbestosis
lung disease caused by asbestos fibers in miners
increased risk of mesothelioma
siderosis
lung disease caused by iron dust in iron miners
Caplan’s lung
pneumoconiosis with progressive pulmonary fibrosis in RA
Hypersensitivity pneumonitis
o allergic lung reactions caused by organic dust
byssinosis
allergic lung reactions cause by cotton dust from mill workers
bagassosis
moldy fibrous waste [bagasse] in sugar cane workers
farmer’s lung
allergic lung reactions cause by moldy hay in farmers
silo-filler’s lung
caused by nitrogen dioxide found in corn-filled silos
Sarcoidosis
o Type IV hypersensitivity reaction
o non-caseous granulomas with epithelioid macrophages
o bilateral hilar lymphadenopathy and pulmonary fibrosis-dyspnea and dry cough
o may affect the spleen, eye, nerves or skin also:
splenomegaly
uveitis
Bell’s palsy
erythema nodusum [red painful bumps over the shins]
o elevated serum calcium due to increased conversion of Vitamin D in the epithelioid
macrophages
o associated with raised levels of Angiotensin Converting Enzyme in 40-80% of patients
o ACE is also produced by the epithelioid cells in the granulomas
Tuberculosis
o Ghon focus: caseous granulomas in the lung
epithelioid cells and Langhan’s giant cells
epithelioid cells are activated macrophages
lower part of the upper lobe or the upper part of the lower lobe
o Ghon complex:
peripheral Ghon focus with involvement of regional lymph node
seen in primary tuberculosis
o Langhan’s giant cells:
fused epithelioid cells with the nuclei arranged in a horse-shoe pattern
o Apical cavitations are common in secondary tuberculosis
Bronchogenic carcinoma
o most common lung cancer
o associated with chronic cigarette smoking, mining, industrial cities
162
o squamous cell type is most common
o more common in males
o may present with chronic cough, hemoptysis and weight loss
o may also present with evidence of the following [SPHERE]:
Superior vena cava syndrome [distended neck and upper limb veins]
Pancoast’s tumor [mass in the lung apex]
Horner’s syndrome [ptosis, miosis and anhydrosis]
Endocrine [paraneoplastic ectopic hormone secretions]
Recurrent laryngeal damage [hoarseness]
Effusions [pleural or pericardial]
Small cell lung carcinoma [25% of lung cancers]
o previously called an oat cell carcinoma
o uncommon cause of lung cancer
o associated with ectopic hormone production such as:
Parathormone
ACTH
ADH
SIADH
o Syndrome of Inappropriate ADH secretion
o secreted by some small cell lung cancers
Pancoast tumor
o bronchogenic carcinoma in one of the lung apices
o may invade roots of the brachial plexus, first rib, sympathetic trunk, subclavian vein
or artery
o may cause Horner’s syndrome due to damage to the sympathetic trunk in the neck:
Ptosis
Anhydrosis
Miosis
Mnemonic: Horny PAM
Pleura
Pneumothorax
o air within the pleural cavity
o spontaneous-no previous underlying lung disease
o secondary-traumatic, underlying asthma or emphysema
o tension
trapped air in the pleural space cannot escape and builds up in the space
causing mediastinal shift away from the affected side
Empyema
o pus-filled pleural cavity
o secondary to bacterial infection in the lungs
Pleural effusion
o fluid-filled pleural cavity
o may be an exudates or a transudate
o exudates are as a result of localized inflammation
o transudates are related to systemic diseases
o protein content is useful to distinguish between the two:
exudate has more protein [>2 g/dl]
o exudates are seen in:
pneumonia
tuberculosis
lung cancer
pulmonary embolism
o transudates are seen in:
congestive heart failure
nephrotic syndrome
renal failure
liver failure
Mesothelioma
o malignant tumor of the pleura
o associated with prolonged exposure to asbestos
163
SEXUALLY TRANSMITTED DISEASES
Diseases transmitted by sexual intercourse may be classified according to the structure affected such as
penile, urethra, vulvar, vaginal, cervical or uterine or by the type of underlying causative agent such as viral,
bacterial or fungal. Some of these infections can also be transmitted from an infected mother to her infant
via the placenta or during child birth.
Penile lesions
Syphilis
o Treponema pallidum
o spirochete infection
o primary stage:
painless hard genital ulcer-chancre
disappears spontaneously
o secondary stage:
generalized maculopapular rash
generalized lymphadenopathy
condylomata lata [flat-topped genital warts]
o latent stage:
asymptomatic
o tertiary stage:
thoracic aortic aneurysm
Argyll-Robertson pupil [easily accommodates, slow to react to light]
gummas [chronic granulomatous lesions in the bone and soft tissue]
Charcot’s joint [grossly destroyed joint due to loss of pain]
General Paralysis of the Insane
tabes dorsalis [dorsal column disease]
Chancroid
o Hemophilus ducreyi
o bacterial infection
o painful soft yellow genital ulcers [ducreyi makes you cry]
o painful swollen inguinal nodes
Granuloma inguinale
o Klebsiella [formally Calymmatobacterium] granulomatis
o bacterial infection
o painless beef red genital ulcers
Herpes genitalis
o HHV type 2 infection
Lymphogranuloma venereum
o Chlamydia trachomatis Type L1-3
o bacterial infection
o transient genital ulcer
o buboes [swollen painful lymph nodes]
o sign of the groove in the inguinal region
o rectal stricture
Urethral discharge
Urethritis
o inflammation of urethra
o caused by Chlamydia trachomatis or Neisseria gonorrhea infection
Chlamydia urethritis
o Chlamydia trachomatis
o most common cause of a urethral discharge in the USA
o mucoid penile discharge
o dysuria
Gonococcal urethritis
o Neisseria gonorrhea
o second most common cause of a urethral discharge in the USA
o purulent penile discharge, dysuria and infection of Bartholin’s gland in females
o may cause ophthalmia neonatorum
o may also cause septic arthritis
164
Vulvar disease
Vulvovaginitis
o Candida albicans infection
o opportunistic fungal infection seen more commonly in females
o thick cheesy vaginal discharge with itching
o recent antibiotics and diabetes mellitus
Condyloma accuminata
o Human Papilloma Viral infection
o Most common STD in the USA
o Affects more women than men
o types 16 and 18 are associated with cervical cancer
o cauliflower-type warts [compared to the flat-topped warts seen in secondary syphilis]
Vaginal disease
Bacterial vaginosis
o Gardnerella species
o Fishy-smelling watery vaginal discharge
o Clue cells +++ [vaginal epithelial cells studded by numerous bacteria]
o Whiff test-amines are released when the slide is flooded with KOH
Trichomoniasis
o Trichomonas vaginalis
o motile protozoal infection
o malodorous green frothy discharge
o motile flagellates seen on wet mount preparation
Cervical disease
Cervical carcinoma
o Squamous cell cancer
o HPV type 16 and 18
o post-coital bleeding [bleeding after sex]
Cervicitis
o Chlamydia [most common] or Gonococcal infection
o pus from external os
o may be part of Pelvic Inflammatory Disease
Uterine
PID
o Pelvic Inflammatory Disease
o Chlamydia, Gonorrhea or E. coli
o infection of the cervix, uterus, uterine tube and pelvic connective tissue
o lower abdominal pain, dysmenorrheal, dyspareunia and pain on cervical movement
Salpingitis
o inflamed tube seen in PID
o may result in an abscess formation
o may heal with fibrosis and partial obstruction of the tube
o leading to an ectopic pregnancy or infertility
TORCHeS Infections
infections caused by microbes which pass from mother to the fetus:
o Toxoplasmosis
o Others including HIV and Hepatitis B
o Rubella
o Cytomegalovirus
o Herpes simplex Type II
o Syphilis
All of the above can be transmitted across the placenta EXCEPT:
Herpes simplex Type II which is transmitted to the baby as it passes through the birth canal of a
mother infected with the virus during labor
165
SKIN DISEASES
Skin diseases
infections caused by viruses, bacteria, fungi or parasites
o viral
cold sores is caused by herpes simplex virus
chickenpox and shingles is caused by varicella-zoster virus
measles is caused by a Paramyxo virus
hand, foot and mouth disease is caused by Coxsackie virus
Kaposi’s sarcoma is caused by Human Herpes Virus Type 8
o bacterial
impetigo which may be caused by Strep and Staph infections
acne vulgaris is caused by Propionibacterium acnes
lupus vulgaris is caused by Mycobacterium tuberculosis
leprosy is caused by Mycobacterium leprae
syphilis is caused by Treponema pallidum
o fungal
tinea [ringworm] is caused by a variety of dermatophytes including:
Trichophyton
Epidermophyton
Microsporum
pityriasis versicolor is caused by Malassezia furfur
candidiasis is caused by Candida albicans
sporothricosis is caused by Sporothrix schenckii
o parasitic
scabies is caused by Sarcoptes scabiei
cutaneous larva migrans is caused by Toxocara canis
unknown such as:
o psoriasis:
possible autoimmune
increased turnover of the epidermal cells
silvery scales over the extensor surfaces of the elbows and knees
pitted finger nails
inflammatory arthritis in some patients [10%]
tumors such as benign nevi, malignant melanoma and skin cancer
o basal cell carcinoma
this is the most common type of skin cancer [60%]
it is the least dangerous because it rarely metastasize
arises from the stratum basalis
appears first as a small shiny bump
later develops a central depression and a beaded pearly edge
o squamous cell carcinoma
second most common skin cancer [20%]
arises from the keratin-producing cells in the stratum spinosum
it often spread locally and metastasizes to nearby lymph nodes
presents as a raised reddened scaly lesion which later ulcerates
o malignant melanoma [1%] contains malignant melanocytes and may present with:
Asymmetric shape
Border irregular
Color change
Diameter greater than 6 mm in diameter
Expanding or evolving lesion
166
MICROBIOLOGY
167
168
HISTORY OF MICROBIOLOGY
Historical background
Lazzaro Spallanzani
o disproved the spontaneous generation of life theory
Girolamo Fracastoro
o suggested transferable spores caused disease such as syphilis
Robert Hooke
o first to see cells in thin slices of cork using a crude microscope
Anton van Leeuwenhoek
o inventor of the microscope
Ignazio Semmelweiss
th
o introduced hand washing in the 19 century
Joseph Lister
o introduced surgical asepsis using carbolic acid
Edward Jenner
o developed the smallpox vaccine from cow [vacca] pox in milkmaids
Robert Koch
o Father of Microbiology who identified the bacillus that caused anthrax
o 4 microbiological postulates:
agent must be found in all patients with the disease
must be able to prepare a pure culture of the agent
injected agent must cause the same disease in new patients
must recover same organism from the newly infected patients
Hans Christian Gram
o Developed a 7-step process staining process for bacteria:
Add Crystal violet [blue stain] and leave for 1 minute
Wash off with H2O
Add Iodine [mordant-fixer] and leave of 1 minute
Wash off with H2O
Add Acetone alcohol [decolorizer-removes the blue stain] for 5 seconds
Counter stain with Safranin stain [red] and leave for 20 seconds
Wash off finally with H2O
o Gram Positive-blue stain and Gram Negative-red stain
Louis Pasteur
o inventor of the pasteurization process
o germ theory
o developed vaccine against rabies and anthrax
Paul Ehrlich
o developed chemicals that killed micro-organisms like syphilis
o sulfa drugs and salvarsan
Alexander Fleming in 1928
o discovered Penicillin
Dmitiri Ivanowski in 1898
o first to postulate the existence of viruses while working with infected tobacco plants
Ernst Ruska in 1931
o made the first electron microscope which was used to prove the existence of viruses
Fredrick Griffith
o discovered transformation of non-virulent bacteria to a more virulent form
Walter Reed
o proved mosquitoes carried Yellow Fever
Jonas Salk
o developed the vaccine from killed polio organisms
Albert Sabin
o developed the vaccine from attenuated live polio virus [Sabin your life]
Stanley Prusiner
o coined the term prion for diseases caused by protein particles
o prion diseases: mad cow disease [cows] and Cruetzfeld Jacobs disease [humans]
Barry Marshall discovered a bacterial cause of peptic ulcers-Helicobacter pylori
169
GENERAL PRINCIPLES
Classification of microorganisms
Microorganisms can be classified according to the following:
Size
Presence or absence of a nucleus
Nature of genetic material;
Number of chromosomes
Nature of cell wall if present
Type of cell membrane sterols
Comparison of microorganisms
Not all microorganisms affect humans. The human gut is filled with all kinds of microorganisms which
contribute to the health and well-being of the body. When some of these escape this natural environment,
they may cause problems. Whether they cause problems in humans or not depends on the infectivity of the
microorganism.
Infectivity
Infectivity is defined as the ability of a pathogen to establish an infection. The infectivity of a microorganism
is dependent on its pathogenicity, adherence, invasiveness, antigenic switching and virulence:
Pathogenicity
o ability to cause disease
Adherence to host cells
o some bacteria for example Escherichia coli use pili [fine hair-like microscopic structures]
to adhere to the surface of host cells
o others like Group A streptococci have fimbriae which have the same effect
o other bacteria have surface particles that allow them to stick to the host cells
o In each of the above situations, adherence enhances the infectivity of the microorganism
by preventing it from being carried away by mucus or being wasked away by fluid flow in
the bowel or the bladder
Invasion
o ability to penetrate host defense
o some microorganisms have enzymes that facilitate their invasiveness
o for example collagensase and hyaluronidase
Antigenic switching
o some microorganisms have developed the ability to change the shape of their surface
antigens to escape detection by the body’s antibody surveillance
o for example the trypanosoma organism on entering the body stimulates the production of
antibodies for specific antigens found in the surface of the organism
o within a matter of hours, some of the trypanosome switch the variable surface
glycoprotein coat and cover themselves with a new antigenically different VSG coat and
slips through the body’s defense mechanism much like the cloaking mechanism
popularized by the Star Wars movies
Virulence
o ability to cause serious illness
o some micro-organisms produce poisons or toxins which are extremely harmful to the
human
o for example, the toxin produced by Clostridium botulinum
170
Other terms related to medically important microorganisms:
Nosocomial
o hospital acquired infection
Iatrogenic
o disease caused by health professionals
o these are often caused by health professionals washing their hands
o one common hospital-acquired infection is caused by he spread of Clostridium difficile
which has become very difficult to treat and can be fatal
Commensal
o organism that is part of normal flora
o one benefits and the other is unaffected
Symbiosis
o two dissimilar organisms living together
Synergism
o both organisms benefit and are needed for function
Stationary
Death
Log
Lag
Disease Triangle
There is an interaction between the host, the agent and the environment that will affect whether
or not the host becomes infected
Some texts call this the Disease Triangle while others call it the Communicable Disease or the
Epidemiological Triangle
The host is the human being
The agent is the microbe
The environment deals with those external factors that cause or allow the disease to spread
It is a delicate balance because not all hosts will be infected with a known pathogen if the
environment is not conducive
171
MEDICALLY IMPORTANT VIRUSES
RNA DNA
Icosahedral
Non-enveloped
Parvo B19
REO [ Respiratory -5th disease aka
Enteric Orphan] Slapped Cheek
(+) sense (-) sense Syndrome
-Rota virus
Non-enveloped Enveloped
Diarrhea in infants
Hepatitis D-incomplete
virus-coexists with
Hepatitis B
Non-enveloped Enveloped
HepaDNA-Hepatitis B
Icosahedral
Pox-Variola [Smallpox]
-Molluscum contagiosum
Calici-Norwalk virus and Human Herpes Virus
Hepatitis E Icosahedral
1-HSV 1: oral herpes
PicoRNA Flavi-Hepatitis C 2-HSV 2: genital herpes
-Hepatitis A -Yellow fever 3-Varicella zoster: chickenpox
-Polio -Dengue fever and herpes zoster
-Rhino: UR -West Nile fever 4-EBV: mononucleosis
-Coxsackie: diarrhea and -St Louis encephalitis 5-CMV: meningitis in AIDS
hand, foot and mouth Helical
Retro-HIV 8-Kaposi sarcoma in AIDS
disease Toga-Rubella, WEE, VEE
-ECHO-meningitis
Corona-Common cold and SARS
General Rules
All viruses are RNA except 6 which are very HHHAPPPy to be DNA
All RNA viruses are single stranded except the REO virus 1st disease: Measles
All single stranded RNA viruses are + sense except the PROFAB 6 2nd disease: Scarlet fever
All the hepatitis viruses are RNA except Hepatitis B 3rd disease: German measles
All of the hepatitis viruses are spread by orofecal route except B and C 4th disease: Dukes’ disease
which are spread by blood and sex 5th disease: Slapped Cheek syndrome
All the DNA viruses are double stranded except the Parvo viruses 6th disease: Roseola infantium
172
VIRAL MICRO-ORGANISMS
DNA Viruses
Herpes simplex 1 and 2
o Human Herpes virus types 1 and 2 spread by direct contact
o causes cold sores [fever blisters] and multiple painful shallow genital ulcers
Chickenpox and herpes zoster
o Human Herpes Virus type 3 virus spread by aerosol droplets
o cause chickenpox in children and shingles in adults
Mononucleosis
o Human Herpes Virus type 4 [Epstein Barr virus] spread by kissing
o causes sore throat, fatigue, cervical lymphadenopathy and hepatosplenomegaly
o Downey cells [atypical lymphocytes] are present and the Paul Bunnel test is positive
o the virus may also cause Burkitt’s lymphoma and nasopharyngeal carcinoma
Cytomegalovirus infection
o HHV type 5 causing interstitial pneumonia in the immunocompromized patient and
congenital abnormalities, brain calcification and hepatosplenomegaly in the neonate
th
Exanthema subitum [Roseola infantium or 6 disease]
o Human Herpes viruses type 6 and possibly 7
o causes a sudden rash in children after a fever
Kaposi’s sarcoma
o Human Herpes Virus type 8
o causes purplish oral or skin lesions in AIDS patients
th
Slapped Cheek Syndrome [Erythema infectiosum or 5 disease]
o Parvo type B 19
o causes a red rash on face after fever
Hepatitis B
o HepaDNA virus which is spread by blood or sex
o causes jaundice and tender hepatomegaly
Viral conjunctivitis
o Adeno virus group spread by aerosol droplets
o causes pink eye [epidemic viral conjunctivitis]
Smallpox [variola]
o Pox virus spread by aerosol droplets
o Guarneri inclusion bodies in the affected epidermis
o irradicated in 1976
Human Papilloma virus
o Papova virus spread by diect contact
o HPV types 16 and 18 causes genital warts and are associated with cervical cancer
o types 1 and 4 causes warts on the hands and the feet
Molluscum contagiosum
o Pox [ds enveloped DNA] virus spread by direct contact
o causes papular lesions with central indentation [umbilication]
173
All hepatitis viruses are spread by the oro-fecal route EXCEPT:
o B and C which are spread by sex, blood transfusions or use of intravenous drugs
o causes jaundice, fever, anorexia, vomiting and tender hepatomegaly
Hepatitis C
o Flavi RNA virus spread by blood and sex
o Blood transfusions [10%], intravenous drug use [40%] and sexual transmission [10%]
o associated with a Carrier state, Cirrhosis and hepatocellular Carcinoma
Hepatitis A
o Pico RNA virus transmitted by the oral-anal [orofecal] route
Hepatitis D [Delta agent or dane particle depends on Hepatitis B to casue an infection]
o Single-stranded RNA virus [Defective virus incapable of infecting on its own]
Hepatitis E
o Calici RNA virus spread by the orofecal route
Human Immune Deficiency Virus
o Single-stranded RNA retro virus spread by sex and blood transfusion
o destroys CD4 T cells causing AIDS and presents in 4 stages:
Flu-like illness [acute]
Feeling fine [latent]
Failing CD4 count [with recurrent opportunistic infections]
Cryptococcus meningitis
CytoMegaloVirus retinitis
Candidiasis
Crypotosporidium diarrhea
Final crisis with Pneumocystis jiroveci pneumonia
st
Measles [aka Rubeola or the 1 disease]
o Paramyxo virus spread by aerosol droplets
o causes Koplik spots, coryza, conjunctivitis and a fine maculopapular erythematous rash
Mumps
o Paramyxo virus spread by dirfect contact and aerosol droplets
o causes parotitis, pancreatitis and orchitis
rd
Rubella [aka German Measles or the 3 disease]
o Toga RNA virus spread by aerosol droplets
o causes sore throat, cervical lymph nodes and a fine maculopapular erythematous rash
Influenza
o Orthomyxo [- ss RNA] virus causes fever, sore throat and severe myalgia
Common cold
o Corona [+ss, enveloped, helical] RNA virus spread by aerosol droplets
o causes fever, sore throat, runny eyes and nose
Upper Respiratory Tract Infection
o Rhino virus of PicoRNA family causes runny eyes, nose, sore throat and fever
Croup [viral]
o Parainfluenza virus causes a braking cough, stridor and hoarseness
Childhood dysentery
o Coxsackie virus of the PicoRNA virus family causes diarrhea with blood in the stool
o may also cause hand, foot and mouth disease-vesicles in these regions
Rabies
o Bullet-shaped Rhabdo RNA virus presenting as Negri bodies in brain
o more commonly spread from raccoons, bats and skunk bites in the USA than dog bites
o causes hydrophobia, dysphagia, agitation, paralysis and coma
Poliomyelitis
o Pico RNA virus causes flaccid muscle paralysis due to anterior horn cell damage
ARBO viruses [Arthropod Borne] [all are caused by Flavi viruses except California encephalitis]
o Encephalitis is spread by a variety of mosquitoes
Western and Venezuelan Equine Encephalitis [Flavi virus]
California encephalitis [Bunya virus]
o Yellow fever
Flavi virus carried by Aedes aegypti mosquito-fever and jaundice
o West Nile fever
Flavi virus carried by Culex pipiens mosquito
o Dengue fever [breakbone fever]
Flavi virus carried by Aedes aegypti mosquito
174
MEDICALLY IMPORTANT BACTERIA
Spirochetes
Mycoplasma Faintly Gram (-)
pneumoniae Borrelia burgdorferi
-Lyme disease
Leptospira interogans
Obligate intracellular Free living -Weil disease
parasites Treponema pallidum-
Syphilis
Rickettsiae Chlamydia
R. rickettsi-RM Spotted Fever C. trachomatis-PID, Reiter’s
R. prowazekii-epidemic typhus syndrome, LGV
R. typhi-endemic typhus C. pneumoniae-pneumonia Gram Stain Ziehl Neelsen Stain
R. tsutsugamishi-scrub typhus C. psittaci-bird fancier’s disease
Mycobacterium
M. tuberculosis-Tuberculosis
Bartonella henselae-cat scratch disease Thick waxy wall with mycolic acid
Acid Alcohol Fast Bacillus
Culture Lowenstein-Jensen medium
M. leprae-Leprosy
95% of the world is immune
Gram (+) Gram (-) Cultured only in armadillos
175
BACTERIAL MICRO-ORGANISMS
Bacterial Characteristics
prokaryotic [no nucleus]
single circular DNA
peptidoglycan wall
organisms with 70S ribosomes
Bacterial types
3 types: lacking cell wall, flexible cell wall and rigid cell wall
o LACKING CELL WALL
Mycoplasma pneumoniae
atypical “walking” pneumonia [x-ray looks worse than the patient]
o FLEXIBLE CELL WALL [spirochetes]
Leptospira interogans [spirochete with a terminal hook]
causes Weil disease which presents with jaundice and hemorrhage
Borrelia burgdorferi [big spirochete]
Lyme disease: bull’s eye rash [erythema migrans] and joint pains
Borrelia recurrentis
Causes relapsing fever
Treponema pallidum [thin spirochete with periplasmic flagella]
causes syphilis which presents with a painless genital ulcer
o RIGID CELL WALL
Needs to live inside cell [obligate intracellular organism-can’t make ATP]
Chlamydia psittaci
o Bird fancier’s disease [psittacosis]
o cough and fever [another cause of atypical pneumonia]
Chlamydia trachomatis
o Type A, B and C: Trachoma
Africa, Blindness, Chronic disease
o Types D-K: Reiter’s syndrome:
Conjunctivitis, urethritis and arthritis
o Type L1, 2 and 3: Lymphogranuloma venereum
Transient genital ulcer followed by draining buboes
Rickettsia organisms
Fever and rash [Rickettsia rash on the wRists, Typhus on the Trunk]
o Rickettsia rickettsii:
Rocky Mountain Spotted Fever [ticks]
o Rickettsia prowazekii:
Epidemic typhus [lice]
o Rickettsia typhi:
Murine endemic typhus [rat fleas]
o Rickettsia quintana:
Trench fever [lice]
o Rickettsia [orientia] tsutsugamishi:
Scrub typhus [mites]
Barteonella henselae
o Cat-scratch disease [scratched by infected cats]
FREE LIVING BACTERIA
Gram stainable wall: positive or negative
Coccus, Bacillus or Vibrio groups
COCCUS
Staphylococcus
Gram + bacteria, Catalase positive coccus in bunches like grapes
Staphylococcus aureus
o coagulase positive, golden colonies on blood agar culture
o Scalded Skin Syndrome, Toxic Shock Syndrome, impetigo,
osteomyelitis, carbuncles and acute bacterial endocarditis
Staphylococcus saprophyticus
o common cause of UTI in teenagers, no nitrites in the urine
176
Streptococcus
Gram + bacteria, catalase negative coccus in strips
Streptococcus pyogenes
o Lancefield group A beta-hemolytic diplococci
o rheumatic fever
o impetigo
o erysipelas
o glomerulonephritis
nd
o scarlet fever [2 disease]
Streptococcus viridans [green]
o alpha-hemolytic [green color-partial hemolysis] streptococcus
o dental cavities [S. mutans]
o affects damaged heart valves
o causes subacute bacterial endocarditis
Streptococcus pneumoniae
o alpha-hemolytic streptococcus
o causes meningitis, otitis media, pneumonia associated with
rust-colored sputum and sinusitis
Neisseria gonorrhoeae
Gram negative intracellular diplococci
Thayer-Martin chocolate agar medium and glucose fermenting
causes gonorrhea, septic arthritis or ophthalmia neonatorum
Neisseria meningitidis
Gram negative cocci
Thayer-Martin medium and maltose and glucose fermenting
causes meningitis and meningococcemia
Mycobacterium tuberculosis
Lowenstein-Jensen medium culture needed
faintly Gram stainable because of thick waxy wall of mycolic acid
stained with Ziehl Neelsen stain
causes tuberculosis
Mycobacterium leprae
only grown in armadillos and the foot pads of suckling mice
prefers cool temperatures like in the skin and peripheral nerves
causes leprosy
BACILLUS
All bacilli are Gram negative EXCEPT the following which are Gram positive:
Bacillus
Clostridium
Corynebacterium
Listeria
Bacillus anthracis [spore-forming rod]
woolsorter’s disease: lung infection
malignant pustule: skin infection leads to bacteremia and death
Clostridium botulinum
Botulism caused by preformed toxin: blocks acetylcholine release
diplopia
dysphagia
flaccid paralysis
due to improperly canned foods especially honey in infants
Clostridium difficile
pseudomembranous colitis after broad-spectrum antibiotics
C. difficile is part of the normal gut flora
broad spectrum antibiotics kills off the helpful gut flora which allows this
organism to proliferate
Clostridium tetani
tetanus caused by bacillus with terminal spores
exotoxin produced-tetanospasmin affects the neuromuscular junctions
causing muscle spasm and trismus [lockjaw]
177
Clostridium perfringens
gas gangrene following infection of deep puncture wounds
produces lecithinase which cause muscle necrosis with bubbles
Corynebacterium diphtheriae
diphtheria caused by club-shaped bacilli, Chinese-letters appearance
grey pseudo-membrane in throat causing suffocation
bacteriophage-related exotoxin is produced-damages heart muscle and
nerves
Schick test is positive
Listeria monocytogenes
unpasteurized milk and cheese
only Gram + bacteria with an endotoxin
causes meningitis in neonates due to vaginal transmission at birth
Gram Negative Enteric [lives in the gut] Bacilli
Helicobacter pylori
multiple polar flagella
urease positive which produces ammonia to neutralize gastric acid
peptic ulcer: gastric [85%] and duodenal [95%]
stomach cancer
Campylobacter jejuni
fever, diarrhea, blood and pus in stool
Yersinia pestis
bubonic plague [black death]
transmitted by infected rat fleas
buboes and pneumonia
Salmonella enterides
food poisoning 1-2 days after ingestion
Shigella dysenteria, sonnei or flexneri
non-lactose fermenting enteric bacillus
bloody diarrhea [dysentery]
Salmonella typhi
non-lactose fermenting motile enteric bacillus
Typhoid fever-looks like typhus hence the name typhoid
step-ladder fever, diarrhea, rose spots on the abdomen
transmitted by Food, Fingers, Feces and Flies
Escherichia coli
lactose fermenting catalase positive enteric bacillus
O, H and K antigens
traveler’s diarrhea [Montezuma’s, Delhi belly]
may also cause UTI, food poisoning, meningitis and HUS
Hemolytic Uremic Syndrome-causes liver and kidney failure
o caused by a very virulent form of E. coli [subtype 0157:H7]
o this is found in contaminated hamburger meat
Proteus mirabilis
urea splitting, maltose fermenting enteric bacillus
urinary tract infection
Serratia marcescens
infection producing red pus
Klebsiella pneumoniae
Gram negative lactose fermenting enteric bacillus
causes pneumonia and lung abscess in alcoholics and UTI in diabetics
red-currant jelly sputum with the pneumonia
178
Brucella abortus
brucellosis or undulant fever
from infected cows, goats or swine
fever with an undulating pattern
Legionella pneumophila
lung infection [atypical pneumonia]
from contaminated air-conditioning
Pseudomonas aeroginosa
non-lactose fermenting, oxidase positive enteric bacillus
blue-green pus in infected burns
due to pyocyanin [blue] and pyoverdin [green] pigments
causes Pneumonia, Sepsis, External otitis, UTI, Drug use Osteomyelitis
Hemophilus aegypti
also known as Koch-Weeks bacillus
causes conjunctivitis [pink eye]
Hemophilus ducreyi
Chancroid caused by Gram negative bacillus
causes yellow painful genital sore [it is so painful that you do cry]
Hemophilus influenzae
also known as Pfeiffer’s bacillus
causes pneumonia, epiglottitis, croup and meningitis in children
VIBRIO
Vibrio cholerae [Gram negative enteric organism]
cholera caused by comma-shaped with single polar flagellum
produces an exotoxin which stimulates cAMP which in turn greatly
increases fluid secretion from the gut
this results in severe diarrhea with rice water stool and raid dehydration
TOXINS
many bacteria produce toxins or poisons which enhance their virulence
2 types:
o endotoxin
o exotoxin
endotoxins
o produced and not secreted from dead Gram negative bacteria
o derived from the lipopolysaccharide found in the cell walls of Gram negative bacteria
o all are heat-stable
o causes system-wide effects such as fever and shock
exotoxins
o produced by live Gram + or - bacteria
o they are polypeptides secreted by bacteria
o heat-labile toxin [except Staphylococcal enterotoxin and E. coli toxin]
o antigenic properties
denatured [by formaldehyde] toxin is a toxoid
toxoids are used to stimulate immunity
o toxins targets specific tissues like nerve, muscle and connective tissue
tetanus tetanospasmin nerve
botulism botulinin muscle
diphtheria diphtheria toxin connective tissue
179
FEVERS
Q fever
o Coxiella burnetti via unpasteurized milk from infected cattle or by aerosol spread
Rocky Mountain Spotted fever
o Rickettsia rickettsii
Trench fever
o Rickettsia quintana
Recurrent [relapsing] fever
o Borrelia recurrentis
Rabbit fever
o Francisella tularemia
Undulant fever
o Brucella abortus
Rheumatic fever and Scarlet fever
o Streptococcus pyogenes
Lancefield Group A beta-hemolytic streptococcus
FOOD POISONING
Staphylococcus aureus
o 2-4 hours after ingestion; preformed enterotoxin: rapid onset of symptoms
o vomiting and diarrhea
Clostridium botulinum
o 6-8 hours; preformed enterotoxin: rapid onset of symptoms
o vomiting followed by flaccid paralysis, diplopia and dysphagia
Clostridium perfringens
o 10-12 hours; preformed enterotoxin: rapid onset of symptoms
o vomiting and diarrhea
Salmonella enterides
o vomiting and diarrhea 12-24 hours after ingestion
o fever, heat resistant toxin produced after bacteria colonizes the gut
Campylobacter jejuni
o 1-7 days after ingestion
o Fever, vomiting and diarrhea; most common cause of food poisoning
Escherichia coli
o Vomiting and diarrhea 1-10 days after ingestion
o Toxin formed after the bacteria colonizes the gut
180
MENINGITIS [Infection of the coverings of the brain]
Neonates
o Escherichia coli
Children
o Hemophilus influenzae
Adolescents and adults
o Neisseria meningitidis
Elderly
o Streptococcus pneumoniae
HIV/AIDS
o Cryptococcus neoformans
OSTEOMYELITIS
Most people: Staphylococcus aureus
Sexually transmitted: Neisseria gonorrhoea
Drug addicts: Pseudomonas aeruginosa
Sickle cell disease: Salmonella species
ANTIBIOTIC TARGETS
Antibiotics are chemicals that have the capacity to kill bacteria in vivo and do so through a variety of ways
including:
blocks cell wall synthesis by inhibiting of peptidoglycan cross-linking
o Isoniazide, ethambutol, β-lactams like penicillin, ampicillin and cephalosporin
blocks cell wall synthesis by inhibiting peptidoglycan synthesis
o Vancomycin
causes cell wall damage
o Bacitracin and Polymyxin
blocks nucleotide synthesis acting as antimetabolites
o Sulfonamides and Trimethoprim
preventing DNA replication
o Metronidazole
o Quinolones [ciprofloxacin]
preventing RNA Synthesis
o Rifampicin
blocking protein synthesis by acting on:
o 50S ribosomal subunit
Choramphenicol and Clindamycin
o 30S ribosomal subunit
Tetracycline and aminoglysides such as Streptomycin and Neomycin
181
MEDICALLY IMPORTANT FUNGI
SUPERFICIAL SUBCUTANEOUS
SYSTEMIC
Others
Pneumocystis jiroveci
infects the lungs causing
pneumonia
Pityriasis versicolor
caused by Malassezia Aspergillus fumigatus
furfur which gives a Infects the lungs causing a
characteristic meatballs chronic cough and
and spaghetti hemoptysis
appearance on KOH
prepared skin scrapings
Cryptococcus neoformans
infects the brains and its
Moist Skin coverings causing meningitis
Candida albicans
It is a dimorphic
organism which exists in
two forms depending on
the temperature: Candida albicans
-cold-mold May be systemic in
-warm-yeast immunocompromized
It causes oral or vaginal patients like those with
thrush presenting with a AODS
thick white cheesy
discharge
182
FUNGAL MICRO-ORGANISMS
Fungal Characteristics
Eukaryotic organism with Ergosterol in membranes
Reproduction by sporulation
o Conidia [asexual] and zygospores [sexual]
Special culture medium is needed for fungi
Grows best on Sabouraud’s medium
Fungal organisms may be classified according to the sites of infection:
o cutaneous or dermatophytes
o subcutaneous
o systemic
o opportunistic
Some fungi can exist in two forms [dimorphic] either as a mold or as a yeast
o These tend to cause systemic infections
Candida albicans
Histoplasma capsulatum
Coccidioides immitis
Blastomyces dermatidis
Paracoccidioides brasiliensis
o The above are thermal dimorphic:
mold or yeast depending on the temperature
O
room temperature [25 C]
cold mold
o multicellular with branching septate or non-septate hyphae
O
body temperature [37 C]
heat yeast
o unicellular which reproduce by budding
Dermatophytes
Fungal organisms which require keratin for growth
Trichophyton
o skin, hair and nails
Microsporum
o hair and skin
o pets are reservoirs
Epidermophyton
o nails and skin
Tinea [ringworm]
o capitis-head [Trichophyton tonsurans is most common]
o corporis-body
o cruris-groin [jock itch]
o pedis-feet [athlete’s foot]
o manum-hand
o unguium-nail
183
Subcutaneous fungi
Sporothrix schenckii
o Dimorphic fungus which lives on vegetation
o bumpy skin lesions in legs or arms of rose growers or gardeners
o causes rose gardener’s disease [sporothricosis]
Madurella mycetomatis or grisea
o warty lesions on the feet of woodcutters-Madura foot
Systemic Fungi
Histoplasma capsulatum
o Histoplasmosis aka Ohio Valley fever also found in the Mississippi river valley
o transmitted by inhalation of spores and not from person to person
o bat droppings in cave explorers [spelunkers], chicken poop in poultry farms
o asymptomatic in immunocompetent persons
o hides inside macrophages
o systemic infection in immunocompromized patients affecting:
o lung
o spleen
o liver
o adrenals
Coccidioides immitis
o Coccidiomycosis aka San Joaquin Valley fever
o found in the desert areas of the southwestern United States
o transmitted by inhalation of spores
o Systemic infection:
lung infection
joint pains
erythema nodosum [painful red bumps on the legs]
Blastomyces dermatidis [North American Blastomycosis]
o East coast of the United States
o transmitted by inhalation of spores
o skin, bone and lung infections
Paracoccidioides brasiliensis [South American Blastomycosis]
o Common in Latin America
o 90% of the affected population is male
o transmitted by inhalation of spores
o spores with multiple buds like the spokes of a wheel
o mouth and nose ulcerations
Opportunistic fungi
affects HIV/AIDS and other immunocompromized patients
Aspergillus fumigatus
o decaying vegetation
o Inhalation of spores
o fungal ball in lung
o hemoptysis
Cryptococcus neoformans
o pigeon poop and other bird droppings
o transmitted by inhalation of spores
o Indian ink preparation shows owl eye appearance
o pneumonia
o meningitis and brain abscess
Candida albicans
o severe systemic infection in HIV/AIDS patients
o causes thrush which presents with severe sore throat and dysphagia
o dimorphic fungus
o pseudohyphae and budding yeasts on tissue scrapings
Pneumocystis jiroveci [carinii]
o causes pneumonia in HIV/AIDS patients
o ground glass appearance on chest x-ray
o previously classified as a protozoa [formerly P. carinii]
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MEDICALLY IMPORTANT PARASITES
PROTOZOA METAZOA
Intestinal
T. cruzi-Chagas disease
-Reduviid sand fly bite Tissue
T. gambiense-Sleeping sickness
-Tsetse fly bite
Onchocerca volvulus
-river blindness
Leishmania -Simulium blackfly bite
Wuchereria bancrofti
-elephantiasis
L. donovania-kala azar -Aedes aegypti mosquito
-phlebotomous sandfly bite Loa loa
L. brasilliensis-espundia -Eye worm
-phlebotomous sandfly bite -Chrysops fly bite
Sporozoa
TREMATODES
Cryptosporidium parvum
Schistosoma
Toxoplasma gondii S. hematobium
CESTODES -bladder
S. mansoni
-liver
Plasmodium S. japonicum
-gut
Taenia Clonorchis sinsensis
T. solium-pork tapeworm -Chinese liver fluke
T. saginatum-beef tapeworm Paragonimus westermani
P. falciparum Diphyllobothrium latum -lung fluke
-most deadly form of malaria -largest fish tapeworm
-causes convulsions and death Hymenolepis nana
-may cause Blackwater fever -smallest [dwarf] tapeworm
P. malariae Echinococcus granulosus
P. ovale -hydatid disease
P. vivax Sheep raising areas
Female Anopheles mosquito bite Accidental contact with contaminated
dog feces
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PARASITIC MICRO-ORGANISMS
General characteristics
Parasite
o organism that requires another organism to survive
Primary host
o required to complete sexual reproductive cycle, e.g. humans in intestinal worms
Secondary host
o involved in asexual reproduction, for example snails in schistosomiasis
Vector
o secondary organism needed to transmit disease, e.g. mosquitoes in malaria
Classification
Number of cells
o Unicellular parasites
protozoa
o Multicellular parasites
metazoa
Protozoa may be further classified by the mode of locomotion in the trophozoite form:
o Ameba [movement by pseudopodia]
Entameba histolytica
Naegleria fowleri
o Flagellata [movement by flagella]
Giardia lamblia
Trichomonas vaginalis
Leishmania donovani
Trypanosoma cruzi and brucei
o Ciliate [movement by cilia]
Balantidium coli
o Sporozoa [no movement]
Cryptosporidium parvum
Toxoplasma gondii
Plasmodium falciparum, vivax, ovale and malariae
Protozoal infections
Ameba:
o Entameba histolytica
amebic dysentery presenting with stool with flecks of blood and mucus
may invade the liver causing an abscess
o Naegleria fowleri
found in warm waters in the south states during summer
invades the brain via the cribriform plate in the nasal cavity
causes a rapidly fatal meningoencephalitis
Flagellata:
o Trichomonas vaginalis
sexually transmitted disease
greenish frothy malodorous vaginal discharge
asymptomatic in males
o Giardia lamblia
hiker’s diarrhea aka beaver fever
most common intestinal parasite in the USA
drinking contaminated stream water
foul smelling loose stools
o Trypanosoma brucei gambiense/rhodesiense
causes sleeping sickness
transmitted by the Tsetse fly
o Trypanosoma cruzi
transmitted by the kissing [reduviid] bug which craps in its bite
causes Chagas disease
dysphagia due to mega-esophagus
heart failure due to dilated cardiomegaly
186
o Leishmania donovani
kala-azar
phlebotomous sand files bites
hepatosplenomegaly
o Leishmania brasiliensis
espundia
phlebotomous sand fly bites
mucocutaneous ulcerations
Ciliate
o Balantidium coli
diarrhea
Sporozoa
o Toxoplasma gondii
sporozoa infection from infected cat feces; crosses the placenta
causes miscarriages, chorioretinitis, intracranial calcification
o Cryptosporidium parvum
opportunistic infection in HIV/AIDS patients
severe chronic recurrent diarrhea and dysentery
o Plasmodium
Malaria spread by female Anopheles mosquitoes
most deadly malaria parasite:
Plasmodium falciparum-daily cycles of fever
causes cerebral infection with convulsions and death
blackwater fever is due to excessive hemoglobin in the urine
less severe forms of malaria: Plasmodium ovale, vivax or malariae
gametocytes are the form ingested by the mosquito
gametocytes develop into sporozoites in the mosquito
sporozoites are injected into uninfected human
the sporozoites become merozoites in the liver
merozoites change into trophozoites which later become gametocytes
Metazoan infection
Nematode infections: intestinal and tissue or blood
Intestinal roundworms which are spread by the orofecal route:
o Enterobius vermicularis
Pinworms are the most common intestinal nematode in the USA
Causes perianal itching and a positive scotch tape test
o Ascaris lumbricoides
Roundworms are the second most common intestinal nematode in the USA
uncommon cause of intestinal and common bile duct obstruction
o Strongyloides stercoralis
threadworms
causes perianal itching at night
o Trichuris trichuria
whipworms
causes weight loss, abdominal pain, bloody diarrhea and rectal prolapse
o Trichinella spiralis
pork roundworm which causes Trichinosis
causes fever, muscle pain and periorbital edema
o Necator americanus
most common hookworm in the USA
causes an iron deficiency anemia
Tissue or blood worms which are spread by biting insects
o Onchocerca volvulus
transmitted by the Simulium blackfly
causes river blindness, hyperpigmented skin [black fly, black skin, black vision]
o Wuchereria bancrofti
elephantiasis; filariasis; chronic lymph blockage, carried by Culex filariasis
blood is best tested at 10 pm when the parasites are in the bloodstream
o Loa loa
transmitted by the Chrysops biting fly
causes eye worm [worm is seen under the conjunctiva]
187
Cestode infections
Tape worms which are spread by eating contaminated food
o segmented hermaphrodite worms
o Diphyllobothrium latum
largest fish tapeworm [10 meters long] in the world
Vitamin B12 deficiency [not pernicious anemia]
o Hymenolepis nana
smallest [dwarf] tapeworm; eggs found in contaminated cereal
causing diarrhea, abdominal pain and weight loss
o Taenia solium
from undercooked infected pork
o Taenia saginatum
from undercooked infected beef
o Echinococcus granulosus
common in sheep-raising areas
accidental contact with contaminated dog feces
hydatid cysts in the liver causing hepatomegaly or cysts in the lung
Trematode infections
Flukes
o non-segmented flattened worms
o Schistosoma species
female worm lies in a split in the body of the male worm
transmitted by snails which are the intermediate hosts
immature stages include cercariae which are found in the intermediate host
causes bilharziasis [named after the German helminthologist-Theodor Bilharz]
Schistosoma hematobium
o egg with a terminal spine found in the urine
o common in Africa and Middle East
o affects the bladder
o causes hematuria and squamous cell bladder cancer
Schistosoma japonicum
o egg with a rudimentary spine
o common in Asia
o affects the gut and the liver
o eggs found in the stool
Schistosoma mansoni
o egg with a lateral spine
o affects the gut and liver
o liver cirrhosis and portal hypertension
o eggs found in the stool
o swimmer’s itch due to schistosoma species found in ducks in
the costal part of New Jersey in the US
o Clonorchis sinensis
Chinese liver flukes
affecting over 30 million people worldwide eating undercooked infected fish
endemic in the Far-East
feeds on the bile in the liver
may present with fever, tender hepatomegaly and mild jaundice
chronic cholangitis and cholangiocarcinoma are late complications
o Fasciola hepatica
liver flukes
from infected sheep
the aquatic snail is the intermediate host
humans are accidentally infected by eating contaminated water cress
may cause diarrhea and abdominal pain
o Paragonimus westermani
lung flukes
undercooked crab meat from infected crabs and crayfish
endemic in Asia, Africa and South America
presents with chronic cough and hemoptysis
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TESTS FOR MICRO-ORGANISMS
189
Specific blood tests
Anti-Streptolysin O Titer >160 Todd units
o recent streptococcal infection
o Streptococcus pyogenes produces toxins called Streptolysin O and S which are
responsible for the β–hemolytic pattern of hemolysis on blood agar
o Streptolysin O stimulates the production of antibodies
o seen in rheumatic fever and post-streptococcal glomerulonephritis
Coombs test
o Rhesus factor
o Hemolytic anemia
o Erythroblastosis fetalis in Rhesus negative mothers
ELISA [Enzyme-Linked Immunosorbent Assay]
o HIV and Lyme disease
o it is a sensitive test but not specific as there are many false positives
FTA-ABS [Fluorescent Treponemal Antibody Absorption] test
o confirmation test for Syphilis
o remains positive long after the syphilis is successfully treated
Ligase chain reaction
o special lest for Chlamydia organisms
o it is a variation of the Nucleic Acid Amplification Test
Mitsuda test
o uses an intradermal injection of lepromin to detect leprosy
o a reaction in the skin at the site of the injection is positive for Mycobacterium leprae
Paul Bunnel test
o Mononucleosis
o uses sheep red blood cells
RPR [Rapid Plasma Reagin] test
o Screening test for syphilis
VDRL [Venereal Diagnostic Research Lab] test
o Screening test for syphilis
o becomes negative after syphilis is successfully treated
o if VDRL is positive but the FTA-ABS is negative, it is probably a false positive
o many causes of a false positive VDRL:
Viral infections: mononucleosis, hepatitis
Drugs
Rheumatic fever
Leprosy
SLE
Weil-Felix test
o Patient’s serum is mixed with Proteus antigens
o if the patient has antibodies to Rickettsiae, the antibodies react with the Proteus antigens
and cause agglutination of red blood cells
o positive for Rickettsiae
o negative test result in Coxiella infection
Western Blot [there are also Southern and Northern Blot tests]
o used to confirm HIV infection after a positive ELISA
o tests for viral protein fragments [Southern blot uses DNA and Northern blot used RNA]
o this is a highly specific test which is used to rule in the disease
Widal test
o Typhoid fever
Skin tests
Kveim test
o Sarcoidosis
o injection of splenic extra from a patient with sarcoidosis causes a specific skin reaction
o skin reaction will show non-caseous granulomas in 4-6 weeks after the injection
Mantoux or Heaf test or Tine test
o Tuberculosis using an intradermal injection of PPD
Purified Protein Derivative from TB bacillus
Positive skin test [>10 mm] indicates exposure to TB
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Others
Urea-splitting bacteria
o Helicobacter pylori
This bacterium secretes an enzyme called urease which breaks down urea to
form ammonia and carbon dioxide
The ammonia neutralizes the hydrochloric acid in the stomach preventing the
gastric acid from destroying the bacteria
This allows the bacteria to multiple and proliferate in the stomach mucosa
causing gastritis and peptic ulcers
o Proteus mirabilis
this bacterium also secretes urease
the resulting alkaline environment in the urine promotes the precipitation of
struvite stones
o Klebsiella pneumoniae
This organism also produces urease
This is helpful in distinguishing it in the lab
Ames test
o this is a biological assay that assesses the mutagenic potential of chemical compounds
o it uses several strains of Salmonella typhimurium
o when positive, the chemical has the potential to cause mutation of genes and thus may
be carcinogenic
Quellung reaction
o German word for “swelling”
o this test is a biochemical reaction in which anticapsular antibodies bind to the capsule of
a bacterium, causing the capsule to swell
o this makes the bacterium more visible
o Strep. pneumoniae has such a capsule and would show a positive Quellung reaction
o Others include Klebsiella pneumoniae, Hemophilus influenzae, Salmonella and
Neisseria meningitides
Sensitivity [a/a+c] is calculated by taking the number of patients with a True positive and dividing it by the
total number of patients with the disease
A highly sensitive test if the result is negative is good at excluding the diagnosis
Sensitive tests are useful in screening out diseases
In a very sensitive test, if the result is negative, then one can rule out the disease [SnOut].
Specificity [d/d+b] is calculated by taking the number of patients with a True negative divided by the total
number of patients without the pathogen
Highly specific tests if the results are positive are useful in confirming or ruling in diagnoses
In a test with a high specificity, if the result is positive, then the person has the disease [SpIn]
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INFECTION CONTROL
Epidemiological terms
Epidemiology: the study of the causes, distribution and control of diseases in populations
Incidence: number of new cases in the population in a given time
Prevalence: number of people with the disease at a given time
Mortality: number of people who die from a particular disease
Morbidity: number of people who have a certain disease
Life Expentancy: An estimate as to how long the general population will live
Epidemic: sudden increase in the number of disease locally
Endemic: normal occurrence of a disease in a particular locality
Pandemic: sudden rise in the number with the disease worldwide
Emerging disease: disease that has newly appeared
Re-emerging disease: disease which has existed previously but is rapidly increasing in incidence or in
the geographic extent
192
CHEMISTRY
193
194
GENERAL PRINCIPLES
Chemical reactions
An enzyme is a protein which speeds up the rate of a chemical reaction by lowering the activation energy:
enzymes are not consumed by the reaction that they catalyze, nor do they alter the equilibrium of
these reactions. Enzymes do not change the ΔG, [Gibbs free energy]
enzymes are specific to the reactions they catalyze
A pro-enzyme (aka zymogen) is an inactive enzyme precursor which requires a biochemical
change for it to become an active enzyme
An apoenzyme is the protein component of an enzyme to which the coenzyme is attached
Oxidation is the process in which there is loss of hydrogen electrons or a gain of oxygen
oxidase is an enzyme that causes the oxygen in a compound to be changed to water
dehydrogenase is an enzyme which oxidizes a compound by removing hydrogen
Reduction is the process in which there is a gain of hydrogen electrons or a loss of oxygen
a reductase is an enzyme which adds hydrogen to a compound
Carboxylation is the chemical process by which a carboxyl group [-COOH] is added or displaces a
hydrogen atom
carboxylase is the enzyme which catalyzes the addition of a carboxyl group
Decarboxylation is the process in which the carboxyl group [-COOH] is removed from an organic
compound as CO2, and is commonly replaced by a hydrogen atom
decarboxylase is the enzyme that catalyzes the release of CO2 from compounds
Hydrolysis refers to the cleavage of a compound by the addition of water, the hydroxyl group being
incorporated in one fragment and the Hydrogen atom in the other
hydrolase is the enzyme that facilitates hydrolysis as in sucrase in the breakdown of sucrose
Phosphorylation is the process of introducing a phosphate group into an organic molecule:
phosphorylase is the enzyme which adds inorganic phosphate to a substrate without using ATP
phosphatase is the enzyme that removes a phosphate group from its substrate by hydrolyzing
phosphoric acid monoester into a phosphate ion and a molecule with a free hydroxyl group
Kinase is an enzyme that transfers a phosphate group from high-energy donor molecules, such as ATP,
to a specific substrate
Transferase is an enzyme that catalyzes the transfer of a functional group from one molecule to another
Ligase is an enzyme that catalyzes the joining of two molecules
Vmax refers to the maximum velocity of a reaction and is proportional to enzyme concentration
Kmax [Michaelis-Menten constant] is the amount of substrate required to reach ½ of the Vmax.
An inhibitor is any substance which slows down the rate of reaction of any enzyme
There are three ways of enzymatic regulation:
non-competitive inhibition
competitive inhibition
allosteric regulation
In non-competitive inhibition, the inhibitor always binds to the enzyme at a site other than the enzyme's
active site and is irreversible. It reduces Vmax. Increasing the concentration of the substrate does not affect
the activity of the inhibitor.
In competitive inhibition, the inhibitor binds to the same active site as the normal enzyme substrate,
without undergoing a reaction and is reversible. Increasing the concentration of the substrate will overcome
the activity of the inhibitor, thus Vmax will not change.
In an allosteric regulation, an enzyme’s activity is regulated by binding an effector molecule at the
enzyme's allosteric site (a site other than its active site):
effectors that enhance the protein's activity are referred to as allosteric activators
whereas those that decrease the protein's activity are called allosteric inhibitors
195
Energy compounds
Nicotinamide adenine dinucleotide phosphate (NADP) is the phosphorylated form of NAD [Nicotinamide
Adenine Dinucleotide]. It is used in anabolic reactions, such as lipid and nucleic acid synthesis and pentose
phosphate pathway, which require NADPH as a reducing agent. NADH is the reduced form of NAD and is
given off in the Krebs cycle to make ATP. Both NAD and FAD [Flavin Adenine Dinucleotide] facilitate the
transport of electrons from the Krebs cycle to the Electron Transport Chain. The following are the 4 basic
energy fuels of the body:
carbohydrates [4 kcal/mol]
proteins [4 kcal/mol]
fats [9 kcal/mol]
alcohol [7 kcal/mol] [empty calories as they have no nutrients]
Catabolism of energy fuels results in heat generation and ATP synthesis.
ATP [Adenosine Triphosphate] is the universal energy currency of the body.
Catabolism is a degradative process which breaks down large molecules into smaller units releasing useful
energy.
Anabolism is a biosynthetic process which constructs large molecules from smaller units. These reactions
require energy.
196
CARBOHYDRATE METABOLISM
Digestion
Types of carbohydrates we eat:
Starch
Sucrose
Lactose
Cellulose
Starch is a polysaccharide carbohydrate consisting of a large number of glucose monosaccharide units
joined together by glycosidic bonds. This complex carbohydrate is similar in function to glycogen as its main
function is to provide an energy source. All plant seeds and tubers contain starch predominantly as amylose
and amylopectin
Amylose is a long, unbranched chains of glucose linked at C1 and C4-α1,4 link, also known as
α1,4 bonds.
Amylopectin is a highly branched polymer of glucose, with glucose units linked in a linear way with
α 1,4 bonds. Branching takes place with α1,6 bonds occurring every 24 to 30 glucose units.
Sucrose is a disaccharide made up of glucose and fructose found in table sugar and in fruit
Lactose is the sugar found in milk and is made up of galactose linked to glucose
Humans can only process sugars with the D conformation [right-handed] not the L [left-handed]
conformation; think D for delicious.
Cellulose is a polysaccharide consisting of a linear chain of several hundred to over ten thousand beta 1,4
linked D-glucose units. It is the primary structural component of the primary cell wall of green plants.
Humans cannot digest cellulose because they lack the enzyme cellulase to break it down
Salivary amylase breaks starch down into maltose
present in the mouth where it begins the chemical process of digestion; deactivated by acid stomach pH
Pancreatic amylase, (aka alpha amylase) facilitates starch breakdown in small intestine cleaving 1,4 links
to release di- and trisaccharides
Trisaccharidase breaks down trisaccharides into di- and monosaccharides
Disaccharidase breaks down disaccharides into the monosaccharide-glucose, fructose, galactose
Sucrase breaks down sucrose into fructose and glucose.
Lactase is secreted by the intestinal villi
This enzyme breaks down lactose into two subunits; galactose and glucose for absorption.
Some people with lactose intolerance might not digest lactose because of a lack of lactase.
Undigested lactose remains in the gut and ferments causing bloating and diarrhea
Glucose is absorbed and stored in the body as glycogen in skeletal muscle and the liver.
When glucose is needed, glycogen in storage in the liver and muscle is broken down.
This breakdown process of glycogen is called glycogenolysis.
The breakdown process of glucose is called glycolysis.
Glucose transport
Glucose is found in the blood and needs to be transported actively from the blood to the cytoplasm of the
cells. Glucose is transported across various cell membranes using a variety of tissue specific transporters
namely GLUT 1-14 of which the more important ones are:
GLUT 1: red blood cells, brain, placenta and testis
GLUT 2: beta cells in the pancreas
GLUT 3: neurons
GLUT 4: adipose cells, skeletal and cardiac muscle
197
Cell site
o Takes place in the cytoplasm
Sequence of events
o There are 10 steps leading to the production of 2 molecules of pyruvate from one glucose
molecule
Key enzymes in glycolysis
o Hexokinase/Glucokinase
o Phosphofructokinase [this is the rate limiting step]
o Pyruvate kinase
There are two phases of the glycolytic pathway:
preparatory phase consisting of the first 5 steps
pay off phase of the last 5 steps.
Preparatory Phase
Step 1
Glucose to Glucose 6-Phosphate
This step is catalyzed by Glucokinase in liver and Hexokinase in all other cells
This step traps the glucose within the cell as glucose 6-phosphate cannot diffuse out of the cell
1 molecule of ATP is used up in this process
This is an irreversible step
Step 2
Glucose 6-Phosphate to Fructose 6-Phosphate
This step is facilitated by phosphoglucose isomerase
o An isomerase is an enzyme which changes spatial arrangement of a molecule without
affecting its chemical composition
Step 3
Fructose 6-Phosphate to Fructose 1,6 Bisphosphate
This step uses another molecule of ATP
This step is catalyzed by phosphofructokinase [PFK]
o This enzyme is irreversible also
o This is the most important rate limiting step in glycolysis
o It is an allosterically regulated enzyme that is the major point of regulation for the entire
glycolysis pathway
Step 4
Fructose 1,6 Bisphosphate to Glyceraldehyde 3-Phosphate and Dihydroxyacetone
phosphate [DHAP]
This step is catalyzed by aldolase
Step 5
Since DHAP is not a desired substrate for continuing the glycolysis pathway, it is converted to
Glyceraldehyde 3-Phosphate
This step is facilitated by triose phosphate isomerase
This reaction is an isomerization reaction, converting a ketone into an aldehyde.
Step 7
1,3 bisphosphoglycerate to 3-phosphoglycerate
This is an energy yielding step which results in the production of 1 ATP molecule for each 3-
phosphoglycerate produced
o So there is a total of 2 ATP that are produced from one molecule of Glucose
This step is catalyzed by phosphoglycerate kinase
o This is known as the BREAK EVEN point as the 2 ATP used in Steps 1-5 is balanced out
by the 2 ATP in this step
198
Step 8
3-phosphoglycerate to 2-phosphoglycerate
This step is catalyzed by phosphoglycerate mutase
This enzyme moves the phosphate group from one carbon to another carbon within the molecule.
Step 9
2-phosphoglycerate to Phosphoenolpyruvate facilitated by enolase
Enolase is an enzyme which removes a molecule of water
Step 10
Phosphoenolpyruvate to Pyruvate
This is the final step in glycolysis
This is facilitated by Pyruvate kinase
This is the final energy releasing step in glycolysis
Each Phosphoenolpyruvate converted to pyruvate releases 1 ATP
Therefore there are 2 ATP created in this step
As a result, there is a net total of 2 ATP that are produced from one glucose molecule entering the
glycolytic pathway
o 4 ATP produced in Steps 6-10 minus 2 ATP used in Steps 1-5
Fate of Pyruvate
+,
Pyruvate cannot actually be the end point of glycolysis. The cell has a limited supply of NAD and without
+ +
regeneration of NADH back to NAD , eventually all NAD will end up as NADH and glycolysis will stop due
+
to lack of NAD .
199
Glycolysis is not a very energy efficient way to producing energy.
Pyruvate enters the mitochondrion and is converted to acetyl CoA to enter the Krebs cycle where a lot more
energy can be efficiently produced.
G lucose
A TP 1
Glucokinase/Hexokinase
G lucose 6-Phosphate
2
Phosphoglucose isomerase
F ructose 6-Phosphate
3
A TP Phosphofructokinase
3 Phosphoglycerate
8
Phosphoglycerate mutase
2 Phosphoglycerate
9
Enolase
Phosphoenolpyruvate + H 2 O
10
A TP Pyruvate kinase
Pyruvate
Sorbitol
An alternative method of dealing with glucose in the cell is to covert it to its alcohol counterpart, called
sorbitol, via aldose reductase. Some tissues which contain sorbitol dehydrogenase, converts the sorbitol
to fructose which can enter the glycolytic pathway by being converted to Fructose 1-phosphate and then
to Glyceraldehyde.
Tissues lacking this enzyme are at risk of sorbitol accumulating within the tissue. Examples of tissue that
lack sorbitol dehydrogenase are the lens, retina and Schwann cells. Sorbitol is osmotically active and
draws water into the cell and this damages the lens, retina and peripheral nerves resulting in premature
cataracts, retinopathy and peripheral neuropathy.
200
GLUCONEOGENESIS
This is a pathway for de novo synthesis of glucose from non-carbohydrate substrates such pyruvate,
lactate from RBCs and muscle during anaerobic exercise, glycerol from adipose tissue, and glucogenic
amino acids from muscle protein, using both mitochondrial and cytosolic enzymes found only in the liver,
kidney and intestinal epithelium. Gluconeogenesis mainly occurs in the liver. During prolonged starvation,
the kidneys become the major glucose-producing organs.
It serves to provide glucose especially for the brain and RBCs which require glucose for energy.
Gluconeogenesis occurs during fasting, starvation or intense exercise and is highly endergonic (energy
requiring). Remember that humans cannot make glucose from Acetyl Co-A.
Purpose:
To maintain blood glucose levels in the fasting state by reversing the process glycolysis.
All of the 10 steps in glycolysis are reversible EXCEPT 3:
The 3 irreversible glycolytic enzymes are the enzymes used in Steps 1, 3 and 10:
Glucokinase/Hexokinase replaced by Glucose 6-Phosphatase
Phosphofructokinase replaced by Fructose-1,6 bisphosphatase
Pyruvate kinase replaced by Pyruvate carboxylase and PEP carboxykinase
4 replacement enzymes are needed to replace the 3 irreversible glycolytic enzymes. The vast majority of
gluconeogenesis takes place in the cytosol of liver cells [and to a smaller extent the kidney and small
intestinal cells]. Gluconeogenesis uses lactate and amino acids as substrates.
Lactic acid, formed during anaerobic respiration in skeletal muscle, is a common substrate for
gluconeogenesis. Lactic acid may also come from red blood cells, which obtain energy solely from
glycolysis as they have no membrane-bound organelles for aerobic respiration. Lactate is transported back
to the liver where it is converted into pyruvate by the Cori cycle using the enzyme lactate
dehydrogenase:
Alanine is an amino acid
o It is derived from the Glucose-Alanine cycle
Both Lactate and Alanine will be converted first to Pyruvate before entering the gluconeogenesis
pathway
The Cori cycle is an energy sapping cycle and comes at a cost of a net loss of 4 ATP/cycle.
This cycle prevent lactic acid from building up in skeletal muscle.
The first part of gluconeogenesis is in the mitochondrion and the rest in the cytosol.
Step 10 reversal
The replacement for Pyruvate Kinase is a 2-step process:
The first step converts Pyruvate to Oxaloacetate which occurs in the mitochondrion
o Pyruvate carboxylase is the replacement enzyme
o Biotin is an essential coenzyme for this step
biotin is vitamin B7
biotin deficiency will result causing pyruvate to build up
this results in excess lactic acid production
o Oxaloacetate passes out into the cytoplasm
o ATP and Acetyl CoA are allosteric activators
The second step takes Oxaloacetate to Phosphoenolpyruvate
o this occurs in the cytoplasm
o this is catalyzed by PEP carboxykinase
o lots of energy is required for this step
energy is provided in 2 ways:
1) decarboxylation is a favorable reaction
2) GTP is hydrolyzed
o this enzyme is facilitated by:
glucagon
cortisol
201
Step 3 reversal
PhosphoFructoKinase converts Fructose 6-Phosphate to Fructose 1,6-bisphosphate
the replacement enzyme for PhosphoFructoKinase is Fructose 1,6 Bisphosphatase
this is the RATE LIMITING STEP for gluconeogenesis
it is stimulated by ATP and citrate
inhibited by AMP and Fructose 2,6 bisphosphate
Step 1 reversal
Glucokinase converts Glucose to Glucose 6-Phosphate
Glucose-6 Phosphatase converts Glucose 6-Phosphate to Glucose
o It is present in the ER of liver and kidney cells making gluconeogenesis possible
o G6P is hydrolyzed as it passes into the ER
Muscle and brain cells do not do gluconeogenesis
ER vesicles filled with glucose diffuse to the plasma membrane, fuse with it and open releasing
glucose into the bloodstream
Gluconeogenesis is inhibited by insulin and stimulated by glucagon
Energy usage
Gluconeogenesis is an energy consuming process.
6 ATPs used in Gluconeogenesis in producing one new Glucose molecule.
Purpose of this ATP consumption is to store energy in the form of Glycogen.
Acetyl CoA is not used as it requires more energy to make glucose from Acetyl CoA than from
lactate or alanine.
Glucose
Glucose 6-Phosphatase
Glucose 6-Phosphate
Fructose 6-Phosphate
Fructose 1,6-Bisphosphatase
Glyceraldehyde 3-Phosphate
1,3 Bisphosphoglycerate
3 Phosphoglycerate
2 Phosphoglycerate
Phosphoenolpyruvate
PEP carboxykinase
Oxaloacetate
202
KREBS CYCLE
The Tricarboxylic Acid Cycle, the Citric Acid Cycle and the metabolic hub are other names for the
Krebs cycle. The Krebs cycle is located in the mitochondrial matrix that occurs under aerobic conditions.
The substrates for Krebs cycle are the breakdown products of carbohydrates, fats and protein metabolism.
The fuel used to drive this cycle is Acetyl CoA. The end product of carbohydrate breakdown is pyruvate
which is turned into Acetyl CoA. Each acetyl-CoA generated from pyruvate is used to produce 3 NADH, 1
FADH2,1 GTP and 2 CO2. Both the NADH and FADH2 deliver electrons to the Electron Transport Chain to
generate energy by the process of oxidative phosphorylation.
4th Step
[Selling] Succinyl CoA is produced from α-ketoglutarate [Selling]
o α-ketoglutarate dehydrogenase catalyzes this reaction
o One NADH is produced
o One molecule of CO2 is released
th
5 Step
[Sex] Succinate is produced from Succinyl CoA
o Succinate thiokinase (aka succinyl CoA synthetase) catalyzes this reaction
o 1 high-energy GTP is produced
o GTP can react with ADP to get ATP and GDP by transferring a phosphate group
203
th
6 Step
[For] Furmarate is produced from Succinate
o Succinate dehydrogenase catalyzes this reaction
Succinate dehydrogenase is the only TCA cycle enzyme that is bound to the
mitochondrial membrane instead of being soluble in the mitochondrial matrix
It is also the only TCA cycle enzyme that directly uses FAD. The FAD is a
covalently-bound prosthetic group.
o 1 FADH2 is produced
th
7 Step
[Money] Malate is produced from Fumarate
o Fumarase catalyzes this reaction
th
8 Step
[Officer] Oxaloacetate is produced from Malate
o Malate dehydrogenase is the catalyst for this reaction
o Oxaloacetate is added to Acetyl CoA to re-enter the cycle
o 1 NADH is produced at this stage
After entering the Electron Transport Chain which is located in the Inner Mitochondrial Membrane:
each NADH produces 3 ATPs
each FADH2 produced 2 ATPs
Each GTP is equivalent 1 ATP and does not go through the ETC.
Therefore each pyruvate molecule eventually yields 12 ATPs [3 NADH+H + 1 GTP + 1 FADH2 = 9 + 1 + 2 =
12]
2 molecules of pyruvate from 1 glucose molecule will yield 24 ATPs from the Krebs cycle.
Total 38 ATPs
NB. No ATP is actually produced in the Krebs cycle as the ATP is only released when NADH and FADH2
enters the Electron Transport Chain in the mitochondrion.
204
In addition to using carbohydrates, proteins and fat can enter the Krebs cycle. Here are the four points at
which proteins can enter [SOFA]:
Succinyl CoA
Oxaloacetate
Fumarate
α-ketoglutarate
There are two points at which fats can enter the Krebs cycle [AS]:
α-ketoglutarate
Succinyl CoA
C O2 + N A D H
PYRUV A T E A C E T Y L CoA
Pyruvate Dehydrogenase
Citrate synthase
1 CITRATE
8 OXALOACETATE Aconitase
Malate dehydrogenase 2 ISO C I T R A T E
NADH
F A D H2 C O2 + N A D H
Fumarase 3 α-K E T O G L U T A R A T E
Below is a diagram showing how the metabolic intermediates are all related:
Glucose
Glucose 6-pshospahate
Fatty Acids
HMG-CoA
205
ELECTRON TRANSPORT CHAIN
The Electron Transport Chain is located in the inner mitochondrial membrane [IMM] and uses a series of
carrier enzymes that pass electrons in a stepwise fashion from NADH and FADH2 to oxygen. The NADH
and FADH2 produced in the Krebs cycle are reduced in this process. The purpose of this process is to
liberate energy that can be used to make ATP. This is done by oxidizing NADH and FADH2 in a process
whereby five protein complexes [I, II, III, IV and V] are used to catalyze the oxidation reactions freeing up the
electrons. NADH produced in the cytosol by the process of glycolysis, cannot directly cross the
mitochondrial membrane. Therefore, the electrons are passed from the cytosol into the mitochondrial
electron transport chain by two systems, namely the malate-aspartate and the glycerol-3-phosphate
shuttles.
Malate-aspartate shuttle
Cytosolic oxaloacetate is reduced to malate by NAHD
Malate enters the mitochondrion carrying an electron
It is oxidized to oxaloacetate regenerating NADH in the mitochondrial matrix
Thus bringing the electron into the matrix
Oxaloacetate cannot cross the mitochondrial membrane
It has to be converted to aspartate
This can now cross the mitochondrial membrane back into the cytosol where it is reconverted to
oxaloacetate
Glycerol-3-phosphate shuttle
Cytosolic DiHydroAcetone Phosphate [DHAP] is reduced to glycerol-3-phosphate by NADH
Glycerol-3-phosphate enters the mitochondrion and reacts with a Flavin Adenine Dinucleotide
[FAD]-linked dehydrogenase to enter the inner mitochondrial membrane
This allows the electron to enter the matrix
DHAP is regenerated from this and re-enters the cytosol
The FADH2 generated gives up its electrons to Complex II
206
There are 5 complexes in the process of oxidative phosphorylation.
The first four complexes [I-IV] are involved in the transfer of electrons.
They are located in the inner mitochondrial membrane [IMM]
The last complex [ATP synthase] is where oxidative phosphorylation occurs and ATP is generated.
Complex I: NADH dehydrogenase complex with Coenzyme Q
o The first component of the ETC through which most excess electrons are funneled
o The hydrogen ions pass from the incoming NADH to FMN and then to Iron sulfur centers
+ +
o In this step, a hydride ion H passes to FMN which then picks up an additional H from the
surrounding aqueous medium
o As a result, NADH is oxidized to NAD and FMN is reduced to FMNH2 which enters the
next stage
Complex II: Succinate dehydrogenase complex with Coenzyme Q
o The FADH2 formed in the TCA cycle enters the ETC
o This FADH2 is oxidized by passing its hydrogens to the iron sulfur groups, which in turn
pass the excess electrons to Coenzyme Q
+
o Coenzyme Q then picks up an additional H ion from the surrounding aqueous medium
o The reduced form of Coenzyme Q, produced by reaction with Complex I and Complex II,
is very lipid soluble and easily diffuses within the inner mitochondrial membrane to the
next ETC component
Complex III: Cytochrome reductase or Cytochrome c complex with Coenzyme Q
o This complex removes in a stepwise fashion two electrons from CoQH2 at the QO site and
sequentially transfers them to two molecules of cytochrome c, a water-soluble electron
carrier located within the intermembrane space. The two other electrons are sequentially
passed across the protein to the Qi site where quinone is reduced to quinol
Complex IV: Cytochrome c oxidase
o Cytochromes, iron-sulfur clusters and copper atoms designated CuA and CuB located
between Coenzyme Q and Oxygen
o The electrons are passed successively from Cytochrome c to CuA, which undergoes a
Cu2+---> Cu+ transition
o The copper passes the electron to Cytochrome a, which in turn passes the electron to Cu B
o A second electron passing through Complex IV also is picked up first by CuA, then by
Cytochrome a, and then finally ends up on Cytochrome a3
Complex V: ATP synthase
o This is the final step in the process of the electron transport chain
+
o The oxygen molecule picks up 2 H from the surrounding medium to make H2O
o This is the only point in which oxygen is consumed and ATP is actually generated
o Oxygen is the electron acceptor
CoQ Cyt
Complex Complex C Complex Complex IMM
I III IV V
Complex
II
NADH NAD ½ O2 H2 O ADP + Pi ATP + H2O
+
2H
FADH2 FAD Matrix
+ +
2H 3H
Figure 108: Electron Transport Chain
Cytochromes
They are heme [iron]-containing compounds that receive electrons from CoQH2
The reduced oxygen produced is used to form H2O and is catalyzed by ATP Synthase
Copper is also important in the Electron Transport Chain
Cyanide and Carbon Monoxide inhibit Cyctochrome C oxidase in the Electron Transport Chain
207
CORI CYCLE
This is a metabolic pathway that is used to prevent lactic acid produced by anaerobic glycolysis from
building up in the muscle. This cycle occurs in the liver and is also known as the Lactic Acid Cycle.
During fasting or exercise, lactate from RBCs or skeletal muscle is sent to the liver to make
glucose that can be returned to the RBCs or muscle
Pyruvic acid is reduced to lactic acid by lactate dehydrogenase, which removes the protons
from the NADH that were created during glycolysis and transfers them to pyruvic acid, creating
lactic acid
This occurs in order to maintain a concentration of NAD+ that can be reduced during glycolysis
Lactic acid goes to the liver where it is converted back to pyruvic acid and then to glucose
through gluconeogenesis
Glucose then re-enters the blood and returns to the muscles to be used for energy
It provides quick ATP production during anerobic glycolysis in the muscle and red blood cells
If muscle activity has ceased, then the glucose is converted back into muscle glycogen to be stored
for future use
The Cori cycle is an energy consuming pathway as it uses up 4 molecules of ATP making the
cycle unable to be sustained on a continuous basis
The other names for this pathway are the Hexose Monophosphate Shunt and Phosphogluconate
Oxidative Pathway. This pathway occurs in the cytosol. There are two distinct phases in the pathway.
The first is the oxidative phase, in which NADPH is generated. The second phase is the non-oxidative
synthesis of 5-carbon sugars like ribose. Ribose is used in DNA and RNA synthesis.
6-Phosphogluconolactone
H2O
Gluconolactonase (Oxidative Phase)
H+
6-Phosphogluconate
N A DP
C O2
Ribulose 5-Phosphate
Phoshopentose isomerase
(Non-Oxidative Phase)
208
GLYCOGEN METABOLISM
Glycogen storage occurs primarily in skeletal muscle and in the liver. Both glycogen synthesis and
breakdown take place in the cytosol. Glycogen is a branched polymer of glucose which can be used
during hypoglycemia or muscle contraction. Synthesis of glycogen [glycogenesis] is mediated by
glycogen synthase while its breakdown [glycogenolysis] is facilitated by glycogen phosphorylase.
Branching of the glycogen polymer occurs via a branching enzyme which breaks an α-1-4 bond and
transfers a block of glucosyl residues to create a new α-1,6 bond.
GLYCOGENESIS:
Process of glycogen synthesis in which glucose molecules are added to chains of glycogen for
storage in the liver and skeletal muscle
The initial step in glycogen synthesis is initiated by the enzyme glycogen synthase:
rate limiting step
used to lengthen the glycogen chain
catalyzes the attachment of UDP-glucose to Glycogenin
Glycogenin is a protein which serves as the site at which the initial glucose unit is attached
The glucose units are linked by glycosidic bonds:
these are chemical bonds between glucose molecules
the main backbone is made up of 1-4 links
the branches are 1-6 links
Glycogenesis Control and Regulation:
is activated by insulin response to high glucose levels
is inhibited by epinephrine (epinephrine release signals a need for glycogen breakdown not
synthesis) and glucagon
G L U C OSE
Glucokinase/Hexokinase
G lucose 6-Phosphate
Phosphoglucomutase
G lucose 1-phosphate
UDP-Glucose Pyrophosphorylase
UPD-G lucose
G lycogenin
(a small protein that forms the primer) Glycogen synthase
Rate limiting E nzyme
209
GLYCOGENOLYSIS
Role of cAMP
Cyclic AMP (cAMP) act as a secondary messenger
It is synthesized from ATP by the action of adenylyl cyclase
cAMP activates phosphorylase kinase
This in turn activates glycogen phosphorylase
cAMP inhibits glycogen synthase
It also regulates the passage of calcium through ionic channels
It is also used for intracellular singal transduction such as transferring the effects of glucagon and
epinephrine which cannot pass through cell membranes
210
FAT METABOLISM
Lipids in the form of triacylglycerols [aka triglycerides] are a major component [90%] of our diet and
are an important calorie source as it stores a large amount of energy. While metabolism of carbohydrates
and proteins produce between 4 to 5 kcal/g, metabolism of triacylglycerols produces 9 kcal/g. The
remainder of dietary lipids consists of cholesterol, phospholipids and free fatty acids. Triglyceride digestion
begins in the small intestine by the action of lipase which hydrolyzes the ester bonds between fatty acids
and glycerol. Lipase is produced in the pancreas and works best in water. The products produced by lipase
are:
monoacylglyerol
2 fatty acids
o fatty acid:
end product of fat digestion
a carbon chain with a carboxyl group at one end
carboxyl group:
this is a group consisting of carbon with oxygen and an
attached hydroxyl [-COOH] group
These are absorbed by the enterocytes. Some are transported to the liver via the portal vein while others
are re-esterified [an ester bond links fatty acids and glycerol] and combined with protein to form
lipoproteins. Chylomicrons are absorbed by the central lacteals in the villi of the small intestine and are
transported via the thoracic duct. There are five main types of lipoproteins depending on their density:
HDL[High Density Lipoproteins]-Happy Cholesterol; cis form; double bonds
IDL[ Intermediate Density Lipoprotein]- Bad Cholesterol; similar to LDL
LDL [Low Density Lipoproteins]-Lethal Cholesterol; trans form
VLDL[Very Low Density Lipoproteins]-Transports triglycerides from liver to tissues
Chylomicrons-are large lipoprotein particles; they transport dietary lipids from the intestine to other
locations in the body
211
Fatty acids are use to make cholesterol from which are made:
Bile acids
Cell membranes
Hormones
Prostaglandins
Vitamin D
Regulation enzyme
Hormone-sensitive lipase
Malonyl-CoA can prevent Acyl-CoA derivatives from entering the mitochondria by inhibiting
carnitine acyltransferase, therefore inhibiting beta oxidation
High citrate levels inhibit beta oxidation
212
LIPOGENESIS
This process is located in the cytoplasm of cells in the liver, adipose tissue and kidney. It uses the
following start up substrates [big MAC]:
Malonyl CoA
Acetyl CoA (the ultimate precursor-primary substrate)
Citrate (required for the activation of the synthesis pathway)
Acetyl CoA carboxylase converts Acetyl CoA to Malonyl CoA and is the RATE LIMITING enzyme in
lipogenesis. This process also has 4 steps: [Condensation Reduces Dehydration even Further]
Condensation
Reduction of NADPH
Dehydration
Further reduction
Steroid hormones are produced from cholesterol in gonads and adrenal glands. Only 20% of the
cholesterol in our body actually comes from the diet. The rest is made by the liver from excess
carbohydrates. Cholesterol is made from Acetyl CoA mainly in the liver, although some is synthesized in
the adrenal cortex and reproductive tissues:
first two acetyl CoA molecules condense to form acetoacetyl CoA
a third molecule of acetyl CoA is added and HMG CoA is produced
HMG CoA is reduced to mevalonic acid by HMG CoA reductase
through a series of steps mevalonic acid is converted into squalene
squalene is converted into lanosterol
lanosterol is converted into cholesterol
213
PROTEIN METABOLISM
Proteins are large organic molecules made up of long twisted chains of amino acids. Proteins are the
building blocks of life. There are more than 100,000 different protein molecules in the body and all of
these diverse chemicals are built on only 20 amino acids. An amino acid is a compound characterized by
the presence of an amine [NH2] and a carboxyl group [COOH] on the first [alpha] carbon atom. There are
10 essential and 10 non-essential amino acids. An essential amino acid is one that cannot be
synthesized by the body. The non-essential amino acids are manufactured in the liver.
The essential amino acids are [PVT TIM HALL]:
Phenylalanine Tyrosine L-Dopa Dopamine Norepinephrine Epinephrine
Valine
Threonine
Tryptophan Serotonin Melatonin
Isoleucine
Methionine
Histidine [essential only during periods of growth and pregnancy] Histamine
Arginine [essential only during periods of growth and pregnancy] Creatinine and Nitric oxide
Leucine
Lysine
The rest are non-essential amino acids [PT GAGA GAS C]:
Proline
Tyrosine is also used to manufacture thyroxin [T4]
Glycine Porphyrin Heme
Alanine
Glutamine
Aspartate
Glutamate GABA and Glutathione
Asparagine
Serine
Cysteine
Some amino acids are derived from intermediates of glycolysis namely:
Glycine is made from serine
Alanine is made from the transamination of pyruvate
Serine is made from 3-phosphoglycerate
Cysteine is made from serine
Other amino acids are derived from the TCA cycle or its intermediates namely:
Glutamate is derived from α-ketoglutarate
Aspartate is derived from the transamination of oxaloacetate
Glutamine is derived from glutamate
Asparagine is produced from aspartate
Proline is derived from glutamate
Arginine is derived from glutamine
Protein structure
Proteins are made in the ribosomes where the genetic code is decoded via strands of mRNA. The shape
of a protein develops in stages or structures:
primary structure
o linear sequencing of amino acids forming a polypeptide chain
secondary structure
o the secondary structure is formed as the protein begins to twist in accordance with the
chemical forces within the primary linear structure
o this occurs in one of two forms:
α-helix [left-handed coil]
β-pleated sheets [folded back on itself in pleats]
o the end product is a 3-D structure stabilized by hydrogen bonds
tertiary structure
o this controls the overall three-dimensional shape of a single protein molecule
o it is the spatial relationship of the secondary structures to one another
o the twisted or pleated secondary form is folded on itself
o tertiary structure controls the basic function of the protein
214
quaternary structure
o refers to the spatial arrangement of subunits in a protein containing two or more
polypeptide chains; each polypeptide chain is known as a subunit
o for example hemoglobin which is made up of 2α and 2β subunits.
Urea cycle
Ammonia is toxic especially to the central nervous system and must be removed from the body
the cycle produces urea (NH2)2C=O from ammonia (NH3), aspartate and CO2
the main sources of nitrogen atoms are Glutamate and Alanine which are degraded to ammonia.
ammonia enters the Urea cycle which consists of 5 steps
the first two steps occur in the mitochondrion
the other three in the cytosol
Step 1: Ammonia is converted to Carbamoyl Phosphate
Step 2: Carbamoyl Phosphate reacts with Ornithine to form Citrulline
Step 3: Citrulline passes out into the cytosol where it is combined with Aspartate to form
Arginonosuccinate
Step 4: Arginosuccinate is split to form Fumarate and Arginine
Step 5: Arginine is cleaved to form Ornithine and Urea
Ornithine is transported back into the mitochondrion where it could be used for another round
of the cycle and urea is excreted in the urine
st
the key RATE LIMITING enzyme in the urea cycle is the 1 step:
Carbamoyl Phosphate Synthase which converts NH3 to Carbamoyl Phosphate
215
NUCLEOTIDE AND NUCLEOSIDE METABOLISM
Nucleotides and nucleosides are two important classes of molecules in the body.
Nucleotides are composed of three subunits:
Pentose sugar: either ribose [for use in making RNA] or deoxyribose [for making DNA]
Nitrogen base: either purine or pyrimidine
Phosphate group
Nucleosides are composed of only two subunits:
pentose sugar
nitrogenous base
The first major role of nucleotides is in the formation of energy-rich compounds like ATP [adenosine
triphosphate], GTP [guanosine triphosphate] and UTP [uridine triphosphate]. Nucleotides are built from
molecules called pyrimidine or purine bases.
DNA synthesis
DNA is made up of two polynucleotide chains joined by hydrogen bonds
Deoxyribose is the sugar base on which the base pairs are attached.
Adenine is paired with Thymine and Guanine is paired with Cytosine
The two strands are twisted to form a double helix
DNA is synthesized by replication
Replication is both bidirectional [begins at a site of origin and simultaneously moves out in both
directions from this point] and semiconservative [after replication, each daughter molecule of DNA
contains an intact parental strand and one newly synthesized strand joined by base pairs]
The parental double strands separates and the helix unwinds ahead of a replication site\
DNA polymerases catalyze the synthesis of DNA and RNA serves as the primer for DNA
polymerase. ATP, CTP, GTP and TTP serve as precursors.
RNA synthesis
RNA is different from DNA in that RNA contains the sugar ribose instead of the deoxyribose in
DNA, uracil replaces thymine and RNA is a single strand compared to the double strands in DNA
RNA existed in three forms: mRNA [messenger], rRNA [ribosomal] and tRNA [transfer]
RNA is synthesized through a process called transcription
This is initiated by an RNA polymerase which does not require a primer like in DNA
Transcription involves a DNA template. ATP, CTP, GTP and UTP which serve as precursors
Protein synthesis
mRNA moves out of the nucleus into the cytoplasm where it will carry the code to the ribosome
tRNA brings amino acids to the rRNA in the ribosomes on the rough endoplasmic reticulum in the
correct sequence in order to make the particular protein
Transcription of RNA comes before translation into protein [C before L in the alphabet]
216
VITAMINS AND MINERALS
Vitamins are vital nutrients that serve as coenzymes or cofactors. Vitamins may be classified as water
soluble or fat soluble. Vitamins D, A, K and E are fat-soluble and Vitamins B and C are water soluble.
The antioxidants are A, C and E plus the mineral Selenium [ACES].
Vitamin A includes the compounds retinal, retinol, and many carotenoids which are found in:
liver
dark green leafy vegetables
yellow-orange fruits and vegetables
meat, fish and poultry
Retinal is used to make rhodopsin and helps in the differentiation of epithelial tissue.
The active form of Vitamin A is retinoic acid.
A deficiency in Vitamin A results in:
nyctalopia
o night blindness
xerophthalmia
o dry eye
Bitot’s spots
o build-up of keratin debris in small opaque plaques in the conjunctiva
phrenoderma
o dry bumpy skin
o due to follicular plugging
Vitamin D is essential for calcium uptake from the gut and resorption from the kidney.
It is much more than a vitamin and should be considered as a prohormone as it affects many tissues.
Vitamin D is found in:
eggs, fatty fish like salmon, tuna and sardines
It is also produced in the skin by exposure to sunlight
The active form of Vitamin D is 1, 25, dihydroxycholecalciferol [Vit D3] and is located in the kidney.
Vitamin D deficiency results in:
rickets in children
o soft bones that bend-bow legs
o rachitic rosary [swollen costochondral joints] in the chest
osteomalacia in adults and the elderly
o soft demineralized bones in adults
o pseudofractures called Looser zones
Vitamin K catalyzes carboxylation of glutamatic acid residues in making clotting factors II, VII, IX and X.
Vitamin K is found in:
green leafy vegetables
liver
It is also produced by the bacterial flora in the large intestine.
Vitamin K deficiency results in:
Hemorrhagic disease of the newborn
o prolonged bleeding from the umbilicus in the newborn and may lead to kernicterus
o kernicterus is brain damage by high levels of bilirubin from excess RBC destruction
Vitamin E [tocopherol] is an antioxidant which protects erythrocytes and membranes from free radical
damage.
Vitamin E is found in:
vegetable oils like soy bean, corn, sunflower, almonds and hazel nuts
wheat germ
A deficiency will cause:
red blood cells are fragile which leads to hemolytic anemia:
o due to the premature destruction of the fragile red blood cells
o this will present with:
fatigue, malaise and muscle weakness
shortness of breath
pale mucous membranes
217
Vitamin B1 [Thiamine] is a cofactor in pyruvate kinase and α-ketoglutarate dehydrogenase.
Thiamine is found in:
brewer’s yeast
milk
liver
beans and nuts
Thiamine deficiency can occur in alcoholics and in fad diets and may present as:
dry beriberi:
o dermatitis and peripheral neuritis with numbness in the extremities
wet beriberi:
o tachycardia, warm skin, edema and high-output heart failure
Wernicke-Korsakoff syndrome:
o Confabulation [telling lies]
o Apathy
o Loss of memory
o Muscle weakness
Vitamin B2 [Riboflavin] is a cofactor for FMN and FAD in the mitochondrial ETC and redox reactions.
Riboflavin is found in:
milk and dairy products
collard greens
liver
meat, fish and poultry
Lack of riboflavin is called ariboflavinosis and may present with:
dermatitis
angular stomatitis [cheilosis]
Vitamin B3 [Niacin] is a precursor for NAD and NADP in the mitochondrial Electron Transport Chain.
It is essential in glycolysis and is paired with Magnesium.
Niacin is found in:
eggs
milk
meat
legumes
It is also formed in the body from dietary tryptophan.
Niacin deficiency may present with:
pellagra
o dermatitis [with Casal’s necklace]
Casal’s necklace:
flaky scaly dermatitis
in the sun exposed skin in the shape of a V below the neck
o diarrhea
o dementia
o death
218
Pyridoxine deficiency will cause:
glossitis [burning tongue]
neuropathy [burning pain in the extremities]
Vitamin B7 [Biotin] is used in carboxylation reactions such as the one that converts oxaloacetate to
phosphoenolpyruvate. It also plays a part in the production of fatty acids and the metabolism of fats and
amino acids.
Biotin is found in:
royal jelly
brewer’s yeast
legumes
beans
liver
meat and poultry
egg yolk
Avidin found in raw eggs avidly binds to biotin prevents its absorption and will cause a deficiency which
will present with:
dermatitis
fatigue
depression
alopecia [hair loss]
lactic acidosis
Vitamin B9 [Folic acid] is used in the transfer of 1-Carbon units in DNA and RNA synthesis, to make
methionine and purines necessary for DNA synthesis and for the transfer of methyl groups.
Folic acid is found in:
liver
green leafy vegetables
legumes
cauliflower
sweet potato
citrus fruits
Folic Acid deficiency is seen in pregnant womrn and alcoholics and causes:
megaloblastic anemia
o low hemoglobin with fatigue
neural tube defects but no spinal cord damage [which distinguishes it from Vitamin B12 deficiency]
o spina bifida-failure of closure of the posterior neuropore
Vitamin B12 [Cobalamin] is a cofactor for methionine and succinyl CoA manufacture.
Source:
meat
dairy products
eggs
Vitamin B12 deficiency:
may be due to lack of intrinsic factor associated with atrophic gastritis
lack of food containing vitamin B12:
decreased vitamin B12 absorption in the terminal ileum:
o Crohn’s disease
o infestation with Diphyllobothrium latum
may cause the following:
o megaloblastic [macrocytic] anemia
o if the deficiency is due to a lack of intrinsic factor, this is known as pernicious anemia
sub-acute combined degeneration of the spinal cord
Vitamin C [Ascorbic acid] is a cofactor in hydroxylation of proline and lysine in the synthesis of
collagen. It also facilitates iron absorption from the gut by keeping it in the reduced state which is more
absorbable.
Vitamin C is found in:
citrus and other fruit like strawberries and cherries
peppers
cauliflower and broccoli
219
Vitamin C also enhances the absorption of iron from the gastrointestinal tract.
Vitamin C deficiency results in scurvy which presents with:
sore, bleeding swollen gums
loose teeth
poor wound healing
Minerals
Certain minerals are essential for health. These following are necessary for certain biochemical pathways in
the body:
iron
copper
zinc
selenium
iodine
calcium
magnesium
220
METABOLIC PATHWAY SUMMARY TABLE
221
GLYCOGENESIS GLYCOLYSIS HMP SHUNT
cytosol cytosol cytosol
H+ H+ H+ H+
222
RAPID REVIEW
223
224
CLASSIC CLINICAL PRESENTATIONS
225
Fever, cough, chest pain in a parrot breeder Bird fancier’s disease
Fever, headache and skin rash on wrists and feet Rocky Mountain Spotted Fever
Fever, conjunctivitis, coryza and fine rash on trunk Measles
Fever, neck stiffness and headache Meningitis
Fever, night sweats, weight loss, cough or hemoptysis Tuberculosis
Fever, maculopapulovesicular rash on trunk Chickenpox
Foul floating feces, fatigue and weight loss Celiac disease
Frequent urination with burning on micturition Urinary Tract Infection
Frothy urine, recurrent infections with normal blood pressure Nephrotic syndrome
Frothy malordorous vaginal discharge Trichomonas vaginitis
Galactorrhea and amenorrhea Prolactinoma
Gumma Tertiary syphilis
Gottron’s papules and heliotrope eyelids Dermatomyositis
Gout and self-mutilation in a child due to pain insensitivity Lesch-Nyhan syndrome
Haygarth’s nodes Rheumatoid arthritis
Heartburn worse on lying down after meals Gastro-Esophageal Reflux Disease
Heat intolerance, fine tremors, weight loss or exophthalmos Hyperthyroidism
Heberden’s and Bouchard’ s nodes Osteoarthritis
Hematemesis following protracted vomiting and retching Mallory-Weiss syndrome
Hemoptysis in a chronic cigarette smoking Lung cancer
Hemoptysis and hematuria Goodpasture syndrome
Honey-colored crusts on the face near the mouth and nose Impetigo
Hyperpigmented oral cavity and intestinal polyps Peutz-Jegher syndrome
Hyperpigmented skin creases, bronze skin and fatigue Addison disease
Hypertension, hypokalemia and metabolic acidosis Conn’s disease
Hypertension, exophthalmos and goiter Graves disease
Indurated painless penile lesion Primary syphilis
Infant with red hair and swollen abdomen Kwashiorkor
Infant with microcephaly and rocker-bottom feet Trisomy 18 [Edwards syndrome]
Infant with microcephaly and indistinct philtrum Fetal Alcohol Syndrome
Infant with mongoloid eyes and mental retardation Trisomy 21 [Down syndrome]
Irregularly irregular breathing Biot’s respiration
Jaundice , chills and fever Ascending cholangitis
Jaundice, ascites and firm non-tender hepatomegaly Cirrhosis
Jaundice with tender hepatomegaly Hepatitis
Large spatulate hands, protruding jaw Acromegaly
Loss of the outer third of eyebrows and slow reflexes Hypothyroidism
Low back pain, bamboo spine in young male adult Ankylosing Spondylitis
Lower abdominal pain and 6-8 weeks of amenorrhea Ectopic pregnancy
Koilonychia Iron deficiency anemia
Koplik spots and fever followed by maculopapular rash Measles
Male child with recurrent infection and no B cells Bruton’s disease
Mental retardation, large scrotal tongue, umbilical hernia Down syndrome
Middle-aged male smoker with intermittent claudication Buerger’s disease
Midsystolic click and atypical chest pain Mitral Valve Prolapse
Mole with irregular margins, change in color or size Malignant melanoma
Mucoid urethral discharge in a sexually active male Chlamydia urethritis
Muscle cramps with a positive Chvostek test Hypoparathyroidism
Newborn with paralyzed arm after difficult vertex delivery Erb-Duchenne palsy
Newborn with claw hand after difficult breech delivery Klumpke’s palsy
Night blindness, dry eyes and dry skin Vitamin A deficiency
Nocturnal back pain, recurrent infections and fatigue Multiple Myeloma
Obesity, hirsutism and irregular periods Polycystic Ovarian syndrome
Osler nodes , Janeway nodules or Roth spots Subacute Bacterial Endocarditis
Painful, pale, cold fingers and toes Raynaud’s syndrome
Painful fingers, wrists bilaterally with morning stiffness >1 hr Rheumatoid arthritis
Painful limp in a young child Legg-Calve-Perthes disease
Painful limp in overweight teenager Slipped Capital Femoral Epiphysis
Painful, pulseless, pale perishingly cold limb Arterial embolism
226
Painful yellow genital ulcer Chancroid
Painless beef-red genital ulcer Granuloma inguinale
Painless jaundice and weight loss Cancer of the head of the pancreas
Pale mucous membranes and spoon-shaped nails Iron deficiency anemia
Palpitations, sweating and pressure headaches Pheochromocytoma
Pancreatic, pituitary and parathyroid tumors Wermer’s syndrome [MEN1]
Pectus excavatum Rickets
Pheochromocytoma, mucosal tumors and thyroid cancer MEN 2b
Pink color, purse-lipped breathing and barrel chest Emphysema
Polyuria, polydypsia but no polyphagia or glycosuria Diabetes insipidus
Polyuria, polydypsia, polyphagia and glycosuria Diabetes mellitus
Ptosis, anhydrosis and miosis on one side Horner’s syndrome
Puffy eyelids, smoky urine and hypertension in a child Glomerulonephritis
Purplish lesions on the arms, legs and oral cavity Kaposi’s sarcoma
Purulent urethral discharge in a sexually active male Gonorrhea
Rachitic rosary Rickets
Rash in palms and soles, oral ulcers and fever in a child Hand, Foot and Mouth disease
Radiofemoral delay Coarctation of the aorta
Recurrent crops of painful vesicles on face Herpes simplex Type 1
Recurrent crops of painful ulcers on the genitals Herpes simplex Type 2
Recurrent episodes of wheezing in a child Asthma
Recurrent peptic ulcers Zollinger-Ellison syndrome
Red-currant jelly sputum with fever an cough Klebsiella pneumonia
Regularly irregular breathing-increase with apneic spells Cheyne-Stokes breathing
Resting tremors, mask-like facies and shuffling gait Parkinson’s disease
Rose-colored spots on trunk, fever and diarrhea Typhoid fever
Rust-colored sputum, cough, fever and pleuritic chest pain Streptococcal pneumonia
Scanning speech, intention tremor and nystagmus Multiple myeloma
Shortness of breath, fatigue and erythema nodosum Sarcoidosis
Short stature, web neck and widely spaced nipples Turner’s syndrome
Single transverse palmar crease and mental retardation Down syndrome
Severe sore throat and swollen postauricular lymph nodes Mononucleosis
Situs inversus, chronic sinusitis and bronchiectasis Kartagener’s syndrome
Skin rash along a dermatome with prodrome of local pain Herpes zoster
Splinter hemorrhages Subacute Bacterial Endocarditis
Strawberry tongue, fever and rash Scarlet fever
Sudden onset of dyspnea, hemoptysis and chest pain Pulmonary embolism
Sudden onset of severe painful swollen big toe Gout
Sudden tearing chest pain, sweating and feeling of doom Dissecting Thoracic Aneurysm
Swollen ankles, shortness of breath and distended neck veins Congestive Heart Failure
Swollen bleeding gums and painful joints in a child Scurvy
Tall, thin male with gynecomastia and small testes Klinefelter’s syndrome
Thyroid, parathyroid and adrenal tumors Sipple’s syndrome [MEN 2a]
Unilateral facial palsy with hyperacusis Bell’s palsy
Unilateral facial palsy with vesicles in the ear Ramsey Hunt syndrome
Unilateral facial palsy with deafness in the same side Acoustic neuroma
Unilateral facial weakness with weakness in the arm and leg Cerebrovascular accident
Unilateral ptosis, anhydrosis and miosis Horner’s syndrome
Unilateral throbbing headache with aura Classic migraine
Unilateral throbbing headache without aura Common migraine
Unilateral swollen leg after long distance travel Deep Vein Thrombosis
Urethritis, conjunctivitis and arthritis Reiter’s syndrome
Vomiting blood in a jaundiced patient Ruptured esdophageal varices
Web neck, widely spaced nipples, underdeveloped breasts Turner’s syndrome
Weight loss and change in bowel habits Carcinoma of the colon
Weight loss, diarrhea, fever and arthritis Whipple’s disease
Weight loss, recurrent infections in young adult HIV/AIDS
Wet, wacky and wonky [incontinence, dementia, ataxia] Normal pressure hydrocephalus
Worst headache in my life Ruptured berry aneurysm
227
KEY PATHOLOGY WORD ASSOCIATIONS
Feature Disease
Alpha-fetoprotein elevation in amniotic fluid Spina bifida
Alpha-fetoprotein elevation in adult Hepatocellular carcinoma
Amyloid deposits in the brain Alzheimer’s disease
Antibodies to acetylcholine receptors in NMJ Myasthenia gravis
Antibodies to Calcium influsx pumps in NMJ Lambert Eaton syndrome
Anti-Glomerular basement membrane antibodies Goodpasture disease
Anti-IgG antibodies Rheumatoid Arthritis
Anti-Nuclear Antibodies SLE
Apical cavitations Tuberculosis
Antischkow cells Rheumatic fever
Apical lung tumor Pancoast tumor
Aschoff bodies Rheumatic fever
Auer’s rods Acute Myelogenous Leukemia
Basophilic stippling Lead poisoning
BCR-abl oncogene Chronic Myelogenous Leukemia
Bence Jones proteins Multiple Myeloma
Berry aneurysms Adult polycystic disease of the kidney
Bilateral adrenal heamorrhage Waterhouse-Friderichsen syndrome
Bilateral hilar lymphadenopathy Sarcoidosis
BRCA-1/2 tumor marker Breast cancer
Brown cysts in bone Hyperparathyroidism
Buffalo hump and truncal obesity Cushing’s syndrome
CA-125 Ovarian cancer
Carcinoembryonic antigen Colon cancer
Caseous granulomas Tuberculosis
Cerebellar tonsillar herniation Arnold-Chiari malformation
Charcot-Leyden crystals Asthma
Chocolate cysts in the pelvis Endometriosis
Clue cells Bacterial vaginosis
Coagulative necrosis Myocardial infarction
Cobblestone appearance of intestinal mucosa Crohn’s disease
Codman’s triangle on x-ray Osteosarcoma
Congenital aganglionosis of the colon Hirschsprung’s disease
Curschmann’s spirals Asthma
Dark urine and dark cartilage Alkaptonuria
Downey cells Mononucleosis
Dry eyes and dry mouth Sjorgen syndrome
Dystrophin defect Duchenne’s muscular dystrophy
Eburnation Osteoarthritis
Fatty necrosis Liver damage
Fibrillin defect Marfan’s syndrome
Ghon’s focus and complex Primary Tuberculosis
Guarneri bodies Smallpox
Heterophil antibodies Mononucleosis
Hirano’s bodies Alzheimer’s disease
HLA-B8 Graves disease
HLA-B27 AS, Reiter’s syndrome, ulcerative colitis
HLA-DR3 or 4 DM type 1, RA and SLE
Hypercoagulabilty, venous stasis and vessel wall damage Virchow’s triad
Hyperelasticty of skin and joint capulse Ehlers-Danlos syndrome
Hyperpigmented skin with fatigue Addison’s disease
Immotile cilia with sinusitis, bronchietasts and situs inversus Kartagener’s syndrome
Kimmelstiel-Wilson nodules Diabetic nephropathy
Langhan’s giant cells Tuberculosis
Lewy bodies Parkinson’s disease
Lines of Zahn Thrombus
228
Liquefactive necrosis Nerve damage
Liver and brain damage after aspirin ingestion Reye syndrome
L-MYC oncogene Colon cancer
Looser’s zone Osteomalacia
MacCallum’s patch in lefrt atrium Rheumatic fever
Macrocytic normochromic anemia Folic acid or Vitamin B12 deficiency
Malignant plasma cells Multiple Myeloma
Microcytic hypochromic anemia Iron deficiency anemia
Minimal change of the basement membrane Nephrotic syndrome
Most common cancer in men Prostate cancer
Most common cancer in women Breast cancer
Most common cause of osteomyelitis Staphylococcus aureus
Most common malignant bone tumor Metastases
Most common benign brain tumor Meningioma
Most common kidney tumor in children Wilms tumor
Most common malignant brain tumor in adults Glioblastoma multiforme
Most common malignant brain tumor in children Neuroblastoma
Most common primary bone cancer in adults Multiple Myeloma
Most common primary bone cancer in teens Osteosarcoma
M spike on serum electrophoresis Multiple Myeloma
Needle-shaped negatively birefringent crystals Gout [uric acid crystals]
Negri bodies Rabies
Neurofibrillary tangles Alzheimer’s disease
N-MYC oncogene Neuroblastoma
Non-caseous granulomas in the gut Crohn’s disease
Non-caseous granulomas in the lung Sarcoidosis
Nutmeg liver Congestive Heart Failure
Onion-skin periosteal reaction on x-ray Ewing’s sarcoma
Oral pigmentation and intestinal polyps Peutz-Jegher syndrome
Osteophytes Osteoarthritis
Owl-eye appearance Cryptococcus neoformans
p16 oncogene Malignant melanoma
Pannus formation Rheumatoid Arthritis
Philadelphia chromosome Chronic Myelogenous Leukemia
Post-coital bleeding Carcinoma of the cervix
Post-menopausal bleeding Endometrial cancer
Prostatic Specific Antigen Prostatic carcinoma
Red and gray hepatization in lung Pneumonia
Red blood cell casts in urine Glomerulonephritis
Recurrent peptic ulcers Zollinger-Ellison syndrome
Rib notching on chest x-ray Coarctation of the aorta
Reed-Sternberg cells Hodgkin’s lymphoma
Rheumatoid factor RA, SLE
Rokitansky-Ashoff sinuses Cholecystitis
Soap-bubble appearance on x-ray Giant cell tumor
Spaghetti and meatballs appearance Malassezia furfur
Splenomegaly and eyethema nodosum Sarcoidosis
Starry sky appearance in lymph node Burkitt’s lymphoma
Stunted small intestinal villi due to gluten sensitivity Celiac disease
Thymic and parathyroid aplasia DiGeorge syndrome
Thyroglobulin antibodies Hashimoto’s disease
Vanilyl mandelic acid in the urine Pheochromocytoma
Virchow’s triad-vessel damage, stasis, hypercoagulability Deep vein thrombosis
Vomiting blood after protracted vomiting and retching Mallory-Weiss syndrome
Wallerian degeneration Nerve damage
White blood cell casts in urine Pyelonephritis
XO chromosomal disease Turner’s disease
XXY chromosomal disease Klinefelter’s syndrome
Zenker’s degeneration Skeletal muscle damage
229
KEY MICROBIOLOGY WORD ASSOCIATIONS
Description Pathogen
All viruses are RNA except 6 HHAPPY ones which are DNA
3 enveloped DNA viruses HepaDNA, Herpes and Pox
2 naked DNA viruses Adeno and Papova
1 single stranded DNA virus Parvo B17
All RNA viruses are single stranded EXCEPT Rota virus of the REO virus family
All RNA single stranded viruses are + EXCEPT 6 PROFAB group
Paramyxo, Rhabo, Orthomyxo, Filo, Arena and Buynya PROFAB group
All hepatitis viruses are RNA EXDCEPT Hepatitis B [hepaDNA group]
All hepatitis viruses are spread by the orofecal route EXCEPT Hepatitis B and C [sex and blood]
Single stranded retro virus Human Immune Deficiency virus
All ARBO viruses are flavi viruses EXCEPT California encephalitis [Bunya virus]
Parotitis, pancreatritis and painful orchitis Paramyxo virus [Mumps]
Common cold with runny nose and sore throat Corona virus
Hand, foot and mouth lesions Coxsackie virus
Bacteria without cell walls Rickettsiae, Chlamydia and Bartonella
Flexible bacteria Borrleia, Leptospira and Treponema
Gram stain resistant Mycobacteria
Infection in bird keepers Chlamydia psittaci
Lung infection in wool sorters Bacillus anthracis
Rheumatic fever and glomerulonephritis Streptococcus pyogenes
Previously damaged heart valves Streptococcus viridans
Infected previously healthy heart valves Staphylococcus aureus
Causes lockjaw [trismus] Clostridium tetani
Transmitted by contaminated honey and causing paralysis Clostridium botulinum
Causes muscle necrosis with gas formation Clostridium perfringens
Grey psuedomenbrane in the throat Corynebacterium diphtheriae
Paroxysmal bouts of coughing with a whoop in a child Bordetella pertussis
Fever from handling infected rabbit skin Francisella tularensis
Lung infection from infected air conditioners Legionella pneumophilia
Infected burns with blue green burns Pseudomonas aeroginosa
Gram negative coccus which ferments glucose Neisseria gonorrhea
Gram negative coccus which ferments maltose Neisseria meningitidis
Causes severe diarrhea with rice water stool Vibrio cholera
Obligate intracellular parasitic bacteria Chlamydia
Causes peptic ulcer and some forms of stomach cancer Helicobacteria pylori
Gram resistant bacteria with thick waxy wall Mycobacterium tuberculosis
Commonest cause of urinary tract infections Escherichia coli
Causes Hemolytic Uremic Syndrome E. coli subtype O157 H7
Rose colored spots and step ladder fever Salmonella typhi
Spread by bat doppings Histoplasma capsulatum
Causes meningitis spread by pigeon poop Cryptococcus neoformans
Causes pneumonia in an immune compromised patient Pneumocystis jiroveci [carinii]
Fatal encephalitis in warm waters Naegleria fowleri
Diarrhea more common in hikers Gardia lamblia
Causes megaoesophagus and spread by sand fly bites Trypanosoma cruzi
Sleeping sickness spread by tsetse fly bites Trypanosoma gambiense
Frothy vaginal discharge caused by flagellate protozoan Trichomonas vaginitis
Recurrent or chronic diarrhea in immune compromised Crpptosporidium parvum
Most dealy form of malaria Plasmodium falciparum
Intestinal parasite associated with iron deficiency Necator americanus
Most common intestinal nematode in the USA Enterobius vermicularis
Associated with rectal prolapse Trichuris trichuria
River blindness spread by the simulium blackfly Onchocerca volulus
Elephantiasis spread by Culex filariasis Wuchereria bancrofti
Intestinal parasite associated with vitamin B12 deficiency Diphyllobothrium latum
Bladder parasite causing blood in the urine Schistosoma hematobium
230
Spread by eating undercooked contaminated beef Taenia saginatum
Smallest tapeworm Hymenolepis nana
Ames test Mutagenic potential
Armadillo Mycobacterium leprae
Ascoli test Anthrax
ASOT Recent streptococcal infection
Bordet-Gegnou medium Bordetella pertussis
Catalase test Staphylococcus [+] from streptococcus[-]
Chocolate agar Neisseria and Hemophilus
Coagulase test Staphylococcus aureus from other Staph.
Coombs test Hemolytic anemia
Darkfield microscopy Syphilis
Dick test Scarlet fever
Eaton agar Mycoplasma pneumoniae
ELISA HIV and Lyme
FTA-Abs Syphilis
Heaf skin test Tuberculosis
Hektoen agar Salmonella
Indian ink stain Cryptococcus neoformans
Kviem skin test Sarcoidosis
Lowenstein-Jensen culture medium Mycobacterium tuberculosis
MacConkey agar Promotes growth of Gram negative rods
Mantoux skin test Tuberculosis
Middlebrook medium Tuberculosis
Mitsuda test Mycobacterium leprae
Paul Bunnel test Mononucleosis
Regan-Lowe agar Bordetella pertussis
Quellung reaction Bacteria with capsules-Strep pneumoniae
Sabouraud medium Fungal organisms
Schick test Corynebacterium diphtheria
Schultz Carlton reaction Scarlet fever
Telluritie agar Corynebacterium diphtheria
Thayer-Martin medium Neisseria organisms
Thiosulfate-Citrate-Bile salts-Sucrose Vibrio cholera
Tine skin test Tuberculosis
VDRL test Syphilis
Weil-Felix test Rickettsiae
Wood’s light Fungal organisms
Wright-Giemsa stain Parasites and syphilis
Ziehl-Neelsen stain Mycobacterium tuberculosis
Test to exclude a disease if test is negative [SnOUT] Sensitivity
Test to include a diagnosis if test is positive [SpIN] Specificty
Sudden increase in the number with a disease locally Epidemic
Normal occurrence of a disease in a particular locality Endemic
Sudden increase in the number with a disease worldwide Pandemic
Number of people with the disease at a given time Prevalence
Number of new cases in the population at a given time Incidence
Number of people who die from a particular disease Mortality rate
Number of people who have a particular disease Morbidity rate
Epidemiology or Disease Triangle Host, Agent [microbe] and Environment
Antigenic shift [virus], spores [bacteria/fungus]cysts [protozoa] Microbial adaptations
Disease that has newly appeared Emergin disease
Previously known disease that has increased or spread Re-emerging disease
Bacteria and fungi form spores and protozoa form cysts Pathogen adapatations to environment
Viral adaptation to the environment and host Antigenic shift
Exposure of milk to progressively higher temperatures Pasteurization
Use of chemicals or heat to destroy all life Sterilization
Use of chemicals to destroy most pathogens Disinection
Use of aluminum to precipitate material from water Flocculation
231
KEY CHEMISTRY WORD ASSOCIATIONS
232
Role of Electron Transport Chain Transfer electrons to O2
A compound which has both reduce and oxidized form of a molecule Redox pair
NAD [oxidized] and NADH [reduced] Redox pair example
Drop-off point for NADH Complex I
Drop-off point for FADH2 Complex II
Alternate name for CoQ10 Ubiquinone
Heme containing compounds that receive electrons from CoQH2 Cytochromes
Other metal which is important to the electron Transport Chain Copper
Purpose of the Cori cycle Prevents lactic acidosis
Purpose of the hexose monophosphate shunt Produce NADPH, ribose
Location of the pentose phosphate pathway Cytosol
Rate limiting enzyme G6P dehydrogenase
Site of glycogen metabolism Cytosol
RATE LIMITING enzyme; used to lengthen the glycogen chain Glycogen Synthase
Chemical bonds between glucose molecules: mainly 1-4 links Glycosidic bond
Rate Limiting enzyme in glycogenolysis, activated by ATP Glycogen phosphorylase
Sites for glycogenolysis Heart, liver and muscle
Name of enzyme that changes G1P to G6P Phosphoglucomutase
Group consisting of Carbon with Oxygen and a hydroxyl attached Carboxyl group
One with no double bond between the carbon atoms [C-C] Saturated fatty acid
One with one or more double bonds between the carbon atoms Unsaturated fatty acid
Linoleic acid [vegetable oil Ω-6] and linolenic acid [fish oil- Ω 3] Essential fatty acids
Location of lipolysis Mitochondria
Site of lipogenesis Cytosol
Rate limiting step in cholesterol synthesis and target for statins HMG CoA reductase
Starting point for steroid hormone synthesis Cholesterol
Phe, Val, Thr, Trp, Ile, Met, His, Leu and Lys Essential amino acids
Pro, Try, Gly, Ala, Glu, Asp, Gln, Arg, Ser and Cys Non-essential amino acids
Removal of the amine NH2 group Deamination
Source of nitrogen for the urea cycle Glutamate and alanine
Location of the urea cycle Mitochondrion then cytosol
Rate limiting enzyme in the urea cycle Carbamoyl PO4 synthase
Purine or Pyrimidine base PLUS sugar Nucleoside
Purine or Pyrimidine base PLUS sugar AND phosphate Nucleotide
Adenine and Guanine; used to make nucleosides and nucleotides Purine bases
Cytosine, Uracil and Thymine Pyrimidine bases
Adenine & Thymine; Cytosine & Guanine; Adenine & Uracil Base pairs
Converts xanthine into uric acid Xanthine oxidase
Process by which RNA template for protein synthesis is made from DNA Transcription
Process by which RNA codon begins to make an protein Translation
Water-soluble vitamins D, A, K and E
Fat soluble vitamins B and C
Anti-oxidants Vitamin A,C, E and selenium
Used to make rhodopsin, helps in the differentiation of epithelial tissue Vitamin A
Used in carboxylation of glutamate residue in making clotting factors Vitamin K
Powerful antioxidant which mops free radicals; lipid antioxidant Vitamin E
Cofactor in Pyruvate kinase and α-ketoglutarate dehydrogenase Vitamin B1 [Thiamine]
Precursor for FMN and FAD in the ETC and Redox reactions Vitamin B2 [Riboflavin]
Precursor for NAD and NADP in the Electron Transport Chain Vitamin B3 [Niacin]
Acyl carrier as part of Coenzyme A; Pantene ProV [V=Five] Vitamin B5 [Pantothenic acid]
Cofactor for several transaminase and decarboxylation reactions Vitamin B6 [Pyridoxin]
Used in carboxylation reactions; deficiency causes lactic acidosis Vitamin B7 [Biotin]
Used in the transfer of 1-Carbon units and make methionine and purines Vitamin B9 [folic acid]
Cofactor for methionine and succinyl CoA manufacture Vitamin B12 [cobalamin]
Cofactor in hydroxylation in the synthesis of collagen Vitamin C [ascorbic acid]
Necessary in the Electron Transport Chain and found in prunes Copper
Cofactor of carbonic anhydrase found in seafood, meat and whole grain Zinc
Forms complexes with ATP and found in nuts Magnesium
Helps with glucose transport into cells and found in oysters Chromium
233
234
INDE X
Amphiarthrosis, 37
A Ampulla of uterine tube, 50
Abdominal aorta, 25 Ampulla of Vater, 58
Abdominal Aortic Aneurysm, 142 Amylase, 111, 112, 197
Abducens nerve, 82, 84 Amylose, 197
ABO blood groups, 112 Amylopectin, 197
Abscess, 135 Amyotrophic Lateral Sclerosis, 154
Acanthosis nigricans, 140 Anal canal, 36
Accessory nerve, 82, 87 Anal sphincter, 36
Accessory pancreatic duct, 30 Anaerobic bacteria
Accessory hemiazygos vein, 54 facultative, 179
Acetylcholine, 101, 119 strict, 179
Acetylcholinesterase, 119 Anaplasia, 136
Achalasia, 147, 156 Anatomical position, 9
Achondroplasia, 149 Anatomical snuffbox, 16
Acid-Base Balance, 126 Anatomical terms, 9
Acidosis Aneurysm, 142
metabolic, 126 Aneurysmal Bone Cyst, 149
respiratory, 128 Angina pectoris, 142
Acne vulgaris, 166 Angiotensin, 125
Aconitase, 203 Ankle joint, 44
Acoustic neuroma, 154 Ankylosing Spondylitis, 150
Acromegaly, 144 Anoxia, 136
Acrosome, 128 Anterior abdominal wall, 32
ACTH, 108 Anterior cervical triangle, 11
Actin, 118 Anterior pituitary lobe, 108
Action Potential, 121 Anterior tibial artery, 26
Acute Lymphoblastic Leukemia, 140 Anterolateral system, 76
Acute Myelogenous Leukemia, 140 Anthracosis, 162
Acyanotic Heart Disease, 141 Antibiotic targets, 181
Adaptations to survive, 171 Antibodies, 116
Addison’s disease, 145 Anti-diuretic Hormone, 109, 125
Adductor canal, 17 Antigenic shift, 192
Adenine, 217 Anulus fibrosus, 71
Adenohypophysis, 108 Aortic valve, 22
Adeno viruses, 172, 174 Aplasia, 136
Adrenal Appendicitis, 147
cortex, 30. 109 Appendix, 35
gland, 30, 109 Arachnoid mater, 76
medulla, 30, 110 ARBO viruses, 174
ADH, 109 Arachidonic acid, 211
Adrenocorticotropin Hormone, 108 Arginine, 215
Aeration, 192 Arnold-Chiari deformity, 153
Aerobic, 178 Arteriosclerosis, 141
Agenesis, 136 Artery
Alanine, 215, 216 anterior cerebral, 81, 82
Aldolase, 198 anterior communicating, 81, 82
Aldosterone, 109, 125 anterior inferior cerebellar, 81, 82
Alkalosis anterior tibial, 26
metabolic, 126 axillary, 25
alkalosis, 127 basilar, 81, 82
Alkaptonuria, 138 brachial, 27
Allosteric regulation, 195 dorsalis pedis, 26
Alpha Fetal Protein, 140 external iliac, 25
Alpha 1-antitrypsin deficiency, 161 femoral, 25
Alpha ketoglutarate, 203 great radicular, 79
Alpha ketoglutarate dehydrogenase, 203 inferior thyroid, 29
Alzheimer’s disease, 154 internal iliac, 25
Amino acids, middle cerebral, 81
essential, 215 popliteal, 25
non-essential, 215 posterior cerebral, 81, 82
235
posterior communicating, 81, 82 Beri beri, 217
posterior inferior cerebellar, 81, 82 Berry aneurysm, 142, 153
posterior tibial, 25 Biliary tree, 34
radial, 27 Bilirubin metabolism, 113
superior thyroid, 29 Biotin, 218
ulnar, 27 Bird fancier’s disease, 176
vertebral, 81, 82, 90 1, 3 Bisphosphoglycerate, 198
Arthritis Bitemporal hemianopia, 84
psoriatic, 150 Bitot’s spots, 217
rheumatoid, 150 Black simulium fly, 187
Arytenoid Bladder, 65
oblique, 95 Blastomyces dermatitis, 184
transverse, 95 Blood
Asbestosis, 162 brain barrier, 90, 130
Arginine, 215, 216 cell production, 114
Ascaris lumbricoides, 186 clotting, 115
Ascending colon, 35 composition, 114
Ascorbic acid, 219 flow, 107
Asparagine, 215 groups, 112
Aspartate, 215, 216 Blood pressure control, 107
Aspergillus fumigatus, 184 Blue bloaters, 161
Association fibers, 81 Bohr effect, 129
Asterion, 92 Bond
Asthma, 161 ester, 196
Astrocytes, 80 glycosidic, 196
Atelectasis, 161 hydrogen, 196
Atherosclerosis, 141 phosphodiester, 196
Atlas, 70 Bone
Atrial Septal Defect, 141 classification, 37
Atresia, 136 histology, 39
Atrioventricular node, 24 Bordetella pertussis, 178
Atrium Borrelia burgdorferi, 176
left, 22 Bowman’s capsule, 124
right, 21 Brachial artery, 27
Atrophic gastritis, 147 Brachial plexus, 96
Atrophy, 136 Brain abscess, 154
Auer rods, 140 Branchial arches, 95
Autonomic Nervous System, 100 Breast, 62
Autosomal Breathing
dominant, 137 Biot, 130
recessive, 137 Cheyne-Stokes, 130
Autosome, 137 Kussmaul, 130
Axilla, 14 Bregma, 92
Axillary artery, 27 Bronchopulmonary segment, 51
Axis, 70 Bronchiectasis, 161
Azygos vein, 54 Bronchogenic carcinoma, 162
Bronchopneumonia, 161
B Bronchus, 52
Bacillus anthracis, 177 Broad ligament, 50
Bacterial Brucella abortus, 179
characteristics, 176 Brucellosis, 179
growth phases, 171 Bruton’s agammaglobulinemia, 136
Bagassosis, 162 Buck’s fascia, 32, 49
B cells, 114 Buerger’s disease, 143
β-HCG, 140 Bulbourethral gland, 66
Baroreceptors, 107 Bundle of His, 24
Barrett’s esophagus, 147 Burkitt’s lymphoma, 139
Barteonella henselae, 176 Burning feet syndrome, 218
Bat droppings, 184 Byssinosis, 162
Basophils, 114
Beck’s triad, 142 C
Benign tumors, 139 Calcium, 220
236
Calcitonin, 109 Cervical cancer, 165
Callot’s triangle, 34 Cervical plexus, 96
cAMP, 210 Cervical triangle
Camper’s fascia, 32 anterior, 11
Campylobacter jejuni, 178 posterior, 12
Canal Cervicitis, 165
adductor, 17 Chagas disease, 186
femoral, 17 Chancre, 164
Guyon, 16 Chancroid, 164
inguinal, 17 Charcot’s joint, 149
spinal, 72 Charcot-Leyden crystals, 161
Candida albicans, 183, 184 Charcot-Marie-Tooth disease, 152
Candidiasis, 166 Chediak-Higashi syndrome, 136
Capacitation, 127 Chemical reactions, 195
Caplan’s lung, 162 Chemoreceptors, 130
Carbohydrate metabolism, 197 Chemotaxis, 135
Carbon monoxide poisoning, 155 Cheiralgia paresthetica, 155
Carbonic anhydrase, 127 Chickenpox virus, 166, 173
Carboxylation, 195 Chlamydia
Carcinoembryonic antigen, 140 psittaci, 176
Carcinogens, 140 urethritis, 164
Carcinoma Chlorination, 192
basal cell, 166 Cholecystitis, 148
squamous cell, 166 Cholecystokinin, 111
Cardiac chambers, 20 Cholelithiasis, 148
Cardiac conduction system, 24 Chronic bronchitis, 161
Cardiac cycle, 106 Chronic Lymphocytic Leukemia, 140
Cardiac muscle, 105 Chronic Myelogenous Leukemia, 140
Cardiac muscle contraction, 105 Chronic Obstruction Pulmonary Disease, 161
Cardiac plexus, 24 Chrysops biting fly, 187
Cardiac tamponade, 142 Chylomicrons, 211
Cardiomyopathy, 142 Circle of Willis, 81
Carotid body, 130 Cirrhosis, 148
Carotid sheath, 11 Citrate, 203
Carotid sinus, 107 Citrate synthase, 203
Carotid triangle, 11 Clonorchis sinensis, 188
Carpal tunnel, 16 Clostridium
Carpal Tunnel Syndrome, 155 botulinum, 177
Carpometacarpal joint, 42 difficile, 177
Cartilage, 39 perfringens, 178
Casal’s necklace, 218 tetani, 177
Cat scratch disease, 175 Colles fascia, 32
Caudate nucleus, 89 Coccidioides immitis, 184
CCK, 111, 113 Coccidiomycosis, 184
Cecum, 35 Coenzyme Q, 207
Celiac disease, 147 Cohort, 191
Celiac trunk, 25, 31 Cold sores, 166
Cells Colon, 35
B lymphocytes, 114 Commensal, 171
plasma, 114 Commissural fibers, 81
red blood, 114 Common bile duct, 34
T lymphocytes, 114 Common cold virus, 174
white blood, 114 Complex 1, 207
Cellulose, 197 Complex II, 107
Center Complex III, 207
apneustic, 130 Complex IV, 207
expiratory, 130 Complex V, 207
inspiratory, 130 Complex Regional Pain Syndrome, 156
pneumotaxic, 130 Compliment activation, 116
Cerebellum, 89 Condyloma accuminata, 165
Cerebral palsy, 153 Congenital Heart Disease, 141
Cerebrovascular accident, 153 Congenital Pyloric Stenosis, 147
237
Congestive Heart Failure, 142 Dehydroepiandrosterone, 213
Conn’s disease, 145 Deltoid, 45
Contrecoup injury, 153 Dengue fever virus, 174
Contraction of muscle Dens, 70
concentric, 119 Dermatome, 69, 99
eccentric, 119 Dermatomyositis, 152
isokinetic, 119 Dermis, 59
isometric, 119 Descending colon, 35
isotonic, 119 Development
Control of blood pressure, 107 brain, 80
Control of respiration, 130 diaphragm, 55
COPD, 161 gut, 31
Copper, 220 heart, 20
Co Q, 207 kidney, 64
Cori cycle, 208 lungs, 52
Coronary artery ovum, 127
left, 23 sperm, 127
right, 23 spinal cord, 76
Coronary blood supply, 23 urinary bladder, 65
Coronary sinus, 23 vertebral, 69
Cor pulmonale, 142 DHAP, 198
Corpuscle Diabetes insipidus, 144
Meissner, 59 Diabetes mellitus, 146, 155
Merkel, 59 Diabetic nephropathy, 159
Pacinian, 59 Diapedesis, 135
Corynebacterium diphtheriae, 178 Diarthrosis, 37
Coxsackie viruses, 174 Diencephalon, 80
Cranial Nerves 1-XII, 82 Diffusion of gases, 129
Craniosacral outflow, 100 Digastric triangle, 11
CREST syndrome, 143 DiGeorge’s syndrome, 136
Cretinism, 158 Dihydroacetone phosphate, 198
Creutzfeldt-Jakob disease, 154 Dihydroxycholecalciferol, 125
Cricoarytenoid Diphyllobothrium latum, 188
lateral, 95 Dimorphic fungi, 188
posterior, 95 Diphtheria, 178
Cricothyroid, 95 Disc, intervertebral, 71
Crohn’s disease, 147 Disinfection, 192
Cryptococcus neoformans, 184 Distal convoluted tubule, 124
CSF circulation, 91 Diverticulitis, 147
Cubital fossa, 15 Diverticulosis, 147
Curschmann spirals, 161 Dorsal columns, 76
Cushing’s disease, 144 Down’s syndrome, 137
Cushing’s syndrome, 144 Duchenne’s muscular dystrophy, 138
Cutaneous larva migrans, 166 Ductus deferens, 48
Cyanotic Heart Disease, 141 Duodenum, 33
Cycle Dura mater, 76
cardiac, 106 Dural sac, 76
menstrual, 128 Dural venous sinuses, 91
Cysteine, 214 Dwarfism
Cystic artery, 34 achondroplasia, 149
Cystic duct, 34 pituitary, 144
Cystic Fibrosis, 138 Dysentery
Cysts, 192 amebic, 180
Cytochrome, 207 bacillary, 180
Cytosine, 216 Dysplasia, 135
Dystrophy
D Becker’s, 151
Dandy-Walker syndrome, 153 Duchenne’s, 151
Darkfield microscopy, 189
Decarboxylation, 195 E
Deep palmar arch, 28 Eastern Equine Encephalitis, 174
Deep Vein Thrombosis, 142 Ebola, 172
238
ECG, 106 transversalis, 32
Echinococcus granulosus, 188 Fasciola hepatica, 188
Ectoderm derivatives, 10 Fat metabolism, 211
Edinger-Westphal nucleus, 85 Fatty acid
Endotoxin, 179 activation, 212
Ehlers-Danlos syndrome, 137 beta oxidation, 212
Ehrlich, Paul, 169 essential, 211
Elbow joint, 41 non-essential, 211
Electrocardiogram, 106 saturated, 211
Electron Transport Chain, 206 transport, 212
Elephantiasis, 187 unsaturated, 211
Embolism, 141, 154 Female genitalia, 50
Emerging diseases, 192 Femoral artery, 25
Emphysema, 161 Femoral canal, 17
Empyema, 163 Femoral triangle, 13
Encephalitis, 154 Fertilization, 128
Endemic, 192 Fetal Alcohol Syndrome, 155
Endoderm derivatives, 10 Fever
Endotoxin, 179 beaver, 186
Enolase, 199 blackwater, 187
Entameba histolytica, 186 Q, 180
Enteric brain, 102 rabbit, 178, 180
Enterobius vermicularis, 187 Rocky Mountain Spotted, 176
Eosinophils, 114 recurrent fever, 180
Epidemic, 192 rheumatic, 180
Epidermis, 59 scarlet fever, 180
Epidermophyton infection, 183 trench, 179
Epididymis, 48 Fibers
Epilepsy, 155 association, 81
Epinephrine, 110 commissural, 81
Epistropheus, 70 fast twitch, 119
Epithelioid cells, 135 projection, 81
Epstein Barr virus, 139, 173 slow twitch, 119
Erb-Duchenne palsy, 97, 155 Fibrin, 115
Erythrocytes, 114 Fibrinogen, 115
Erythropoietin, 124 Fibrous joint, 37
Escherichia coli, 178 Filariasis, 187, 189
Esophageal cancer, 147 Filtration, 192
Esophageal varices, 147 Filum terminale, 76
Espundia, 187 Fistula, 135
Estrogen, 110, 127, 213 Flavin-linked dehydrogenase, 206
Ewing’s sarcoma, 150 Flavi virus, 174
Exercise, vascular response, 107 Fleming, Alexander, 169
Exotoxin, 179 Flocculation, 192
Expiratory Reserve Volume, 130, 131 Flukes, 188
External bladder sphincter, 65 Follicle Stimulating Hormone, 108
External iliac artery, 25 Foramen
Enzyme, 195 cecum, 93
cribriform, 93
F ethmoidal, 93
Facet joint, 73 hypoglossal, 93
Facet joint orientation, 73 intervertebral, 71
Facial nerve, 82, 85 jugular, 93
Fallopian tube, 50 lacerum, 93
Fallot’s tetralogy, 21, 141 ovale, 93
Farmer’s lung, 117,162 rotundum, 93
Fascia transverse, 70
Buck, 32 Forced Expiratory Volume, 130, 131
Camper, 32 Fracastoro, Lazzaro, 169
Colles, 32 Francisella tularensis, 178
Scarpa, 32 Friedreich’s ataxia, 155
Sibson, 54 FSH, 108, 127
239
Functional Reserve Capacity, 130, 131 Gram, Hans Christian, 169
Fructose 1,6 Bisphosphate, 198 Gram stain, 169
Fructose 6-Phosphate, 198 Granulocyte, 114
Fumarase, 204, 205 Granuloma, 135, 162
Fumarate, 204, 205 Granuloma inguinale, 164
Graves disease, 145
G Grawitz tumor, 160
Galactose, 111 Growth Hormone, 108
Gallbladder, 33, 113 Guanine, 216
Gallstones, 148 Guarneri bodies, 173
Gaseous exchange, 130 Guillain-Barré Syndrome, 156
Gas gangrene, 178 Gut embryology, 31
Gastroesophageal reflex disease, 147 Guyon’s canal, 16
Gastric carcinoma, 147
Gastric Inhibitory Peptide, 113 H
Gastrin, 113 Haldane effect, 130
Gastrinoma, 146 Hashimoto’s thyroiditis, 145
Gaucher’s disease, 137 Haversian canal, 39
Genitalia Heart rate control, 107
female, 49 Heart valves, 22
male, 48 Helicobacter pylori, 178
GERD, 147 Hemangioma, 143
Gestational Diabetes, 146 Hemiazygos vein, 54
Giardia lamblia, 186 Hemochromatosis, 158
Giant cell tumor, 149 Hemophilia, 138
Gigantism, 144 Hematoma
Glabella, 92 extradural, 153
Gland subdural, 153
adrenal, 30 Hemolytic Uremic syndrome, 177
Brunner’s, 111 Hemophilus
bulbourethral, 66 aegypti, 179
parathyroid, 30, 109 ducreyi, 179
pituitary, 27 influenzae, 179
sebaceous, 59 Hemorrhagic disease of newborn, 158
sweat, 59 Hepatitis, 148
thyroid, 29, 109 Hepatitis A virus, 148, 174
Globus pallidus, 89 Hepatitis B virus, 148, 173
Glioblastoma multiforme, 154 Hepatitis C virus, 148, 174
Glomerular Filtration Rate, 123 Hepatitis D virus, 174
Glomerulonephritis, 159 Hepatitis E virus, 174
Glomerulus, 123 Hepatocellular carcinoma, 148
Glossopharyngeal nerve, 82, 86 Hepatolenticular disease, 158
Glucagon, 110 Hering-Breuer reflex, 130
Glucagon-like peptide 1, 113 Herpes simplex virus, 166, 173
Glucokinase, 198, 199 Herpes zoster, 156, 173
Gluconeogenesis, 201 Hexokinase, 198
Glucose 6-Phosphate, 198 Hexose monophosphate shunt, 209
GLUT 1-4, 110, 205 HGPRT deficiency, 138
Glutamic acid, 215 Hilton’s law, 39
Glutamine, 215 Hip joint, 42
Glutathione peroxidase, 220 Hirano bodies, 154
Glyceraldehyde 3-Phosphate, 198 Histidine, 214
Glycerol 3-phosphate shuttle, 206 Hirschsprung’s disease, 148, 156
Glycogenesis, 209 Histoplasma capsulatum, 184
Glycogen metabolism, 209 Histoplasmosis, 184
Glycogenolysis, 210 HIV, 172, 174
Glycogen Phosphorylase, 210 HLA-B27 arthritis, 150
Glycolysis, 197 Hodgkin’s lymphoma, 139
Gomphosis, 35 Homonymous hemianopia, 84
Gonalgia paresthetica, 155 Hook, Robert, 169
Gonococcal urethritis, 164, 177 Hookworm, 187
Gout, 151, 216 Horner’s syndrome, 156, 163
240
Hormone production, 213 Insulinoma, 146
Host Intercostal space, 61
primary, 186 Internal acoustic meatus, 86, 93
secondary, 186 Internal bladder sphincter, 64, 65
Human Immune Deficiency virus, 174 Internal capsule, 88
Human Papilloma virus, 173 Intracerebral hemorrhage, 154
Hunter’s canal, 17 Internal iliac artery, 25
Huntington’s chorea, 154 Interphalangeal joint, 42
Hutchinson’s teeth, 154 Interstitial cystitis, 159
Hyaluronidase, 128 Interstitial pneumonia, 162
Hydatid cysts, 188 Intervertebral disc, 71
Hydrolysis, 195 Invasion, 170
Hymenolepis nana, 188 Iodine, 220
Hyperparathyroidism, 145 Iodine deficiency, 158
Hyperplasia, 136 Iron, 220
Hyperprolactinemia, 144 Iron deficiency, 158
Hypersensitivity reactions, 117 Irritable Bowel Syndrome, 148
Hypertension, 142 Ischemia, 136
Hyperthyroidism, 145 Ischemic Heart Disease, 142
Hypertrophy, 136 Ischium, 51
Hypoglossal nerve, 82, 87 Islet cells, 110
Hypoparathyroidism, 145 Isocitrate, 203
Hypothyroidism, 144 Isocitrate dehydrogenase, 203
Hypoxia, 136 Isoleucine, 214
Ivanowski, Dimitri, 169
I
Iatrogenic, 170 J
Ileum, 33 Jejunum, 35
Ilium, 51 Jenner, Edward, 169
Immunoglobulins, 116 Joint classification, 37
Immunity Joint
acquired, 117 ankle, 44
artificial, 117 atlantoaxial, 38, 73
cell-mediated, 117 atlanto-occipital, 73
humoral, 117 carpometacarpal, 42
innate, 117 condyloid, 38
natural, 117 costochondral, 74
non-specific, 117 costotransverse, 74
passive, 117 costovertebral, 74
specific, 117 elbow, 41
Implantation, 128 ginglymus, 38
Incidence, 192 hip, 42
Indian ink preparation, 184, 189 interphalangeal, 42
Infection control, 192 knee, 43
Inferior colliculus, 86 manubriosternal, 74
Inferior mesenteric artery, 25, 35 planar, 38
Inferior salivary nucleus, 87 sacroiliac, 74
Inferior thyroid artery, 27, 29 sellar, 38
Inflammation shoulder, 40
acute, 135 spheroidal, 38
cardinal signs, 135 sternochondral, 74
chronic, 135 sternoclavicular, 41
Influenza virus, 174 temporomandibular, 40
Inhibition trochoid, 38
competitive, 195 wrist, 41
non-competitive, 195 xiphisternal, 74
Inguinal canal, 17 zygapophyseal, 73
Inguinal triangle, 13 Juxtaglomerular apparatus, 125
Inosine, 216
Intrinsic Factor, 112, 219 K
Intussusception, 147 Kala-azar, 187
Insulin, 110 Kaposi sarcoma, 143, 166, 173
241
Kartagener’s syndrome, 161 pulmonary, 53
Karyolysis, 136 supraspinous, 70
Karyorrhexis, 136 transforaminal, 71
Kayser-Fleisher rings, 158 Treitz, 33
Keto acids, 214 Ligamentum flavum, 70, 71
Keloid, 135 Ligase, 195
Kenshan’s disease, 220 Linoleic acid, 211
Kidney, 64 Lipogenesis, 213
Kinase, 195 Lipolysis, 212
Kissing bug, 186 Lipoprotein, 211
Klebsiella pneumoniae, 178 high density, 211
Klumpke’s palsy, 97, 155 intermediate density, 211
Kmax, 195 low density, 211
Knee joint, 43 very low density, 211
Koch, Robert, 169 Listeria monocytogenes, 178
Koch-Weeks bacillus, 179 Listeriosis, 178
Korsakoff’s psychosis, 154 Liver, 57
Krebs cycle, 203 Liver fluke, 188
Kuru, 154 Lobe
Kussmaul’s breathing, 130 frontal, 81
Kwashiorkor, 157 limbic, 81
occipital, 81
L parietal, 81
Lactase, 113 temporal, 81
Lactation, 128 Loop of Henle, 123
Lactic acid, 201 Looser’s zone, 158
Lactose, 113, 197 Lou Gehrig’s disease, 154
Lambert-Eaton syndrome, 151 Lowenstein-Jensen medium, 177, 189
Langhan’s cells, 135 Lumbar plexus, 97, 98
Lao lao, 187 Lumbar triangle, 12
Large intestine, 35, 112 Lumbosacral plexus, 98, 99
Lateral corticospinal, 76 Lung, 53
Lateral geniculate body, 84 Lung abscess, 162
Law Lung compliance, 131
Boyle, 129 Lung volumes, 131
Charles, 129 Lupus vulgaris, 166
Fick, 129 Luteinizing Hormone, 108, 127
Frank-Starling, 105 Lyme disease, 151, 176
Hilton, 39 Lymph node, 56
La Place, 107 Lymphocytes, 114
Lead poisoning, 155 Lymphogranuloma venereum, 164, 176
Legg-Calvé-Perthes disease, 152 Lymphoid cell line, 114
Legionella pneumophila, 179 Lysine, 214
Leishmania
brasilliensis, 187 M
donovani, 187 Macrophages, 114, 115
Leprosy, 156, 166, 177 Madurella grisea/mycetomastis, 184
Leptospira interrogans, 176 Magnesium, 220
Lesch Nyhan syndrome, 138 Main pancreatic duct, 34
Leucine, 214 Malaria, 187
Libman Sacks endocarditis, 141 Malassezia furfur, 183
Life exp[ectancy, 192 Malate, 204, 205
Ligament Malate-aspartate shuttle, 206
anterior longitudinal, 70 Malate dehydrogenase, 204, 205
broad, 50 Male genitalia, 48
cruciate, 70 Malignant pustule, 177
dentate, 76 Malignant melanoma, 166
inguinal, 15 Malignant tumors, 139
interspinous, 70 Mallory-Weiss syndrome, 147
intertransverse, 70 Maltase, 111
nuchal, 70 Maltose, 111
posterior longitudinal, 70 Marasmus, 157
242
Marfan’s syndrome, 137 anopheles, 187
Margination, 135 culex filiriasis, 187
Marie-Strumpell’s disease, 150 culex pipiens, 187
McArdle disease, 137 aedes aegypti, 174
McBurney’s point, 35 Mouth, 111
Measles, 166, 174 Mullerian duct, 48
Meckel’s diverticulum, 31, 147 Multiple myeloma, 139, 150
Medial geniculate body, 86 Multiple sclerosis, 154
Mediastinum, 62 Mumps, 174
Medium Muscle
chocolate agar, 189 biceps brachii, 45
Hektoen enteric agar, 189 brachioradialis, 46
Loeffler’s medium, 189 cardiac, 105
Lowenstein-Jensen, 189 contraction, 120
MacConkey’s agar, 189 deltoid, 45
Middlebrook, 189 diaphragm, 55
Purified Chick Embryo Culture, 189 erector spinae, 75
Regan-Lowe agar, 189 extensor hallucis longus, 47
Sabouraud, 189 facial expression, 94
Thiosulfate-Citrate-Bile salts-Sucrose, 189 frontalis, 94
Meningitis, 154, 177, 181 gastrocnemius, 47
Meningocele, 153 gluteus maximus, 47
Menstrual cycle, 127 infraspinatus, 46
MEN Type 1, 146 inferior oblique, 84
MEN Type II, 146 interspinales, 75
MEN Type III, 146 intertransversarii, 75
Meralgia paresthetica, 155 lateral cricoarytenoid, 95
Mesencephalon, 80 lateral rectus, 84
Mesoderm derivatives, 10 latissimus dorsi, 45
Mesophile, 178 levator scapulae, 45
Mesothelioma, 163 medial rectus, 84
Metabolism multifidus, 75
acidosis, 126 oblique arytenoid, 95
alkalosis, 126 orbicularis oculi, 94, 94
bilirubin, 113 orbicularis, oris, 94
carbohydrate, 197 palatoglossus, 87
lipid, 212 pectoralis major, 45
protein, 215 peroneus longus, 47
Metaplasia, 135 posterior cricoarytenoid, 95
Metencephalon, 80 psoas major, 46
Methionine, 214 quadratus femoris, 47
Microsporum infection, 183 scalenus anterior, 45
Midgut derivatives, 31 scalenus medius, 45
Minamato disease, 155 serratus anterior, 45
Minerals, skeletal, 119
calcium, 220 stapedius, 86
copper, 220 sternocleidomastoid, 45
iodine, 220 stylopharyngeus, 86, 95
iron, 220 subscapularis, 46
magnesium, 220 superior oblique, 84
selenium, 220 superior rectus, 84
zinc, 220 teres major, 46
Mitral valve, 22 teres minor, 46
MODY [Mature Onset Diabetes in Young], 146 tibialis anterior, 47
Mold, 182 tibialis posterior, 47
Molluscum contagiosum, 173 triceps, 46
Monocytes, 115 supraspinatus, 46
Mononucleosis, 173 trapezius, 45
Mons pubis, 49 Muscle types, 39
Morbidity, 192 Muscular triangle, 12
Mortality, 192 Myasthenia gravis, 151
Mosquito Mycobacterium leprae, 177
243
Mycobacterium tuberculosis, 177 oculomotor, 82. 84
Mycoplasma pneumoniae, 176 optic, 82, 84
Myelencephalon, 80 phrenic, 96
Myeloid cell line, 114 pudendal, 98
Myelomeningocele, 153 radial, 96
Myocardial Infarction, 142 sciatic, 98
Myopathies, 151 spinal accessory, 82, 87
Myosin, 118, 119 subscapular, 97
Myotome, 69 superficial peroneal, 99
Myxedema, 158 superior gluteal, 98
supraclavicular, 96
N suprascapular, 97
NAD, 198, 206 thoracodorsal, 97
NADH, 198, 204, 206 tibial, 99
NADP, 206 transverse cervical, 96
Nasion, 92 trochlear. 82, 84
Necator americanus, 187 ulnar, 96
Necrosis vestibulocochlear, 82, 86
caseous, 136 Nerve conduction, 121
coagulative, 136 Nerve ending types, 123
enzymatic, 136 Nerve fiber type, 123
fatty, 136 Nervus intermedius, 93
liquefactive, 136 Neural crest cells, 76
Negri bodies, 174 Neuroblastoma, 145
Neisseria Neurofibromatosis, 154
gonorrhoea, 177 Neurohypophysis, 109
meningitis, 177 Neuromuscular junction, 119
Nematodes, 187 Neurulation, 76
Neoplasia, 139 Neutrophils, 11
Nephritic syndrome, 159 Niemann-Pick disease, 137
Nephron, 123 Night blindness, 217
Nephrotic syndrome, 159 Nitrogen removal
Nerve ammonia formation, 215
abducens, 82, 84 deamination, 215
accessory, 87 transamination, 215
ansa cervicalis, 96 urea formation, 215
axillary, 96 Nociceptor classification, 122
chorda tympani, 86 Nodes,
common fibular [peroneal], 99 Bouchard’s, 150, 151
cranial accessory, 82, 87 Heberden’s, 151
deep peroneal, 99 Haygarth’s, 150
dorsal scapular, 97 Ranvier, 121
facial, 82, 86 Nor-epinephrine, 101, 110
femoral, 97 Nosocomial, 171
genitofemoral, 97 Notochord, 69
glossopharyngeal, 82, 87 Nucleus
great auricular, 96 ambiguus, 87
greater splanchnic, 100 paraventricular, 109
hypoglossal, 82, 87 pulposus, 71
iliohypogastric, 97 solitarius, 86, 87
ilioinguinal, 97 supraoptic, 109
inferior gluteal, 98 Nyctalopia, 217
lateral femoral cutaneous, 97
lateral pectoral, 97 O
least splanchnic, 100 Obturator nerve, 97
lesser occipital, 96 Oculomotor nerve, 82, 84
lesser splanchnic, 100 Odontoid process, 70
long thoracic, 97 Ohio Valley fever, 184
medial pectoral, 97 Olfactory nerve, 82, 83
median, 96 Oligodendrocytes, 80
musculocutaneous, 96 Onchocerca volvulus, 186
obturator, 97 Oncogenes, 140
244
Optic chiasm, 84 Phlebotomous sand flies, 187
Optic nerve, 82, 84 Phosphoenolpyruvate, 199
Optic radiation, 84 Phosphoenolpyruvate carboxykinase, 201
Orthomyxo virus, 172, 174 Phosphofructokinase, 198, 199
Osteochondroma, 149 Phosphoglucomutase, 209
Osteogenesis imperfecta, 137, 149 Phosphoglycerate kinase, 199
Osteoma, 150 Phosphoglycerate mutase, 199
Osteitis fibrosa cystica, 149 Phosphorylation, 195
Osteoarthritis, 151 Phrenoderma, 217
Osteomalacia, 149, 158, 217 Pia mater, 76
Osteomyelitis, 149 Pico RNA virus, 174
Osteoporosis, 149 PID, 165
Osteosarcoma, 139, 150 Piedra hortae, 183
Ovary, 50 Pigeon poop, 184
Owl-eye appearance, 184, 189 Pink puffers, 161
Oxaloacetate, 203, 206 Pin worm, 187
Oxidation, 195 Piriformis syndrome, 155
Oxidative phosphorylation, 206 Pituitary gland, 29, 108
Oxytocin, 109, 128 Pityriasis versicolor, 166, 183
Pityrosporum orbiculare, 183
P Plate
Paget’s disease, 149 alar, 76
Palmitic acid, 211 basal, 76
Pancoast tumor, 163 Plasmodium
Pancreas, 30, 110 falciparum, 187
Pancreatic cancer, 148 malariae, 187
Pancreatitis, 148 ovale, 187
Pandemic, 192 vivax, 187
Paul Bunnel test, 173, 190 Pleura
Paracoccidioides brasiliensis, 184 effusion, 163
Paragonimus westermani, 188 parietal, 53
Paramesonephric duct, 48 visceral, 53
Paramyxo virus, 172, 174 Plexus
Paranasal sinuses, 95 Auerbach, 102
Parasites, 185 brachial, 95
Parasympathetic nervous system, 100, 101 cervical, 95
Parathyroid gland, 30 lumbar, 97
Pars interarticularis, 69 lumbosacral, 98
Parvo virus, 172, 173 Meissner, 102
Pasteurization, 169, 192 vertebral venous, 66
Pasteur, Louis, 169 Plumbism, 155
Patent Ductus Arteriosus, 141 Plummer-Vinson syndrome, 158
Pathogenicity, 170 Pneumocytes
Pavementation, 135 Type I, 129
Pectinate line, 36 Type II, 129
Pellagra, 218 Pneumoconioses, 162
Pelvic Inflammatory Disease, 165 Pneumocystis
Pelvis, 51 carinii, 184
Penis, 49 jiroveci, 184
Pentose Phosphate Pathway, 208 pneumonia, 162
Peptic Ulcer Disease, 147, 178 Pneumonia, 161, 162
Perfusion, 129 Pneumothorax
Peripheral Arterial Disease, 143 secondary, 163
Peripheral resistance, 107 spontaneous, 163
Peritoneum, 32 tension, 163
Peutz-Jegher syndrome, 148 Podagra, 151
Pfeiffer’s bacillus, 179 Poisoning
Phagocytosis, 114, 116 carbon monoxide, 155
Pharyngeal arches, 95 lead, 156
Phenylalanine, 214 mercury, 156
Phenylketonuria, 138 Poliomyelitis, 154, 174
Pheochromocytoma, 139, 145, 146 Polio virus, 174
245
Polyarteritis nodosa, 143 R
Polymyalgia rheumatica, 152 Rabbit fever, 180
Pompe disease, 137 Rabies, 174
Popliteal artery, 25, 26 Radial artery, 25
Popliteal fossa, 18 Randomized Controlled Trial, 191
Posterolateral sclerosis, 154 Raphespinal tract, 76, 77
Posterior columns, 76 Rathke’s pouch, 29
Posterior pituitary lobe, 109 Raynaud’s disease, 143
Posterior tibial artery, 25 Raynaud’s phenomenon, 143
Pox virus, 173 Receptors
Prevalence, 192 adrenergic, 122
Prinz Metal angina, 142 cholinergic, 122
Process muscarinic, 122
accessory, 70 nicotinic, 122
mammillary, 70 Rectum, 35
odontoid, 70 Rectus abdominis, 32
Proenzyme, 195 Rectus sheath contents, 32
Progesterone, 108, 110, 127, 128 Rectus sheath formation, 32
Projection fibers, 81 Recurrent fever, 180
Prolactin, 109 Recurrent laryngeal nerve, 29
Proliferative phase, 127, 128 Red blood cells, 114
Proline, 214 Red currant jelly sputum, 178
Prosencephalon, 80 Reduction, 195
Prostatic Specific Antigen, 140 Reed, Walter, 169
Protein Calorie Deficiency, 157 Re-emerging diseases, 192
Protein structure Reflex
primary, 214 deep tendon, 120
quaternary, 214 Hering-Breuer, 130
secondary, 214 pain withdrawal, 120
tertiary, 214 somatosomatic, 120
Proteus mirabilis, 178, 190 somatovisceral, 102
Prothrombin, 116 sympathetic dystrophy, 156
Protozoa, 185 viscerosomatic, 102
Proximal Convoluted Tube, 123 viscerovisceral, 102
Prusiner, Stanley, 169 Regions of the abdomen, 31
Pseudomembranous colitis, 177 Reiter’s syndrome 150, 176
Pseudomonas aeruginosa, 179 Relapsing fever, 180
Psittacosis, 176 Renal blood flow, 123
Psoriasis, 166 Renal calculi, 160
Psychrophile, 179 Renal Cell Carcinoma, 160
Pterion, 92 Renal function, 123
Pubic bone, 51 Renal stones, 160
Pulmonary Renin, 124
embolism, 143 Respiratory
ligament, 53 acidosis, 126
Purine metabolism, 216 alkalosis, 126
Purkinje fibers, 24 Reticulospinal tract, 76, 77
Putamen, 89 Rexed laminae, 79
Pyelonephritis, 159 Reye’s syndrome, 148
Pyknosis, 136 Rhagades, 154
Pyridine-linked dehydrogenase, 206 Rheumatic Fever, 141, 180
Pyrimidine metabolism, 216 Rheumatoid Arthritis, 117, 150
Pyruvate carboxylase, 201 Rhino virus, 172, 174
Pyruvate kinase, 199 Rhombencephalon. 80
Ribs
Q atypical, 61
Quadrangular space, 15 false, 60
Quadrants of the abdomen, 31 true, 60
Quadratus lumborum, 64 typical, 60
Quinones, 206 Rice water stool, 179
Rickets, 149, 158, 217
Rickettsia
246
prowazekii, 176 Siderosis, 162
rickettsii, 176 Silicosis, 162
tsutsugamishi, 176 Sinu-atrial node, 23, 24
typhi, 176 Sinus, 135
Riedel’s thyroiditis, 145 Sipple’s syndrome, 146
Ringworm, 166, 183 Silo-filler’s lung, 162
River blindness, 187 Sjörgen’s syndrome, 150
Root of the lung, 53 Skeletal muscle, 39
Roseola, 166 Skin layers, 59
Roundworm, 187 Skull, 92
Rubella, 172, 174 Slapped cheek syndrome, 173
Rubeola, 172, 174 Slipped capital femoral epiphysis, 152
Rubrospinal tract, 76, 77 Sludge digestion, 192
Ruska, Ernst, 169 Small cell lung cancer, 163
Small intestine, 35, 111
S Smallpox virus, 173
Sabin, Albert, 169 Smooth muscle, 39
Salk, Jonas, 169 Solitary nucleus, 87
Salmonella Somatostatin, 112, 113
enterides, 178, 180 Sorbitol, 200
typhi, 178, 180 Space
Salpingitis, 165 quadrangular, 14
Sand filtration, 192 triangular, 15
San Joaquin Valley fever, 184 Specificity, 191
Sarcoidosis, 162 Spelunker’s disease, 184
Sarcolemma, 118 Spermatic cord, 49
Sarcomere, 118 Sperm development, 127
Sacroplasmic reticulum, 118 Sphincter of Oddi, 30, 34, 112
Sarcoptes scabiei, 166 Spina bifida, 153
Scabies, 166 Spinal canal, 72
Scalp, 92 Spinal cord
Scar, 135 structure, 76
Scarlet fever, 166 organization, 76
Schistosoma blood supply, 79
hematobium, 188 Spinothalamic tract, 77
japonicum, 188 Spleen, 56
mansoni, 188 Spores, 192
Schwann cells, 80 Sporothricosis, 166, 184
Sclerotome, 69 Sporothrix schenckii, 166, 182, 184
Schultz-Carlton test, 189 Stain
Scurvy, 220 Eosin-Methylene blue, 189
Secretin, 113 Gram, 169
Secretory phase, 127 Indian ink, 184, 189
Selenium, 220 Wright-Giemsa, 189
Sella turcica, 29 Ziehl-Neelsen, 189
Semmelweiss, Ignazio, 169 Staphylococcus
Sensitivity, 191 aureus, 176
Septal development, 21 saprophyticus, 176
Serine, 214 Starch metabolism, 197
Seronegative, arthritis, 150 Stearic acid, 211
Seropositive arthritis, 150 Sterilization, 192
Serratia marcescens, 178 Sternoclavicular joint, 41
Severe Combined Immunodeficiency, 136 Still’s disease, 150
Sheehan’s syndrome, 144 Stomach, 33, 111
Shigella Stratum
dysenteriae, 178 basale, 59
flexneri, 178 corneum, 59
sonnei, 178 granulosum, 59
Shoulder joint, 40 lucidum, 59
SIADH, 163 spinosum, 59
Sickle Cell Disease, 138 Streptococcus
Sickle Cell Trait, 138 pneumoniae, 177
247
pyogenes, 177 Sipple, 146
viridans, 177 Sjörgen, 150
Strongyloides stercoralis, 187 Slapped Cheek, 166
Study population, 191 Turner, 137
Subarachoid hemorrhage, 153 Tarsal tunnel, 155
Subarachnoid space, Waterhouse-Friderichsen, 145
Subclavian artery, 27 Wermer, 146
Submental triangle, 12 Wernicke, 154, 218
Suboccipital triangle, 11 Wiskott-Aldrich, 136
Subsartorial canal, 17 Zollinger-Ellison, 146
Substantia gelatinosa, 78 Synergism, 170
Succinate, 204 Synovial joint, 38
Succinate dehydrogenase, 204 Syphilis, 164, 176
Succinate thiokinase, 203 congenital, 154
Succinyl CoA, 203 primary, 164
Sucrase, 111 secondary, 164
Sucrose, 111, 197 tertiary, 164
Sudeck’s atrophy, 156 Syringomyelia, 155
Surface markings of the heart, 21 Systemic Lupus Erythematosus, 117, 151
Surfactant, 129
Superficial palmar arch, 28 T
Superior laryngeal nerve, 29 Tabes dorsalis, 164
Superior mesenteric artery, 31, 35 Taenia
Superior thoracic aperture, 14 saginatum, 188
Superior thyroid artery, 29 solium, 188
Suprapleural membrane, 54 Takayasu’s arteritis, 143
Symphysis, 37 Tapeworm, 188
Synchondrosis, 37 Tarsal tunnel, 19
Swimmer’s itch, 188 Tarsal Tunnel Syndrome, 155
Symbiosis, 171 Tay-Sachs disease, 137
Sympathetic nervous system, 100 T cells, 114
Synaptic conduction, 121 Tectospinal tract, 76, 77
Synchondrosis, 37 Temporal arteritis, 143
Syndesmosis, 37 Temporomandibular joint, 40
Syndrome. Test
Addison, 144 Ascoli, 189
Bruton’s agammaglobulinemia, 136 Ames, 189
Carpal tunnel, 155 Anti-Streptolysin, 190
Chediak-Higashi, 136 Bordet-Gengou, 189
Chronic Regional Pain, 156 Catalase, 189
Conn, 145 Coagulase, 189
Cushing, 145 Coombs, 190
DiGeorge, 136 Dick, 189
Down, 137 ELISA, 190
Ehlers-Danlos, 137 Heaf, 190
Elbow tunnel, 155 Kvein, 190
Felty, 150 Mantoux, 190
Goodpasture, 160 Paul Bunnel, 190
Horner, 156, 163 Quellung, 191
Inappropriate ADH secretion, 163 Schultz Carlton reaction, 189
Kartagener, 161 Tine, 190
Klinefelter, 137 RPR, 190
Lambert-Eaton, 151 VDRL, 190
Lesch-Nyhan, 138 Weil-Felix, 190
Mallory-Weiss, 147 Western Blot, 190
Marfan, 137 Widal, 190
Peutz-Jegher, 148 Testis, 48
Piriformis, 155 Testosterone, 111, 213
Plummer-Vinson, 158 Tetanus, 177
Reiter, 151 Thalassemia, 138
Reye, 148 Thermophile, 179
Sheehan, 144 Thoracic aorta, 25
248
Thoracic cage, 60 Trigeminal nerve, 82, 85
Thoracic duct, 58 Triglyceride, 211
Thoracic outlet, 14 Triose phosphate isomerase, 198
Thoracolumbar outflow, 100 Trochlear nerve, 82, 84
Threadworm, 187 Troisier’s sign, 147
Threonine, 214 Tropical sprue, 147
Thromboangitis obliterans, 143 Troponin, 118, 119
Thrombosis, 141, 154 Tropomyosin, 118
Thrombophlebitis, 143 Truncus arteriosus, 20
Thymine, 218 Trypanosoma
Thymoma, 151 cruzi, 186
Thymus, 58 gambiense, 186
Thyroarytenoid, 95 rhodensiense, 186
Thyroid gland, 29 Tryptophan, 215
Thyroid Stimulating Hormone, 108, 109 Tuberculosis, 162, 177
Thyroxin, 109 Tumor markers, 140
Tidal Volume, 130, 131 Tunnel
Tinea carpal, 16
capitis, 183 ulnar, 16
corporis, 183 Type I pneumocytes, 130
cruris, 183 Type II pneumocytes, 130
versicolor, 183 Types of joints, 36
Toga virus, 172 Typhoid fever, 178, 180
TORCHeS infections, 165 Typhus
Total Lung Capacity, 130, 131 edemic, 176, 180
Toxoplasma gondii, 187 epidemic, 176, 180
Toxoplasmosis, 165, 187 murine, 176, 180
Trachea, 52 scrub, 176, 180
Tract Tyrosine, 214
dorsal columns, 76,
dorsal spinocerebellar, 76 U
lateral corticospinal, 76 Ubiquinone, 206
raphespinal, 76 Ulcerative colitis, 148
reticulospinal, 76 Ulnar artery, 27, 28
rubrospinal, 76 Ulnar tunnel, 16
spinothalamic, 76 Ulnar tunnel syndrome, 155
tectospinal, 76 Undulant fever, 180
ventral corticospinal, 76 Uracil, 216
ventral spinocerebellar, 76 Urea cycle, 215
vestibulospinal, 76 Urea-splitting bacteria, 190
Transferase, 195 Ureter, 65
Transient Ischemic Attack, 154 Urethra, 66
Transmigration, 135 Urethritis
Transposition of the great vessels, 141 chlamydia, 164
Transverse colon, 35 gonococcal, 164
Treponema pallidum, 177 Uric acid, 216
Triacylglycerols, 211 Urinary bladder, 65
Triangle US Health Agencies, 192
Auscultation, 12 Uterine tube, 50
Callot, 34 Uterus, 50
inguinal, 13
lumbar, 12 V
Petit, 12 Vagina, 47
suboccipital, 11 Vagus, 82, 87
Triangular space, 15 Valine, 214
Trichinella spiralis, 187 Van Leeuwenhoek, 169
Trichinosis, 187 Varicose vein, 143
Trichomonas vaginalis, 185 Vascular response to exercise, 107
Trichomoniasis, 165 Venous drainage of the heart, 23, 24
Trichophyton infection, 183 Valves
Trichuris trichuria, 187 aortic, 22
Tricuspid valve, 22 mitral, 22
249
pulmonary, 22 Von Recklinghausen disease, 154
tricuspid, 22 VSD, 141
VDRL false positive, 190
Vector, 186 W
Vein Wallerian degeneration, 136
accessory azygos, 54 Waterhouse-Friderichsen syndrome, 145
accessory hemiazygos, 54 Water purification, 192
azygos, 54 WEE, 172, 174
brachiocephalic, 54 Weil disease, 175
cardiac, 23 Wermer’s syndrome, 146
femoral, 13 Wernicke’s syndrome, 154, 218
Ventilation, 129 Wernicke-Korsakoff psychosis, 218
Ventilation/Perfusion ration, 129 Western Equine Encephalitis, 172, 174
Ventral corticospinal tract, 76, 77 West Nile virus, 174
Ventricle Whipple’s disease, 147
right, 22 Whipworm, 187
left, 22 White blood cells, 114
Ventricular septal defect, 141 Whooping cough, 178
Vertebra Wilms tumor, 159
cervical, 70 Wilson’s disease, 158
lumbar, 70 Wiskott-Aldrich syndrome, 136
prominens, 70 Wood’s light, 189
regional characteristics, 70 Wool sorter’s disease, 176
thoracic, 70 Worms
typical, 69 eye, 187
Vertebral development, 69 hook, 187
Vertebral end plate, 71 pin, 187
Vertebral venous plexus, 66 round, 187
Vestibulocochlear nerve, 82, 86 tape, 188
Vestibulospinal tract, 76, 77 thread, 187
Vibrio cholerae, 179 whip, 187
Virchow’s triad, 142 Wuchereria bancrofti, 187
Virulence, 170
Viruses, 172 X
Vital capacity, 131, 132 Xanthine, 216
Vitamin A, 157, 217 Xanthine oxidase, 216
Vitamin B1, 157, 218 Xerophthalmia, 217
Vitamin B2, 157, 218 Xiphoid process, 60
Vitamin B6, 157, 218
Vitamin B7, 157, 219 Y
Vitamin B9, 157, 219 Yeast, 183
Vitamin B12, 157, 219 Yellow fever virus, 172, 174
Vitamin D, 158, 217 Yersinia pestis, 178
Vitamin E, 158, 217
Vitamin K, 158, 217
Vmax, 197 Z
Vocalis, 95 Zenker’s degeneration, 136
Volvulus, 148 Ziehl-Neelsen stain, 177, 189
Von Gierke disease, 137 Zollinger-Ellison syndrome, 146
250