NMS Erd Practical Book Official

ERD - ANATOMY Ninja medical squad
SWIFT HEALING, SILENT HEROES 1










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ERD - PHYSIOLOGY Ninja medical squad
Practical (1):
Thyroid function tests
A) Specific tests:
(1) Measurement of protein bound iodine (PBI):
• Normal level: 4-7 mcg %.Increases in hyperthyroidism and decreases in
hypothyroidism.
• Not conclusive in the diagnosis of thyroid diseases because the amount of
thyroid binding proteins vary normally by various factors, and consequently
high and low levels of PBI may be found in individuals with euthyroid
activity.
• False high levels occur in pregnancy and patients taking contraceptive pills,
but false low levels occur in nephrotic syndrome.
(2) Measurement of total thyroid hormonal blood level:
• Increases in thyrotoxicosis and decreases in hypothyroidism.
• Not conclusive, as high or low levels may be found in individuals with
euthyroid activity.
(3) Estimation of radioactive iodine uptake by the thyroid gland:
• The iodine uptake by the thyroid gland is a good index of its function.
• A tracer dose of radioactive iodine e.g. I131 or better I123 that has no
damaging effect on the thyroid is administrated and the thyroid uptake is
determined.
• In hyperthyroidism, the iodine uptake is more than normal and in
hypothyroidism, it's less than normal.
(4) TSH stimulation test:
Differentiates between primary and secondary hypothyroidism.
A test dose of TSH is injected, and then the thyroid hormonal level is measured
It increases in cases of secondary hypothyroidism and not affected in cases of
primary hypothyroidism.

(5) TRH stimulation test:

Differentiates between pituitary and hypothalamic lesions in cases of
secondary hypothyroidism.
A test dose of TRH is injected, then the TSH blood level is measured.
Increases in cases due to hypothalamic lesions, and not affected in cases due
to pituitary lesions.
(6) Estimation of plasma free T3 & T4 and TSH levels:
This is accurately done by radioimmunoassay.
The most reliable test.
Increases with hyperthyroidism and decreases with hypothyroidism.
TSH free levels increases in hypothyroidism and decreases in
hyperthyroidism (if the disease is due to a thyroid disorder).
B) Nonspecific tests:
(1) Measurement of total cholesterol level:
Normally, 200mg % in average.
Increases with hypothyroidism and decreases with hyperthyroidism.
(2) Measurement of basal metabolic rate (BMR):
The average in adult male is 40 KC/ m2/ hour.
Increases with hyperthyroidism in decreases with hypothyroidism.
Provocation tests for latent tetany
A) Trousseau's test:
The cuff of the sphygmomanometer is wrapped around the arm and the
pressure is elevated above systolic B.P for 3 minutes.
In latent tetany, carpal spasm appears because the effects of
hypocalcaemia are potentiated by ischemia.
B) Chvostek,s test:
Tapping over the facial nerve by hammer in front of the ear (at angle of the
jaw) causes quick contractions of the ipsilateral facial muscles specially those of
the upper lip.

C) Erb,s test:
Stimulation of superficial motor nerve by a weak galvanic current.
Normally, no response.
In tetany, causes prolonged spasmodic contraction of the muscles supplied by
the stimulated nerve.
Adrenocortical function tests
(A) Measurement of the serum levels of Na and K, cortisol, DHEA,
aldosterone and ACTH as well as the plasma PH.
(B) Determination of the steroid metabolites in the urine:
The commonly measured metabolite is 17-ketosteroid.
Increases in Cushing's disease and the adrenogenital syndrome.
Decreases in Addison's disease.
(C) ACTH test:
A test dose of ACTH is injected I.V and the plasma cortisol level is determined
after 1 hour.
Increases in normal subjects and in cases of secondary and tertiary
adrenocortical insufficiency but not in primary type.
(D) Saline suppression test:

An isotonic solution is given I.V for 4 hours at rate of 400ml l hour, and then
the plasma level of aldosterone is measured.
It decreases in normal subjects.
Not affected in Conn's disease
(E) Salt deprivation test:
A salt free diet is given for 3 days, and then the NaCl level in urine is
determined.
Normally, the urinary NaCl content should be decreased or may be absent.
In adrenocortical insufficiency, the NaCl urinary content is not affected.

Prctical (2):
Testicular function tests
1) Seminal analysis
Semen contains sperms and secretion of the accessory glands. Also, it contains
buffers and hyaluronidase.
Seminal vesicles secretion contributes by 60% of total volume of semen and
contains important substances for sperm viability and nutrition as fructose and
ascorbic acid. While, prostatic secretion accounts 20% of total volume of semen.
1- Fructose content:
Is important for sperm nourishment. Normally, it is 1.5 – 6.5 mg/ml.
If it is less than 1.3 mg/ml→ indicates ↓ in testosterone secretion.
2- pH: alkaline 7.35-7.5
3- specific gravity: 1028
4- Volume:
2.5 – 3.5 ml/ejaculate after several days of obstination.
If less than 2 ml/ejaculate, it suggests testicular hypofunction.
5- Viscosity:
If increased → decrease sperm movement.
6- Number of sperms:
Normally 80- 120 million /ml ( average 100 million /ml)
less than 20 million /ml = oligospermia
Azospermia = no sperm
Necrospermia = dead sperm
7- Abnormal sperms; should not be more than 25%
8- Motility:
60% of sperms should be motile 6 hours after ejaculation
9- liquefaction:
Normally it liquefies after 15-20 minutes by fibrinolysin system.

2) Estimation of urinary gonadotropins

To differentiate between primary and secondary hypogonadism. They are
increased in primary and decreased in secondary hypogonadism
3) Estimation of neutral 17 ketosteroids in urine
They are decreased in disease affect interstitial cell of Leydig.
If they are normal in a case of sterility, this suggests disturbed Gametogenic
function.
4) Testicular biopsy
A sample is taken from the testis and examined histopathologically. This gives
an idea about the state of different cell types and the stages of spermatogenesis.
Tests of ovulation
A) Hormonal assay
Estimation of blood GTHs levels: a sudden rise in LH level 36 h just before
ovulation (LH surge) suggest ovulation
Estimation of progesterone level in the plasma or pregnandiol in urine:
their increase in the second half of the cycle suggest ovulation.
B) Folliculometry (Follicular monitoring )
Is a simple technique for assessing ovarian follicles at regular intervals and
documenting the pathway to ovulation using trans-vaginal ultrasound.
Seeing the ruptured follicle and minimal pelvic fluid indicates
ovulation.
C) Tests to detect the effect of progesterone as mark of ovulation.
Examination of vaginal smear and mucus from the uterine cervix:
The presence of characteristic changes produced by progesterone indicates
ovulation (progestational changes)
a) The vaginal smear shows due to the effect of progesterone:
epithelial proliferation and infiltration with leukocytes.
b) Cervical mucus ; Progesterone makes cervical mucus thick, tenacious and
cellular but it fails to form a fern like pattern when dried.

Examination of an endometrial biopsy in the second half of the cycle:

The presence of secretory changes in endometrium indicates ovulation these
features includes:
a) Thickening of the endometrium (6-12mm), so it becomes ready for
implantation of the fertilized ovum.
b) Deposition of large quantities of fat, protein and glycogen in the endometrial
cells.
c) The endometrium becomes more vascularized and the spiral arteries reach the
endometrial surface.
d) The endometrial glands become tortuous and secrete a clear fluid.
D) Manifestations observed by the female
Measurement of basal body temperature in the morning before getting out
of bed:
its rise about 0.5ºC at about the middle of the cycle in absence of disease is
indicative of ovulation due to thermogenic effect of progesterone.
Observation of a fleeting lower abdominal pain at the middle of the cycle:
the presence of such pain in absence of diseases often
indicates ovulation. It is due to peritoneal irritation due to minor
bleeding in the abdominal cavity after rupture of graffian follicle.
Observation of mid-cyclic bleeding:
may occur in some females due to drop of estradiol level after rupture of graafian
follicle.

Early pregnancy test:

Pregnancy is suspected when amenorrhea occurs in normal married woman. In
this case, early diagnosis of pregnancy can be achieved by detection of human
chorionic gonadotropin (hCG) in blood or urine.
Indications of pregnancy tests;
Diagnosis and confirmation of early normal uterine pregnancy
Evaluation of ectopic pregnancy
To monitor pregnancy following invitro fertilization and embryo transfer
Pregnancy tests in urine and blood
hCG can be detected in blood 6 days after conception and in urine 14 days after
conception. It can be measured by radioimmunoassay.
hCG is eliminated from the mother’s body through urine so, the following tests
for the early diagnosis of pregnancy can be also used and they depend on
Detection of hCG in the woman's urine:
1) Immunological tests:
These tests depend on the interactions between hCG as an antigen and its
antibodies. In the agglutination test which is the commonest used immunological
test, the woman's urine is mixed with a solution that contains granules of certain
substances (latex) coated with hCG antibodies.
Agglutination of the substances indicates pregnancy and vice versa.
2) Chemical test:
woman's urine is added to a solution of an indicator substance that change its
color on contacting hCG. this change of color
indicates pregnancy.

Detection of hCG in blood;

Blood tests can confirm pregnancy by checking the presence of the hormone,
human chorionic gonadotropin (hCG).
These tests are more sensitive than urine tests and can detect a pregnancy
earlier. Blood pregnancy tests yield a positive result if they detect 1 to 2 mIU/mL
(milliinternational units per milliliter), while urine tests require hCG levels to
reach 20 to 50 mIU/mLs
There are two types of blood pregnancy tests:
Qualitative blood serum test:
This will confirm whether or not hCG is present, basically offering a yes
(you're pregnant) or a no (you're not pregnant) result.
The qualitative hCG blood test is about as accurate as a home urine test.
Quantitative blood serum test:
This test is also known as the beta hCG test, measuring the exact amount of
hCG in blood.
Because this test can detect even trace amounts of hCG, it is highly accurate.
and it is more specific as it measures only the beta subunit HCG, as alpha subunit
is identical to LH and FSH.
Serial quantitative measurement of beta hCG is helpful in diagnosing
ectopic pregnancy and distinguishing viable pregnancy from non- viable one

ERD - BIOCHEMISTRY Ninja medical squad
Practical (1):
Lab Investigation Used in Measuring Hormone Levels
Hormone measurement is necessary for the diagnosis of a wide range of clinical
conditions and is essential for monitoring the effectiveness of treatment.
The Methods of Hormonal Assay
1. Bioassay and/or chemical methods: Low sensitivity, need large samples
2. RIA (RadioImmunoAssay): It has a potential health threat
3. ELISA (Enzyme Linked ImmunoSorbent Assay)
4. Recently, Non-isotopic Immunoassay Methods utilizing chemiluminescence,
fluorescence and enzymes as labels are widely used.
Important Components in Immunoassay
1- Antigen
2- Antibody (Antiserum)
3- Labeling Materials
Principle of Immunoassay
❑ Immunoglobulins are proteins produced by the immune system to
recognize, bind to, and neutralize foreign substances in the body.
❑ Immunoassays are tests based on the very specific binding that occurs
between an immunoglobulin (called an antibody) and the substance that it
specifically recognizes (the foreign molecule, called an antigen).
❑ Immunoassays can be used to test for the presence of a specific antibody
or a specific antigen in blood or other fluids.
Radioimmunoassay
Principle: Uses an immune reaction [Antigen – Antibody reaction] to estimate a
ligand by measuring radioactivity of bound residue measured.
Advantages:
1. Highly specific.
2. High sensitivity

Disadvantages:
1. Radiation hazards: Uses radiolabelled reagents
2. Requires specially trained persons
3. Labs require special license to handle radioactive material
4. Requires special arrangements for storage of radioactive material &
radioactive waste disposal.
Enzyme Linked Immunosorbent Assay
Principle: Detection based on
➢ Enzyme catalysed reaction or
➢ Fluorescent probe NOT radioactivity [great advantage!]
Advantages of ELISA:
1. Sensitive: nanogram levels or lower
2. Reproducible
3. Minimal reagents
4. Qualitative & Quantitative
1. Qualitative → eg HIV testing
2. Quantitative assays → eg Drug Monitoring
5. Greater scope: Wells can be coated with Antigens or Antibodies
6. Suitable for automation →high speed
7. NO radiation hazards
Hypothalamic – Pituitary – Thyroid – Axis:
Thyroid Tests
I. Measure the Concentration of Products Secreted by the Thyroid Gland
Free T4: Measures unbound fraction of T4
Used for detection of
• Hyperthyroidism.
• Detection of primary and secondary hypothyroidism.
• Monitoring of TSH-suppression therapy.

Free T3: active form of T3, unbound to proteins

Used in diagnosis of
• Euthyroid.
• Hyperthyroid.
• Hypothyroid state.
• T3 toxicosis (increased T3 and normal T4).
II- Evaluate the Integrity of the Hypothalamic – Pituitary - Thyroid Axis:
TSH:
Ref range: 0.3 - 5 milliunits/L
Symptomatic primary hypothyroidism: >20 mu/L
TRH:
Regulates the TSH secretion from pituitary
TRH test measure the ability of TRH to stimulate the pituitary to secrete TSH
III- Assess Inherent Thyroid Gland Function
➢ Radioactive iodine uptake test is used to assess intrinsic function of the
thyroid gland
▪ This test is not specific and the reference range should be adjusted based
on local population
▪ This test is indirect measure of thyroid activity
➢ Increased radioactive iodine uptake in:
▪ Thyrotoxicosis
▪ Iodine deficiency
▪ Post thyroiditis
➢ Decreased radioactive iodine uptake in:
▪ Acute thyroiditis
▪ Patients on exogenous thyroid hormone therapy
▪ Patients taking anti-thyroid drugs
▪ Hypothyroidism

IV- Detect Antibodies to Thyroid Tissue (Anti Thyroid Antibodies)

▪ Found in Hashimoto’s thyroiditis (95% of patients) and Grave’s disease
(55% of patients)
▪ In Grave’s disease, hyperthyroidism is caused by antibodies activating
TSH receptors.

Practical (2):
Sex hormone-binding globulin (SHBG) or sex steroid-binding
globulin (SSBG)
Introduction
• DEF of SHBG: is a glycoprotein that binds to androgens and estrogens.
• Other steroid hormones such as progesterone, cortisol, and
other corticosteroids are bound by transcortin.
• SHBG is found in all vertebrates apart from(except) birds.
Biosynthesis:
• Mostly by the liver and is released into the bloodstream.
• Other sites that produce SHBG
b p u T
r l t e
• Tests produce SHBG is called androgen-binding protein(ABP)
a a e s
• Gene for SHBG is called Shbg located on chromosome 17 on the short
i c r t
arm between the bands 17p12→p13
n e u i
• Structure is homodimeric, meaning it has two identical peptide chains
n s s
making up its structure.
t
• Androgen-binding protein ..The amino acid sequence is the same as
a
SHBG but that has different in
1-oligosaccharides Attached 2- is produced in testes
HOMODIMERIC HETERODIMERIC

Regulation:
• SHBG has both enhancing and inhibiting hormonal influences.
• High levels of:
Insulin
growth hormone
insulin-like growth factor 1 (IGF-1)
androgens Decreases SHBG
prolactin
transcortin
• High level of :
estrogen
thyroxine levels Increase SHBG
Function
Testosterone and estradiol
1- Loosely bound mostly to serum albumin (~54%)
2- A lesser extent bound tightly to SHBG (~44%)
3- Small fraction of about 1 to 2% is unbound, or "free,"
❑ 1 To 2% Is Unbound, Or "Free," And Thus Biologically Active And Able
To Enter A Cell And Activate Its Receptor.
❑ So function of SHBG inhibits the function of these hormones. Thus,
bioavailability of sex hormones is influenced by the level of SHBG.
Condition that decreases level of SHBG:
➢ Androgens
➢ administration of anabolic steroids
➢ polycystic ovary syndrome
➢ Hypothyroidism
➢ obesity, Cushing's syndrome
➢ Acromegaly
N.B: Low SHBG levels increase the probability of Type 2 Diabetes

Condition that increases level of SHBG:

SHBG levels increase with:
➢ estrogenic states (oral contraceptives)
➢ pregnancy
➢ Hyperthyroidism
➢ cirrhosis
➢ anorexia nervosa
➢ and certain drugs
➢ Long-term calorie restriction of more than 50 percent increases SHBG,
while lowering free and total testosterone and estradiol
N.B:- DHEA-S(dehydroepiandrosterone sulphate) which is androgen produced
by adrenal cortex lacks affinity for SHBG, is not affected by calorie restriction.
Polycystic Ovarian Syndrome(pco) is associated with:
1-insulin resistance
2- excess insulin
PCO lowers SHBG, which increases free testosterone levels.
The Methods of Hormonal Assay:
1- Bioassay and/or chemical methods low sensitivity, need large samples
2- RIA (RadioImmunoAssay)It has a potential health threat
3- ELISA (Enzyme Linked ImmunoSorbent Assay(
4- Recently, Non-isotopic Immunoassay Methods utilizing
chemiluminescence, fluorescence and enzymes as labels are widely used
What are normal SHBG levels?
➢ The normal ranges for SHBG concentrations in adults are:
➢ Males: 10 to 57 (nmol/L(
➢ Females (nonpregnant): 18 to 144 nmol/L.

Interpret abnormalities in level of SHBG

If your SHBG levels are too low, it can be a sign of:
1- Hypothyroidism
2- Type 2 diabetes.
3- Overuse of steroid medications.
if my SHBG high! Increased SHBG levels may be seen in:
1- Liver disease.
2- Hyperthyroidism
3- Eating disorders (anorexia nervosa)
If SHBG levels are too high ‫؟‬
Mean both testosterone and estrogens are bound to it.
So High levels of SHBG increase one's risk for osteoporosis WHY? because the
testosterone and estrogens needed to assist with bone formation are not
available for use.
SHBG in men:
to help determine the cause of:
➢ Infertility ➢ erectile disfunction
➢ decreased sex drive
So SHBG and total testosterone levels may be ordered
(Measurement of SHBG in addition to testosterone is especially helpful when
total testosterone results are inconsistent with clinical signs.)
SHBG Test
• Measurement of total testosterone in the blood does not distinguish
between bound and unbound (bioavailable) testosterone .
• Increased SHBG in men may be associated with :
1- symptoms of low testosterone levels (hypogonadism) because less
testosterone is available to the body's tissues .
2- Low testosterone leads to increase production of SHBG lead to further
decreasing the amount of testosterone available to tissues

CASE Female reproductive system

MENOPAUSE
A 52-year-old female presents to your office with complaints of hot flushes,
mood swings, irritability, and vaginal dryness and itching. Her last menstrual
period was a little over a year ago. She denies any vaginal discharge. The
patient is concerned about having thyroid problems because her friend has
similar symptoms and was diagnosed with hyperthyroidism. On examination,
the patient is in no acute distress with normal vital signs. Her physical is normal
other than thin, atrophic vaginal mucosa. A thyroid-stimulating hormone (TSH)
level is drawn and is normal. The follicle-stimulating hormone (FSH) level is
drawn and is markedly elevated.
◆ What is the organ that secretes the follicle-stimulating hormone (FSH)?
Organ secreting follicle-stimulating hormone (FSH): Anterior pituitary gland.
◆ What is the signal that stimulates the release of FSH?
Signal stimulating FSH release: Gonadotropin releasing hormone from the
hypothalamus binds to membrane receptors of the anterior pituitary cells,
triggered phosphatidylinositol signaling to stimulate FSH production and
release.
Discussion and clinical correlation:
At menopause, beginning on an average at age 51, ovarian production of
estrogen and progesterone gradually declines. The resulting release of feedback
inhibition on the pituitary leads to its greatly increased release of FSH and LH.
The adrenal glands continue to produce a minor amount of estrogen. Ovulation
stops, and menstruation becomes less frequent and eventually ceases. The
postmenopausal ovary and the adrenal gland continue to secrete androgens. The
conversion of these androgens to estrogens mainly in fat cells and skin via the
enzyme aromatase provides most of circulating estrogen in postmenopausal
women.

This case of 52-year-old woman has symptoms of estrogen insufficiency, such

as hot flushes, mood swings, and vaginal dryness. Her last menstrual period was
1 year ago, consistent with the menopause. The etiology of the hypoestrogen
state is follicular atresia of the ovaries. Once in puberty, a woman usually has
fairly regular menstrual cycles as dictated by the estrogen and progesterone
secretion of the ovaries until about age 40 to 50 years. During a period of 2 to 4
years, some women may experience irregular menses because of irregular
ovulation until finally there are no further menses .
The diagnosis of the menopause is made by:
1- clinical criteria,
2- The gonadotropins, FSH, and luteinizing hormone (LH) are usually
elevated.
COMPREHENSION QUESTIONS:
1- An obese 57-year-old woman did not yet exhibit symptoms of menopause
but was diagnosed with polycystic ovary syndrome (PCOS) and insulin
resistance. Her plasma levels of testosterone were above normal. Which one
of the following is most likely in this case?
A. Hyperinsulinemia leading to androgen overproduction by the ovary and
its conversion to estrogen in fat cells
B. Androgen overproduction by the adrenal gland and its conversion to
estrogen in fat cells
C. Progesterone overproduction by the polycystic ovary leading to its
conversion to estrogen
D. LH/FSH ratio = 1
E. Estrogen overproduction by the ovary and conversion to testosterone
Answer:
Hyperandrogenism is primarily ovarian in origin in PCOS women, although a
minor contribution from the adrenal gland may occur. Hyperinsulinemia is the
primary stimulus. Fat cells convert androgens to estrogens. This may explain

the late menopause in this case. In normal postmenopausal women, ovarian

production of testosterone continues and this provides the main source of
circulating estrogen. Typically an LH/FSH ratio of at least 2.5 is associated with
PCOS.
2- Which one of the following changes is most likely to be observed in a
postmenopausal woman who is not taking hormone supplementation ?
A. Cessation of androgen secretion
B. Increased levels of FSH and LH
C. Increased osteoblast activity
D. Decreased levels of gonadotropin-releasing hormone
E. Increased progesterone levels
Answer:
B-Increased levels of FSH and LH result from decreased estrogen levels and
release of feedback inhibition. Androgen secretion continues although
diminished. Osteoblast activity decreases, eventually leading to risk of
osteoporosis. Progesterone levels decrease, and GnRH levels increase.
3- In a normal premenopausal woman, which one of the following is
stimulated by progesterone?
A. Release of gonadotropin-releasing hormone by the pituitary
B. Ovulation
C. Development of the endometrium in preparation for possible pregnancy
D. Uterine contraction
E. Follicle development
Answer:
C- Progesterone is secreted by the corpus luteum under the influence of LH.
Together with estrogen, it promotes the thickening and maintenance of the
endometrium. Progesterone inhibits GnRH release, uterine contraction, and
follicle development.

ERD - MICROBIOLOGY Ninja medical squad
Microbiological Examination of urogenital specimens







ERD - PARASITOLOGY Ninja medical squad
Toxoplasma gondii Trophozoites
Congenital anomalies caused by Toxoplasma gondii

- Hydrocephalus

Congenital anomalies caused by Toxoplasma gondii

- Microcephally
Trichomonas vaginalis trophozoites

Strawberry cervix caused by T. vaginalis trophozoite
Inflammation, redness and leucorrhea of

trichomoniasis

Pthirus pubis female
Eye lashes infestation of Pthirus pubis

ERD - PATHOLOGY Ninja medical squad
THYROID
❖ Nodular Goitre:
Gross:
✓ The gland is markedly and asymmetrically enlarged in size.
✓ Outer surface is Nodular with a thickened capsule and prominent blood
vessels.
✓ Cut section shows Multiple variable sized nodules separated by fibrous
tissue septa.
✓ Some of the Nodules are cystically dilated and filled with pale brown
colloid.
✓ Areas of Hemorrhage are seen.

Microscopic:
✓ Section shows variably-sized follicles (small, hypercellular, and compact
with little Or no colloid and large follicles lined by flattened epithelium and
containing large Amounts of colloid).
✓ Follicles are separated by dense fibrosis.
❖ Toxic Goitre:
Gross:
✓ The thyroid gland is diffusely and symmetrically enlarged giving a butterfly
Shaped swelling.
✓ The outer surface is smooth without nodularity.
✓ Cut section is Homogenous not nodular and is devoid of olloid.

❖ Hashimoto’s Thyroiditis:
Microscopic:
✓ Thyroid reveals a conspicuous chronic
inflammatory infiltrate mainly lymphocytes
Forming prominent lymphoid follicles with
germinal centers Destruction and atrophy
of thyroid follicles.
✓ Oxyphilic metaplasia of follicular epithelial
cells (Hürthle or Askanazy cells).
❖ Follicular Adenoma:
Microscopic:
✓ Well-differentiated follicles contain
colloid, resembling normal.
✓ Other histological forms: (trabecular,
microfollicular, macrofollicular)
✓ Capsule integrity is important to
differentiate follicular adenoma from
Carcinoma.

❖ Papillary Thyroid Carcinoma:

Microscopic:
✓ Branching papillae with fibrovascular stalk covered by as single to multiple
layers of cuboidal epithelial cells.
✓ Definitive diagnosis (nuclear features): Nuclei contain finely dispersed
chromatin, which Imparts an optically clear or empty appearance, With
coffee bean grooving.
MALE GENITAL SYSTEM

❖ Benign Prostatic Hyperplasia:
Gross:
✓ There is nodular appearance of enlarged
prostate.
✓ The nodules are yellow-tan of Variable
size.
✓ Cut section of enlarged nodular prostate,
it has intact capsule.
✓ The cut surface is showing multiple well-
circumscribed nodules of variable sizes
and shapes, grayish-white and firm.

✓ The nodules are separated by thick

fibromuscular stroma.
Microscopic:
✓ There is proliferation of both
elements of prostate; epithelial cells
and Fibromuscular stroma
✓ The glands are lined by two layers:
tall columnar cells thrown into
papillary Projections and flat basal
cells.
✓ Glands lamina are full of inspissated
proteinaceous material giving rise to
corpora Amylacia.
✓ Fibromuscular stroma is abundant

❖ Testicular tumor for DD (Seminoma):

Gross:
✓ Seminoma appear as large, soft, pale, fleshy, fairly well-demarcated,
Homogeneous, grey-white mass that bulge from the cut surface of the
affected Testis and confined to the testis by tunica albuginea.
✓ Cut Section of enlarged testis showing well circumscribed, white,
homogenous, Solid firm tumor nodule.
✓ The tumor is contained within the surrounding tunica Albuginea and not
infiltrating it

BREAST
❖ Fibro adenoma, Breast:
Microscopic:
✓ Transverse section in a breast tissue shows:
Proliferated ducts in a fibromyxoid stroma.
✓ Some ducts are rounded or oval with patent
lumen (Pericanalicular pattern).
✓ Others are compressed and invaginated and
appear elongated or star shaped
(intracanalicular pattern).
✓ The ducts are lined by two layers; outer
flattened and inner cubical cells.
✓ The epithelial lining may be hyperplastic.
❖ Invasive Duct Carcinoma (NOS), Breast:

Microscopic:
✓ Transverse section in a breast tumor
shows: Malignant cells arranged in small
groups, solid masses, trabeculae and cords
In a desmoplastic stroma.
✓ The malignant cells are pleomorphic with:
Increased nucleocytoplasmic ratio
Hyperchromatic nuclei & prominent
nucleoli Increased mitotic activity.
✓ The stroma is abundant, dense fibrotic and
show focal infiltration by Lymphocytes.
✓ Areas of hemorrhage and necrosis are evident in the tumor.

❖ Fibrocystic Disease, Breast:

Microscopic:
✓ Transverse section in a breast
tissue shows: Adenosis:
hyperplastic and proliferated ducts
and acini.
✓ Epitheliosis: the lining epithelium
is hyperplastic, formed of two
layers or More (and may be thrown
into papillary infolding
(papillomatosis).
✓ Cyst formation: dilated ducts lined by cuboidal to flattened epithelium.
✓ Apocrine metaplasia of the lining epithelium.
✓ The cells become tall columnar With granular eosinophilic cytoplasm with
rounded vesicular nuclei and Prominent nucleoli. Fibrosis of the stroma.
❖ Paget’s disease, Breast.
Gross:
✓ Jar containing part of female breast
with the covering nipple and areola
✓ The nipple is flat with malignant
erosion of the areola and skin
retraction
✓ There is a mass grey pink in color
measuring 6x6cm infiltrating the
fibrofatty
✓ Tissue of the breast with areas of
hemorrhage and necrosis.

❖ Breast Cancer:
Gross:
✓ Jar containing female breast
There is ill defined, non
capsulated greyish white firm
mass infiltrating breast Tissue.
✓ The covering skin is wrinkled
giving (Peau d’orange)
appearance. The nipple is
retracted.

FEMALE GENITAL SYSTEM

❖ Simple endometrial hyperplasia:
Microscopic:
✓ Transverse section of endometrium
showing Increased number of
endometrial Glands.
✓ Glands are of variable sizes, some are
rounded, some with budding and others
are Cystically dilated.
✓ Single layer of low columnar
epithelium lines glands.
✓ Stroma is Still present between glands.
✓ No atypia is detected
❖ Vesicular mole:
Gross:
✓ Jar containing cystic grape like tissue show: The tissue formed of multiple
vesicles of variable sizes from 0.5 to 3 cm in Diameter.
✓ The wall of vesicles is thin and translucent and held together by delicate
fibrous Strands.
✓ These vesicles represent hydropic degeneration in chorionic villi.

Microscopic:
✓ Section in vesicular mole shows: Enlarged chorionic villi formed of
connective tissue Core and a covering of hyperplastic trophoblastic
Epithelium (cytotrophoblast and Syncytiotrophoblast).
✓ The connective tissue cores show hydropic Degeneration and decreased or
absent vascularity.
❖ Endometrial carcinoma:
Gross:
✓ An opened uterus. The uterus is moderately
enlarged in size.
✓ The uterine cavity is distended by a
protruding mass originating from the
Posterior wall.
✓ The mass is measuring 3x5 cm, grayish
white in color with necrotic and dark area
of hemorrhage.

❖ Mature cystic teratoma ovary:

Gross:
✓ An ovarian cystic mass.
✓ The mass is cystic, measures
14x8cm, grayish white in color.
✓ The outer surface is smooth with
prominent blood vessels.
✓ Cut section shows a thin wall
capsule surrounding the cyst.
✓ The cyst contains sebaceous
material and tuft of hairs and
tooth projecting into the Lumen.
Microscopic:
✓ Transverse section in the ovarian cyst shows:
Mature adult tissues formed of a mixture of
Ectodermal, endodermal and mesodermal
structures.
✓ Ectodermal structures in the form of skin
with Stratified squamous epithelium, and skin
adnexa Such as sebaceous glands, and hair.
✓ Endodermal structures in the form of
respiratory type pseudo-stratified columnar
Ciliated epithelium.
✓ Mesenchymal structures in the form of
smooth Muscle, bone, and cartilage.

❖ Serous cyst adenoma ovary:

Gross:
✓ Jar containing opened ovary.
✓ The ovary is enlarged in size measuring
about.
✓ The cyst is grayish in color with smooth
inner and outer surfaces.
✓ The inner surface of the cyst is thin and
multilocular.
❖ Mucinous cyst adenoma:

Gross:
✓ Jar containing opened ovary.
✓ The ovary is enlarged in size
measuring about.
✓ The outer surface is smooth with
areas of haemorrhage giving a
dark brown Appearance.
✓ The cyst is multilocular with
thick wall, the loculi varies in size
containing thick Greyish brown gelatinous
material.

❖ Ovarian Cancer:
Gross:
✓ Jar containing huge bisected
ovarian mass.
✓ The mass is oval in shape,
measuring 20x15 cm and
occupied the whole ovary.
✓ The outer surface is slightly
irregular with exophytic mass
projecting from the Surface.
✓ Cut section shows alternating
solid and cystic areas with marked hemorrhage and Necrosis.
❖ Endometrial polyp:
Gross:
✓ An opened uterus with attached
right, left ovary with both fallopian
tubes and Cervix
✓ The uterus is slightly enlarged in
size, grayish in color with smooth
outer Surface and measures
8x5x3cm.
✓ The inner surface shows oval
polypoid grayish white mass
measuring 3x1cm Protruding into
the uterine cavity.

❖ Leiomyoma:
Gross:
✓ bisected uterus
✓ The Outer surface of the uterus is
smooth.
✓ Cut section shows thickened wall with
interstitial rounded mass measuring
3x3x2 cm in diameter.
✓ The mass is well circumscribed with
false capsule and shows whorly cut section.
Microscopic:
✓ Intersceting bundles of smooth muscle cells with fibroblasts without atypia
✓ The tumor has no fibrous capsule

ERD - PHARMACOLOGY Ninja medical squad
THYROID GLAND DISORDERS
Case 1: Samira is a female, 35-year-old with a swelling in her neck for 2

months. She has noticed a recent onset of myalgia, fatigue, hair loss, weight
gain, constipation, cold intolerance and dry skin. She also noticed buffnes of
her eye. The physician told Samia that she has thyroid gland dysfunction.
A-What do you think about possible thyroid disorder of Samira?
B- Name the drugs that used in treatment of such case?
C- What is the route of drug administration, mechanism of action of prescribed

drugs in Samira case?
D- List the main adverse effects of the prescribed drugs?
E- What other thyroid dysfunctions do you know?
Case 2: A 32-year-old female complained of nervousness, mood swings,

weakness, and palpitations with exertion for the past 3 months. Recently,
she was intolerance to heat. Menstrual periods had been regular but there
was less bleeding.
1- What do you think about diagnosis?
2- What is the treatment of such case?
3- What are common side effects of prescribed drugs?
4- If the patient gets pregnant, what is the drug of choice to this case?

DRUG SAMPLES
Every group of students chooses drug samples and answer the following questions:
1) Name the group to which the drug belongs to, rout of administration, and relation to
food intake?
2) Write the mechanism of action, clinical uses?
3) List the main adverse effects of each of them?

DIABETES MELLITUS
Case-1:
A 48-year woman suffering from polyuria, polydipsia with history of loss of weight.
Clinical examination and laboratory investigation revealed the diagnosis of type 2
diabetes mellitus.
1. What is the first step in treatment of such case?
2. After two months, hyperglycemia is persisted. Mention suggested groups of drugs that
could be prescribed?
3. After one month of therapy by the prescribed drug, hyperglycemia was not controlled.
And the patient admitted at chest hospital due to severe chest infection' what is the best
anti-diabetic to be used
Objectives
✓ To know types of diabetes
✓ Treatment of each type
✓ Adverse effects of drug therapy
Types of diabetes mellitus
➢ Type-1 DM
➢ Type-2 DM
➢ Gestational DM

ANTI-DIABETIC DRUGS
1- Classify insulin preparations according to duration and onset of action
2- Mention oral hypoglycemic drugs groups
3- Mention mechanism of action of previous drugs
4- Mention medical conditions that require shifting to insulin in treatment of type-2 diabetes

QUIZ-2
1- Which of the following drugs is preferred as anti-thyroid drug during pregnancy

a- Carbimazole
b- Propylthiouracil
c- K iodide
d- Levothyroxine
2- Which of the following is the treatment of choice for hypothyroidism
a- Iodide
b- Levothyroxine
c- Propylthiouracil
d- None of the above
3- Which of the following is the most appropriate initial oral agent for management of
type-2 DM in patient with no other comorbid conditions
a- Insulin
b- Metformin
c- Glipizide
d- Pioglitazone
4- Which of the following classes of oral diabetes drugs is paired most appropriately
with its primary mechanism of action
a- DPP-4 inhibitors-inhibit breakdown of complex carbohydrates
b- Glinide- increase insulin sensitivity
c- Sulfonylureas-increase insulin secretion
d- None of the above
5- Mention treatment of thyroid storm
6- Mention most common complications of insulin therapy
7- Mention injectable anti-diabetic drugs

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ERD - ANATOMY Ninja medical squad

SWIFT HEALING, SILENT HEROES 1

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(5) TRH stimulation test:

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(D) Saline suppression test:

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2) Estimation of urinary gonadotropins

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Examination of an endometrial biopsy in the second half of the cycle:

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Early pregnancy test:

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Detection of hCG in blood;

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Free T3: active form of T3, unbound to proteins

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IV- Detect Antibodies to Thyroid Tissue (Anti Thyroid Antibodies)

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Condition that increases level of SHBG:

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Interpret abnormalities in level of SHBG

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CASE Female reproductive system

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This case of 52-year-old woman has symptoms of estrogen insufficiency, such

SWIFT HEALING, SILENT HEROES 37

the late menopause in this case. In normal postmenopausal women, ovarian

SWIFT HEALING, SILENT HEROES 38

Microbiological Examination of urogenital specimens

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Toxoplasma gondii Trophozoites

Congenital anomalies caused by Toxoplasma gondii

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Congenital anomalies caused by Toxoplasma gondii

Trichomonas vaginalis trophozoites

SWIFT HEALING, SILENT HEROES 47

Strawberry cervix caused by T. vaginalis trophozoite

Inflammation, redness and leucorrhea of

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Pthirus pubis female

Eye lashes infestation of Pthirus pubis