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NEET PG High Yield Topic Synopsis NEET 2019 PDF Version - Final
NEET PG High Yield Topic Synopsis NEET 2019 PDF Version - Final
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2. CLAVICLE
Clavicle
3. SHOULDER JOINT
• The inferior part of shoulder joint capsule is the weakest area of shoulder joint capsule
• Long head of the biceps muscle crosses through the shoulder joint
• The tendon of the long head of biceps brachii muscle passes superiorly through the joint and
restricts upward movement of humeral head on glenoid cavity.
• Rotator cuff is called the dynamic stabiliser of the shoulder joint
4. HUMERUS BONE
5. RADIAL NERVE
• Movements that take place during abduction of shoulder are axial rotation of humerus at
acroclavicular joint ,elevation of humerus & movement at clavicular end of sternoclavicular joint.
• Movement in every direction (Flexion, extension, abduction, adduction, rotation, circumduction)
7. BRACHIAL ARTERY
• Bicipital aponeurosis passes superficial to the brachial artery and median nerve
• BP is measured in Brachial artery.
• In case of occlusion resulting from fracture of humerus immediate surgery is required.
8. AXILLARY ARTERY
• Cords of brachial plexus are named as per relation with axillary artery behind teres major
• Axillary artery is divided into 3 parts by pectoralis minor muscle
• Axillary artery extends from the outer border of the first rib to inferior border of teres major
muscle
• First part (1 branch) Superior thoracic artery
• Subscapular and scapular circumflex arteries are from the third part of the axillary artery, thus
providing a bypass for obstructions of the first or second parts of the axillary artery.
DEFINITION:
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• It is defined as Sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock like
pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point, across the
distribution of one or more branches of the trigeminal nerve
• Trigeminal neuralgia also known as Prosopalgia or Fothergill’s disease is a neuropathic disorder
characterized by episodes of intense pain in the face, originating from trigeminal nerve.
ETIOLOGY:
• Vascular compression
• Usually idiopathic
• Demylination of the nerve
• Multiple sclerosis
• Petrous ridge compression
• Post – traumatic neuralgia
• Intracranial tumors
• Intracranial vascular abnormalities
• Viral etiology
CLINICAL SYMPTOMS:
• INCIDENCE 8:100000
• AGE-5th-6th decade of life
• SEX-female> male
• AFFLICTION FOR SIDE- right> left
• DIVISION OF TRIGEMINAL NERVE INVOLVEMENT- V2>V3>V1
• Manifests as a sudden, unilateral, intermittent paroxysmal, sharp, shooting, lancinating , shock
like pain, elicited by slight touching superficial ‘trigger points’ which radiates from that point,
across the distribution of one or more branches of the trigeminal nerve
• Pain is usually confined to one part of one division of trigeminal nerve
• Pain rarely crosses the midline.
• Attacks do not occur during sleep common during day time.
• Pain is of short duration, but may recur with variable frequency.
• In extreme cases, the patient will have a motionless face – the ‘frozen or mask like face’.
• Common trigger zone include- cutaneous( corner of the lips, cheek, ala of the nose, lateral brow);
intraoral( teeth, gingivae, tongue). Trigger area on the face are so sensitive that touching or even
air currents can trigger an episode.
• 10-12% of cases are bilateral, or occurring on both sides. This mainly seen in cases with systemic
involvement include multiple sclerosis or expanding cranial tumor.
DIAGNOSIS
• MIGRAINE- severe type of periodic headache is persistent, at least over a period of hours and it has
no trigger zone.
• SINUSITIS- pain is not paroxysmal, in this pain is persistent, associated nasal symptoms.
• DENTAL PAIN- localized, related to biting or hot or cold foods, visible abnormalities on oral
examination.
• Tumors of nasopharynx- in this similar type of pain is produced, manifested in the lower jaw,
tongue and side of the head with associated middle ear deafness. This complex lesion is called
TROTTER’S syndrome. Patient exhibit asymmetry and defective mobility of the soft palate and
affected side. As the tumor progresses, trismus of internal pterygoid muscle develops, and patient
is unable to open the mouth. Here actual cause of pain is involvement of mandibular nerve in the
foramen ovale.
• Post herpetic neuralgia- pain is usually involved in ophthalmic division. The history of skin lesion
prior to onset of neuralgia, pain is persistent, associated nasal symptoms.
TREATMENT:
MEDICAL
SURGICAL
• Varicella zoster virus lying dormant within the trigeminal ganglion can reactivate and spread
through the ophthalmic division of the trigeminal nerve.
• Largest branch of ophthalmic nerve is frontal nerve
• Most frequently involved in herpes zoster ophthalmicus branch of ophthalmic nerve is frontal
nerve.
• Anterior ethmoidal artery accompanies the Nasociliary nerve.
• If a patient has herpes zoster, tip of the nose is affected it means the nasociliary nerve is affected
and eye will definitely get involved. This is known as theHutchison’s rule.
• Supply the ethmoidal cells of ethmoidal sinus
• Anterior ethmoidal nerve supplies the ethmoid sinus, nasal cavity, and skin on the tip of the nose.
• Dura mater of anterior cranial fossa is supplied by anterior and posterior ethmoidal nerves.
• Function- General sensation (touch, pain & temperature).
• Cranial exit point- superior orbital fissure.
1. Skin:
• It is freely movable on the pericranium along with the overlying and adherent scalp and fascia.
• On each side it is attached to the superior temporal lines.
• Anteriorly, it receives the insertion of the frontalis.
• Posteriorly, receives insertion of the occipital bellies.
• Containing the emissery veins & allowing free movement of layers 1 to 3 as a unit.
• Layer 4 is a "dangerous area" because it allows spread of infection even, by way of the emissery
veins, to intracranial structures.
• Loosely attached to the surface of the bones, but is firmly adherent to the sutures where the
sutural ligaments bind the pericranium to the endocranium.
BLOOD SUPPLY:
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ARTERIAL SUPPLY:
• IN FRONT OF AURICLE-
1. Supratrochlear
2. Supraorbital
3. Superficial temporal arteries
1. Posterior auricular
2. Occipital arteries
VENOUS DRAINAGE:
LYMPHATIC DRAINAGE:
• Lymph vessels from the frontal region above the root of the nose drain into the submandibular
nodes.
• Vessels from rest of the forehead,temporal region,upper half of the lateral auricular aspect and
anterior wall of the external acoustic meatus drain into superficial parotid nodes, just anterior to
the tragus ,on or deep to the parotid fascia.
• The occipital region of the scalp is drained by the occipital nodes,and partly by the vessel that runs
along the posterior borderof the sternocleidomastoid to the lower deep cervical nodes
• A strip of the scalp above the auricle drains to the upper deep cervical and retro auricular nodes.
• The retro auricular in turn drain to deep cervical.
NERVE SUPPLY:
CLINICAL ANATOMY:
1. SEBACEOUS CYST- due to collection of sebum as a result of obstruction of sebaceous cyst, secondary
infection may sets in.
2. Scalp wounds bleed profusely- because elastic fibres of underlying galea aponuerotica prevent initial
vessel retraction, the wounds may be associated with significant blood loss which can result in clinical
shock.
3. Scalp flaps -used in craniofacial surgery for correction of congenital deformity,for release of
craniosynostosis, treatment of craniofacial fractures and for repair of scalp defects after excision of skin
tumors.
5. When suturing scalp lacerations, it is essential to control all bleeding points before repairing the scalp
itself.
6. It is necessary to tie off larger arterioles and veins and use bipolar diathermy to control smaller
arterioles and veins.
7. Repair of scalp require full thickness tension sutures because galea aponuerotica will otherwise gape as
the occipital and frontal bellies contract.
9. Failure to control bleeding points can result in significant hematomas, often subgaleal, leading to
breakdown of the orginal wound and sometimes necessitating surgical drainage.
• The muscles of mastication are temporalis, masseter, medial pterygoid, lateral pterygoid
• Masseter originates from mesencephalic nucleus and the motor nucleus of trigeminal nerve
• All primary muscles of mastication are supplied by mandibular nerve
• Muscles that elevates mandible to close the mouth are temporalis, masseter & medial pterygoid
• The only primary muscle that depress mandible to open mouth is lateral pterygoid
• All Muscles of mastication are supplied by branches from Ant. div. of mandibular branch of
TRIGEMINAL NERVE except Medial Pterygoid.
TYPES:
• Superior oblique rotates the eye downward and away from midline.
• All the extra ocular muscles except inferior oblique arise from the apex of orbit.
• Anteroposterior stability of eyeball is provided by Superior oblique,Superior rectus & Orbital fat.
• The Superior oblique is the longest, thinnest extraocular muscle.
• Superior oblique muscle is involved in intorsion, depression and abduction of the eyeball.
• Terminal branches of facial nerve are temporal, zygomatic, buccal, marginal mandibular & cervical
• Branch of facial nerve passing through pterygotympanic fissure is chorda tympani
• The arrangement of Branches of Facial nerve after exiting from Parotid gland is given the name
as Pes Anserinus
• Facial nerve is developmentally derived from the second pharyngeal arch
• Chorda tympani is a branch of facial nerve
• chorda tympani joins lingual nerve to supply submandibular gland and tongue
• chorda tympani carries secretomotor fibers to submandibular & sublingual gland
• Chorda tympani branch of facial nerve carries taste sensation from anterior 2/3rd of tongue
• Blood supply of facial nerve is by Anterior inferior cerebellar artery,Labyrinthine artery, Superficial
petrosal artery, Stylomastoid artery
• The terminal branches of facial nerve are Temporal, Zygomatic, Buccal, Marginal mandibular &
cervical
• Facial nerve supplies lacrimal, mucosal ,sublingual , submandibular glands but not parotid
• The muscles supplied by facial nerve include all muscles of face, scalp, auricle, eyelid, around
mouth, neck
• The intracranial branches of facial nerve are greater petrosal, stapedius, chorda tympani
• All the muscles of the face are supplied by facial nerve except levator palpebrae superioris
• Posterior belly of digastric is supplied by facial nerve
• Greater petrosal nerve is the First branch of facial nerve.
• stapedius is supplied by facial nerve
The general visceral afferent column is represented by part of the dorsal nucleus of the vagus nerve.
Dorsal vagal nucleus belongs to general visceral efferent component of vagus
Functional components of facial nerve are GSA, GVA,GVE,SVE,SVA (Facial nerve doesnot contain Somatic
Efferents).
• Lesion occurring at the level of geniculate ganglion will injure greater petrosal branch and will lead
to dryness of eyes
• The Ramsay Hunt Syndrome is caused by reactivation of Herpes Zoster in the geniculate ganglion
• The most common cause of fracture of roof of orbit is Blow on the forehead.
• Unilateral lacrimal gland destruction may be caused by fracture of roof of Orbit.
• Le Forte II facial fracture runs through zygomatic process of the maxilla, floor of orbit, root of nose
on both the sides.
• The walls of the orbit which are removed in the two wall decompression for proptosis of thyroid
ophthalmopathy include part of Orbital floor and medial wall.
• Inferior orbital fissure occupies the posterior part of function between lateral wall & floor.
• Superiororbital fissure occupies thew posterior part of the junction between the roof and lateral
wall.
• Optic canal lies at the junction of roof and medial wall, and is enclosed by lesser wing and body of
sphenoid.
• Facial Nerve stimulation during testing of nerve indicated by contraction of orbicularis oris muscle
• Facial nerve involvement in herpes zoster is known as Ramsay hunt syndrome
• Melkersson-Rosenthal syndrome consists of recurrent facial paralysis
• Schirmer's test is done to assess the function of Facial nerve
• Inability to close left eyelid, drooping of ipsilateral angle of mouth and inability to taste food.
History of discharge from his left ear are the symptoms of facial nerve palsy after herpes zoster
infection
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• Prognosis of Ramsay hunt syndrome is poor than Bell's palsy
• Deviation of angle of mouth towards opposite side shows facial nerve palsy occurring due to lesion
at the outlet of stylomastoid.
• Frey's syndrome is caused by Post traumatic nerve fibres of facial nerve with parasympathetic of
auriculotemporal nerve
• The arterial supply to the parotid gland is from the external carotid artery and its branches within
and near the gland.
• The only medial branch of external carotid artery is Ascending pharyngeal
• Nasal mucosa is supplied by mainly external carotid artery.
• Superior thyroid artery originates from external carotid artery.
• Maxillary artery is the Larger terminal branch of external carotid artery.
• Maxillary artery develops from 1st branchial arch.
• Inferior alveolar artery which gives off its mylohyoid branch just prior to entering the mandibular
foramen.
• Sphenopalatine artery (Nasopalatine artery is the terminal branch of the Maxillary artery) major
blood supply to nasal mucosa.
• Middle meningeal artery is direct branch of Internal maxillary artery.
• Common carotid artery ends at the level of upper border of the thyroid cartilage C4 (C3-C4
disc) where they bifurcate into internal & external carotid artery.
• The left common carotid arises directly from the aortic arch.
• Right common carotid artery arises from brachiocephalic trunk.
• Internal carotid artery at the bifurcation from the common carotid is Lateral to the external carotid.
• Common carotid artery can be compressed against anterior tubercle of transverse process of C6
vertebra, known as carotid tubercle (Chassaignac tubercle), at cricoid cartilage level.
• Common carotid artery can be felt along the anterior margin of sternocleidomastoid at the level of
laryngeal prominence.
• Common carotid artery is palpated at upper border of cricoid cartilage.
• The commonest variation in the arteries arising from the arch of aorta is Left common carotid
artery arising from brachiocephalic trunk.
• Hanging causes large amount of injury to common carotid artery.
• Dye is injected in common carotid in cerebral angiography.
• Right common carotid artery arises from brachiocephalic trunk.
BRANCHES:
1. Cervical Part:
• It ascends vertically in the neck from its origin to the base of skull to reach the lower end of the
carotid canal.
• This part is enclosed in carotid sheath along with internal jugular and vagus nerve.
• No branches arises from the internal carotid artery in the neck.
• Its initial part shows slight dilation, carotid sinus, which acts as a baroreceptor.
2. Petrous Part
• Within the petrous part of the temporal bone,in the carotid canal runs upward forward & medially
at rt. Angle.
• Branches:
1. Caroticotympanic- enter middle ear & anastomose with ant. & post. Tympanic branches
2. Artery of the Pterygoid Canal- anastomose with greater palatine artery
3. Cavernous Part
1. Cavernous branch
2. Superior & inferior Hypophyseal artery
3. Meningeal branch
4. Cerebral Part-
• Lies at the base of the brain after emerging from the cavernous sinus.
• Largest
• Branches:
1. Ophthalmic Artery
2. Anterior Cerebral Artery
3. Middle Cerebral Artery
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4. Posterior Communicating Artery
5. Anterior choroidal Artery
• Berry aneurysms in Circle of Willis is commonly associated with adult polycystic kidney disease.
• Rupture of saccular aneurysm of Circle of Willis is the commonest cause of subarachnoid
haemorrhage.
• Most common site of saccular aneurysms is the anterior circulation on the circle of Willis.
• Vasospasm is the leading cause of morbidity and mortality following aneurysmal subarachnoid
hemorrhage.
• Distal part of the Circle of Willis requires access to the vertebral artery via Suboccipital triangle.
• Circle of Willis lies in subarachnoid space within the deep interpeduncular cistern.
• Anterior communicating arteries in the circle of Willis is derived from Anterior cerebral artery.
• Circle of willis is formed by Anterior cerebral artery (left and right), Anterior communicating artery,
Internal carotid artery (left and right), Posterior cerebral artery (left and right) & Posterior
communicating artery (left and right)
• Structures passing through cavernous sinus are internal carotid artery & abducent nerve.
• As afferents each CS receives spheno parietal sinus, frontal trunk of middle meningeal, superior &
inferior ophthalmic vein, superficial middle cerebral vein, inferior cerebral vein.
• III , IV, V1, V2, VI are the cranial nerves that travels through the cavernous sinus.
• Superior ophthalmic vein directly communicates with cavernous sinus.
• Abducent nerve & internal carotid artery Are the direct content of cavernous sinus
• Facial vein is connected to cavernous sinus via superior opthalmic vein.
• Veins communicating the cavernous sinus to pterygoid plexus pass through fossa of vesalius.
34. TONGUE
• Lymphatic drainage of lateral wall of nose Submandibular nodes, Retropharyngeal nodes & upper
deep cervical nodes.
• Angular vein communicares with Cavernous sinus.
• Dangerous area of face are upper lip & lower part of the nose.
• Angle of mandible supplied by Greater auricular nerve.
• Tip of nose is supplied by External nasal branch of Ophthalmic nerve.
• Muscles of face are supplied by Facial nerve except Levator palpebrae superioris.
• Levator palpebrae superioris muscle is supplied by sympathetic fibers & Occulomotor nerve.
• Complication of trauma to danger area of face- Cavernous sinus infection.
• Lymphatic drainage of lateral part of lower lip by Submandibular nodes.
38. LARYNX
• Superiorly placed larynx in infants helps child to breathe & suckle at same time.
• Larynx is funnel shaped in infant
• Larynx is cylindrical shaped in adults
• Cricoid Cartilage is the narrowest part of infantile larynx.
• Laryngofissure is opening of larynx in midline.
• The maxillary sinus opens into middle meatus at the level of Hiatus semulinaris.
• Maxillary Sinus drains into middle meatus of nose.
• Osteomeatal complex (OMC) connects Nasal cavity with maxillary sinus.
• Maxillary sinus fully develops as the human being reaches the age of 16 at secondary dentition .
• Maxillary sinus is the first paranasal sinus to develop at birth.
• Antrum of Highmore is another name for maxillary sinus.
• Sudden death occur after maxillary sinus irrigation is due Air embolism.
• Frontal sinus drains into anterior part of the corresponding middle nasal meatus of the nose.
• Frontal sinus is absent at birth.
• Frontal sinus is the Most superior sinus.
• Periodicity is a characteristic feature in frontal sinus infection.
• Mucocele is commonly seen in sinus.
• Most common site for osteoma is frontal sinus.
• The most common mucocele of the paranasal sinuses involving the orbit arises from frontal sinus.
• Kiesselbach's area or little's area involves 4 arteries anastomosis that are Anterior ethmoidal, Septal
branch of supeior labial, Septal branch of sphenopalotine & Septal branch of greater palatine
• Anterior ethmoidal artery supplying nasal septum is a branch of opthalmic artery.
• Kisselback's plexus is situated in anteroinferior part of the nasal septum.
• Structures that forms nasal septum are columella, Membranous septum, ethmoid, vomer
bone, septal cartilage, Crest of nasal bone, Nasal spine of frontal bone,Rostum of sphenoid, Crest of
palatine bone & Crest of maxilla and anterior nasal spine of maxilla
• Anterior half of the nasal septum drain to the submandibular node.
• Most common cause for nose bleeding is trauma to little's area.
• Most common site for nose bleeding in children is little's area.
• Apple jelly nodules on the nasal septum are found in cases of Lupus Vulgaris.
CONCHAE/ TURBINATES:
→ The inferior turbinate is a separate bone, while rest of the turbinates are a part of ethmoidal bone.
→ Sometimes fourth turbinate is also present just above superior turbinate known as Supreme turbinate.
→ The middle , superior & supreme turbinates are part of erhmoidal complex, they may be called
as "ethmoidal turbinates".
MEATUS:
• Give opening to nasolacrimal duct (at junction of ant.1/3 & post. 2/3) guarded by Hasner's
valve or lacrimal fold.
i). Ethmoidal bulla: round elevation produced by underlying ethmoidal sinus. Gives opening to middle
ethmoidal air sinus.
ii). Hiatus semilunaris: semicircular sulcus below bulla. Gives opening to:
4. Sphenoethmoidal Recess:
• Triangular Fossa above superior conchae that recieves opening of sphenoidal air sinus.
• Superior orbital fissure is formed by Greater wing of sphenoid and lesser wing of sphenoid.
• Optic canal is a part of lesser wing of sphenoid.
• Vertical crest in fundus of the internal carotid artery os known as Bill's bar.
• Gland derived from foramen caecum is Thyroid.
• Foramen transversarium transmit Vertebral artery.
FORAMEN CECUM • Emissary veins to superior sagittal sinus from the upper part of
the nose
SUPERIOR ORBITAL FISSURE • Divided into 3 parts by common tendinous ring of Zinn:
• Cranial part of accessory nerve supplies all palatal muscles, except tensor veli palatini
• The sensory supply of the palate is through Glossopharyngeal, maxillary nerve, facial nerve
• Pharyngeal plexus supply muscles of soft palate
• Tensor veli palatini is supplied by mandibular nerve
• Middle and posterior lesser palatine nerves supply soft palate and tonsil
• Pharyngeal plexus supply all muscles of soft palate except Tensor veli palatine
• Primary and secondary palates are divided by Incisive foramen
• Sensory fibres from the taste buds in the hard and soft palate travel along Facial nerve
• Tensor veli palatine, Levator veli palatini helps to open Eustachian tube while sneezing
• Palatoglossus is derived from the 6th arch
• Passavant ridge is formed by Superior constrictor and palatopharyngeus
50. PHARYNX
• The chorda tympani nerve is related to the lateral wall of middle ear.
• The auditory tube connects the nasopharynx with the anterior wall of middle ear
• Tympanic plexus present in Medial projection of middle ear cavity
• The distance between tympanic membrane and medial wall of middle ear at the level of center is 2
mm
• Mesotympanum Narrowest part of middle ear
• Sensory nerve supply of middle ear cavity is provided by Glossopharyngeal nerve
• Tegmen seperates middle ear from the middle cranial fossa containing temporal lobe of brain by
roof of middle ear
• Floor of middle ear cavity is in relation with Bulb of the internal jugular vein
• Promontory seen in the middle ear is Basal turn of cochlea
• Lateral wall of middle ear is formed byTympanic membrane
• Scutum is present in Lateral wall of middle ear
• The middle ear cleft in the temporal bone includes Air cells,Mastoid Antrum,Aditus ad Antrum,Attic
(Epitympanum),Eustachian Tube,mesotympanum,Hypotympanum
BORDERS
RIGHT BORDER • Formed by right atrium
LEFT BORDER (Obtuse margin) • Formed mainly by left ventricle & partly by left
auricle
UPPER BORDER • Mainly by left atrium & partly by right atrium where
SVC enters
SURFACES
ANTERIOR (Sternocostal Surface) • Formed mostly by right ventricle (major) &
right auricle & partly by left ventricle & left
auricle.
INFERIOR (Diaphragmatic Surface) • It is formed by left ventricle (left 2/3) & right
ventricle (right 1/3)
BASE (Posterior surface) • Formed mainly by left atrium & partly by right
atrium.
• It is separated from T5 to T8 vertebrae by
pericardium, oblique pericardial sinus,
esophagus & descending aorta.
ARTERIAL • Right atrium & a part of left atrium • Most of left atrium
SUPPLY • Most of the right ventricle (except the • Most of the left ventricle
area adjoining the anterior • Anterior 2/3 of ventricular
interventricular groove) & small part of septum
left ventricle adjoining posterior • Right bundle branch
interventricular groove • Left bundle branch
• Posterior interventricular septum • SA Node- 35% of cases
• Whole conducting system (except right
bundle branch & a part of left branch of
AV bundle).
• SA Node- (in 65%)
• The physiological right & left lobes have separate biliary drainage & vascular supply, i.e. they are
supplied respectively by right & left branches of portal vein & hepatic artery & bile is conveyed by
the corresponding hepatic ducts (bile ducts).
• Based on the distribution of portal vein & hepatic vein, Couinaud divided each physiological
(functional) lobe of liver into 4 segments each & hence liver is divided into 8 segments.
• The physiological left lobe is composed of 4 segments designated I to IV & is supplied by left
branch of hepatic artery, left branch of portal vein & drained by left hepatic duct.
• The physiological right lobe consists of segment V, VI, VII & VIII & is supplied by right hepatic
artery, right branch of portal vein & drained by right hepatic duct.
• RIGHT LOBE is subdivided into anterior & posterior segment & left lobe into medial & lateral
segments.
• Thus the segments of liver are:
• Liver has dual blood supply & receives 20% of its blood supply through hepatic artery & 80%
through portal vein.
• Digastric muscles refers to muscles with two bellies are Muscle fibers in the ligament of
Treitz, Omohyoid, Occipitofrontalis.
• Posterior belly of digastric is supplied by Facial nerve.
• Mylohyoid nerve - branch of CN V3 (Mandibular division of Trigeminal nerve) innervates anterior
belly of trigeminal nerve.
• Second branchial arch give rise to stylohyoid, posterior belly of digastric muscles.
• Stylohyoid & digastric are elevators of larynx.
• Stylohyoid muscle is supplied by Facial nerve.
• Submandibular gland is divided into superficial and deep parts by mylohyoid.
• The greater omentum is folded back on itself and is therefore made up of four layers .
• Greater omentum is generally referred to as "policeman of abdomen".
• The blood supply to the greater omentum is derived from the right and left gastroepiploic arteries.
• Greater omentum develops from caudal part of dorsal mesogastrium.
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• Lesser omentum develops from ventral mesogastrium (dorsal part).
• Junction of the anterior horn and posterior horn of lateral ventricle is called as Trigone of lateral ventricle
• Drainage of CSF from lateral to third ventricle is through Foramen of munro
• Floor of 4th ventricle is formed by Sulcus limitans,Post. surface of pons & Post. surface of medulla
• Magendie foramen or the median aperture drains CSF from 4th ventricle to the cisterna magna
• Fourth ventricle develops from Rhombencephalon
• Infundibulum ,Mammillary body & Optic chiasma are seen in floor of 3rd ventricles
• Abducens nuclei, hypoglossal nuclei, vestibular nuclei & Dorsal vagal nuclei are found in floor of fourth
ventricles
• Cerebral aqueduct (Duct of Sylvius) connects III ventricle to IV ventricle.
• CSF is produced by modified ependymal cells of the choroid plexus
• Floor of fourth ventricle is formed by rhomboidal fossa.
• Ventricles of brain are lined by Ependymocytes
• Anterior horn of lateral ventricle is closed anteriorly by the genu and rostrum of corpus callosum.
• Ligamentum Venosum connects inferior vena cava to the left branch of the portal vein.
• Inferior vena cava forms the posterior wall of the epiploic foramen.
• The tributaries of the inferior vena cava include hepatic veins, inferior phrenic vein, right suprarenal
vein, renal veins, right gonadal vein, lumbar veins, common iliac vein
• Inferior vena cava is formed from vitelline vein .
• The most important structure involved in development of inferior vena cava is Supracardinal vein &
Subcardinal vein.
• The right suprarenal vein drains into the Inferior vena cava.
• Double inferior vena cava is formed due to Persistance of both supracardinal and subcardinal veins.
• Obstruction of Inferior vena cava presents Thoraco-epigastric dilation.
• Segment I, the caudate lobe, has its own biliary drainage. Variations of this are common, and in
78% of individuals the caudate lobe drains into both the left and right hepatic duct.
• Pancreatic & bile duct open into duodenum at Ampulla of vater.
• Cell lining of common bile duct is Simple columnar.
• Common bile duct injuries are most commonly seen in Laparoscopic cholecystectomy operation.
• Onion skin" fibrosis of bile duct is seen in Primary sclerosing cholangitis.
• Cystic lymph node lies b/w cystic duct & common hepatic duct.
• Valves of Heister is seen in Cystic duct.
• Spiral valve is seen in Cystic duct.
• 'U' shaped defect in the fascia tranversalis which form the posterior wall of inguinal canal.
• It lies 1.25 cm above the midpoint of the inguinal ligament.
• Inferior epigastric vessels run upwards & medially along the medial margin of deep inguinal ring.
• Indirect inguinal hernia enters inguinal canal through it.
• Anterior: Skin, superficial fascia, external oblique aponeurosis,fibers of internal oblique in lateral
1/3
• Posterior: Fascia transversalis, extraperitoneal connective tissue, parietal peritoneum, conjoint
tendon in medial 2/3, reflected part of inguinal ligament at medial end.
• Roof: Medial crus of aponeurosis of external oblique Musculoaponeurotic arches of internal oblique
and transverse abdominal
• Floor: Union of inguinal ligament with fascia transversalis, Lacunar ligament at medial end.
• Same as above except ilioinguinal nerve, which enters between external and internal oblique
muscles and passes out through superficial inguinal ring.
• Lymphatics from glans penis, women's clitoris,prostatic urethra, spongy urethra ,deep parts of
lower limb and superficial inguinal nodes drains into deep inguinal lymph nodes.
• Integument of the penis, Scrotum, Perineum ,Buttock, Abdominal wall below the level of the
umbilicus ,Back below the level of the iliac crest, Vulva, Anus (below the pectinate line) ,The thigh
and the medial side of the leg (the lateral leg drains to the popliteal lymph nodes first). drains into
superficial inguinal lymph nodes.
75. KIDNEY
• Nerves passing through lesser sciatic foramen are obturator internus & pudenal nerve
• Superior gluteal nerve supplies Gluteus medius, Gluteus minimus & Tensor fasia lata
• Pudendal nerve supplying motor part to external sphincter is derived from S2-S4 roots
• Gluteus medius is supplied by superior gluteal nerve
• Pudenal nerve is both sensory and motor
• Sacral plexus, Nervi erigentes (S2,3,4) & pudenal nerve are involved in process of erection of penis
• Pudendal nerve leaves pelvis and enters gluteal region through greater sciatic foramen
• Pudendal nerve leaves the gluteal region by passing through the lesser sciatic foramen and enters
the pudendal canal
• Anal canal Supplied by pudendal nerve
• Ischial spine is related to pudenal nerve
• Structures passing through lesser sciatic foramen:
1. Pudendal nerve( leaves gluteal region to enter pudenal canal) lies in relation to Ischial spine
2. Internal pudendal vessels
3. Nerve to obturator internus
4. Tendon of obturator internus
• Skin overlying the region where a venous "cut-down" is made to access the Great saphenous vein is
supplied by Great saphenous vein is supplied by femoral nerve
• Saphenous nerve is a branch of femoral nerve
• Femoral nerve supplies anterior thigh muscles that flex the hip joint (pectineus, iliacus, sartorius)
and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis and
vastus intermedius)
• Anterior division of femoral nerve gives Intermediate femoral cutaneous nerve (intermediate
cutaneous nerve of thigh), medial femoral cutaneous nerve (medial cutaneous nerve of thigh) and
muscular branch to sartorius.
• Structures lieing in relation to common peroneal nerve are Head & neck of femur, biceps
femoris, lateral head of the gastrocnemius,peroneus longus , head & neck of fibula
• Nerve that winds around neck of fibula is common peroneal nerve
• Muscles of the anterior compartment of the leg which are: tibialis anterior, extensor hallucis
longus, extensor digitorum longus, and the peroneus tertius are innervated by deep peroneal
• Deep peroneal provides sensory innervations to space between the first and second toe and a small
area just proximal to the first and second toe on the plantar aspect of the foot.
• Muscles of the anterior compartment of the leg are innervated primarily by deep peroneal nerve
• Nerve supply of adductor magnus is through tibial nerve & obturator nerve
• Popliteus Muscle supplied by tibial nerve
• Gluteus maximus, piriformis, obturator internus, obturator externus, quadratus femoris, superior
gemellus, and inferior gemellus are responsible for external rotation of the hip
• Gluteus medius, gluteus minimus and the deep gluteals are abductors of thighs
• Tensor fasciae latae causes Abduction of hip , Flexion of hip, Extension of knee
• Iliopsoas, rectus femoris, sartorius are muscles causing flexion
• Iliofemoral ligaments limits extension at the hip joint
• Medial rotation and Abduction is caused by Gluteus medius and Gluteus minimus
• Femoral ring is bounded by inguinal ligament, Lacunar ligament,pectineus, septum, femoral vein
• Distance between femoral ring and saphenous opening is 1.25cm
• Structure forming medial boundary of femoral ring is Lacunar ligament
• Femoral artery lies outside the femoral sheath
• Adductor canal contains the femoral artery, femoral vein, nerve to the vastus medialis and the
saphenous nerve .
• Adductor canal is located in thighs.
• Middle genicular artery is a branch of popliteal artery and supplies the cruciate ligaments & the
synovial membrane of knee joint
• Posterior cruciate ligament Prevents posterior dislocation of tibia
• Anterior cruciate ligament prevents Anterior dislocation of tibia
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• Middle genicular artery pierces the oblique popliteal ligament of knee
• Posterior cruciate ligament Originates from Posterior part of intercondylar area of tibia
• When a person gets up from sitting position the femur internally (medially) rotates on the fixed
tibia.
• Abduction of hip , Flexion of hip ,Extension of knee are the action of tensor fasciae latae
• Extension at the knee is caused by quadriceps femoris muscle
• Popliteus unlocks knee
• Chief extensor of knee joint in hip flexion is Rectus femoris
• Extension of knee joint is caused by Quadriceps femoris
• Flexion is coupled with lateral rotation
• In full extension collateral ligaments are taut
• Locking of knee joint can be caused by Osgood shalter & Loose body in knee joint
• Biceps femoris responsible for Lateral Rotaion of Flexed Knee Joint
• The tendon of the Obturator internus, Internal pudendal vessels, Pudendal nerve, Nerve to the
obturator internus are the structures passing through lesser sciatic foramen.
• Structures passing through Greater sciatic foramen:
1. Sciatic Nerve
2. Superior Gluteal Nerve
3. Inferior Gluteal Nerve
4. Pudendal Nerve
5. Posterior Femoral Cutaneous Nerve
6. Nerve to Quadratus Femoris
7. Nerve to Obturator Internus
8. Superior Gluteal Artery & Vein
9. Inferior Gluteal Artery & vein,
10. Internal Pudendal Artery & vein
11. Piriformis muscle
• METANEPHROS forms EXCRETORY UNIT of kidney i.e. Glomerulus , proximal convoluted tubule ,
loop of henle , distal convoluted tubule.
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• URETERIC BUD forms COLLECTING PART of kidney i.e. pelvis , Major calyces, Minor calyces,
Collecting tubules, Ureter.
• URINARY BLADDER (except TRIGONE) is derived from Vesicourethral canal, cranial part of
urogenital sinus(endodermal).
• TRIGONE is derived from absorbed part of Wolffian duct/ mesonephric duct(mesodermal).
• Upper 2/3 or 3/4 of vagina is derived from paramesonephric (mullerian duct)- mesodermal.
• Lower l/3 or l/4 of vagina is derived from urogenital sinus-endodermal.
• Differentiation of genital ridge into female or male gonads (ovary & testes) occurs at 6-10 weeks.
• Germ cells in the OVARY are derived from yolk sac endoderm.
• Leyding cells, develop from mesoderm of the gonadal ridge and are located between sex cords.
• Cowden’s syndrome associated with GENITOURINARY SYSTEM.
• Malformations of genitourinary system of foetus are found to be m/c associated with single
umbilical artery.
• In newborns and infants, kidneys have a larger medullary and a smaller cortical volume than in
later life.
• Most common site of genitourinary tuberculosis is - KIDNEY.
• In Genitourinary TB, Sterile pyuria is consistent finding.
• Pipe stem ureter appearance is seen in patients with Genitourinary TB.
• Cystic fibrosis affects GENITOURINARY SYSTEM.
• Horse shoe kidney is the most common congenital renal anomaly.
• Congenital anomalies : Renal agenesis (unilateral/ bilateral) failure of the ureteric bud to contact
the ipsilateral metanephric blastema.
• Associated anomalies -in females: Unicornuate uterus, Uterus didelphys, Mayer- Rokitansky-
Küster-Hauser(MRKH), Gartner duct cyst
In males: Seminal vesicle cysts, Absence of the Vas deferen, Cystic dysplasia of the rete testis
103. DIAPHRAGM
• Structure passing along the aorta in the diaphragmatic opening is Thoracic duct & Azygous vein.
• Aortic hiatus contains Azygous vein & Thoracic duct.
• The opening in central tendon of diaphragm transmits IVC & Branches of right phrenic nerve.
• Oesophagus enters through muscular part of diaphragm.
• Anterior diaphragnatic hernia is through Foramen of morgagni.
• The skull forms the cranial end of the axial skeleton. It is composed of 22 bones of which 8 bones
are present in calvaria (brain case) and 14 bones in facial skeleton.
• Mandible is the only mobile bone in skull. It is the strongest bone of body.
• Cribriform plate is thinnest and is a part of ethmoid.
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• Greater wing of sphenoid presents following foramina: Foramen rotundum, foramen ovale,
foramen spinosum, canaliculus innominatus, and emissary sphenoidal foramen (Foramen of
Vesalius).
• Optic canal (foramen) is enclosed by lesser wing of sphenoid and body of sphenoid.
• Arcuate eminence in petrous part of temporal bone is caused by superior semicircular canal.
• Cartilaginous part of auditory tube (Eustachian tube) lies inferior to spheno-petrosal synchondrosis.
• Clinically Sternberg’s canal is important as it is clinically associated with:Craniofacial angle is 130
degree.
• Dorello canal is an opening to cavernous sinus that transmits abducent nerve underneath the
superior petrosal sinus.
• Anterior fontanelle (bregma) is closed by 18 months and posterior fontanelle (lambda) by 2-6
months.
• Premature closure of foramen ovale results in Right ventricular hypertrophy.
• Maxillary bone does not articulate with Sphenoid.
• Pierre Robin sequence is caused by defect in development of first (1st) pharyngeal arch.
• Branchial cyst derived from 2nd branchial cleft (2nd pharyngeal cleft).
• First pharyngeal arch (mandibular arch) develops two prominences: smaller maxillary
prominence (forms maxilla, zygomatic bone, squamous temporal bone) and larger mandibular
prominence (forms mandible).
• Tympanic membrane derived from first pharyngeal membrane (which seperates 1st pharyngeal
groove from 1st pharyngeal pouch) represents all three layers of embryonic disc.
• Parafollicular 'C' cells develop from Ultimobranchial body.
• Tongue muscles originate from myoblast of occipital somites (occipital myotomes).
• Anterior 2/3 of tongue develops from 1st (lingual swelling) and tuberculum impar.
• Posterior 1/3 is developed from 3rd arch (cranial part of hypobronchial eminence).
7. Pharyngeal Clefts
Derivatives of Neuroectoderm
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From NEURAL TUBE: From NEURAL CREST:
• CNS (brain, spinal cord), A) NEURAL DERIVATIVES
• Astrocytes • Sensory neurons of 5th, 7th, 8th, 9th. 10th cranial nerve ganglia
(trigeminal, geniculate, sphenopalatine, submandibular,
cochlear, vestibular, otic and vagal parasympathetic
ganglia).
• Glomus cells
B) MESENCHYMAL DERIVATIVES
DERIVATIVES OF MESODERM
1. PARAXIAL MESODERM:
1. Sclerotomes: Forms axial skeleton including vertebrae, ribs and parts of neurocranium.
2. Myotomes: Form all voluntary (skeletal) muscles of head, trunk and limbs.
3. Dermatomes: Form dermis of skin, especially over dorsal regions.
2. INTERMEDIATE MESODERM:
1. Urinary organs: Kidney, ureters, trigone of bladder, posterior wall female urethra, posterior wall of
upper half of prostatic part of male urethra, inner glandular zone of prostate.
2. Reproductive organs: Gonads (testis and ovary), epididymis, ducts deferens, seminal vesicle,
ejaculatory duct, uterus, uterine tube and upper part of vagina.
• It forms:-
• All connective tissues including specialised connective tissue like bone, cartilage, adipose tissue.
• Dermis of skin over ventrolateral body wall and limbs.
• Smooth muscle and connective tissue of respiratory tract, gut, blood vessels and heart.
• Adrenal cortex.
• Mesothelium (visceral layer) of pleural, peritoneal and pericardeal cavities.
• Mesenchyme surrounding pericardial coelom gives rise to myocardium and serous pericardium.
• Spleen and lymph nodes.
• Diaphragm
• Fibrous pericardium
• Endocardium of heart
• Endothelium of blood and lymphatic vessels.
• Microglia, tissue macrophage.
• Circulating blood vessels.
DERIVATIVES OF ENDODERM
• Gastrointestinal tract including gall bladder, extrahepatic duct system and pancreatic duct.
• Pharyngotympanic tube (eustachian tube), middle ear, inner layer of tympanic membrane,
mastoid antrum and air cells.
• Respiratory tract including larynx, trachea, bronchi and lungs (alveoli).
• Genitourinary tract urinary bladdet except trigone (mesodermal), female urethra except part of
posterior wall (mesodermal), male urethra except posterior wall of prostatic urethra (mesodermal)
2) Glandular tissue
3) Reticular tissue
• The isthmus lies against the 2nd and 3rd tracheal rings at the level of C7.
• Ligament of Berry in thyroid fixes Cricoids cartilage.
• Lymphatic drainage of thyroid gland mainly from deep cervical lymph node.
• Inferior thyroid artery is a branch of Thyrocervical trunk.
• Inferior thyroid vein drains into Brachiocephalic vein.
• Middle thyroid vein drains into internal jugular vein.
• The Recurrent laryngeal nerve lies very close to the inferior thyroid artery near the base of the
thyroid lobe.
i) The primary olfactory neurons lie at the body surface in the epithelium lining the roof of nasal cavity
(olfactory epithelium).
ii) The primary olfactory neurons undergo continuous turnover being replaced from stem cells in the
olfactory epithelium.
iii) It is the only cranial nerve that projects directly to forebrain (telencephalon).
iv) The olfactory neurons enter the allocrotex directly without relaying through thalamus.
General visceral afferent • Nucleus tractus solitarius (lower part) receives sensations
from pharynx,larynx, trachea, esophagus and thoracic and
abdominal viscera.
Special visceral afferent • Nucleus tractus solitarius (upper part) receives taste
sensation from posterior most part of tongue (vallecula)
and epiglottis through internal laryngeal nerve.
General somatic afferent • Distributed to skin of auricle, external meatus and tympanic
membrane and terminate in spinal nucleus of trigeminal.
ACCESSORY NERVE
• CRANIAL ROOT arises from medulla and leaves the cranial cavity through jugular foramen.
2. SPINAL ROOT also contains special visceral (branchial) efferent fibers which arise from the spinal
nucleus in the ventral horn of C1 to C5 spinal cord segments.
PHARYNGEAL PLEXUS
i) Pharyngeal branch of vagus carrying fibers of cranial accessory nerve→ Motor supply for muscles of
pharynx (except stylopharyngeus) & soft palate (except tensor palati).
ii) Pharyngeal branches of glossopharyngeal nerve→ for sensory supply of mucosa of pharynx (except
nasopharynx above the level of opening of auditory tube).
iii) Pharyngeal branches of superior cervical sympathetic ganglion.
• Posterior cord of brachial plexus is formed by Dorsal divisions of upper, middle & lower trunks.
• Radial nerve is the largest branch of brachial plexus and is the continuation of posterior cord (root
value C5- C8, T1).
• Axillary nerve is a branch of Posterior cord of brachial plexus .
• Axillary nerve supplies teres minor & deltoid.
• Musculocutaneous nerve is injured at the lateral cord of brachial plexus, positive clinical findings
would be Sensory loss on the radial side of forearm.
• Brachial plexus is surrounded by fascia derived from prevertebral fascia
• It starts from above the fifth cervical vertebra to underneath the first thoracic vertebra(C5-T1).
• Cord of brachial plexus are named as per their relation with the axillary artery behind PECTORALIS
MINOR muscle.
• All the muscles of pectoral girdle are supplied by Brachial Plexus except trapezius muscle which is
supplied by CN1
• Nocturnal parasthesias of the thumb and the index and middle fingers with atrophy of the thenar
eminence & positive Tinel sign is suggestive of Carpal tunnel syndrome.
• Carpal tunnel syndrome is caused by Hypothyroidism, Pregnancy & Acromegaly.
• Median nerve involvement is present in Carpal tunnel syndrome.
• Carpal tunnel syndrome is associated with Acromegaly,Rheumatoid arthritis,Gout, Wrist
osteoarthritis,Diabetes Mellitus,Hypothyroidism, Myxedema & Pregnancy
• The carpal tunnel involves Median Nerve, Flexor pollicis longus & Flexor digitorum superficialis.
• Compression of a nerve within the carpal tunnel products inability to Oppose the thumb.
• Most sensitive test for carpal tunnel syndrome is Phalen's test.
• Injury or compression of median nerve at wrist (eg carpel tunnel syndrome) can be tested by
4. Sensory loss - lateral 31/2 of digits & 2/3 palm (autonomous zone is tip of index & tniddle finger)
• Median nerve injury at wrist, is commonly tested by Contraction of abductor pollicis brevis
• Carpal tunnel syndrome is caused by the compression of the median nerve at wrist and is most
common type of nerve entrapment syndrome.
• In High median nerve palsy sensory loss in the thumb, index, middle & radial half of the ring fingers
& lateral 2/3 of the palm.
134. STOMACH
• Lateral & posterior cutaneous nerves of arm and posterior cutaneous nerve of forearm are spared
in low radial nerve lesions.
• Most common complication of mid shaft humerus fracture is Radial nerve palsy.
• Wrist drop is seen with Radial nerve palsy.
1. deltoid paralysis
2. teres minor paralysis
3. loss of rounded contour of shoulder
4. sensory loss in small patch of skin & on the outer surface of arm
5. There is loss of abduction from 15-90 degree due to paralysis of deltoid (first 15 degree of flexion is
not lost as it is caused by supraspinatus & overhead abduction is preserved as it is caused by
trapezius & serratus anterior).
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137. MUSCULOCUTANEOUS NERVE
• Musculocutaneous nerve branch of lateral cord of brachial plexus with root value C5,6,7.
• Musculocutaneous nerve supplies Biceps brachii, corachobrachialis, and brachialis.
• Damage to musculocutaneous nerve results in:
• Radial artery is the terminal branch of brachial artery, arising in cubital fossa
• Radial artery is the only content of anatomical snuff box.
• Musculocutaneous nerve supplies coracobrachialis, biceps brachii, and the greater part of the
brachialis.
• Abductor pollicis brevis is supplied by Median nerve .
• Deltoid & teres minor muscles supplied by Axillary nerve (C5,6).
• In deltoid paralysis Axillary nerve is involved.
• Teres major muscles supplied by Lower subscapular nerve.
• Pectoralis major & minor muscles is supllied by Medial pectoral nerve.
• Pectoralis major is the most common muscle to be congenitally absent (POLAND SYNDROME)
• Winging of scapula is caused most commonly by serratus anterior palsy.
• Dropped shoulder is caused by paralysis of trapezius.
• Palmar brevis is a remnant of panniculus carnosus.
• Third head of coracobrachialis is denoted as struther’s ligament.
• Rotator cuff consists of supraspinatus, infraspinatus, teres minor & subscapularis.
• Most commonly tendon damaged among rotators is supraspinatus.
• Femur is the longest & strongest bone of the body. It is proximal end, shaft & distal end.
• True Supracondylar fracture of femur is Type A.
• Main blood supply to the head and neck of femur comes from Medial circumflex femoral Artery.
• Lower end of femur is ossified from 1 ossification center.
• Distal end of femur is the growing end.
• Bronchial arteries are branches of the descending thoracic aorta. They supply the bronchial wall as
for as the respiratory bronchioles.
Crista terminalis divided the right atrium into smooth posterior part & rough anterior part.
The SA node is composed of a cluster of small fusiform cells in the sulcus/crista terminalis at the right
atrial–superior vena caval junction.
SA node acts as a pacemaker of the heart because of the fact that it Generates impulses at the highest
rate.
SA Node is supplied by nodal artery, a branch of RCA in 65% cases & a branch of circumflex branch of LCA
in 35% cases.
SA node is supplied by right vagus/parasympathetic (inhibitory) and right Sympathetic (excitatory) system
152. OESOPHAGUS
• 3rd constriction of the oesophagus is at the level of Where it pierces the diapharm.
• Barrett's oesophagus is Lower esophagus lined by columnar ephithelium.
• Ilnd constriction in oesophagus is seen at the Crossing of Aorta
• Oesophagus crosses the diaphragm at the level of T10.
• Arterial supply of cervical part is by inferior thyroid artery, thoracic part by azygous vein,
& abdominal part by left gastric artery & left inferior phrenic artery.
153. TRACHEA
155. AORTA
• Aorta with thoracic duct & azygous vein crosses through aortic hiatus of diaphragm.
• Brachiocephalic trunk, Left common carotid artery & Left subclavian artery are the direct branches
of arch of aorta.
• Tracheal bifurcation lies at the level of arch of aorta.
• Left common carotid artery arising from brachiocephalic trunk is the commonest variation in the
arteries arising from the arch of aorta.
• Celiac trunk, Superior mesenteric & Inferior mesenteric are the branches of anterior part
of abdominal aorta.
• Inferior phrenic, Middle Suprarenal, Renal are lateral branches of abdominal aorta.
• External iliac Artery make anastomosis with superior epigastric artery.
• Muscular component of dorsal aorta develops from Lateral plate mesoderm.
• Arch of aorta crosses the esophagus at 25 cm from the incisor teeth.
• Sequestrated Lung lobes are supplied by descending aorta.
• Arch of aorta develops from Left fourth aortic arch artery.
• Aortic arch ends at level of left 2nd costal cartilage.
• Arch of aorta begins and ends at which level T4.
• Aortic arch Lies behind manubrium sterni.
• Coarctation of the aorta is common in Turner's syndrome.
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156. SUPERIOR VENA- CAVA
• Superior vena cava opens into right atrium at the level of T5.
• Left sided superior vena cava drains into coronary sinus.
• Azygous vein drains into Superior vena Cava.
• Superior vena cava enters the heart at the level of 3rd costal cartilage.
• Pierces paricardium at 2nd costal cartilage.
• Superior vena cava receive azygous vein behind sternal angle.
Parts & relations • Apex: Bare area of liver • Upper end: Close to spleen
• Base: Upper pole of right • Lower end: Presents hilum,
kidney left vein emerges from here
LYMPHATIC DRAINAGE:
158. URETER
• The lumen of the ureter isn’t consistent throughout and presents 3 constrictions at these sites:
1. At the pelviureteric junction where the renal pelvis joins the upper end of ureter.
It’s the upper most constriction, seen roughly 5 cm far from the hilum of kidney.
2. At the pelvic brim where it crosses the common iliac artery.
3. At the uretero-vesical junction (i.e., where ureter enters into the bladder).
POSTERIOR : Ureter lies on psoas major, transverse process (tips), & Genitofemoral nerve
BLOOD SUPPLY:
LOWER (PELVIC) PART • Supplied by branches from the vesical, middle rectal or uterine
vessels.
• Locus coeruleus is the most important source of noradrenergic innervation to the cerebral cortex.
• Broca's area is formed of two minor gyri, called pars opercularis and pars triangularis, that lie in the
posterior end of the inferior frontal gyrus. This area subserves expressive language function.
• Area 8 (the frontal eye field) is concerned with eye movements.
• Spongiform degeneration of cerebral cortex occurs in Creutzfeldt-Jakob disease
• Trunk has small representation in somatosensory area of cerebral cortex
• Cervical vertebrae can be differentiated from thoracic vertebrae on the basis of Presence of
foramen transversarium.
• First cervical vertebra (atlas) is ring like bone having lateral mass.
• Second cervical vertebra (axis) is characterized by presence of odontoid process or dens.
• Seventh cervical vertebra is called as vertebra prominens because it has most prominent spinous
process.
• The hyoid bone is found at the level of third cervical vertebrae in adults.
• Primary vertebral curve is Thoracic.
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• The anterior tubercle on transverse process of C6 vertebra is prominent & is called carotid tubercle
or chaissagnac’s tubercle.
• Chassaignac’s tubercle loes at the level of Erb's point.
• Movements permitted at atlanto-axial joints are side to side rotation of head (looking towards right
or left).
• Maximum flexion in thoracic vertebrae accurs at Lower Thoracic.
• Membrane tectoria is a continuation of posterior longitudinal ligament.
• Anterior atlanto-occipital ligament is considered as continuation of anterior longitudinal ligament
• Membrane tectoria is continuation of posterior longitudinal ligament.
• Transverse ligament forms the horizontal part of cruciform or cruciate ligament
162. SPLEEN
163. PANCREAS
• The omohyoid muscle is an important landmark in both the anterior and posterior triangles of the
neck.
• Base of the posterior triangle of neck is formed by superior surface of middle third of clavicle.
• Superficial incision on posterior triangle of neck leads to difficulty in shrugging of shoulder.
• Contents of Suboccipital triangle are:
Physiology
RENIN-ANGIOTENSIN SYSTEM
• High Anion Gap Acidosis is seen in Renal Tubular Acidosis, Diabetic Ketoacidosis, Lactic Acidosis, &
Methanol Poisoning
• Starvation, Ethylene glycol poisoning are causes of increased anion gap
• The anion gap is calculated as AG = Na+ – (Cl- + HCO3-)
• Urinary anion gap is an indication of excretion of NH4+
• Cholera & Diarrhoea is associated with normal anion gap metabolic acidosis
• Renal Tubular Acidosis is diagnosed using a positive urinary anion gap
• Anion gap is mostly due to protein
• Normal anion gap is 10-12 mEq/L
• ANP causing natriuresis (Increased Na+ excretion), by increasing GFR & reducing Na+ reabsorption
from distal tubule & collecting ducts.
• Cyclic GMP act on Atrial natriuretic peptide.
• Effects of ANP are physiologically antagonistic to angiotensin II, mainly acts on kidney & blood
vessels.
• Reduces secretion of renin, aldosterone & ADH, inhibit ADH-stimulated water reabsorption
across collecting ducts.
• ANP is "Powerful vasodilator" relaxes vascular smooth muscle in arterioles & venules, lowering BP.
4. SPERMATOGENESIS
SPERMATOGENESIS
STEPS:
• Initial phase:
o Spermatogonia 1° spermatocytes 2° spermatocytes
• Maturation phase:
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o Spermatids spermatozoa (sperms)
Hormonal influence:
Step 1:
Step 3 - Spermiation
HORMONES INVOLVED:
Individual action:
1. FSH -
2. LH -
3. Testosterone -
4. Estrogen -
5. Growth hormone -
6. Inhibin -
Metrics:
• Healthy human adult forms up to 120 million sperm each day from both of testis together.
• Formation of mature sperm from primitive germ cells require average of 74 days
5. PARATHROMONE
PARATHORMONE/PARATHYROID HORMONE/PTH
RECEPTORS
• Type 1:
• PTH 1R (h-PTH/ Parathyroid Hormone-related Protein PTH-rP)
• Bone (osteoblast) & kidney
• 2nd messenger - cAMP (main), IP3 & calcium.
• Osteoclasts do not have any PTH receptors.
ACTIONS:
1. ON BONE:
ON KIDNEY:
On intestine:
6. CHOLECYSTOKININ (CCK)
FUNCTIONS:
BASAL GANGLIA
• Caudate nucleus
• Lenticular nucleus -
o Divided into 2 by,
o External medullary lamina - Vertical plate of white matter
• Sub-divisions:
o Putamen
o Globus pallidus - Principle output nuclei & efferents arise here.
2. Subthalamic nucleus
3. Substania Nigra -
1. Afferent connections:
2. Efferent connections:
• Connection 1:
o Dopaminergic nigrostriatal projection from "Substantia Nigra Pars Compacta"
(SNPC) striatum (caudate nucleus & putamen)
o Corresponding GABAergic projection from stratium Substantia Nigra Pars Reticulata
(SNPR).
o Dopamine - Major neurotransmitter in Substantia nigra
• Connection 2:
o Inhibitory GABAergic projections from Striatum to both Globus Pallidus Inner Segment
(IS) & External Segment (ES).
• Connection 3:
o GABAergic projections from Globus pallidus ES Subthalamic nucleus & to Globus pallidus
lS
• Connection 4:
o Excitatory Glutamate-ergic projections from Subthalamic nucleus Globus pallidus IS & ES
1. Dopaine -
• Neuromodulatory neurotransmitter
• Used by SNPC selectively modulate areas of stratium(caudate/putamen)
2. Glutamate
• Excitatory neurotransmitter
• From Subthalamic nucleus Stimulate ventrolateral thalamus1° localized motor cortex.
3. GABA -
• Inhibitory neurotransmitter
• Caudate/striatum
o Direct Inhibit GPIS
o Indirect Inhibit GPES
1. Hyperkinetic:
2. Hypokinetic:
3. Parkinsonism:
4. Huntington chorea
5. Wilson's disease -
• Hepato-lenticular degeneration.
• Affects lenticular nuclei (pallidus & putamen)
• Features: Rigidity, dystonia, chorea, athetosis, dysarthria, & tremor
6. Ballism -
• Subthalamic nucleus
7. Athetosis -
• Sigmoid shaped-
o "Due to phenomenon "Cooperative binding of Oxygen to hemoglobin".
• Hemoglobin is a tetramer
o Four O2 molecules binds 1 Hb molecule.
st
o 1 O2 molecule bonds with greatest difficulty.
o Increasing affinity to next O2 molecule
o Saturation increases steeply between PO2 15mm Hg & 40 mm Hg.
o Beyond PO2 60mm Hg, curve becomes almost flat.
• PO50 higher
o Indicating decreased hemoglobin affinity for oxygen.
Conditions associated:
• PO50 lower.
• Indicating increase in affinity of hemoglobin for oxygen.
Conditions associated:
BOHR EFFECT:
10. SPIROMETRY
CEREBELLUM
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Embryologically cerebellum is derived from Metancephalon
DIVISIONS:
• Anterior lobe
• Posterior lobe
• Flocculonodular (lateral flocculus & medial nodulus)
• Midline vermis
• Left cerebellar hemisphere
• Right cerebellar hemisphere
• Two hemispheres are joined by vermis.
ATTACHMENTS:
• Medulla -
o By three cerebellar peduncles
PARTS OF CEREBELLUM:
• Climbing fibers -
o From inferior olivary nuclei only.
• Mossy fibers -
o From all other parts of body
• Axons of Purkinje cells are the only output from cerebellar cortex.
• Deep Nucleus - Ultimate & final efferent output of cerebellum.
• 3 parts,
o Vestibulocerebellum/ Flocculonodular lobe
o Spinocerebellum
o Cerebrocerebellum/ Neocerebellum
1. Vestibulocerebellum/Flocculonodular lobe:
Parts:
Connections:
• Receives afferents -
o From vestibular apparatus
• Sends efferents -
o To Vestibular nuclei
• Direct connection to vestibular nuclei without involvement of deep nuclei
Functions:
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Works with vestibular apparatus to,
2. Spinocerebellum:
Functions:
• Compares plans.
• Smoothens & coordinates ongoing movements
3. Cerebrocerebellum/ Neocerebellum:
Functions:
FUNCTIONS OF CEREBELLUM:
• Co-ordination of movements
• Regulation of tone, posture & equilibrium
• Smoothening & coordination of voluntary movements
• Coordination of eye movements
• Planning & initiation of movements.
• Learning of frequently performed voluntary movements.
• Timing & comparison:
o Cerebellum - Timing device.
o Times duration of agonistic muscle activity & latency of antagonistic activity.
o Ensures halting movement at correct point.
LIMBIC SYSTEM
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• The neuronal circuit controlling emotional behavior & drives motivations.
COMPONENTS
• Surrounds hypothalamus
Parts:
• Septum
• Hippocampus
• Amygdala
• Para-olfactory area
• Anterior nucleus of thalamus
• Portion of basal ganglia
3. Hypothalamus
NEURONAL CONNECTIONS
Pathways:
1. Papex circuit:
• Hippocampus
• Mamillary body
• Anterior thalamic nuclei
• Cingulate gyrus
Reward center:
3. Other connections:
• Subiculum
o Provides reciprocal connections bt limbic system & neocortex
• Amygdala:
• Linking unit:
o Along with hippocampus, amygdala is extensively connected with Association cortex area &
Hypothalamus.
o Thus, provides link between limbic system & neocortex.
Neurophysiology of emotions:
• Peripheral component:
o Hypothalamus - Co-ordinates peripheral & autonomic component of emotions.
• Co-ordinating component:
o Amygdala - Pivotal role in co-ordinating pperipheral & central component
2. Autonomic responses:
• Fear
o Produced by Amygdala
• Rage
o Produced by stimulation of lateral hypothalamus
• Placidity
o Caused by bilateral destruction of amygdala
• Punishment center:
• Reward/pleasure center:
ASSOCIATED CONDITIONS:
KLUVER-BUCY SYNDROME:
• Neuro-behavioural syndrome.
Causes:
• In humans occurs due to destruction of amygdaloid body & inferior temporal cortex
o Commonly due to Herpes Simplex Encephalitis (HES)
Features:
• Visual agnosia.
• Emotional changes
o Loss of normal fear & anger responses - "Placidity".
• Hypersexuality
o Less pronounced.
• Suprachiasmatic nucleus
• Feeding center
o Lateral hypothalamic nucleus
• Satiety center
o Ventromedial nucleus
4. Regulation of thirst:
• Lateral nucleus
• Supra-optic nucleus
5. Regulation of BP:
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• Pressor effect
o Posterior & lateral nuclei.
• Depressor effect
o Preoptic nucleus
• In males:
o Medial preoptic nucleus
• In females:
o Lateral preoptic nucleus
7.Osmoreceptor:
• Anterior hypothalamus
8. Response to smell:
• Posterior hypothalamus
• Sleep center
o Preoptic (Ventrolateral)
• Wakefulness center
o Reticular Activating System (RAS) in brainstem & hypothalamus
• Reward center
o Lateral & ventromedial nuclei of hypothalamus
• Punishment center
o Periventricular nuclei (mainly)
• Arcuate nucleus
o Releases activator hormone somatostatin
o For Growth hormone secretion.
• Preoptic nucleus
o Releases activator hormone Gonadotrophin Releasing Hormone (GnRH)
o For FSH & LH secretion
• Paraventricular nucleus
o Releases activator hormone Corticotropin-releasing hormone (CRH)
PITUITARY GLAND:
Anatomical considerations:
• Lies in bony walled cavity - Sella turcica of sphenoid bone at base of skull
• Closely associated with hypothalamus.
Embryological facts:
HORMONAL SECRETIONS
1. Secretions from anterior lobe/adenohypophysis -
2 major cell types
• No hormones secreted
• Acidophils-
• Basophils-
o Forms 20% - 30 % of total cells
o Gonadotropes - Follicle Stimulating Hormone (FSH) & Leutinizing hormone (LH)
o Thyrotropes -Thyroid stimulating hormone (TSH) Thyrotropin
o Corticotrophs- Adrenocorticotropin hormone (ACTH) Corticotropin
Note:
• ACTH & MSH are derived from larger molecule named "Proopiomelanocortin"
• Oxytocin -
o From secretory granules of axons of paraventricular nuclei
• Antidiuretic hormone (ADH)/vasopressin
o From secretory granules of axons of hypothalamic supraoptic nucleus
Classification:
2. Pituitary apoplexy:
3. Diabetes mellitus:
• Metabolic acidosis is due to decreased plasma HCO3- which results in decreased pH and acidosis.
• Also associated with increased renal ammoniogenesis, which increases amount of ammonia
available in the tubule for buffering augmented H+ secretion.
ABSORPTION OF IRON
GLUCOSE TRANSPORTERS
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Transport of glucose -
TRANSPORTER LOCATION
PANCREATIC SECRETIONS
REGULATION:
1. SECRETIN:
2. CCK:
• Aortic elastic recoil property & arteriolar resistance maintains relatively high aortic pressure during
diastole.
• An incisura/dicrotic notch in an aortic pressure curve, corresponds to aortic valve closure.
PRESSURE-VOLUME LOOP:
• Begins in stomach.
Enzyme involved:
1. Pepsin activity:
Enzyme activation:
• Sodium-dependent co-transport.
1. Peptidases (Proteases)
1b). Exopeptidases(Exoproteinases)
Enzymes involved:
1. Pancreatic juice
2. Bile salts
• After fat digestion, fatty acids & monoglycerides are absorbed in small intestine (especially
jejunum)
• Emulsification increases surface to volume ratio of the lipid droplets facilitating lipases action.
• Hence, emulsification facilitates action of lipases & mainly helps in digestion of ingested fats.
• Bile salts help in fat emulsification in small intestine
o Due to detergent action of bile salts.
2. Micellar formation:
• Micellar formation solubilizes digested fats & facilitates absorption into enterocytes.
o I.e., Helps in absorption of digested fats
• Bile salts have the property of forming micelles.
• Each micelle contains detergents (Bile salts) & absorbable fats.
• Starch - Polysaccharide composed of glucose units linked by 1, 4 - alpha linkage & 1, 6 branching
point.
• Enzymes involved:
o Salivary amylase (Ptyalin).
o Pancreatic amylase.
-
o Both activated by Cl
• Optimal pH is 6-7. (vs acidic in stomach).
Digestion in Intestine:
Enzymes involved:
1. Maltase (c-glucosidase):
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• Breaks 1:4 linkages in maltose & maltotriose
3. Sucrase:
4. Lactase (β-glucosidase):
3. Mechanism:
• Rapid absorption - Seen with monosaccharides specially hexoses (glucose, fructose, galactose).
• By facilitated diffusion
• Absorbed along concentration gradient
• Carrier protein- GLUT-2.
• Stimulation of skin.
• Anxiety.
• Jendrassik's maneuver.
• Increased Glycogenesis.
• Increased glycolysis
o By inducing phosphofructokinase & pyruvate kinase enzymes.
Glucose uptake:
• Stimulates anabolism -
o Increasing the rate of synthesis of mRNA
• Inhibits catabolism -
o Increases active transport of amino acids into tissues.
EFFECTS ON ELECTROLYTES
• Causes Hypokalemia
• On Adipose Tissue:
o Increased glucose entry converted to triglycerides.
o Increased fatty acid synthesis.
o Increased lipogenesis.
o Increased glycerol phosphate synthesis.
o Activation of lipoprotein lipase.
o Increased clearance of VLDL & chylomicron.
o Inhibition of lipolysis.
o Inhibition of hormone-sensitive lipase
• On Muscle:
o Increased glucose entry.
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o Increased K+ uptake
• On Liver:
o Decreased ketogenesis.
o Increased protein synthesis.
o Increased lipid synthesis.
o Decreased glucose output.
o By ↓ing gluconeogenesis & ↑ing glycolysis.
o Increased glycogen synthesis.
o Inhibits glycogenolysis.
• Alpha
• Beta
• Theta
• Delta
Alpha Wave
Beta Wave
• ALPHA BLOCK
o Replacement of beta rhythm for alpha rhythm is called Arousal / Alerting response / Alpha
block.
o Phenomenon occurs during any form of sensory stimulation or mental concentration such
as solving arithmetic problems.
• Also seen during transition state from wakefulness to sleep. Similar to Stage 1 of REM.
• Frequency: 4 - 7 Hz
• Occur normally in parietal & temporal in children,
o In adults during EMOTIONAL STRESS, particularly during disappointment & frustration.
o Brain disorders like degenerative brain conditions.
Delta Rhythm
Farady Cage
• EEG cabins completely shielded by a continuous sheet of copper wire mesh to avoid picking up of
noise from external electromagnetic disturbances
• This shielding is Faraday cage.
SYNTHESIS:
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• In Hypothalamus
• Supra-optic nucleus
• Along with binding protein Neurophysin-I
• Stored in Pituicytes
RECEPTORS:
Vaso-constriction
V2 Kidney
Regulation of secretion:
• By Osmoregulators
• Circum-ventricular organs, primarily from
o Organum Vasculosum of Lateral Terminalis (OVLT)
o Antero-lateral wall in 3rd ventricle
Stimulating factors:
• Hyperosmolarity
• Decreased ECF volume
• Drugs - Carbamazepine, Morphine
Inhibiting factors:
Effects on Kidney:
• Retention of water:
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o Increase permeability & water absorption
Characteristics:
Causes:
Investigations:
Treatment:
• Characteristics features:
o Large volumes of dilute urine formation
o Resulting in severe dehydration in unconscious patients
Treatment:
• Desmopressin
Causes:
PULMONARY COMPLIANCE
Variations in compliance:
• Increased compliance:
o Emphysema (COPD)
o Old age
• Decreased compliance:
o Pulmonary interstitial fibrosis
o Pulmonary congestion
o Reduced surfactant (Pre-mature infants)
• Surface tension:
• More surface tension = Less compliance
• Emphysema (COPD) -
o Increased pulmonary compliance
o Pressure-volume curve is shifted upward & to left.
Mechanism of action:
• Breaking water molecule inside alveoli and its surface tension subsequently
Functions:
• Acts on alveoli
• Alveolar stabilization
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• Reduction in alveolar surface tension.
• Increases lung compliance
• Decreased compliance
• Hyaline membrane formation
Important metrics:
• Total compliance of both lungs together in the normal adult human - 200 ml/cm water (0.2 L/cm)
NEUROTRANSMITTERS
Classification:
• Class I - Acetylcholine
• Class II - Amines:
o Norepinephrine
o Epinephrine
• Class III - Amino Acids
o Glutamate
o Glycine
o GABA
o Aspartate
• Acetylcholine
• Serotonin
• Glutamate
• Glycine
• GABA
• Aspartate
• Nitric oxide
• Excitatory:
o Glutamate - Cheif excitatory neurotransmitter in brain & spinal cord
o Aspartate - Cheif excitatory neurotransmitter in cortical pyramidal cells
• Inhibitory:
o Gamma-AminoButyric Acid (GABA)
Major inhibitory neurotransmitter of CNS
Exerts indirect inhibition
o Glycine - Direct inhibition.
Inotropic:
Functions:
Characteristics of neurotransmitters:
2. Nor-epinephrine:
Origin:
5. Serotonin:
6. Nitric oxide:
7. Neuropeptide transmitters:
Substance P:
• Dorsal horn of spinal cord, hypothalamus & from nigrostrial pathway of basal ganglia.
Opioid peptides:
SECOND MESSENGERS:
CLASSIFICATION:
• Group I hormones:
• Group II hormones:
o Acts on cell membrane receptors.
o Hormone/ligand is 1st messenger effecting on 2nd messenger
MECHANISM OF ACTION:
1. Intracellular receptors:
1. Protein kinases -
2. Phosphatases I-
CALMODULIN:
• Adenylyl cyclase.
• Ca2+ dependent protein kinase.
• Ca2+-Mg2+ ATPase.
• Phosphodiesterase.
• Ion channels.
• Nitric acid synthase.
• Phosphorylase kinase.
CALCULATION OF RMP
• Depolarization occurs.
• Mechainsm:
+
o Decreases K movement to ECF.
o Decreases RMP magnitude.
o Increases positivity/decreases negativity (depolarization).
2+
o Opens voltage-gated Na channels.
• Hyperpolarization occurs.
o Increases RMP magnitude.
o Decreases positivity/increases negativity of membrane (hyperpolarization)
• Sodium-potassium pump:
2+
o Pumps 3Na out of cell & 2K+ into cell.
• Neuron: -70 mV
• Ventricle (cardiac muscle) : -90 mV
• Smooth muscle: -30 to -50 mV
• Hair cells baseline membrane potential: - 60mV
4 phases:
1) Resting stage:
2) Depolarization phase:
2a) Depolarization:
3. Repolarization phase:
5) After-hyperpolarization :
• K+ - "Leak" channels.
NERVE CONDUCTION
• In a motor neuron, axon hillock & initial segment of axon have lowest excitation threshold.
• Because they have a much higher density of voltage-gated sodium channels.
• Axon hillock of body & initial segment of axon Generator area (Nerve impulse is generated).
• Schwann cells are found both in myelinated & non-myelinated nerve fibers of peripheral nervous
system.
o ln myelinated nerves Schwann cells provide structural support & form myelin sheath.
o Schwann cells are derived from neuroectoderm
CONDUCTION PROCESS:
"Antidromic conduction":
• The rate of propagation of nerve impulse is faster in a myelinated nerve fiber than in unmyelinated
nerve fiber.
2. Membrane capacitance:
• Measure of quantity of charge that must be moved across a unit area of membrane to produce a
unit change in membrane potential.
• If membrane has low capacitance Number of ions (charge) crossing membrane is less.
FEATURES OF FIBERS:
• Local anesthesia, hypoxia & pressure can block the conduction of nerve impulses.
• Hypoxia:
o Most susceptible - "B" fibers.
o Least susceptible - "C" fibers.
• Local anesthesia:
o Most susceptible - "C" fibers.
o Least susceptible - "A" fibers.
SUMMARY:
1. For Pressure: A>B>C
2. For Hypoxia: B>A>C
3. For Local anesthesia: C>B>A
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36. SPINAL REFLEX & PROPERTIES
• Sensory impulse is automatically converted into a motor effect through CNS involvement.
1. Receptor organ
2. An afferent neuron
4. An efferent neuron
5. Effector organ
TYPES OF REFLEXES:
1a) Monosynaptic:
• Only example of monosynaptic reflex in body is "Stretch reflex" like knee-jerk & ankle jerk.
1b) Bisynaptic:
1c) Polysynaptic:
• Local segmental reflex & intersegmental reflex are mediated entirely by spinal cord, without any
participation of brain.
• These are referred as "Spinal reflex".
• Bell-Magendie Law:
o Principle wherein spinal cord dorsal roots are sensory & ventral roots are motor.
1. Delay
2. Subliminal fringe
3. Summation:
4. Adaptation:
5. Fatigue:
• Fatigue of synptic transmission can cause fatigue of stretch reflex, if the muscle spindle k stimulated
repetitively.
8. Irradiation.
37. NEPHRON
NEPHRON
Inturn,
1. Oxygen trap:
2. Oxygen transport:
2b) As oxyhemoglobin:
Oxyhemoglobin content:
At rest:
• Tissues remove about 4.6 ml of O2 each deciliter of blood passing through them.
• Hence, 230 ml (by 5 liters of blood) of O2 per minute is transported from blood to tissue, at rest.
3. Oxygen transfer:
• As bicarbonate
Metrics:
Haldane effect:
3. Expulsion of CO2:
PRODUCTION OF BILE:
Introduction:
Synthesis:
Components:
1. Bile acids:
2. Bile salts:
• Are sodium & potassium salts of bile acids, conjugated to amino acids, glycine or taurine.
REGULATION:
Stimulating factors:
Cholerectics:
Cholagogues:
Neruonal circuit:
• CLIMBING FIBERS-
o From inferior olivary nuclei only
o Establish excitatory synapses with Purkinje cells
MOSSY FIBERS-
PARALLEL FIBERS:
Actions:
2. Olivocerebellar tract -
• Proprioceptive impulses from all over body relayed through inferior olive
3. Cuneocerebellar tract -
4. Tectocerebellar tract -
• Axons of Purkinje cells are the only output from cerebellar cortex.
• Deep Nucleus - Ultimate & final efferent ouput of cerebellum
Reason:
• Afferent -
o With Basket & stellate cells
o Climbing & Parallel fibers
• Efferent -
o Deep cerebellar nuclei
DISORDERS OF CEREBRELLUM:
Clinical features,
1. Dysmetria:
4. Dysdiadochokinesia
5. Dysarthria
• Defect in speech
• Scanning speech - Breaking every word & articulating separately
• Due to incoordination of muscles of vocalization
6. Rebound phenomenon
• Truncal ataxia –
• Inability to sit unsupported.
• Gait ataxia –
• Wide based gait
• Drunken gait
• Imbalance - Falling in any direction
2. Medulloblastoma:
41. SURFACTANT
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SURFACTANT
Composition:
Mechanism of action:
Functions:
• Acts on alveoli
• Reduces surface tension of fluid-lined alveoli
• Increases lung compliance
• Decreased compliance.
• Hyaline membrane formation.
• Treatment:
o Corticosteroid administration to pregnant women.
o Promote accelerated fetal lung maturation.
o Production of surfactant.
2. Cigarette smoking:
• Decreased surfactant
Composed of 6 layers -
Other functions:
Neuronal functions:
• Heat regulation:
o By anterior hypothalamus
• Response to coldness:
o By posterior Hypothalamus (Shivering center)
• Feeding center
o Lateral hypothalamic nucleus
Mechanism involved:
4. Regulation of thirst:
• Osmoreceptors
o Present in anterior hypothalamus
• Baroreceptors:
o Subfornical organ & Organ Vasculosum of Lamina Terminalis (OVLT)
5. Regulation of BP:
• Pressor effect
o By Posterior & lateral nuclei
• Depressor effect
o By Preoptic nucleus
• By Anterior hypothalamus
• In males:
o Medial preoptic nucleus
• In females:
o Lateral preoptic nucleus
7. Response to smell:
• By Posterior hypothalamus
• Sleep center
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By Preoptic (Ventrolateral)
o
• Wakefulness center
o By Reticular Activating System (RAS) in brainstem & hypothalamus
• Reward center
o By Lateral & ventromedial nuclei of hypothalamus
• Punishment center
o Periventricular nuclei (mainly)
V/Q ratio:
• Value is 0.8
o "Ventilation-Perfusion matching"
• Main reason for V/Q ratio differences between base & apex of lung
• Values:
• V/Q at apex
o About 3.0 (maximum)
• Ventilation-perfusion mismatch.
2. Carbon-di-oxide:
IMPORTANT METRICS:
• 690 ml/minute.
Filtration barrier/surface:
• Glomerular membrane.
• Basement membrane acts as "Functional barrier"
• Performs selectivity & filtration function of glomerular membrane.
• Filtration done by, hydrated channels approx. 6 nm wide
Factors influencing:
• Membrane charge:
• Membrane glycoproteins are strongly negatively charged.
• Hence, filtration surface is impermeable to negatively substances.
• e.g., like plasma proteins, albumin.
• Clinical implication:
• Albuminuria is such a sensitive indicator of glomerular disease
• Size of filtration channels:
o About 7 nm
Metrics:
DETERMINANTS OF GFR:
1. Net effective filtration pressure:
• 10 mm/Hg
EFFECTS ON GRF:
• ↑ed Bowman's capsule hydrostatic pressure ↑ed tubular hydrostatic pressure (result of
es
obstruction) inturn results in ↓ GFR
RENAL VASODILATION:
GFR - MEASUREMENT
1. Clearance test:
Criteria for selection:
• Creatinine clearance:
o Less accurate method since gets secreted in renal tubules.
o Yet, more convenient to determine creatinine clearance
o Is a metabolic product with constant levels.
o Hence, used as "Index of GFR".
2. Radiological methods:
Factors influencing:
1. Substance filterability:
a) Free filterability:
• Filterability value = 1
o Means freely filtrable through glomerular membrane barrier.
o Eg., Water, sodium, bicarbonate, inulin, Creatinine
b) Partial filterability:
1. Tubuloglomerular feedback:
2. Myogenic autoregulation:
• Arteriole stretching opens "stretch-sensitive Ca2+ channels on arteriolar smooth muscle cells.
• Results in Ca2+ influx causing constriction.
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51. GALL BLADDER - FUNCTIONS
FUNCTIONS OF GALLBLADDER
• Storage of Bile.
• Concentration of Bile
o Increases 5 to 10 times
3. Secretion of Mucin
SPLAY EFFECT:
53. PERISTALSIS
PERISTALSIS
Activation:
1. Neuronal activation factors:
Factors influencing:
Peristaltic rush -
• A 25-fold increased oxygen consumption as well as carbon dioxide production during exercise.
• Pulmonary ventilation increases abruptly with onset of exercise.
• Abrupt increase due to psychic stimuli & afferent impulses from proprioceptors in muscles,
tendons, and joints.
• During moderate exercise, increased pulmonary ventilation due to increased respiratory depth.
• During strenuous exercise, increased pulmonary ventilation due to increased respiratory rate.
• In severe & sustained exercise, lactic acid accumulates in blood & pH of blood may drop as low as
7.2.
• During this period arterial PCO, may drop significantly.
• Exercise increases body temperature.
• Arterial pH & HCO decrease with severe exercise.
• Strenuous exercise causes hyperkalemia
• Oxygen-hemoglobin dissociation curve is shifted to right.
• Increased O2 extraction by tissues
• Lactic acid accumulation causes muscle soreness.
Distal stomach:
• Pacemaker location -
o Along the greater curvature of an upper part of distal stomach (middle third of body)
o Generates BER of 3 to 4/min
Gastric contraction:
Inter-digestive phase:
• Gastric antrum shows bursts of propulsive (peristalitic) muscular activity every 90 minutes.
• MMCs are initiated by motilin
• Purpose of MMC is to clear stomach & small intestine of luminal contents in preparation for next
meal.
• Activity is conducted along entire length of small intestine, from stomach to distal ileum at a rate
of about 5 cm per minute
• On reaching terminal ileum, a new wave begins in stomach.
1. Increasing factors:
2. Decreasing factors:
• Duodenal distension.
• Duodenal hyperosmolarity (Hyperosmolar chyme).
• Presence of acid, fats, & end products of fat digestion.
• Done by release of several intestinal hormones like secretin, cholecystokinin, VIP, & GIP.
Adrenal cortex:
Mineralocorticoid hormone:
Aldosterone -
• Chief mineralocorticoid.
• Acts primarily on kidney.
1. Action on sodium:
2. Potassium hemostasis:
• Expressed at high levels in renal distal tubules & cortical collecting ducts.
• Also in brain (hippocampus), myocardium, peripheral vasculature, brown adipose tissue, salivary
gland & colon.
REGULATION:
Glucocorticoids:
Mechanism of action:
Functions:
Effects:
1. Carbohydrate metabolism -
2. Protein metabolism -
• Cortisol has both catabolic (in muscles) & anabolic (in liver) effects.
• In muscle -
o Cortisol inhibits protein synthesis
o Enhances protein breakdown (proteolysis)
• In Liver -
o Cortisol has an anabolic effect
o Increases synthesis of enzymes involved in hepatic proteins production
Overall effect -
• Anti-anabolic (catabolism).
o Hence, excess cortisol (Cushing syndrome) causes negative nitrogen balance
5. Anti-growth effects -
CALCITROPIC HORMONE
VITAMIN D/CHOLECALCIFEROL
Synthesis process:
Step 1:
Step 2:
Enzyme hydrolase
In Kidney
Important points:
Lab tests:
PARATHORMONE/PARATHYROID HORMONE/PTH:
CALCITONIN:
Regulation:
Action on Bone:
MENSTRUAL CYCLE
60. LACTATION
LACTATION
OVARIAN HORMONES
ESTROGEN:
• Primarily secreted by granulosa cells of ovarian follicles, corpus luteum & placenta.
• Estradiol - Major estrogen secreted by ovary.
Receptors:
1. Metabolic effects:
PROGESTERONE:
• 21 carbon steroid.
1. In Uterus
2. On Body temperature:
3. On Metabolism
• Raises LDL
• Lowers HDL
4. On Pituitary
1. Inhibin:
• Secreted by granulosa cells & corpus luteum in ovary & Sertoli cells in males.
• Inhibits FSH secretion in feedback manner.
• Sudden exposure to any type of stress initially produces sympathetic alarm reaction.
• Eg: Seen typically in patients undergoing major abdominal surgery - "Surgical Stress"
EVENTS:
• ACTH
• Glucocorticoid - Cortisol
• Growth hormone
• Adrenal medullary catecholamines (epinephrine)
• Thyroxine
• Antidiuretic hormone
2. Sympathetic reaction:
2b) On Pancreas:
1. On protein metabolism:
2. On Carbohydrate metabolism:
GASTROINTESTINAL HORMONES
1. Gastrin family:
• Gastrin
• Cholecystokinin (CCK)
2. Secretin family:
• Secretin
• Glucagon
• Vasoactive Intestinal Polypeptide (VIP).
• Gastric Inhibitory Polypeptide (GIP).
3. Other:
• Motilin
1. GASTRIN
• Polypeptide.
• Produced mainly by,
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• G cells of gastric mucosa in stomach antrum.
• lso present in Pituitary gland, Brain & Nerves and in Fetal pancreatic islets.
Forms:
Factors influencing:
Functions:
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• Stimulates pancreatic acinar cell enzymes secretion.
• Causes contraction of gall bladder.
• Relaxation of sphincter of oddi.
• Secretion of enzyme-rich pancreatic juice.
• Potentiates action of secretin on pancreas.
• Inhibits gastric emptying
• Increases motility of small intestine & colon.
• Increases enterokinase secretion
• Produces satiety
• Augments contraction of pyloric sphincter.
o Prevents reflux of duodenal contents into stomach.
3. SECRETIN:
Functions:
PRODUCTION STEPS:
• Iodide uptake via "Secondary active transport"- Na2+: I- symporter in folllicular cells.
• Trapping is TSH stimulated.
• Na2+: I- symporter also found in,
• Salivary glands.
• Mammary glands.
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• Placenta.
• Oxidation, iodination, coupling & thyroglobulin proteolysis are TSH stimulated.
• Thyroid hormones are stored in thyroid follicles for 2-3 month.
• Wolff- Chaikoff Effect: Excess iodide inhibits its self-transport in thyroid cells, results in
reduced T4 / T3 synthesis.
GASTROINTESTINAL MOTILITY
Pacemaker cells -
1. MOTILITY IN STOMACH:
• Gastric contraction.
• Gastric emptying.
• Propulsive movements.
• Mixing movements / Haustrations
Reflexes involved:
Transit time:
• From sigmoid colon to anus, slower transport & quarter of test meal residue retained in rectum
upto 3 days.
• Food residue spends more than 20 hrs in colon before lost in feces
Propulsive movement:
• Referred as "Peristalsis".
• Stimulus - Distention of gut
Activation:
1. Neuronal activation factors:
Peristaltic rush -
2. MIXING MOVEMENTS:
REFLEXES INVOLVED:
1. Gastroileal reflex:
1. Mixing movement/Haustrations:
• Resulting in a division of large intestine into very distinct segments called "Haustra".
• Hence "Haustration".
REFLEXES:
2. Defecation reflex:
Transit time:
• From sigmoid colon to anus, slower transport & quarter of test meal residue retained in rectum for
upto 3 days.
• Food residue spends more than 20 hrs in colon before lost in feces.
Properties:
• T4 - "Prohormone of T3".
• Most T4 secreted by thyroid is converted to T3 in liver, kidney & pituitary, by action of enzyme 5'-
deiodinase.
• T3 -"Principal Thyroid Hormone".
• Half-life of T4 - 6 days.
• T4 - Major circulating hormone.
• Half-life of T3 - 1 day.
• T3 - More avidly bound to nuclear receptor than T4.
• T3 - More potent & acts faster.
• Hence, T3 - Active hormone.
• T4 - Mainly a transport form & functions as "Prohormone of T3".
• Only 20% circulating T3.
TRANSPORT:
Thyroxine-binding globulin-
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• Major thyroid hormone binding protein.
• Level increase in pregnancy & by drugs estrogens, methadone, heroin, tranquilizers & clofibrate.
• Level decreased by glucocorticoid, androgen, danazol, asparaginase (Cancer
chemotherapy) & nephrotic syndrome.
METABOLISM:
REGULATION:
FUNCTIONS:
Insulin:
Synthesis:
RECEPTORS:
REGULATION:
FACTORS INFLUENCING:
1. Stimulating factor:
2. Inhibiting factors:
• α-adrenergic stimulation.
• K+ depletion
• GLP-1 (7-36):
• According to Starlings law, there is an optimal length at which force generated by a muscle
is maximal.
• Isotonic contraction: Contraction in which there is change of length at constant tension.
• Isometric contraction: Contraction in which there is constant length with increased tension.
• Hence, generates more force of contraction/tension.
• Muscle strength is best increased by isotonic exercise.
• Exercises one does in the gym are isotonic exercises as muscle length changes in each step but not
tension.
• Tonus involves γ-motor neuron activity leading to muscular contraction.
• Fine irregular contraction of individual fiber appears, referred as "Fibrillation".
• Fasiculations - Jerky, visible contractions of muscle group.
• Type II motor units:
o Type IIa/"Fast-Fatigue Resistant" (FR) units.
o Type IIb/"Fast-Fatigable" units.
MUSCLE SPINDLE
o 2 per spindle.
• Central/equatorial region:
o Does not contain contractile protein.
o Hence, non-contractile portion of muscle spindle.
o Are more sensitive to stretch & acts as "Stretch receptors".
• Peripheral region:
o Contain contractile proteins.
o Hence, contractile part of muscle spindle.
• Annulospiral/primary endings:
o Found wound around central region of both nuclear bag & nuclear chain fiber.
o Are "Aα" / "Ia" fibers.
• Flower-spray/secondary endings:
o Innervates peripheral parts/ends of nuclear chain fiber.
o Are "Aβ" / "II" fibers.
• γ1/dynamic γ-fibers:
o Innervates nuclear bag fiber.
o Their terminals are called 'Plate ending'.
• γ2/static γ-fibers:
o Innervates nuclear chain fibers.
o Their endings are called 'Trail ending'.
SENSORY RECEPTORS
• Exteroreceptors.
• Proprioceptor
• Interoceptors/Visceroreceptors.
EXTERORECEPTORS:
1. General exteroreceptors:
• Superficial
o Detect touch.
o Slowly adapting Merkel's disk.
o Rapidly adapting Meissner's corpuscle.
• Deep
o Detect deep touch, pressure, & Vibration.
o Slowly adapting Ruffini's end organ.
o Rapidly adapting Pacinian corpuscle.
1b) Thermoreceptors:
• Thermal nociceptors.
2. Special Exteroreceptors:
INTEROCEPTORS / VISCERORECEPTORS:
TYPES:
• General interoceptors:
o Chemoreceptors - Osmoreceptors.
o Glucoreceptors.
Features include,
1. ADAPTATION:
• When steady stimulus is applied to a receptor Frequency of action potential generated declines
gradually.
• This gradual decline in receptor response referred as "Adaptation".
Subtypes:
• Hence,
o In turn, Increases firing rate of sensory neuron (frequency of action potentials generated).
• Dendritic ends of a single neuron are connected to several superficial sensory receptors.
o Such neuron, with all its peripheral terminals & their attached receptors, referred as
"Sensory unit".
• Receptors detecting sensations from larger surface area is referred as "Receptor area"
Summary:
• Is "Minimum distance between two points that can be perceived as a separate point stimulation.
• Measure of tactile acuity or sensory acuity.
Factors influencing:
5. PROPRIOCEPTIVE SENSATIONS:
• Receptors for sense of position - Chiefly located in joint capsules & ligaments around joint.
• Most important receptors - Ruffini's end organs
• ensations are carried by thick myelinated nerve fibers
• I.e. Group I (Aα) - All proprioception
• Group II (Aβ) for kinesthesia to Dorsal columns of spinal cord.
• Ultimately, conscious proprioceptive sensations reach somatic sensory cortex.
GENERAL EXTERORECEPTORS
• Provide information about external environment, like touch, pressure, temperature, light, sound,
taste, & smell.
SUBTYPES:
1a) Cutaneous mechanoreceptors/Tactile/Touch receptors -
• Includes Ruffini's end organ (slowly adapting) & Pacinian corpuscle (Rapidly adapting).
1. Slowly adapting:
2. Rapidly adapting:
• Pacinian corpuscle -
o Useful to detect vibrations.
• Meissner's corpuscle -
o Detect surface texture.
2. Deep sensations:
SUMMARY:
1. Superficial cutaneous receptors:
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• Merkel's disk -
o Slowly adapting & detect two-point discrimination.
• Meissner's corpuscle -
o Rapidly adapting & detect surface texture.
• Pacinian corpuscle -
o Rapidly adapting & detect vibrations.
PAIN RECEPTORS/NOCICEPTORS:
TEMPERATURE RECEPTORS/THERMOCEPTORS:
• Pain and temperature are carried by Aδ (type III) & C (type IV) sensory neurons.
• For temperature:
o C (Type IV) neuron - Both cold & warmth.
THERMO-REGULATORY MECHANISM
• Shivering.
• Increased catecholamines secretion.
• Increased thyroxine secretion.
• Cutaneous vasoconstriction.
• Piloerection -
o Important for animals with fur or feathers but not for human
• Sweating
• Cutaneous vasodilation (Earliest response).
• Earliest response to heat stress - Cutaneous vasodilatation
Factors influencing:
1. Brown fat:
Events:
SWEATING:
HEAT ACCLIMATIZATION:
Functions:
↓
Release of acetylcholine at NM junction from presynaptic vesicles.
↓
Interaction of Di-Hydropyridine (DHPR) & Ryanodine (RyR) receptor in terminal cisterns of sarcoplasmic
reticulum.
↓
Ca2+ ion release from sarcoplasmic terminal cisterns through Ryanodine receptor.
↓
Increased sarcoplasmic Ca2+ concentration.
↓
Binds with troponin C & Ca2+.
↓
Lateral movement of tropomyosin with uncovering of active sites of actin.
↓
Cross-linkage of myosin with actin & Muscle contracts.
Summary:
↓
Release of Ca2+ from Troponin.
↓
Tropomyosin covering active sites of actin.
↓
Cessation of interaction between myosin & actin with resultant muscle relaxation.
• H Zone -
o Comparatively lighter zone in middle of A band.
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Due to non-overlapping of actin over myosin filament in central portion.
o Absence of actin filament.
o Disappears on muscle contraction.
SARCOLEMMA:
Has two protein types:
• Integral/Transmembrane proteins -
o Dystroglycan.
o Sarcoglycans (SG).
• Peripheral/surface proteins:
• Dystrophin.
• Sarcotubular T-system contains "Transverse tubules"
• Infoldings of cell membrane/sarcolemma.
• Allows penetration of electrical membrane discharge to inner core of muscle cell.
• Sarcoplasmic reticulum contains high calcium concentration.
• Is concerned with sarcomeric calcium transport.
• "Triad" - Central longitudinal part with two cisterns at both ends.
• Terminal cistern is where maximum calcium is stored. Hence, "Storehouse of calcium ions".
• Foot processes are mainly of Dihydropyridine receptors (DHPR).
• Ryanodine receptors function as calcium channels.
o Gene mutation on Ryanodine receptor encoding causes malignant hyperthermia.
o Due to excessive uncontrolled calcuim release.
• Characteristics of:
o Type I/red fibers
o Type II/white fibers.
•
o Late recruitment
threshold
Steps:
↓
Causes Na2+ influx & postsynaptic membrane depolarization.
↓
Increases post-synaptic neuron excitability.
Characteristics:
• Graded in nature.
• Not follows all or none law.
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• Magnitude depends upon stimulus intensity.
• Stimulus here is amount of neurotransmitter released.
• Not-self propagated.
• Travels with decrement.
• May or may not be followed by an effect
Steps:
↓
Causes Cl- influx & postsynaptic membrane hyperpolarization.
↓
Reduces post-synaptic neuron excitability.
↓
Hence, "Inhibitory Post-Synaptic Potential (IPSP).
• Slow EPSP/Slow IPSP are particularly important in autonomic-sympathetic ganglia & is very
complex.
• Slow IPSP -
o Mainly due to dopaminergic & adrenergic receptors
stimulation by catecholamines products (dopamine & norepinephrine).
o Mediated by acetylcholine action on M2 muscarinic receptors.
• Action potential mainly generated in axon hillock & its initial segment.
o Because of their maximum concentration of voltage-gated Na+ channels
o Also are site of lowest threshold
EXCITATION-CONTRACTION COUPLING
85. CYANOSIS
CYANOSIS
• In Hypoxic Hypoxia:
o Cyanosis is seen - Yet, only in severe hypoxia.
o Note: Cyanosis appears at saturation <85%.
o Thus, cyanosis considered as "Late sign of hypoxia in trauma patients".
• In Anemic hypoxia:
o No cyanosis observed.
o Because in case of severe anemia causing hypoxia, there will not be enough deoxygenated
hemoglobin to produce cyanosis.
o In CO poisoning, CO-Hb color - cherry red.
o No cyanosis is seen in CO poisoning.
• In Stagnant hypoxia:
o Cyanosis is seen.
• Small amounts of CO is formed in body functions as "Gaseous Transmitter Vasodilator" (along with
NO & H2S).
• Because Hb amount carrying O2 is reduced but total Hb amount of blood is unaffected by CO.
TREATMENT:
2. Hyperbaric oxygen - Oxygen administered at high pressure (up to 2000 mmHg) - More beneficial.
RESPIRATORY REFLEXES
2. "J-REFLEX" ("J-RECEPTORS"):
PRE-BOTZINGER COMPLEX:
90. HYPOXIA
HYPOXIA
HYPOXIC HYPOXIA:
Conditions associated:
ANEMIC HYPOXIA:
HISTOTOXIC HYPOXIA:
HYPOXEMIA:
CAUSES:
ALTITUDE PHYSIOLOGY
• Because at higher atmospheric pressure, nitrogen dissolved in body fluid & even more easily
dissolves in fatty substances in neuronal membrane & produces necrosis.
Eg:
DEAD SPACE
RESPIRATORY PRESSURE
Muller's maneuver:
• During "Forceful Inspiratory Effort" against a closed glottis producing intrapulmonary pressure as
low as -80 mm Hg.
INTRAPLEURAL/PLUERAL PRESSURE:
• Pleural pressure is more negative during inspiration & less negative during expiration.
• Yet, always negative during quiet breathing.
• 2 major reasons for negativity:
o Because both thoracic cage & lungs are elastic structures & both tend to recoil but in
opposite direction.
o Lymphatic drainage of pleura.
• Difference between alveolar pressure (intra-alveolar pressure) & pleural pressure (intrapleural
pressure).
• Is a measure of "Elastic recoil pressure".
• More expanded at end of inspiration:
• Hence, Transpulmonary pressure = 0 - (- 8.0) = + 8 cm H2O.
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• Less expanded at end of expiration:
• Hence, Transpulmonary pressure = 0 - (- 5.0) = 5cm H2O.
• Airway dynamic compression causes expiratory flow limitation.
o I.e., Beyond a limit increased expiratory efforts do not produce further increase in flow.
BLOOD PRESSURE
• Cuff is rapidly inflated until pressure is well above expected systolic BP so that brachial artery is
occluded.
• Blood pressure measured by an auscultatory method using sphygmomanometer tends to be higher
than true intra-arterial pressure measured by arterial cannulation.
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o Because some cuff pressure gets dissipated between the cuff and artery in soft tissue.
IDEAL METHODOLOGY:
• While measuring BP, patient should be in resting position (seating or lying down).
• Patient's arm with attached cuff shows be at heart level.
• Cuff should be applied to upper arm.
• Cuff should encircle at least 80% of arm.
o I.e. Cuff length of bladder should be at least 80% arm circumference.
o Cuff width should be at least 40% of the circumference.
TYPES OF METHODOLOGY:
1. PALPATORY METHOD:
3. AUSCULTATORY METHOD:
AUSCULTATORY GAP:
• Vasomotor Center (VMC) & Cardiovagal/Cardio-Inhibitory Center act together to maintain BP.
• "Pressor area" of VMC, located in Rostral Ventrolateral Medulla (RVLM).
• Under resting conditions, neurons of VMC pressor area have an inherent tonic discharge in
vasomotor nerve supplying blood vessels.
• Vasomotor center (VMC) receives afferent fibers from cerebral cortex, both directly &
via hypothalamus (cortico-hypothalamic pathways.
• Receptors for baroreceptor reflex process is located in the adventitia of carotid artery & aorta,
at specialized locations called "Sinuses".
• Baroreceptors are highly sensitive to any change in mean blood pressure.
o Respond to BP changes between 70 mm Hg & 150 mm Hg.
1. ON INCREASED BP:
Inhibits VMC pressor area. i.e., Rostral Ventrolateral Medulla (RVLM) Decreased sympathetic outflow.
Increases parasympathetic (vagal) output through vagus Decreases heart rate, cardiac output, & BP
eventually.
2. ON DECREASED BP:
1. VASOCONSTRICTORS:
• Noradrenaline.
• Adrenaline.
• ADH (Vasopressin).
• Angiotensin II.
• Endothelins.
• PGF2.
• Thromboxane A2.
2. VASODILATORS:
• NO synthase -
• Complex cytosolic enzyme.
• Employs five redox cofactors -
o NADPH.
o FAD.
o FMN.
o Heme.
o Tetrahydrobiopterin.
9. CARDIOPULMONARY REFLEXES
CARDIOPULMONARY REFLEXES
• Cardiac output - Oxygen consumption (uptake) per minute / Arteriovenous oxygen difference.
3. Thermodilution method:
PRELOAD:
• Increased preload
• Results in higher end-diastolic volume.
• Conditions associated with ↑ed Stroke volume:
• Increased total blood volume.
• Increased venous tone.
• Increased negative intrathoracic pressure.
• (e.g. inspiration).
ed
• Conditions associated with ↓ Stroke volume:
• Sitting or standing.
• Increased ventricular contractile strength Increased stroke volume.
INCREASED CO:
DECREASED CO:
1. OHM'S LAW:
• "Critical velocity" -
o Limit beyond which flow velocity exceeds resulting in turbulent flow instead laminar.
o Most important determinant of blood flow turbulence.
5. Axial Streaming:
6. LAW OF LAPLACE:
• States that tension (T) in wall of a cylinder is equal to product of transmural pressure (P) & radius (r)
divided by wall thickness (w).
o I.e., T = Pr/w.
7. Perfusion pressure:
102. ERYTHROCYTES
ERYTHROPOIESIS:
HEMOGLOBIN:
RBC DESTRUCTION:
CARDIAC CONDUCTION
• SA node - Located in superolateral wall of right atrium, at SVC junction with right atrium.
• Conduction system entirely made up of modified cardiac muscles.
• Fastest conduction - Purkinje system.
• Conduction velocity - 4 (Maximum).
• Slowest conduction - AV node & SA node.
• Conduction velocity in AV & SA node - 0.05 (Minimum).
• SA node discharges impulses at fastest rate.
o Thus, rate at which SA node fires, determines heart rate.
o Hence, SA node is "Normal pacemaker of Heart".
o I.e., Determines pace of heart.
• AV conduction speed nodal is only 0.05 min/sec so that impulses take 0.1- 0.13 sec to travel across
AV node.
o This 0.1 - 0.13 sec delay called "AV nodal delay".
o Due to fewer gap junctions Leading to impaired conduction.
• Phase 2 -
o Plateau phase.
o Due to opening of "Voltage-gated slow Ca2+channels.
o Also referred as "Calcium-Sodium Channels" - Causing calcium influx.
• Parasympathetic innervation -
o Right vagus is distributed primarily to SA node & left vagus mainly to AV node.
2. Sympathetic stimulation:
COAGULATION SYSTEM
Factor I Fibrinogen.
Factor II Prothrombin.
Pre - K Pre-Kallikrein.
Ka Kallikrein.
Prothrombin 60 hrs
COAGULATION PATHWAYS:
1. INTRINSIC PATHWAY:
2. EXTRINSIC PATHWAY:
3. COMMON PATHWAY:
1. α2 - Macroglobulin -
2. Heparin cofactor II -
105. HEMOSTASIS
HEMOSTASIS
CARDIAC CYCLE
• Isovolumetric contraction:
o Closure of AV valves - Marks 1st Heartbeat.
• Causes bulging into atrium.
o Resulting in small, sharp rise in atrial pressure.
o Referred as "C" wave on Jugular Venous Pulse (JVP).
• Both AV & semilunar valves are closed.
o Thus no volume change.
o Hence, "Isovolumetric" contraction.
• Isovolumetric contraction ends with opening of semilunar (aortic & pulmonary) valves.
• Ventricular ejection:
o Begins with semilunar valve opening.
o Sharp fall in atrial pressure.
o Represents "X-decent" in JVP.
• Iso-volumetric relaxation:
o Phase is period between semilunar valve closure & AV valve opening.
o Ends with AV valve opening.
o Coronary blood flow is maximum during this period.
PLASMA PROTEINS
FUNCTIONS:
1.Osmotic pressure:
2. Defense mechanism:
3. Carrier proteins:
• Albumin -
o Transport of FFA.
• Pre-albumin -
o Thyroxine transport & Vitamin A.
• Haptoglobin -
o Binds to hemoglobin.
• Ceruloplasmin -
o Binds to copper.
• β-lipoproteins -
o Transport of triglyceride & cholesterol (I.e., Chylomicrons).
• Transferrin -
o Iron transport.
2. ALDOSTERONE:
• Causes natriuresis.
• Due to increased GFR, by relaxing glomerular mesangial cells.
• Decreases Na2+ reabsorption from distal tubule & collecting duct.
• Relaxes arteriolar & venular smooth muscle lowering BP.
4. PARATHORMONE/PARATHYROID HORMONE/PTH:
Actions on kidney:
GROWTH HORMONE
• α-subunit inactivates itself by converting its bound GTP to GDP, with help of GTPase activity.
• Active G protein may either be effector activator/inactivator, because of different α-subunits (Gα -
subunits).
• Gαs (Gs alpha) Stimulates adenylyl cyclase & ↑es cAMP.
• Activation of AC results in increased synthesis & intracellular accumulation of cAMP.
• cAMP acts through "cAMP-dependent Protein Kinase'A' phosphorylates.
o Examples:
o Corticotropin-releasing hormone (CRH).
o FSH.
o LH.
o ACTH (corticotropin).
o Catecholamines (α2, β2).
o Glucagon.
o Dopamine (D1 & D2).
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o Histamine (H2).
• Phospholipase activation by stimulatory G protein hydrolyzes "Membrane Phospholipid
Phosphatidylinositol 4, 5-Bisphosphates (PIP2), in turn, generating second messenger "Inositol I, 4,
5 triphosphate" (IP3) & "Diacylglycerol" (DAG).
• Ca2+ acts as "Third messenger".
• Protein kinase-C phosphorylates various intracellular proteins.
o Examples of IP-DAG system:
o Cholecystokinin.
o Catecholamines (some actions via α1 receptors).
o Histamine - H1.
STAGES OF SLEEP
• Features of REM sleep in EEG recording - Beta-wave, reappearance of alpha wave & ponto- genital-
occipital spike, dreaming, generalized muscular atony & increased pulse rate & BP.
• REM sleep - 20-30% of total sleep.
• N-REM Sleep - 60-70% of total sleep.
o Stage 2 - 40-50%.
o Deep sleep/Slow wave sleep disorder - Occur during stage 3 & 4 of N-REM.
o Somnambulism - Night walking.
o Sleep terror/Night terrors - Pavor nocturnus.
o Bruxism - Teeth grinding.
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• Events during REM sleep include,
LEPTIN:
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• Acts on hypothalamus to reduce food intake.
• Increases lipolysis.
• Inhibits Agouti-related peptide (AgRP) secretion.
• Plasma leptin levels are proportional to amount of body fat; Hence, higher in women & obese
individuals.
• Levels increased in obesity.
• Levels decreased in testosterone (androgen), exercise & starvation.
NEUROPEPTIDES:
BLOOD-BRAIN BARRIER
ANATOMICAL BASIS:
PERMEABILITY OF BBB:
• Highly permeable - Water, CO2, O2, Lipid-soluble substances (alcohol & most anesthetics).
• Totally impermeable - Plasma proteins.
• Circum-ventricular organs.
• Posterior pituitary (neurohypophysis)
• Area postrema
• Organ Vasculusum of Lamina Terminalis (OVLT).
• Subfornical organs (SFO).
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117. CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
118. SPEECH
SPEECH
119. GUSTATION
GUSTATION
RESPIRATORY FAILURE
121. OLFACTION
OLFACTION
TRANSPORT MAXIMUM
• Transport maximum is "Maximum limit allowed for transportation (either absorption/secretion) for
actively transported substances".
• Transport maximum for glucose is 375 mg/min.
• If plasma glucose concentration rises > 200 mg/dl, increases filtered load 250 mg/min & is "Renal
Glucose Threshold point".
123. MEMORY
MEMORY
124. LEARNING
LEARNING
125. THALAMUS
THALAMUS
• Acts as "Sensory Relay Station" for all sensory pathways, includes Gustatory & Olfactory
tracts reaching cortex.
• Concerned with conscious interpretation of crude touch, pain & temperature.
• Every thalamic nuclei sends output to different cortical areas.
• Motor thalamic nuclei relay & process messages from basal ganglia & cerebellum to motor &
premotor cortex.
o Mainly by Ventral anterior nuclei.
• Specific sensory nuclei receives all sensory afferents from ascending pathways projecting to
somato-sensory cortex.
o Mainly by Ventro-posterior nuclei.
126. SALIVA
SALIVA
• Salivary pH is 6.5 - 7.
• Saliva contains salivary amylase or tylin.
• Lingual lipase is secreted by Ebner's glands on dorsum of tongue.
• Saliva is secreted is around 1-1.5 L/day.
• Predominant ions in saliva in HCO3- & K+.
128. SEMEN
SEMEN
• GFR & its volume is reduced to 1/3rd (About 60-70% reabsorbed) in proximal tubule.
• Fluid out of proximal tubule is isotonic with GR & plasma.
• Primary active step for sodium reabsorption in proximal tubule involves Na+-K+-ATPase at baso-
lateral membrane.
• About 60-70% of water reabsorbed in proximal tubules because of osmosis through aquaporin-1
channel.
• Passive water reabsorption is coupled mainly to sodium reabsorption.
• Glucose is absorbed completely (100%) in proximal tubule by Na2+-Glucose cotransporter-1 (SGLT -
1) in luminal membrane & by glucose transporter GLUT-1 in basolateral membrane.
• Amino acids are completely reabsorbed in proximal tubules.
• H+ ions secreted into tubular fluid is mainly by Na2+-H+ exchanger.
• Phosphate reabsorption occurs along with sodium co-transport.
• Maximum (90%) bicarbonate absorption in proximal tubules is coupled with H+ ions secretion
by Na2+-H+ exchanger.
• About 40-50% of urea reabsorbed.
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• Glucose, amino acids, & bicarbonate are reabsorbed along with Na+ in early portion of proximal
tubule.
1. Potassium transport:
2. Calcium transport:
3. Urea transport:
• Over-all impact of reabsorption in early distal tubule is to dilute urine by removing solutes.
• Late segment of distal tubule is functionally similar to cortical collecting duct.
• Principal (P) cells reabsorb sodium & water from lumen & secrete potassium into lumen.
• Intercalated (I) cells reabsorb potassium & secrete hydrogen into lumen.
• Cl- is reabsorbed into late distal tubule.
• H+ secreted by proton pump (H+-K+-ATPase) into gastric lumen in exchange for K+ ion.
• Sight/smell/even thought of food stimulate acid secretion in cephalic phase.
• Cephalic phase is mediated by Parasympathetic system activation via vagus.
• Cephalic phase accounts for 20% of acid secretion.
• Gastric phase is stimulated hormonally due to gastrin.
• Stretching of stomach wall during gastric phase is mainly due to gastric distension.
• Gastric phase accounts for 72-80% acid secretion.
• Local GI hormones released inhibiting gastric acid secretion & motility are secretin, CCK, VIP &
Somatostatin.
• Presence of food plays a lmajor role in inhibiting duodenal acid secretion.
• Only water is reabsorbed from thin descending limb of Henle loop due to its high permeability to
water.
• Tubular fluid in thin descending limb is hypertonic.
• Thick ascending limb is totally impermeable to water.
• Tubular fluid in thick ascending limb is hypotonic.
• In thick ascending limbcarrier pump Na-K-2Cl transporter, transports one Na, one K & two Cl.
• Parietal/Oxyntic cells secrete Hydrochloric acid (HCl) & Intrinsic factor of castle.
• Chief/Zymogen/Peptic cells secretes pepsinogen.
• Delta (D) cells secrete Somatostatin.
• Pylorus contains "mucus-secreting pylorus gland".
• In human - 2.5 L (105ml/hr) gastric juice secreted daily.
• Important cationic constituents in acid - Na2+, K+, & Mg2+.
• Main activators of acid secretion are mainly Histamine (H2 receptors), Acetylcholine (M3 receptor)
& Gastrin.
• Vagal (Parasympathetic) stimulation increases acid secretion through acetylcholine.
• Proton Pump/H+ inhibitors act by blocking H+ receptors.
• Inhibitors of acid secretion are Somatostatin, Secretin, Cholecystokinin (CCK), GIP & VIP.
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• Best established inhibitor of acid secretion is "Low pH" (Acid itself).
• Normal BAO - < 10 (2 - 5) mmol/hr.
• Maximal Acid Output (MAO)/Total Acid Output values reflect total parietal cell population in the
stomach, hence referred “Parietal cell mass".
REGULATION OF THIRST
REGULATION OF POSTURE
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• In decorticate rigidity, rigidity is less pronounced than decerebrate rigidity.
• Reflex absent in decorticate animal Long loop stretch reflex.
• Decorticate rigidity is not seen as a manifestation of uncal herniation.
• Decorticate child shows in acute brain injury, subthalamic, CT & frontal lobe lesion and shows
flexion of arm & extension of lower limb.
ASSOCIATION AREAS
RETICULAR FORMATION
• Reticular Activating System (RAS) causes arousal from sleep producing "δ-block" where EEG
pattern changes from high voltage slow δ-wave to high-frequency low voltage β-wave activity.
• Tidal Volume (TV) - Volume of air that moves in or out of the lung with each normal breath.
• Residual volume (RV) - Volume of air remaining in lungs after maximal expiration.
• Expiratory reserve volume (ERV) - 1200 ml
• Inspiratory capacity (IC) calculated by sum of tidal volume & inspiratory reserve volume IC = TV
+ IRV.
• Functional residual capacity (FRC) - Volume of air in lungs after expiration.
o Calculated by FRC - ERV + RV.
o About 2400 ml
• Total Lung Capacity is about 5900 ml. Depends on lung compliance.
• Vital capacity (VC) is about 4700 ml.
• Fraction of FVC breathed out in 1st second - Forced Expiratory Volume 1 (FEV1).
Actions:
Eyes • Mydriasis.
• Due to α2 action:
o Decreased insulin release from pancreas.
MOLECULAR MOTORS:
• Kinesin
• Dynein
• Dynamin
• Myosin
ORGANELLE MARKERS
Peroxisome Catalase
145. CYTOSKELETON
MICROTUBULES:
Properties of microtubules:
• Polar.
• Dynamic instability.
• Microtubule assembly utilizes GTP energy.
Functions:
INTERMEDIATE FILAMENTS:
• Very stable
• Important components included,
o Lamins.
o Keratins.
o Desmin - Used diagnostically in pathologic cases to indicate disorders of muscle origin.
o Neurofilaments.
MICROFILAMENTS:
5. Plasticity:
• Smooth muscle usually defies the usual length-tension relationship valid for skeletal muscle.
6. Percentage of shortening.
2. Neural control
3. Local factors:
• Local factors causing smooth muscle relaxation in arterioles & pre-capillary sphincters include,
o Lack of oxygen.
o Excess of carbon dioxide.
o Lower pH
4. Hormones
(ECF)
40% 33% Total body water & 20% body weight - 14 litres
• ECF:
o Most abundant cation-Na+ (142 meq/l)
o Most abundant anion- Cl- (103 meq/l)
o Bicarbonate concentration HCO3 (28 meq/l)
• ICF:
o Most abundant cation - K+ (150 meq/l) & Mg2+ (58 meq/l)
o Most abundant anion - Phosphates (75 meq/l) > Proteins (40 meq/l).
o pH - Slightly alkaline in nature.
VOLUME MEASUREMENT
PLASMA VOLUME(PV) • By using Evans blue (T1824), Serum albumin labeled with
radioactive Iodine
INTERCELLULAR JUNCTIONS
Functions:
2. Gap junctions/Nexus/Hemichannels/connexons:
3. Desmosomes:
4. Hemi-desmosomes:
149. OSMOSIS
OSMOSIS
• Osmosis is the passive transfer of solvent, especially water, across the membrane.
o Also, there is diffusion of solvent towards an area of higher solute concentration.
OSMOTIC PRESSURE:
Contributors:
• Plasma proteins have lower molar mass (weight) & high plasma molar concentration (number).
o Hence, contribute greatly to plasma osmotic pressure.
• Albumin with low molecular weight contributes more.
• 1 osmotically active molecule (1 osmole) of a substance exerts osmotic pressure equal to 22.4
atmospheres.
• Major contributor to body fluid (ECF) osmolarity is Na+.
Types:
“Osmolarity":
• Refers to influence exerted by, allowing solvent through membrane on simultaneous solute
movement through membrane.
NEURONAL/AXOPLASMIC TRANSPORT
Types:
NERVE INJURIES
Classification:
Intact endoneurium
NERVE DEGENERATION:
1. Wallerian/Secondary degeneration:
• Secondary degeneration occurring distal to site nerve injury site (within 24hrs)
• Axon degeneration followed by myelin degeneration.
2. Retrograde/primary degeneration:
1. Distal to injury:
Biochemistry
1. HMP Shunt
The pentose phosphate pathway is an alternative route for the metabolism of glucose. The two major
functions of this pathway are:
• The formation of NADPH for synthesis of fatty acids and steroids, and maintaining reduced
glutathione for antioxidant activity.
• The synthesis of ribose for nucleotide and nucleic acid formation.
Three molecules of glucose 6-phosphate give rise to three molecules of CO2 and three 5-carbon sugars
• Two Phases
o Oxidative – Non Reversible
o Non Oxidative -Reversible
o No ATP is produced or consumed in HMP Shunt
o Rate Limiting Step glucose-6-phosphate is oxidized to 6-phosphogluconolactone by glucose-
6-phosphatase.
2. Glutathione
4. GLUT
5. Gluconeogenesis
6. Urea Cycle
8. Vitamin A
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• Vitamin A is present in milk, egg yolk, fish , liver, fruit and vegetables
• Vitamin A promotes maintenance of epithelial tissue
• Vitamin A is stored mainly as retinol esters in Liver
• Vitamin A consist of Retinol, retinal and retinoic acid
• During the dark phase of visual cycle 11-cis-Retinaldehyde combines with opsin to make Rhodopsin
• Anti infective vitamin is vitamin A
• Daily dose of vitamin A in a 6-12 months old child is 300 microgram
• The highest concentrations of Vitamin A is seen in Cod liver oil
• Vitamin 'A' requirment for a Pregnant woman is 800 mg/d.
• Dose of vitamin A prophylaxis given in age group 16 years 200000 iu
• Absorption of vitamin A can be enhanced by giving the child a diet rich in Fat
• Highest vitamin A content is seen in Green leafy vegetables
• First dose of vitamin A should be given at 9 months
• Vitamin A prophylaxis is given to children every 6 months
9. Vitamin A Deficiency
11. Glucokinase
• Glucokinase enzyme plays an important role in regulating blood glucose levels after feeding.
• Glucokinase is not inhibited by Glucose-6-phosphate.
• Insulin increases the activity of Glucokinase.
• The rate-limiting enzyme in Glycolysis is Glucokinase.
• Insulin acts on Glucokinase enzyme in glycoysis.
• An inherited deficiency of branched chain a keto acid dehydrogenase result in Maple syrup urine
disease.
• In maple syrup disease, the amino acids excreted in urine are Valine, Leucine ,Leucine.
• Decarboxylation of valine, leucine and isolucine is defective in Maple syrup urine disease.
• Enzyme deficient in maple syrup urine disease is α-ketoacid dehydrogenase.
• In maple syrup urine disease FeCI3 test with urine gives blue color.
16. Vitamin C
17. Collagen
• The best indicator for monitoring the impact of Iodine Deficiency Disorders Control Programme
is Neonatal hypothyroidism.
• The Iodine content in iodized salt at production point should be 30 ppm.
• The recommended content of Iodine in salt at the consumer level is 15 ppm.
• Iodine deficient population in the world is 20 million.
• Endemic cretinism is seen when Iodine uptake is below 20 micro gram/day of daily intake .
• The impact and efficiency of an iodine control program can be determined by Neonatal thyroxine
levels.
• Highest concentration of iodine is found in lobsters and oysters.
• Iodized salt in iodine deficiency control programme is a type of primary prevention.
• Total body iodine is about 50mg.
• Richest source of iodine is sea food.
• The RDA of iodine for adults is 150 microgram.
• Fortification of salt is a component of Iodine deficiency control programme .
• Efficiency of the goiter control program can be assessed by Neonatal thyroxine levels.
• As per the World Health Organisation guidelines, iodine deficiency disorders are endemic in a
community if the prevalence of goiter in school age children in more than 5%.
• Hypothyroidism in sub-himlayan region/India is due to deficiency of Iodine.
• Neonatal Hypothyroidism is the best indicator of environmental iodine deficiency .
24. NIACIN
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• Nicotinamide is preferred over Niacin because Flushing is seen with niacin
• A 54-year-old man has a total cholesterol of 272 and LDL level of 210. His therapy is initiated with
dietary modification and an exercise regimen, but he is unresponsive and so is prescribed nicotinic
acid (Niacin) develops facial flushing
• Consumption of maize may aggravate Pellagra because Some strains of maize contains excess of
Leucine which interferes in the conversion of Tryptophan into Niacin
• Pigmented rash of sun-exposed areas, bright red tongue, diarrhea, apathy, memory loss and
disorientation are symptoms of niacin deficiency
• Development of pellagra like skin lesion in carcinoid syndrome is due to Inadequate conversion of
Tryptophan to Niacin
• Niacin is synthesised from Tryptophan
• About 60 mg of tryptophan is required to result in I mg of niacin.
• Diarrhea, Dementia & Dermatitis are seen in niacin deficiency
25. Proline
26. Histidine
28. Hartnup Ds
• Massive aminoaciduria without a corresponding increase in plasma amino acid level is characteristic
of Hartnup disease
• Metabolism of Tryptophan amino acid is at fault in Hartnup's disease
• Hartnup disease is related to Pellagra symptoms
• A severely retarded infant is noted to have hepatosplenomegaly and a cherry-red spot in the
macula is diagnosed to have Niemann-Pick disease
• A 2 year old retarded child is evaluated by a metabolic specialist. The child's history is significant for
failure to thrive and progressive neurologic deterioration, including deafness and blindness.
Physical examination is remarkable for hepatosplenomegaly, as well as a cherry-red spot on
funduscopic examination. These symptoms are consistent with a diagnosis of Niemann-Pick disease
• Examination of the fundus shows Cherry red spot in Niemann-Pick disease
• Accumulation of sphingomyelin in phagocytic cells is feature of Niemann-Pick disease
• Foam cells seen in Niemann-Pick disease
• Deficiency of sphingomyelinease causes Niemann-Pick disease
• Niemann-Pick disease is autosomal recessive
• Riboflavin
• Thiamine is co-enzyme for pyruvate dehydrogenase and α-ketoglutarate dehydrogenase.
• Niacin
• Pantothenic acid
STEP 1
Acetyl CoA (2C) + Oxaloacetate (4C) + H20 Citrate synthase Citrate (6C) + CoA + H
STEP 3
STEP 4
α-Ketoglutarate (5C) + NAD+ + CoA α-Ketoglutarate dehydrogenase complex Succinyl CoA (4C) + CO2 + NADH
STEP 5
Succinyl CoA (4C) + Pi + GDP + H20 Succinyl CoA synthase/Succinate thiokinase Succinate (4C) + GTP + CoA
STEP 6
STEP 7
STEP 8
Products
o The cycle produces three moles of NADH and one mole of FADH2 per mole of acetyl CoA oxidized
to CO2 and H2O
o NADH is produced and CO2 is liberated at 3 steps :
o Conversion of isocitrate to a-ketoglutarate by isocitrate dehydrogenase
o Conversion of a-ketoglutarate to succinyl CoA by oc-ketoglutarate dehydrogenase
o Conversion of L-malate to oxaloacetate by malate dehydrogenase.
INTERMIDIATE PRODUCTS
1. Pyruvate dehydrogenase
3. α-Ketoglutarate dehydrogenase
• Inhibited by high levels of: ATP, succinyl CoA and NADH, arsinate
ANABOLIC PROPERTIES
Valine Glucogenic/Essntl/Aliphatic(neutral)
Valine Glucogenic/Non-Essntl/Aliphatic(neutral)
Proline Glucogenic/Non-Essntl/Heterocyclic
Glutamate Glucogenic/Non-Essntl/Acidic GABA, glutathione, gamma-
carboxy glutamate
Asparagine Glucogenic/Non-Essntl/acidic
Glutamine Glucogenic/Non-Essntl/acidic Purines, pyrimidines, amino
sugars
34. Antioxidant
ANTIOXIDANT
CLASSIFICATION OF ANTIOXIDANTS
1. ANTIOXIDANT ENZYMES
1. Catalase
2. Glutathione peroxidase(selenium imp.component)
3. Glutathione reductase
4. Super oxide dismutase(both Cu -Zn and Mn)
2. METAL BINDING PROTIENS
1. Ceruloplasmin
2. Ferritin
3. Lactoferrin
4. Metallotheinein
5. Transferrin
6. Hemoglobib
7. Myoglobin
3. Bilirubin
4. Caroteniod
5. Beta Carotene
6. Alpha carotene
7. Lutien
8. Lycopene
9. Zeaxanthin
10. Vitamins A,C,E,D
11. Uric acids
12. Thiols
13. Other-Copper, Selenium,Zinc,Alpha lipoic acid,Glutathione
MECHANISM OF ACTION
b) Cn(H2O)n
c) Both of above
Answer- Cn(H2O)n
Explaination- The general formula for carbohydrates is Cn(H2O)n where n= no of carbon atoms.
2. Glycogen is the main source of energy for human beings. What is the percentage of that-
Explanation- Primary source of energy for human beings is Carbohydrates as Glycogen which is around 45-
65% of total energy.
a) Glucose
b) Fructose
c) Galactose
d) Mannose
Answer- Glucose
Explaination- Glucose is the main metabolic fuel for mature erythrocytes in a starving state.
a) Glucose
c) Fructose
d) Mannose
Answer- Sucrose
a) Glucose
b) Mannose
c) Fructose
d) Galactose
Answer- Fructose
Explanation-
Triose Glyceraldehyde
Tetrose Erythrose
Heptose
a) Maltose
b) Mannose
c) Fructose
d) Galactose
Answer- Galactose
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Explanation- Galactose is a constituent of Lactose(milk sugar) synthesized in the mammary gland for
synthesis of lactose.
a) Glucose oxidase
c) Dextrostix
d) Folin-Wu method
Phenyl Ketonuria.
9. Cellulose is-
a) Complex Lipoprotein
b) Starch Polysaccharide
c) Nonstarch Polysaccharide
Explanation- Foods contain a wide variety of other polysacdnarides that are collectively known as
nonstarch polysaccharides. They are not digested by human enzymes/ and are the major components of
dietary fiber.
Examples are cellulose from plant cell walls (a glucose polymer) and inulin, the storage carbohydrate in
some plants (a fructose Polymer)'
a) Heparan Sulfate
b) Heparin
c) Chondritin sulphate
d) Keratan sulphate
Explanation-
The only metabolic fuel for mature erythrocytes in fed and starving state is glucose.
Galactose is the constituent of lactose (milk sugar) and part of glycosaminoglycan in proteoglycans
glycolipids.
If ring structure formed by cyclization is six sided called as pyranose ring (pyran) (seen in glucose)
37. Mucopolysaccharidoses
1. Derived Sugars include- Acid sugars, Sugar alcohols, Deoxy sugars, Amino sugars, Glycosides, Furfural
derivatives.
39. Isomerism
3. Glucose and mannose are C2 epimers and glucose & galactose are C4 epimers.
10. Perioxidase and oxidase enzymes are used for estimation of glucose.
3. Mature Erythrocytes which lack mitochondria are completely dependent on glucose for metabolic fuel.
5. Fructose 6 phosphate to Fructose 1,6 bisphophate is the major regulatory step in glycolysis and is a
committed step also.
2,3 BPG shifts the oxygen Dissociation curve to right due to reduced affinity towards oxygen
No ATP is generated (only one molecule generated through glycolysis in RBC utilized)
Cancer cells switching to glycolysis even in the presence of adequate O2 for oxidative phosphorylation c/d Warburg
effect
1. In Glucose- alanine cycle, amino acid increased in blood during starvation is Alanine.
45. Gluconeogenesis
1. Most common GSD in adolescent and adults- Type V GSD (McArdles Disease)
1. Amino acids not coded by genetic code are all derived amino acids.
2. The charge of carboxyl group and amino group at physiological pH (pH= 7.4)
3. Carboxyl group is negative & amino acid group is positive.
4. Aromatic amino acids absorbs UV light.
5. Most polar amino acid is Arginine.
6. Most abundant amino acid in the body present is Alanine.
CO CO2
a) Melanin
b)Catecholamines
c) Thyroxine
52. TRYPTOPHAN
53. PHENYLKETONURIA
54. ALKAPTONURIA
55. TYROSINEMIA
56. Albinism
2. Most common cause is due to deficiency of enzyme tyrosinase leading to defective synthesis of melanin.
1. Cysteine and cystenine are synthesized from 2 amino acids, methionine and serine.
58. HOMOCYSTINURIA
2.
a) To Succinyl CoA
- Valine
- Isoleucine
- Methionine
- Threonine
b) To Fumarate
- Tyrosine
- Phenylalanine
- Aspartate.
c) To Oxaloacetate
1. Most of the structural proteins are fibrous proteins. E.g.- collagen, elastin and keratin
4. Secondary derived proteins are formed with successive breakage of peptide bonds.
- Lactate dehydrogenase
- Alcohol dehydrogenase
65. NUCLEOTIDES
3. Tissues which cannot synthesis purine nucleotides by de nevo pathway are- brain, erythrocytes and
leuckocytes.
1. Glucose-6- phosphate deficiency (Van Gierke’s disease)- generates large amout of ribose -5-
phosphate.
2. Gout is caused due to overproduction of uric acid.
3. The typical characteristic of Gout is Tophi deposits, hyperuricemia, acute gouty arthritis.
4. The most common joint affected by gout is the Knee joint.
5. Lead poisoning leads to gout.
75. HISTONES
• Brain
• Erythrocytes
• Polymorphonuclearleukocytes
• Bone marrow.
i) Glutamins provides N3
3. Pyrimidines are degraded to amino acids, namely β- alanine and β- aminoisobutyrate which are then
metabolized.
1. The end products of pyrimidine catabolism are highly water soluble. E.g. CO2, NH3, β-
aminoisobutyrate, beta alanine.
2. Pseudouridine is excreted unchanged as it cannot be catabolized in human.
3. Humans have no enzyme that can catabolise pseudouridine derived from degradation of t-RNA.
4. There is no energy generated in pyrimidine catabolism.
5. The end products of pyrimidine catabolism is CO2 and H2O.
3.Type II orortic aciduria is caused due to deficiency of Orotic acid decarboxylase (orotidylate
decarboxylase)
4. 6-Azauridine (after its conversion into 6-azauridylate) also cause orotic aciduria and orotinuria by
inhibiting orotidylate decarboxylase.
82. ANTIMETABOLITES
88. ENZYMES
89. COENZYMES
1. Co- substrates- In a group transfer reaction coenzyme acts either a donar or acceptor. Most
common mechanism of coenzymes.
2. Non protein- chemical components are organic molecules(coenzyme)
3. Classification of coenzymes-For transfer of hydrogen- Lippoic acid
4. Zinc- carbonic anhydrase, Alcohol dehydrogenase
5. Metalloenzymes (Cofactors)-
Metal Metalloenzymes
Copper (Cu+2/Cu+) Cytochrome oxidase, Lysyl oxidase, ceruloplasmin
Iron (Fe+2/Fe+) Xanthine oxidase
Zinc (Zn+2) Carbonic anhydrase, alkaline phosphatase, alcohol dehydrogenase,
carboxypeptidase, glutamate dehrdogenase, lactate dehdrogenase,
superoxide dismutase
Magnesium (Mg+2) Phosphatases, kinase, glutathione synthase
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Selenium Glutathione peroxidise
Molybdenum Xanthine oxidase, sulphite oxidase
6.
1. Reversible Inhibition- binds through non-covalent bonds and activity of enzyme is restored.
2. Competitive inhibitor- Km increased, Vmax unchanged.
3. Competitive inhibitor- Succinate dehydrogenase by melanate.
4. Non competitive inhibitor- Km unchanged, Vmax decrease, mostly irreversible.
5. Non competitive inhibitor- E.g.- Cyanide by Cytochrome C Oxidase.
6. Suicidal Inhibitor- Allopurinol inhibit Xanthine oxidase.
• The most common covalent modification is the addition or removal of a phosphate group.
• Irreversible covalent modification- partial proteolysis/ zymogen activation
• Methods of Reversible covalent modifications-
LDH-2 RBC
LDH-3 Brain
CK-1 Brain
CK-2 Heart
2. BI-BI Reactions-
96. Lipids
5.
• Polyunsaturated fatty acids (PUFA) are 3 fatty acids- linoleic acid, linolenic acid and arachidonic
acid are called essential fatty acids.
• Fatty acids requires but not synthesized fatty acids in humans.
• Human cannot synthesize linoleic acid and linolenic acid.
• Linoleic acid is the most important essential fatty acids.
• Linoleic acid in decreasing order-
• Safflower oil > cornoil > sunflower oil> Soyabean oil
• Arachidonic acid has maximum carbon atoms (20).
• Linolenic acid- (3 double bonds)- C17 H29COOH
100. TRIACYLGLYCEROL
101. PHOSPHOLIPIDS
a) Phosphatidylcholine (lecithin)
102. GLYCOLIPIDS
4. Gangliosides
103. SPHINGOPHOSPHOLIPIDS
105. BIOMEMBRANES
Regulation of lipolysis-
1. Epinephrine
2. Catecholamines
3. Thyroid hormones
4. Growth hormone
5. ACTH
6. Glucocorticoids
1. Insulin
2. Prostaglandin
d) E5- hydratase
f) E7- Thioesterase
Dephosphorylation Phosphorylation
• Oxidation of Very Long Chain Fatty Acid- It takes place in Peroxisomes till Octanoyl CoA.
• Oxidation in peroxisome produces Acetyl CoA and H2O2
• Oxidation of Unsaturated Fatty Acid- It occurs in mitochondria
• The energy yield by oxidation of Unsaturated Fatty Acid is 1.5 ATP less per double bond.
• Odd chain fatty acids are also Beta-oxidized normally but the last step produces a 3-carbon
propionyl.
• Alpha- oxidation of fatty acids- It occurs in endoplasmic reticulum and mitochondria.
• VLDL is synthesized in liver contains high triglyceride, cholestryl ester, cholesterol, phospholipid
and Apo B-100.
• IDL is taken up in the liver by apo E Receptor present in the liver.
• Apo C- II activates Lipoprotein lipase
• apo B-100 acts as ligand for LDL receptors
• LDL elevated serum concentration of LDL causes excessive deposition of cholesterol in peripheral
tissues and enhance atherosclerosis therefore it predisposes to MI.
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• LDL is metabolized by LDL receptor.
• LDL is a bad cholesterol considered as a marker for cardiovascular disease called as lethally
dangerous lipoprotein (LDL).
• LDL receptor present in hepatic and extrahepatic tissues.
• Fatty liver is the excessive accumulation of fat i.e. triacylglycerol in the liver (25- 30%)
• Triglycerides is stored in the adipose tissue.
• Nonalcoholic fatty liver disease (NAFLD) is the most common liver disorder.
• Causes- Overproduction of triacylglycerols and Raised levels of plasma free fatty acids- (VLDL
synthesis impaired)
• Lack of lipotropic factors (choline, betaine, methionine, lecithine and inositol, vitamin B12, Vitamin
E)
• Lipotropic Factors- which prevents the accumulation of fat (triglycerides) in liver.
117. HYPERLIPOPROTEINEMIA
a. Cholic acid
b. Chenodexycholic acid
c. Glycocholic acid, glycochenodeoxycholic acid, taurocholic acid.
a. Deoxycholic Acid
b. Lithocholic Acid
• Free fatty acids (FAA) is metabolically most active of the plasma lipids.
• Non polar lipid contains cholesterol ester, cholesterol, phospholipid, triacylglycerol.
• Protein part of lipoprotein is apolipoprotein.
• Chylomicrons- These are principal form in which dietary lipids (exogenous lipids) are carried from
intestine to liver.
• Low density lipoproteins (LDL)- major source of cholesterol to peripheral tissues.
Electrophoresis-
Ultracentrifugation-
120. Hypolipoproteinemia
• Abetalipoproteinemia-
• There is deficiency of apo-B containing lipoproteins i.e. chylomicrons, VLDL lDL, LDL.
• Low plasma levels of cholesterol and triacylglycerols occurs.
• HDL levels are normal.
• Deficient Vitamin E and fat soluble vitamins (vitamin A & K).
• Hypoalphalipoproteinemia (Tangier disease)
• Due to marked deficiency of major lipoprotein HDL (apo-A-I and apo-A-II)
• Enlarged tonsils
1. Linoleic acid
2. Oleic acid
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3. Palmitic acid
4. Arachidonic acid
122. VITAMIN A
a. Retinol (alcohol)
b. Retinal (aldehyde)
c. Retinoic acid (acid)
124. Vitamin D
Vitamin K deficiency-
Thiamine nutritional status is best assessed by erythrocyte or whole blood transketolase activity.
• Sources-
• Aleurone layer of cereals.
• Yeast is also good source of thiamine.
• Meat
VITAMIN B1 DEFICIENCY
3. Lactic acidosis
• Glossitis
• Angular stomatitis
• Seborrheic dermatitis
• Corneal vascularisation
1. Oxidoreduction reaction-
• Isocitrate dehydrogenase
• Malate dehydrogenase
• α-ketoglutarate dehydrogenase
• glutamate dehydrogenase
• glyceraldehydes-3- P dehydrogenase
• lactate dehydrogenase
• β-hydroxyl acyl CoA dehydrogenase
• Pellagra-
o Caused due to niacin deficiency
o Common in people consuming maize and sorghum (poor in niacin & tryptophan and rich in
leucine)
Clinical Manifestations-
• Characterized by 4Ds-
• Dermatitis, Diarrhea, Dementia and Death
• Casal’s necklace- rash form around neck
a. Pyridoxine
b. Pyridoxial
c. Pyridoxamine
1. Transamination
2. Decarboxylation
3. Non-oxidative deamination
4. Condensation
5. Transsulfuration
6. Tryptophan Metabolism
c) Pyruvate carboxylase
Biotin Deficiency-
• Depression, Hallucination
• Anorexia
• Seborrheic and erythematous rash near nose, eyes, mouth.
• Alopecia
• It is absorbed in Ileum.
• The internal absorption of Vitamin B12 requires intrinsic factor (IF), secreted by parietal cells of
the stomach.
Clinical Manifestations-
1. Megaloblastic anaemia
2. Homocysteinemia
3. Methyl Malonic Aciduria
4. Subacute Combined degeneration
5. Demyelination
a. Cholic acid
b. Chenodexycholic acid
c. Glycocholic acid, glycochenodeoxycholic acid, taurocholic acid.
a. Deoxycholic Acid
b. Lithocholic Acid
Vitamin C Deficiency-
1. Scurvy-
MINERALS CLASSIFICATION
Macronutrients-
1. Proteins
2. Fats
3. Carbohydrates
Micronutrients-
i. Vitamins
1. Copper
2. Iodine
3. Iron
4. Mangnese
5. Selenium
6. Zinc
a) Sodium
b) Calcium
140. Hemochromatosis
I)Herediatry- hemochromatosis
• Iron loading-
i) Thalassemia major
• Antidotes for iron poisoning:Desferrioxamine is given parenterally (IM or IV), whereas deferiprone
and deferasirox are used orally.
ii) Causes- Decreased iron absorption- diet, malabsorption of iron, surgery or gastrectomy.
Treatment
• The iron is held in the centre of porphyrin ring in ferrous form (Fe+2)
• 5th bond- between nitrogen atoms of histidine residue of globin chain called as proximal histidine.
• Distal histdine (His E7) reduces affinity of heme for carbon monoxide (CO).
• Each molecule of haemoglobin combine upto 4 molecules of oxygen.
• Heme is synthesized in all cells but mainly in bone marrow and liver.
• Organelle- cytoplasm and mitochondri
• Synthesis of ALA occurs in mitochondria (Rate limiting step)
• Synthesis of porphobilinogen, hydroxymethylbilane, uroporphyrinogen, coproporpyrinogen-
occurs in cytosol.
• Synthesis of protporphyrinogen occurs in mitochondria
• Formation of heme occurs in mitochondria.
EXAM POINTS-
Types of Hemoglobin-
• Embryonic haemoglobins
a) Hb Portland ?2γ2
b) Hb Gower I- ?2ε2
• Fetal Hemoglobins
a) Hb F- α2γ2
• Adult Hemoglobins
a) Hb A1 – α2β2
b) Hb A2 – α2δ2
Charateristics of Hemoglobin
148. MYOGLOBIN
Congenital Hyperbilirubinemia
• Unconjugated hyperbilirubinemias
a) Glibert’s disease
• Physiological Jaundice
• Breast Milk Jaundice
• Lucey Driscoll Syndrome
Conjugated Hyperbilirubinemias
• Insulin is the first hormone to be extracted in pure form by Banting and Best.
• Sanger’s reagent was used for sequencing the protein.
1. Salt fractionation
2. Ultracentrifugation
3. Electrophoresis
4. Chromatography
5. Ultra filtration
• Ammonium sulphate is most commonly used reagent for salting out in proteins.
• Chromatography- The most non-polar amino acids migrate the farthest, due to their greater
solubility in the organic solvent.
• Gel filtration chromatography or molecular sieving- Used for separation of molecules based on their
size are Hydrophilic cross linked gels like agrose (Sepharose), dextran ( Sephadex)
• Ion-exchange chromatography- Separation is made on the charge difference.
• The charged group commonly attached are
1. diethylaminoethyl (DEAE) group- the negatively charged proteins associate with positively charged
DEAE groups and replace chloride ions.
2. carboxylmethyl (CM) cellulase chromatography- negatively charged or neutral proteins have no
affinity for CM, move faster.
3. Affinity chromatography- based on the high affinity of specific proteins for specific chemical groups
called ligand. Specific protein molecules bind to specific ligand.
4. Hydrophobic interaction chromatography- hydrophobic ligand.
5. Electrophoresis- isoelectric net charge is zero and do not move.
• Electrophoresis is the most common method of protein separation in the clinical laboratory.
• Types of electrophoresis are-
1. Double diffusion- concentration gradient is established for both antibody and antigen and the
technique is called ouchterlony technique. (widely used)
2. Crossed immunoelectrophoresis used in second dimension to drive antigen into gel containing
antibodies specific for the antigen interest
• Defect in Type I Collagen leads to osteogenesis imperfect, osteoporosis, Ehlers- Dahlos syndrome.
• Defect in Type II collagen leads to osteoarthritis.
• Defect in Type III collagen leads to Ehlers-Dahlos syndrome
• Defect in Type IV collagen leads to Alport Syndrome
• Defect in Lysyl hydroxylase leads to Ehlers- Dahlos Syndrome, Scurvy.
Classic EDS
Clinical Manifestations-
• Joint hypermobility
Type V EDS
SUBTYPE DEFECT IN
Hypermobility Type III collagen, Tenascin X
Classic Type I and V collagen
Vascular Type III collagen
Kyphoscoliosis Lysylhydroxylase
Arthochalasis Type I collagen
Dematosparaxis ADAM metallopeptidase with thrombospondin
type I motif
• X-linked disorder.
• Type IV collagen is affected.
CLINICAL FEATURES-
• Hematuria
• Sensorineural deafness
• Conical deformation of the anterior surface of the lens (lenticous).
• The pathognomonic feature of classic Alports syndrome lenticonus together with hematuria.
HISTOLOGICAL FEATURE-
• HSP 70
• HSP 90
• HSP 40
158. Ubiquitin
MULTIPLE MYELOMA
POEMS SYNDROME
• Polyneuropathy
• Organomegaly
• Endocrinopathy
• Multiple myeloma
• Skin changes
161. Glycoprotein
• Glycoprotein consists of protein to which short branched, oligosaccharides are covalently attached.
• Length of oligosaccharide chain is relatively short in glycoproteins.
• Carbohydrate chain is often branched in glycoproteins.
• Oligosaccharide chains of glycoproteins lack a serial repeating units.
• BIOLOGICALLY IMPORTANT GLYCOPROTEINS-
a) O-linked glycosides
b) N-linked glycosides
SYNTHESIS OF GLYCOPROTEINS
a)O-linked glycosides-
b) N-linked glycosides
162. Dissaccharides
163. Polysaccharides
165. Mucopolysaccharidosis
• Scheie Disease
• Morquio Disease [Keratan Sulphate and Chondroitin Sulphate]
• Maroteaux Lamy Disease
• Hunter's Disease
• Sanfilippo Disease
Brown's classification:
2.β- hemolitic(clear)
3. γ-hemolitic: Entrococcus
a. E. faecalis
b. E. faecium
Lancefield grouping
• Group A - S. pyogenes
• Group B - S. agalactiae
• Group C - S. equisimilis, S. equi, S. zooepidemicus, S. dysgalactiae
• Group D -E. faecalis, E. faecium, E. durans and S. bovis(most heat resistant > 60)
• Group E - Enterococci
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• Group F, G & L - S. anginosus
• Group H - S. sanguis
• Group K - S. salivarius
• Group L - S. dysgalactiae
• Group M & O - S. mitior
• Group N - L. lactis
• Group R & S - S. suis
Other Streptococcus species are classified as 'non-Lancefield Streptococci'
CAPSULE
VIRULENCE FACTOR
M. protein
Streptolysin O
Streptolysin S
Streptokinase(Fibrinolysin)
DNAase or Streptodornase
• Besides Str. pyogenes, streptococci belonging to group B, C, D, F, G and rarely H, K, 0 and R may
also cause human infections.
• Streptococcus causes destruction of skin grafts
Group B streptococci
• Str. agalactiae.
• Lives in female genital tract
• CAMP +ve
• It is the single most common cause of neonatal meningitis.
• Newborn infection acquired from mother's vagina during birth
2. Streptococcus Pneumonia
MORPHOLOGY:
• Lanceolate appearance
CULTURAL CHARACTERISTICS:
Optochin sensitivity:
Quellung reaction:
Biochemical reactions
Antigenic Structure
• Polysacchaide capsule:
• CellWall
LYSOGENY:
• Hemolysin
• Streptolysin
• Pyrogenic Exotoxin = Erythrogenic = Dick = Scadatinal Toxin
• Streptokinase (Fibrinolysin): Facilitates spread of infection.
• Spy Lep: A serine protease that cleaves and inactivate IL-8
• Deoxyribo nuclease (Streptodornase): Responsible for thin serous character of strep
• Exudates. Also called as DNAase.
• Nicotinamide Adenine Dinucleotidase (NAD-ase).
• Hyaluronidase: Favor spread of infection.
• Serum opacity factor: Lipoproteinase.
• Anti Streptolysin O titre used in retrospective diagnosis; > 200 units is significant.
4. Streptococcus Viridans
• During the asymptomatic latent phase of AIDS, the virus is actively proliferating
• Can be found in association with Follicular dendritic cells in lymph nodes
• Serve to trap HIV virions coated with anti-HIV antibodies.
• Sero conversion take place in 3-4 weeks
METHOD OF TRANSMISSION:
1. Sexual transmission
• Risk of HIV transmission is not seen with Plasma derived hepatitis B vaccine, Cryoprecipitate)(least
common> 1%)
• Use of contaminated clotting factors by hemophiliacs0.5%.
• Sharing contaminated needles (IV drug users> 25%).
• Health worker gets HIV from an accidental needle prick in1% cases
• Risk of getting HIV infection from transfusion of a unit of infected blood is > 95o/o.
4.Mother to fetus
DIAGNOSIS
Virus isolation
• Cultivation of patient CD4 + (Helper) T Lymphocyte with uninfected lymphocyte in presence of lL-2
T cell anergy
HISTOPATHOLOGY OF HIV:
WINDOW PERIOD
• The time period between primary infection and antibody detection is called window period
• Window period in HIV infection is 4-8 weeks
• During the Window period ELISA & western blot both are negative
• Associated with increased p24 antibody: basis for detection in window period.
• For p24 detection(antigen) - 16 days
• RNA PCR - 12 days
• Average incubation period of AIDS is 10 years
DISEASE MONITORING
• According to CDC recommendations, HIV screening of pregnant women is Opt out testing
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• The infants continue to test positive for IgG antibodies for upto 18 months.
• Uptil 18 month of age this method of diagnosis cannot be used.
• Direct viral detection assays:
Penicillium marneffi:
• It forms yeast like cells that are often intracellular resembling histoplasmosis.
Candida tropicalis:
Tuberculosis:
• In tuberculosis in an AIDS patient the chest X-ray looks like Miliary shadow
Major Signs:
1097
• Providing 3 million people treatment by end of 2005 was "3 by 5" initiative.
• February 12, 2014 launched NACP VI, under the banner of NACO.
• Diagnosis and treatment of STD one of the major strategies to control spread of HIV infection.
• For treatment of STDs, blue colored pack is used for treatment of Genital ulcer
HIV surveillance -
• Training module called Learning for life prepared to bring an uniformity in approach
• 91 ART centres
• Combination of three potent drugs, given to the persons with advanced stage of AIDS.
• "Suraksha clinic" .
• Established at :
9. WHO clinical staging of HIV/AIDS for children with confirmed HIV infection
WHO clinical staging of HIV/AIDS for children with confirmed HIV infection
Clinical stage 1
• Asymptomatic
• Lymphadenopathy
Clinical stage 2
• Unexplained persistent hepatosplenomegaty
• Papular pruritic eruptions
• otitis media, oton'hoea, sinusitis or tonsillitis
Clinical stage 3
• Persistent oral candidiasis (after first 6-8 weeks of life)
• Severe recurrent bacterial pneumonia
• Unexplained anaemia (9 per litre) and or chronic thrombocytopaenia (9per litre)
Clinical stage 4
• Pneumocystis pneumonia
• Recurrent severe bacterial chest infections (such as empyema, pyomyosrtts, bone or joint
infection or meningitis but excluding pneumonia)
• Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Extrapulmonary
tuberculosisKaposi sarcoma (in adult)
• Progressive multifocal leukoencephalopathy
• Depression is most common psychological feature
Necrotizing Granuloma
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• Numerous acid-fast bacilli are demonstrated by Ziehl-Neelsen staining within the cytoplasm of
epithelioid cells.
Misc
1.Adults
a) lmmunocompetant host
2. Children
a) Congenital
• May present with hydrocephalus, microcephaly mental retardation, deafness, blindness, epilepsy.
• Chorioretinitis
• Intracerebral calcification may occur
• NOT infective in 3" trimester in pregnancy
b) Acquired
• C/Fs are
o Macular scarring
o Retinochoroiditis(Most common)
o Vitritis
Diagnosis of Toxoplasmosis
Serology
Congenital infection
Treatment of Toxoplasmosis
• Congenital infection
o Pyrimethamine and sulfadiazine
• Infection in pregnancy: Spiramycin (rovamycine) is DOC.
. LUNGS IN HIV
• AIDS patient most common mico-organism responsible for pneumonia is Pneumocystis carinii
Parasitic
Fungal
Neoplasm
Helminthic
• Strongyloides stercoralis
• In AIDS, lymphadenopathy is most often due to Non specific enlargement of lymph node
Kaposi Sarcoma
17. Eye, Endocrine system, Hematopoietic system, CVS and Dermatological system In HIV
• CMV retinitis is the most frequent and serious ocular opportunistic infection and is the leading
cause of blindness in AIDS patients.
• Viral, bacterial & fungal infection, Kaposi sarcoma, CMV retinitis, lymphoma are the Ocular
manifestation of HIV
• Commonest opportunistic organism to cause ocular inflammation in AIDS is Cytomegalovirus
• Central toxoplasma chorioretinitis , CMV retinitis, Candida endophthalmitis are the ocular lesions
may occur in patients suffering from AIDS
• Vision loss in HIV is commonly due to infection with Cytomegalovirus
• White patch on the side of the tongue with a corrugated or hairy appearance.
• Virtually pathognomic of HIV disease in the context of HIV risk factors.
• It is caused by Epstein-Barr virus (EBV) .
Esophagitis
Intestinal Infection
Diahrrea in AIDS patient can be caused by:
Bacterial Salmonella, Shigella, Campylobacter jejuni
Viral CMV,HIV,Enteropathy
19. Chlamydia
INTRODUCTION:
• Obligate gram -ve intracellular bacterial parasite unable to grow in cell free media (against Koch's
postulates)
• They do not have peptidoglycan and N-acetylmuramic acid in cell wall.
• Most common organism associated with reactive arthritis is Chlamydia
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• Elementary bodies are infectious
• Forms chlamydial microcolony called Inclusion body.
.Classification
1. C. trachomatis
2. C.pneumoniae
3. C.psittaci
4. C.pecourum
Antigen
RESISTANCE:
Molecular mimicry:Chlamydia induced INF-y inhibits INF-y dependent expression of MHC class-II proteins.
• Yolk sac inoculation is used for diagnosing chlamydia from tissue specimen.
NAATs:
Non-NAATs:
TREATMENT:
CDC-recommended regimens
• tetracycline
CDC-recommended regimens
CDC-recommended regimen
• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days
INTRODUCTION:
• John Snow (1813-1858) found the link between cholera and contaminated drinking water in 1854,
using spot map.
• Robert Koch Isolated V.cholrae in 1883
• Cholera is caused by Vibriocholera .01 and 0139
• Cholera belongs to category-B of bioterrorism
• Cholera is WHO notifiable disease
• Father of public health is Dr. John Snow
VIBRIO'S IN NATURE
• They appear curved gram negative aerobic rods and are motile
• Possesing a polar flagellum that shows Darting motility (shooting star)
• V. cholera is able to stay in GIT because of motility
• It is non halophilic
V.cholrae - typing
1. Classic
2. El Tor
El Tor Vibrio's:
• V.cholrae 0139 is very similar to epidimologically & clinically V.cholrae .01 El Tor biotype
• V.cholrae 0139 Epidemic: The epidemic of cholera caused by V cholerae 0139 was discovered in
chennai
Plating media
1. TCBS
Growth Characteristics
• Vibrio's grow at a very high pH ( 8-5 – 9-5 ) and are rapidly killed by acid
• Quarantine period of cholera 5 days
DIAGNOSIS
Stool Examination
Specimen Collections
• Stool specimens are collected in acute stage of the disease. before the antibiotics are administered.
Transport:
• Stool culture:
• Use Cary Blair Transport media if available for transport.
• Use TCBS media for culture
Characteristics
Serological Examination
1. Catalase +ve
2. Oxidase +ve
3. Indole +ve
4. Nitrates reduced to Nitrites
5. Surcose fermenter
Manifestations
• Acidosis
• Arsenic poisoning
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o Can be detected from hair & nails long after death
o Confused with cholera
o Clinically present with rain drop pigmentation & mees line
PANCREATIC CHOLERA:
PATHOLOGY:
ENTEROTOXIN(CTX/CT/Choleragen/Permeability factor)
MECHANISM OF ACTION:
TRANSMISSION:
EPIDEMIOLOGY:
Cholera Control
• Patients isolated .
• Wells needs to be disinfected every Day
• Excreta disinfected
• The most effective disinfectant for general use is a coal-tar disinfectant with a Rideal-Walker (RW)
coefficient of 10 or more such as cresol.
• Notification
• Cholera is notifiable disease locally, nationally and internationally
• Notifiable to WHO within 24 hours of its occurrence by national government.
• Water control Boiling or chlorination(emergency sanitary).
VACCINES:
Killed vaccine
• Cholera vaccine effectiveness is 85% for 6 months which declines to 50% for 12 months
• Oral cholera vaccine is effective for 3 years
• Dukoral (WC-rBS)
• Dukoral is a monovalent vaccine based on formation and heat-killed whole cells (WC) of V. cholerae
01 (classical and El Tor, Inaba and Ogawa) plus recombinant cholera toxin B Subunit.
• Shanchol and mORCVAX.
• NEWER VACCINES:Cholera vaccine is no longer required, nor recommended for the vast majority of
travellers by the Centres for Disease Control and Prevention (CDC).
o CDC – On Vaccination for Cholerae
STRUCTURE OF ANTIBODIES:
Immunoglobulin molecule:
• Fc fragment of Ig
• Determines the biological properties of Ig
o Complement fixation
o Placental transfer
o Skin fixation
o Catabolic rate
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Amino terminus/Variable unit/FAB/ANTIGEN BINDING SITE
Heavy chain
28. Immunoglobulin A
STRUCTURE:
PROPERTIES:
LOCATION:
• IgA nephropathy may occur following an episode of mucus membrane infection of the respiratory
or gastrointestinal tract.
• Henoch-Schonlein purpura is characterized by the deposition of IgA around the vessels
IgA DEFICIENCY:
29. Immunoglobulin M
PROPERTIES:
STRUCTURE:
Functions
Clinical Importance:
30. Immunoglobulin E
Properties
Functions
• Seen in type I allergic conditions (asthma, hay fever, eczema, children living in unsanitary conditions
with high load of intestinal parasites
• Main defence against helminthic infestations
31. Immunoglobulin G
INTRODUCTION:
STRUCTURE:
PROPERTIES:
Antigenic Structure
Toxin
• Hemolysins .
• Enterotoxins: Important in pathogenesis of diarrhea
• Heat-stabile :Activates cGMP
• Heat-labile enterotoxins
• Shiga toxins STEC /Verocytotoxin
33. STAPHYLOCOCCI
INTRODUCTION:
CLASSIFICATION:
• Based on pathogenecity:
• Pathogenic:- includes only one i.e., S.aureus
• Non-pathogenic:- includes S.epidermidis, S.saprophyticus, S.albus, S. citrus, S.hominis,etc.
• Based on coagulase production:
• Coagulase positive: S. aureus
• Coagulase negative: S. epidermidis, S. saprophyticus
• Based on Novobiocin susceptibility(for cogulase -ve group)
+ve -ve
S. epidermidis S. saprophyticus
S. hemolyticus S. saprophyticus
S.hominis
S. logdunesis
S. schleiferi
CLINICAL SYNDROMES:
• Conjuctivitis
CUTANEOUS INFECTIONS:
• Bullous Impetigo:
• It is characterized by watery bristles, which become pustules and then honey coloured crust
• Botryomycosis
DEEP INFECTIONS:
• Osteomyelitis
• Both acute & chronic osteomyelitis is caused by S.aureus
• Periostitis
Staphylococcal pneumonia
Exfoliative diseases:
• Caused when Toxin shock syndrome toxin (TSST) liberated by S.aureus enters bloodstream
• It is a multisystem illness, that occurs due to superantigen
• Caused when consuming food in which S.aureus has multiplied and pre-formed endotoxin
• Intradietic toxin is responsible for intestinal symptoms.
• Commonly occurs with dairy products
• Optimum temperature for toxin production is 37°C
• Incubation period is 1-6 hours
• Gastroenteritis within 4-6 hrs of consumption of cooked food indicates the cook to be in the carrier
state of staphylococcus
• Staphylococcus appear in stool
Bacteriological Investigation:
MRSA:
• Most strains of S.aureus, even those acquired in community, are penicillin resistant
• Resistance is attributable to beta-lactamase production due to genes located on extrachromosomal
plasmids.
• Some are resistant to the newer beta-lactamase resistant semisynthetic penicillins,
o methicillin
o oxacillin
o nafcillin
TREATMENT:s
INTRODUCTION:
• Gram-positive
MORPHOLOGY:
• Appear in short chains (“V” or “Y” configurations) or in clumps resembling “Chinese letters”.
• Metachromatic granules
o Give Club shape
o Present of at one or both ends
o Also called volutin or babes-Ernst granules.
o Special stains like albert [ malachite green & toludine blue], neisser or polychrome
methylene blue are used for staining.
CULTURAL CHARACTERISTICS:
• Tinsdale agar
o Brown halo surrounding the colony is differentiating feature.
Diphtheria Toxin
• An increased frequency of infections due to salmonella has been reported among patients with
achlorhydria
• The infectious dose of Salmonella typhi causing typhoid fever is 103 - 106 colony forming units.
• Selenite F broth is an enrichment media for Salmonella & shigella
• S.typhi do not produce gas
• Incubation period of salmonella typhi is 3-21 days
• Blood culture in S.typhi is + ve in 3-7 days
• Vi antigen found in Salmonella Typhi & paratyphi
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• Salmonella can enter through the shell if eggs are left on contaminated chicken feed or feces and
grow inside.
• S.typhi need tryptophan as a growth factor
• Salmonella infection is most commonly caused by contaminated water, milk and/or food
• Deoxycholate citrate agar (DCA) medium is used in differentiation of Salmonella from lactose
fermenter
• Salmonella is non-lactose fermenting bacteria
• Salmonella have human reservoir
TOXINS:
• α toxin-
o lethal,dermonecrotic & hemolytic( principle toxin)
ENZYMES
• Hemolysin
o shows double zone of hemolysis
• Lecithinase
o produce opacity around colonies
o by spliting lecithin into phosphorylcholine and diacylglycerol
o appear opalescence in serum or egg yolk media.
• The main reservoir of cl. tetani:soil and intestine of animals and humans
• The main mode of transmission: trauma and contaminated wound
MORPHOLOGY :
CULTURAL CHARACTERSTICS:
• Produces 2 toxins -
o tetanolysin (hemolysin)
o tetanospasmin(neurotoxin)
• Tetanotysin (hemolysin)
• Tetanospasmin:
o block release of inhibitory neurotransmitters glycine and GABA of spinal cord
o Acting pre-synaptically → aboliƟon of spinal inhibiƟon → spread of uncontrolled impulses
initiated elsewhere in the CNS
INTRODUCTION:
TOXINS:
CLINICAL FINDINGS:
Food borne botulism
• Source
o Preformed toxin is important in food poisoning.
o Canned food eaten without cooking.
• Symptoms
o Begin 18–24 hours after ingestion of the toxic food
o Cranial Nerve involvement
o Dysphagia, diplopia, dysarthria are seen
o Signs of paralysis are progressive
o Death occurs from respiratory paralysis or cardiac arrest.
Infant botulism
Wound botulism
MORPHOLOGY:
RISK FACTORS:
VIRULENCE :
• Watery diarrhea (at least three bowel movements per day for two or more days)
• fever, loss of appetite, nausea, abdominal pain/tenderness .
• May cause crohn's disease
DIAGNOSIS:
MORPHOLOGY:
PATHOGENESIS
HSV includes
CLINICAL MANIFESTATION:
• Mucocutaneous manifestations
• Face most common site
o gingivostomatitis
o herpes genitalis
o herpetic keratitis
o dermal whitlows.
o Herpes Gladiatorum
• Encephalitis
o Herpes Simplex Virus is the commonest cause of sporadic encephalitis
• Neonatal herpes simplex virus infection and herpes simplex virus encephalitis shows:
o fever
o followed by headache
o confusion
o focal seizures
o Alterations in behaviour
o Olfactory hallucinationand right hemiparesis.
o Mollaret meningitis is also caused by herpes simplex-2
• Meningitis
o Mollaret's Meningitis
• Eye Infection
o Type 1 herpes simplex virus is usually
o Follicular conjunctivitis
o Decreased corneal sensations
o dendritic and geographical ulcer
o Accompanied by stromal keratitis in more severe infection.
• Genital lesions
o Type 2
o Bilateral lesion
o women: Cervix and Urethre
o Males: Penis
• Latent infection often persists at the initial site despite high antibody titers.
• Recurrent disease triggered by
o temperature change
o emotional distress
o hormonal factors.
• MRI
o shows bilateral frontotemporal hyperintense lesion in herpes encephalitist
• EEGmembrane.
o Periodic temporal lobe spikes on a background of slow or low amplitude activity on EEG
• Herpes simplex virus produces small white shiny non-necrotic pocks on chick embryo
chorioallontoic
TREATMENT:
44. Prion
INTRODUCTION:
Classification
Group A
1. Scrapie
2. latrogenic Creutzfeldt -Jakob disease ;
Infection from prion contaminated human growth hormone, duramater graft, corneal transplant
Mechanism
Resistance to protease
Accumulation
Group C
Subacute sclerosingpanencephalitis (SSPE)
• Caused by JC virus(papovavirus)
• Affect elderly persons whose immune process is impaired .
CLINICAL FEATURES:
Materials required:
• Two primers:
• each about 20-35 bases long
• With sequence complementary to the sequence immediately adjacent to the DNA segment of
interest ( flanking sequence) .
• Divalent cations, magnesium or manganese ions; generally Mg2+ is used,
• DNA polymerase (e.g., Taq polymerase) which can sustain high temperature
• A large number of free deoxynucleotides (dNTPs)
• The target DNA fragment.
METHOD:
USES:
• The most sensitive method for detecting cervical chlamydia trachomatis infection
• Prenatal diagnosis of Hemophilia
• HIV can be detected and confirmed
• Oncogenic
• The DNA is surrounded by a protein nucleocapsid.
DISEASE ASSOCIATION:
• Infectious Mononucleosis
• Lymphoproliferative disease and CNS lymphoma in the immunosuppressed.
• X-linked lymphoproliferative syndrome
• Malignancies caused by EBV includes
o Burkitt’s lymphoma
o Hodgkins disease
o Post transplant lymphoma
o Tcell lymphoma
o Nasopharyngeal carcinoma
o Gastric carcinoma
o Leiomyosarcoma
• Oral leukoplakia in AIDS patients
• G.B syndrome
• Transverse myelitis
• Glandular fever
• Chronic interstitial pneumonitis with pleural effusion in AIDS patients.
Hematologic complications
• hemolytic anemia
• thrombocytopenia
• neutropenia
Neurologic involvement:
• aseptic meningitis
• lymphocytosi
• encephalitis
• isolated neuropathy such as Bell palsy
• Guillain-Barré syndrome.
PATHOGENESIS:
To infect cells, EBV uses a cell surface receptor (CR2,CD21) found primarily on
• B lymphocytes
• Nasopharyngeal epithelial cells.
DIAGNOSIS:
• Leucopenia
• Raise in TLC
• Lymphocytosis
• more than > 70 % atypical lymphocytes(CD8 + cells)
• Thrombocytopenia
Serological testing:
• Serological marker present during window period in hepatitis B infection is Anti HBc
• Anti HBs is the protective antibody present after recovery from hepatitis B or immunization.
• First antibody to appear in plasma/blood in acute hepatitis B is Ig M Anti HBc
• Recumbent stage of Hepatitis B is characterized by Anti HBc
• The presence of hepatitis B surface antigen means actively replicating virus, and in the context of
the history of recent needle-stick injury, this likely represents a hepatitis B infection.
• Hepatitis B virus is least likely to cross placenta
• Highest transmission of hepatitis B from mother to fetus occurs if the mother is infected during IIIrd
trimester
• 10-15% of anti-HBe- positive mothers transmit HBV infection to their offspring
• HBsAg + HBeAg suggest highly infective stage
• Incubation period of HBV is 45 to 180 days
• HBV present in India is Ayw, Adr
• Reverse transcriptase of HBV is coded on p gene
• P gene is the longest DNA of hepatitis B virus
• HBcAg is found within the nuclei of infected hepatocytes and not usually in the peripheral
circulation in Hepatitis B' infection
• The serological marker of acute Hepatitis B infection is HBsAg+Core antibody
• Acute Hepatitis B can be earliest diagnosed by IgM anti HBc ab
• Epidemiologic study of Hepatitis B is by Anti HBc
• Active replication in Hepatitis B infection is indicated by HBeAg
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• Hbs Ag a component of HBV causes glomerulonephritis
• Early diagnosis of active hepatitis B infection is done by IgM HBcAg antibody
• Serological markers for active viral replication include HBe Ag, presence of DNA polymerase and
circulating HBV DNA.
• HBsAg is also known as australian antigen
• E antigen (HBeAg) of hepatitis B virus is a product of C gene
• DNA polymerase of HBV is encoded by P gene
• Super carrier of HBV shows HbsAg + HBeAg + HBV DNA
48. Shigella
CULTURAL CHARACTERISTIC:
Culture media:
• High selective
• Deoxycholate citrate agar
• Hektoen agar/SS agar
• Mannitol ferment
• Subgroup D: S. sonnei: only one serotypes(lactose non-fermeter)
• Shigella dysenteriae: most serious form of bacillary dysentery (Shiga toxin)
MYCOBACTERIUM LEPRAE
MORPHOLOGY
CULTIVATION
• Not possible
• Can be propagated in foot pad of mice
• Granulomas appear at site of inoculation
LEPROSY
Agent:
• M. leprae
Source of infection:
Transmission
Primarily affect
• Skin
• Peripheral nerves
• Nasal mucosa
Not affect
• Deficient
Prevalence
Incidence
Infectivity
Southeast Asia BT
Mexico Lepromatous(LL>BL)
LEPROSY VACCINE
• Launched in 1983
AIM
HOW
SET centres
b.In moderate to low endemic districts, services through mobile leprosy treatment units and primary
health care persons.
RABIES VIRUS
1. Street virus
2. Fixed virus
STUCTURE
MODE OF TRANSMISSION
1. Licks or aerosols
2. Transplantation of cornea.
INCUBATION PERIOD
CLINICAL MANIFESTATIONS
• Incubation
• prodrome,
• acute neurologic period
• coma
• Death
SENSETIVE TO
• Ethanol
• Soap
• Iodine Preparations
• Detergents
• Quaternary ammonium Compound
• Lipid Solvents such as ether, chloroform and acetone
INACTIVATED BY
• Phenol
• UV irradiation
• Formalin
• Sun Light
• Beta propiolactone (BPL)
• Thermal inactivation (one hour at 500 C and 5 min at 60°C)
DIAGNOSIS
RABIES
DISTRIBUTION
1. Australia
2. china (Taiwan)
3. Cyprus
4. Iceland
5. Ireland
6. Malta
7. Japan
8. Newzealand
9. Britain
MODE OF TRANSMISSION
1. Licks or aerosols
2. Transplantation of cornea.
PATHOGENESIS
TYPES
SYMPTOMS
Five stages
• incubation
• prodrome
• acute neurologic period
• coma
• death
1. Antemortem
2. Corneal smear
3. Skin biopsy from neck or saliva
4. Postmortem
5. Brain biopsy
NEGRI BODIES
STRUCTRE
SITE OF OCCURENCE
DETECTION
PRE-EXPOSURE VACCINATION
GIVEN TO
SCHEDULE
REGION OF ADMINISTRATION
ADVERSE REACTION
• Well tolerated
• Minor Adverse reactions
• local pain
• erythema
• swelling
• Puritis
• Neurological comlication with semple vaccine.
POST-EXPOSURE PROPHYLAXIS
VACCINATED PREVIOUSLY
Dosage HRIG
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• The dose for HRIG is 20 IU/kg body weight
• For ERIG and F(ab’)2 products 40 IU/kg body weight.
• Administered into and around the wound site.
• Standard WHO Intramuscular regimen- 0,3,7,14,28 (one dose each at day 0,3,7,14,28)
• Reduced Multisite Intramuscular regimen — 2-1-1 (two dose on each arm on day 0, one dose each
at day 7 & 21)
• Intradermal schedules : 2 site= 2 2 2 0 1 1 (At 2 sites on day 0,3,7 and single site on day 28, 90)
• Intradermal schedules: 8 site= 8 0 4 0 1 1 (on 8 sites at day 0, on 4 sites at day 7, on one site at day
28 & 90)
• Pre exposure prophylaxis — 0,7,28
• Post exposure prophylaxis for those already immunized- 0,3,7
• Common in patients between the two poles of the leprosy spectrum with immunologically
unstable borderline forms
• Higher incidence in BB and BL patients as compared with BT patients.
Manifestations
Cytokines involved
Treatment:
• DOC glucocorticoids
• Clofazimine also given
• Thalidomide - ineffective.
• Irreversible nerve damage can set in less than 24 hours
• So treat promptly with steroids
• Foot drop d/t involvement of common peroneal nerve
Manifestations
• Red, painful, tender, cutaneous nodules (deep) appear that are not associated with leprosy
patches.
• ENL may appear commonly on face, arms, legs.
• TNF
• Tumor necrosis factor-alpha play a central role in the pathobiology of type II lepra reaction/ ENL.
Treatment
Lepromin test
SMEAR SAMPLE
• ample from the skin should be obtained from the edges of the lesion rather than from the centre.
Uses
Tuberculiod Positive
Lepromatous Negative
Borderline Variable
SLIT SMEAR
WHO Clasiification
• Paucibacillary(tuberculiod)
• Multibacillary(lepromatous)
• Asymmetrical
Occurs When • Infected person unable to mount a
cell-mediated immune response to the
• Infected person able to mount a bacterium
robust, cell-mediated immune
response to the bacterium
Defined by WHO as • >5 patches associated with leprosy.
No
PROGNOSIS Cure from disease possible, however, underlying
disease complications (such as limb damage due
Good to infection) may not be reversible or require
reconstructive surgery
Lepromin test
Positive Negative
Erythema Nodosum Leprosum
Treatment
• Paucibacillary leprosy
• should be treated for 6 months with dapsone 100 mg/day unsupervised plus rifampin 600 mg/
month supervised.
• Multibacillary leprosy
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• hould be treated for 12 months with dapsone 100 mg/day unsupervised, clofazimine 50 mg/day
unsupervised, and rifampin 600 mg plus clofazimine 300 mg/month supervised.
• Follow-up in paucibacillary leprosy 2 years
• Follow-up in multibacillary leprosy 5 years
• In paucibacillary leprosy, the multidrug therapy is stopped after 6 months of treatment regardless
of the presence of clinically active disease".
Eyes
• epidermis is normal
Lepromatous • rete flattened.
• clear space separates the
• Early nerve involvement may go unnoticed epidermis from diffuse
• Normoesthetic, small, symmetrical and granulomatous reaction
NERVES INVOLVED
DISEASES:
DISEASES:
NON-INVASIVE DISEASES:
• SINUSITIS(MC)
• OTITIS MEDIA (middle ear)(MC)
• PNEUMONIA (lungs)(lobar & community acquired commonly)
1. Complication :Empyema
• MENINGITIS (CNS)
• ENDOCARDITIS (CVS)
• PERITONITIS (body cavity)
• SEPTIC ARTHRITIS
• UVEITIS
• SUBDURAL EMPYEMA
• OTHERS (appendicitis, salpingitis, soft tissue infections)
Australian syndrome
Concurrence of pneumococcal pneumonia,endocarditis and meningitis.
Diagnosis:
Treatment
Amoxicillin for otitis media/sinusitis/pneumonia
Ceftriaxone +vancomycin for meningitis
Ceftriaxone/cefotaxime +vancomycin for endocarditis
Pencillin resestance due to alteration in pencillin binding protien.
Introduction
• MC cause of
1. STD worldwide
2. Opthalmia neonatorum
3. Epididymitis
4. Post-gonococcal urethritis
5. Inclusion conjunctivitis of neonate
6. Adult form is called as "swimming pool disease
LIFE CYCLE
Elementary body.
• Extracellular
• Infectous
• Inactive
SEROTYPES
D to K-Inclusion Conjuctivitis
Clinical manifestations
Trachoma
Stages
• Trachoma dubium
• Protrrachoma
• Established trachoma(stages I to IV)
Details
• In established trachoma,
o superior epithelial keratitis
o sub epithelial keratitis
o pannus, or superior limbal follicles
o Ultimately the pathognomonic cicatricial remains of these follicles, known as Herbert's
pits—small depressions covered by epithelium at the limbo corneal junction.
• With disease progression, there is:
o tissue necrosis
o granulation tissue deposition
o scar formation leading to blindness
o Lacrimal duct obstruction and distortion of the eyelids.
o Loss of an adequate tear system
o Cornea becomes vulnerable to dehydration and opacification.
GENITAL INFECTIONS
Genital chlamydiasis
• Mostly asymptomatic
• MC of nongonococcal and postgonococcal urethritis
• Men:
• urethritis (non-gonococcal)
• epididymitis
• proctitis
• conjunctivitis
• Reiter's syndrome
• Women: Salphingitis due to chlamydia and gonnorrea are common causes of tubal block resulting
in infertility
• acute urethral syndrome
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• bartholinitis
• mucopurulent cervicitis
• endometritis
• salphingitis(infertility)
• pelvic inflammatory disease
• conjunctivitis
• perihepatitis (Fitz-Hugh-Curtis syndrome)
• Reiter's syndrome
• Gram stained smears of urogenital exudates show significant number of neutrophils
Reiter’s Syndrome
Treatment
Trachoma
• Tetracycline
• Erythromycin
• Rifampicin
CHLAMYDIA PSITTACOSIS
• Human infection is acquired from inhalation of aerosols liberated from birds (parrots) dropping and
nasal discharge.
• IP : 7-14 days
• Usual presentation is pneumonia
• Others: Meningoencephalitis, Arthritis , Splenomegaly ,Thrombophlebitis, Pericarditis, Typhoid like
syndrome, Hepatomegaly, Pulmonary infarction, Endocarditis, Horder's spot, GI symptoms
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Treatment
• Tetracycline(DOC) or Erythromycin
CHLAMYDIA PNEUMONIAE
SYNTHESIS OF IMMUNOGLOBULINS:
• Differential RNA processing decides whether an immunoglobulin will remain membrane bound or
secreted.
Isotype:
Idiotypes
DISEASES:
Bacteremia
• UTI is MC source of. E.coli bacteremia leading to septic shock (within 2month)
• Ascending cholangitis
Pnenumonia
Neonatal meningitis
DIAGNOSIS:
Assay LT ST
In vivo tests ± +
Ligated rabbit deal loop
+ ?
Read at 6 hours
Read at 18 hours
In vitro tests
Genetic tests
Lactoferrin
STAPHYLOCOCCUS AUREUS:
Morphology:
BIOCHEMICAL REACTION:
STAPHYLOCOCCUS SAPROPHYTICUS :
• Causes 0%-20% of acute urinary tract infections in young, sexually active females & acute cystitis
Introduction
Incubation period
• 2-5days
Mode of transmission
• Droplet spread
Types
1. Faucial(commonest )
2. Laryngeal
3. Nasal
4. Conjunctival
5. Otitic
6. Vulvovaginal
7. Cutaneous mainly around mouth and nose
Respiratory Diphtheria
Cutaneous Diphtheria
Invasive infection
• Rare
DIAGNOSIS:
Culture:
Virulence tests:
• Schick test:
o Done to demonstrate circulating diptheria antitoxin.
o Skin test based on neutralization reaction
This fadesslowly
Red flush but less circumscribed Pseudo positive Allergic type
than positive fades by 4th day Red flush equally in both arms interpreted as
Combined reaction
TREATMENT:
• Erythromycin DOC
• Procaine penicillin G .
• Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.
• Diphtheria antitoxin is given intradermal
• Post exposure prophylaxis in health care professionals is not indicated in infections with diphtheria
Introduction:
INFECTIVE DOSE:
Toxins:
• Endotoxin
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• LPS
• Cause irritation of bowel.
• Shigella Dysenteriae-
• Produces heat labile exotoxin (Shiga bacillus exotoxin)
• Affect gut and CNS:
• Show neurotoxicity on blood vessel of CNS
• Cytotoxicity = Verotoxin I or Shiga like toxin
• Toxins produce early, non bloody voluminous diarrhea.
CLINICAL SYMPTOMS:
COMPLICATIONS
• HUS
o Schistocytes are suggestive of hemolytic-uremic syndrome (HUS)
DIAGNOSIS
TREATMENT:
Food poisoning:
Gangrenous appendicitis
Necrotizing enteritis
Emphysematous cholecystitis
Urogenital infections(myoglbinuria)
LABORATORY DIAGNOSIS:
• Specimen:
o Wound swabs
o human faeces
o necrosed tissue
o muscle fragments,
o exudates from active parts etc.
• Microscopy:
o Gram +ve, non-motile, capsulated bacilli.
o Spores are rarely observed in Cl.perfringens
• Culture:
o On RCM→ meat turned pink but not digested
o On blood agar → target hemolysis
• Nagler’s Reaction
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o Rapid detection of Cl.perfringens from clinical sample
• Reverse CAMP Test:
o CAMP +ve Group B Streptococcus is streaked in SBA & Cl.perfringens is streaked
perpendicular to it “arrowhead”(enhanced) hemolysis is seen between growth of
Cl.perfringens & Group B streptococcus
1. Primary Stage
o Formation of Ag-Ab complex
o Ag-Ab combined by weaker intermolecular forces
o van der Waals,
o ionic bond
o H2 binding
2. Secondary stage
o agglutination
3. Tertiary stage (reaction):
o Leads to tissue damage
Precipitation reaction
Mechanism of precipitation.
Method
• Soluble antigen combines with its antibody in the presence of electrolytes (NaCI)
• At a suitable temperature and pH
• Antigen antibody complex forms an isoluble precipitate.
Plot in a curve
1. Zone of Ag excess :
o insufficient Ab
o Too small complexes to precipitate
2. Equivalence zone :
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o Large lattice is formed
o Visible precipitates
3. Zone of Ab excess :
o not enough Ag
o Too small complexes to precipitate.
Types
1. Ring test
o e.g. Ascoli's thermoprecipitin test and streptococcal lancefield grouping.
2. Slide flocculation test
o VDRL test of syphilis
o Antigen and antibody complex are suspended..
o The flocculation can be observed by using microscope
3. Tube test
o Kahn test of syphilis
4. Immunodiffusion/Counter Current immunoelectrophoresis
o e.g. Elek test for toxigenicity in diphtheria (double diffusion).
5. Electroimmunodiffusion
o e.g. rocket electrophoresis for quantitative estimation of antigen.
74. AGGLUTINATION
Agglutination
1. Slide agglutination
o used for blood grouping and cross matching.
2. Tube agglutination
o Widal test Brucellosis
o Weil-Felix reaction
o Paul Bunnel test
o cold agglutination
o Streptococczs MG test.
3. Antiglobulin
o Coombs test
o used for detecting incomplete Ab of brucellosis
o anti- Rh Ab.
4. Passive agglutination test
o used to detect Ab
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o by adsorbing soluble Ag on carrier particles so precipitation reaction converts into
agglutination test
o more convenient and more sensitive.
o e.g. Rose waller test, test detecting RA factor by using amboceptor.
5. Latex agglutination test
o latexfixation test
o for detection of ASO, CRP, RA factor
o HCG; Streptozyme test.
o Rapid test for acute Pyogenic meningitis
6. Reversed passive agglutination
o Estimation of antigen by adsorbing antibody to carrier particles.
Introduction
Examples
• Urticaria
• angioedem
• hay fever
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• some forms of asthma
• eczema
• Anaphylactic shock
• Casoni's test
• Theobald Smith phenomenon
• Schultz Dale phenomenon
• Prausnitz Kustner (PK) reaction
Introduction
• Most common
• Example —*Transfusion reactions, Erythroblastosis fetalis
• Transfusion reactions
• Erythoblastosis fetalis (Hemolytic disease of neontates)
• All hemolytic anemia or agraulocytosis or thrombocytopenia
• Pemphigus syndrome
• Bullous pemphigoid
• Pernicious anemia
• Thrombotic phenomenon
• Acute rheumatic fever
• Some forms of vasculitides and certain drug reactions.
• Phagocytosis of tumor cells or parasite .
• Some role in graft rejection
• Thyrotoxicosis / Grave's disesas
• Myasthenia gravis
Introduction
Glomerulonephritis
Insect bites
Arthus reaction:
Serum sickness
SLE
Hypersensitivity pneumonitis
Other Examples
• Rheumatoid arthritis
• lnfective endocarditis
• PAN
• Henoch-Schonlein purpura
• Toxin is given intradermally and this toxin reacts with circulating antitoxin
• Produce local type of type III hypersensitivity, i.e. Arthus reaction.
• Example Schick test.
Introduction
• after 24 hours
Initiated by
• activated T-lymphocytes.
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Includes
Examples
• Tuberculin test
• Lepromin test
• Fairleys (Schistosomiasis) test
• Frie's (LGV) test
• Granulomatousinflammation
• Contact dermatitis
• Defence against intracellular pathogen
• Type I lepra reaction
• Graft rejection
• Resistance to virus infection
• Reaction against tumour cells
79. INTERLEUKINS
Interleukins
Interleukin-1
Interleukin-2
Interleukin-3
lnterleukin-7 (IL-7)
IL28B
Infection is acquired by
• Not transmitted from person to person , i.e. herd immunity is not protective
• Minimum lethal human dose of exotoxin is 2.5 ng/kg.
• Seen more often in the summer season and in hot, damp climates with soil rich in organic matter.
• Wounds contaminated with fecal matter and soil are most prone
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Symptoms
Diagnosis of tetanus
Treatment of tetanus
1. Antimicrobial therapy
2. Antitoxin :-
o Human tetanus immune globuline (TIG) is the preparation of choice.
o Administered within time it neutralizes tetanus toxin and significantly lowers the mortality
o Serious wound + uncertain about immunization should receive both
1. Tetanus toxoid (active immunity)
2. Tetanus immune globulin (Passive immunity)
Prevention
Active immunization
Combined Vaccine :
• DPT .
Passive immunization :
Pregnancy
Primigravida
Morphology
Culture
• Selective medium:
o PLET medium.
• OnAgar plates -
o frosted glass appearance seen.
o On microscopy it has Medusa head appearance.
• On Gelatin stab -
o characteristic Inverted Fir tree appearance.
VIRULENCE FACTORS :
1) Capsular polypeptide -
2) Anthrax toxin
Introduction:
• Anthrax is a zoonoses
• "Man is relatively resistant to infection with B. anthracis"
• Few as one to three spores may be adequate to cause disease in some setting
• According to The Workmen's Compensation Act, 1923, Antrax is considered an occupational disease
Forms
1. Cutaneous anthrax
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• Cutaneous anthrax is most common.
• The whole area is congested and edematous
• The lesion starts as macule
• Progress through papular and vesicular or pustular stages
• Formation of an ulcer with a blackened necrotic eschar.
• The lesion is painless.
• Its called malignant pustule.
• Hide porter's disease.
• Cutaneous anthrax generally resolves spontaneously
• But 10-20% of untreated patients may develop septicemia.
2. Pulmonary anthrax
• Woolsorters' disease
• Occupational hazard for people who sorted wool
• Most dangerous form of inhalational anthrax
• It causes hemorrhagic pneumonia.
3. Intestinal anthrax(rare)
• Laboratory Diagnosis
• Mc-Fadyean's Reaction
• Blood films containing anthrax bacilli are stained with polychrome methylene blue stain for few
seconds
• Examined under microscope
• Amorphous purplish material is noticed around bacilli.
• This represents the capsular material and is characteristic of anthrax bacilli.
• Culture Characteristics of Bacillus anthracis
• On agar plate: Frosted glass appearance
• On gelatin stab culture: Inverted fir tree appearance
• Ascoli's thermoprecipitin /Elek's gel precipitation test
• Penicillin G is the DOC
87. Bacteriophage
Introduction
Types of phages
Example
Transformation
Conjugation
Transduction
• Occurs when bacteriophage carries a piece of bacterial DNA from one bacterium to another.
• Confined to transfer of chromosomal DNA, episomes and plasmid may also be transduced.
• Plasmid is a DNA molecule that is separate from and can replicate independently of chromosomal.
Just as there are two types of phages, there are two types of transduction.
Phage Assay
• Used for titrating number of viable bacteriophage and for purification of phages.
Features
Culture
Clinical manifestations
Infections
Renal Stones
• Magnesium-ammonium-phosphate stones
• Secondary to urinary tract infection
Diagnosis
Urease test
• Distinguish Proteus organisms, which produce urea, from other enteric bacteria.
Urine
• Alkaline urine
• Cloudy with plenty of pus cells
• The basis of the test is the sharing of an alkali - stable carbohydrate antigen by some rickettsiae and
by certain strains of proteus
• P. vulgaris OX - 19 and OX - 2 and P. mirabilis OX - K.
Treatment
Morphology
• Capsulated
• It is a strict human pathogen
Culture
Virulent Factors
1. Pertussis toxin
• Piracy of Adhesins
3.Tracheal cytotoxin
Introduction
Source of infection:
Age group:
Mode of transmission:
lncubation period:
7 - 14 days.
Clinical features
• Catarrhal stage:
• Infectivity is maximum .
• Paroxysmal stage: -
• Post-tussive vomiting
• Mucus Plug.
• Vomiting with cough.
• Episodes are often worsen at night and interfere with sleep.
• Most complication occur during paroxymal stage.
• Paroxysm is precipitated by noise, eating and physical contact
• Leukocytosis due to absolute lymphocytosis is characteristic in late catarrhal or paraoxysmal stage
• Convalescent stage
Complications of Pertussis
• Respiratory -
• Patchy Atelectasis
• Subcutaneous emphysema
• Neurological-
• Persistent seizures
• Paraplegia
• Ataxia: Not of cerebellar origin. There is no involvement of the cerebellum in Pertusis
Diagnosis:
• Presence of recurrent bouts of severe cough followed by an audible whoop suggests a diagnosis of
pertusis.
• Culture of nasopharyngeal secretions remains the gold standard of diagnosis.
• Best specimen is collected by nasopharyngeal aspiration.
• DNA detection by polymerase chain reaction (PCR) increased sensitivity and quicker results.
Cases:
Contraindication
Acellular vaccine
Immunization:
• The pertussis component in DPT vaccine is not recommended after the age of 6 years.
• 92-94%
92. Brucella
Introduction
Morphology
• noncapsulated
Sensitive to
• sunlight
• Heat
• Pasteurization destroys brucella
• Transmitted by unpasteurized milk
Culture
Classification
93. Brucellosis
Cause:
• Brucella
• Most virulent cause of brucellosis: B. melitensis .
• mediterranean fever/Malta/undulant fever.
Source:
• Sheep, goats,camels.
Route of transmission:
• Occupational exposure
• Infected meat (slaughterhouse workers)
• placentae of infected animals (farmers, veterinarians)
• Ingestion of untreated milk or milk
• products, raw meat (blood)
• inhalation
• transplacental
• during breasffeeding
• during sexual activity.
Symptoms
Diagnosis
Culture
Serological tests
Treatment
94. Rickettsiae
Morphology
• Gram negative
• Pleomorphic coccobacilli
• Obligate intracellular organisms
Culture
Rickettsial Diseases
Important Points:
• Most severe
• Rocky mountain spotted fever
• Most mild
• Rickettsia pox
• Symptoms
• fever
• headache
• malaise
• Prostration
• hepatosplenogy
Rash is seen in
1) Epidemic typhus
2) Endemic typhus
3) Scrub typhus
4) Rocky Mountain spotted fever
5) Indian tick typhus
Lymphadenopathy is seen in
1) Scrub typhus
2) Rickettsial pox
Eschar is seen in
1) Scrub typhus
2) Rickettsialpox
3) Indian tick typhus
Mortality
• Treatment
• Tetracyclines (e.g., doxycycline are DOCs)
Morphology
Staining
Cultivation
Susceptibility
Antibodies:
Introduction
Incubation period:
1.Venereal Syphilis
• Primary chancre is well defined punched out ulcer with following characteristics:
• Single lesion
• Painless
• Avascular (non-bleeding)
• Firm inducation
• Usually superficial (but may be deep)
• Well circumscribed with elevated round or oval edges
• Cartilagenous consistency
• Lymphadenopathy:
• painless
• firm
• nonsuppurative.
• Sites of involvement are :
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• penis in heterosexual males
• rectum, anal canal
• mouth in homosexual males
• cervix and labia in females.
(c)Tertiary Syphilis:
2. Congenital Syphilis
• Treponema pallidum isolation from CSF is maximum in the secondary stage of syphilis.
• Infection leads to lifelong immunity.
• Penicillin is the only recommended agent for treatment of syphilis in pregnancy.
• If the patient has a documented penicillin allergy, desensitization and penicillin therapy should be
given.
• Seropositive infant not treated at birth if mother received penicillin in 3rd trimester
• Biological False positive/ BFP serological test for syphilis may be encountered in:
• Viral Hepatitis, SLE, and Leprosy.
• Primary or secondary syphilis - Benzathine penicillin G 2.4 million units intramuscularly (IM) in a
single dose
• Congenital syphilis can be best diagnosed by IgM FTA- ABS
• Most sensitive diagnosis during secondary stage of syphilis is VDRL.
• Treponemal Test
• Fluorescent treponemal antibody-absorption (FTA-ABS)
• Microhemagglutination assay T pallidum (MHA-TP)
• T pallidum hemagglutination (TPHA)
• FTA-ABS-Confirmatory test
• TPI (Treponemal pallidum immobilization) test(most specific)
• Non-treponemal tests
• RPR (Rapid plasma reagin)
• VDRL
98. Parvovirus
Parvovirus
• Smallest virus.
• Not a cultivable virus
Pathogenesis of parvovirus
Transmission
Clinical manifestations:
Polyarthropathy syndrome
Aplastic crisis
Hydrops fetalis
• Hydrops fetalis
• Fetal death due to severe anemia.
Diagnosis
Treatment
• Class:
• Orthopoxvirus
Variola
Vaccinia
Cultivation of Poxvirus
Antigenic cross-reactivity
Morphology
Types
Culture
Antigenic structure
a.Internal Antigen:
• Antigenic variation is highest in type A, less in type B and not seen in type C
• Two types:
Gradual and sequential change in genome Abrupt, drastic and discontinuous variation
occurring at regularly at frequent intervals resulting in a novel virus
New antigen related to previous antigen New surface antigen not related to previous
Inaccurate viral RNA polymerase frequently Due to genetic reassortment between 2 strains,
produces point mutations in certain error-prone presumably during coinfection of a single host.
regions in the genes.
Hemagglutinin:
• Cause hemagglutination.
• 16 subtypes
Neuraminidase
Mode of transmission:
• 18-72 hour
Prevalence:
Cyclic trend:
101. Influenza virus: Clinical manifestations, Complications, Diagnosis, Treatment and Prevention
Clinical manifestations
• H1N1
• causes swine flu is also known as swine influenza, hog flu, and pig flu.
• Swine Flu pandemic in 2009
• causes serious systemic manifestations
• Most infections are subclinical
• Fever, cough, rhinorrhea, fatigue, and headache.
• Vomiting in type B seen.
• There is no viremia
• A pandemic of H1N1 is suspected when :
• Cases are spread over 5 or more cities
Complications
• Pneumonia:
• M.C. by str. pneumoniae
• Occurs most frequently in high-risk individuals with chronic pulmonary and cardiac disease and in
elderly individuals
• Worsening of COPD
• Encephalitis
• Reye's Syndrome:
• with type B virus
• GB. Syndrome
• G I Symptoms (gastric flu):
• With type B virus
• Six phases
• H1NI influenza pandemic is in phase 6
Prevention
a. Killed vaccine:
• Contains H, N antigens
• Guillain-Barre syndrome (ascending paralysis) rarely seen.
c. New Vaccines
School Closure:
Treatment
Type A & B
Type A
Introduction:
Avian Influenza
Treatment:
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• Drug of choice:
• Oseltamivir (Tamiflu) 75 mg BD x 5 days
• contraindicated in infants
Morphology
Types
Clinical Manifestations:
For Bronchiolitis:
• Hyperinflation
• Multiple areas of interstitial infiltration
Treatment
Prevention
• Palivizumab:
• Humanized monoclonal antibody
• Directed against an epitope in the A antigen site on the F surface protein of RSV.
• Licensed for the prevention of RSV infection in high-risk infants and children.
• Once-monthly intramuscular injections (15 mg/kg) for 5 months beginning at the start of the RSV
season
• Rotavirus is the major cause of diarrhea in infants and children under the age of 2
• Rotavirus, a double-stranded RNA virus, infects only the mature villous cells in the duodenum.
• Rota B cannot be grown in cell culture
• Viral enterotoxin is detected as a possible of mechanism pathogenesis in Rotavirus.
• Rotavirus can be diagnosed by immunofluorescence antigen in a stool ,antigen in stool by ELISA.
• Electron microscopy is helpful in diagnosis of Rotavirus.
• Best vaccine for rotavirus infection is Genetic reassortment
• Roatvirus vaccination causes intussusception .
• Viral enterotoxin is detected as a possible of mechanism pathogenesis in
Hepatitis E (HEV)
• HEV is non-enveloped, positive-sense, single stranded RNA genomic ,HAV like virus
• Most common cause of sporadic Hepatitis amongst adults in India
• Most common cause of epidemic Hepatitis amongst adults in India
• Most common cause of Fulminant Hepatitis amongst pregnant women
• Worst prognosis in pregnancy
• Most common route of transmission is, fecoral route
• Hepatitis B, C and D are essentially spread by parenteral routes.
• Hepatitis A & E are non parenteral hepatitis.
• HDV superinfection of a person with chronic Hepatitis B (HBV) has the worst prognosis with a high
likelihood of fulminant hepatitis and death.
• HEV most common type of hepatitis responsible for epidemics in India.
• Hepatitis E usually affects adults.
• It is defective RNA virus dependent on the helper function of HBV for its replication and expression.
Dengue Fever
Caused by :
Morphology:
• Clinical diagnosis
• Laboratory diagnosis
• Diagnosis of Dengue fever can be made earliest by:
• NS-1 antigen detection
• X-ray of the chest (may demonstrate pleural effusion).
• Treatment
• Blanket/ mass treatment
• Immediate treatment of choice for severe hypotension in Dengue shock syndrome
• plasma volume replacement is most urgent, IV crystalloids are used for that purpose.
110. Chikungunya
111. Candida
Candida
Morphology:
• It is dimorphic.
• In Gram-stained smears, Candida appears as gram positive budding yeast cells (blastoconidia)
• Pseudohyphae showing regular points of constriction.
• Spores form on the pseudohyphae called chlamydospores
• C. albicans can take on either a unicellular (yeast) or multicellular (hyphae, pseudohyphae) form.
Culture:
A. Mucocutaneous candidiasis
B. Cutaneous candidiasis
• Candida paronychia:
• Common in patients whose hands are frequently immersed in water.
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• The nail fold becomes red and swollen and there is loss of cuticle with detachment of nail fold from
nail plate.
• Candida onychomycosis:
• Chronic paronychia leads to onychomycosis.
• The commonest type of candida onychomycosis is distal and lateral subungual onychomycosis
(DLSO).
• Intertriginous candidiasis
• Chronic mucocuatenous candidiasis
• Diaper rash.
• The commonest fungal lesion of the eyelid
• Candidial granuloma:
C. Systemic candidiasis
• Pseudohyphae of candida with budding yeasts are present on this potassium hydroxide preparation
• Ketoconazole would treat both dermatophysis and candidal infection
• Drug of choice in systemic candidiasis is Amphotericin
• Drugs used for candidiasis include Fluconazole, Nystatin, Clotrimazole, Itraconazole
• Different species of Candida can be identified by following tests:
• Chlamydospore formation on Cornmeal Agar (Dalmau plate)
• Germ tube test (Reynaud Braude)
Introduction
• Opportunistic fungi.
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• Cannot be cultured
• Analysis of gene sequence for ribosomal RNA, mitochondria, proteins and major enzymes
• Presence of b-1, 3 glucan in the cell wall
• The efficacy of antifungal drugs that inhibit b-glucan synthesis.
• AIDS
• Patients receiving Immunosuppressive therapy (especially Glucocorticoids) for cancer, organ
transplantation etc.
• Children with primary immunodeficiency diseases
• Premature malnourished infants (immunodeficient)
Clinical Manifestations
Lab Diagnosis
Treatment
• DOC cotrimoxazole
• Trimethoprim, sulphamethoxazole.
• Dapsone, pentamidine.
Histoplasma capsulatum
• A dimorphic fungus
• Non encapsulated
Source of Infection:
• Infection is acquired by inhalation of microconidia (small spores) in dust contaminated with bird or
bat dropping
Culture:
• On Sabourauds agar,
Pathology:
Clinical Manifestations
Symptoms
• Asymptomatic
• Mild (acute primary pulmonary histoplasmosis).
• fever
• cough
• chest X-ray finding of hilar adenopathy due to caseation necrosis or calcification
• which mimics TB
• with or without 1 or more areas of pneumonitis are typical features.
• Chronic pulmonary histoplasmosis or chronic fibrocavitary pneumonia
• Related to mediastinal fibrosis
• Disseminated disease
• fever and malaise
• seen in immunocompromised
• Mimic disseminated TB
• Adrenal glands are the most commonly involved organs
• adrenal glands are usually symmetrically enlarged
Diagnosis
• Culture:
• Tuberculate spore is diagnostic
• Millary mottling on X-ray chest
Mode of Transmission:
1. Faecal-oral route
2. Oral-rectal contact
3. Transmission through vectors ( flies, cockroaches and rodents)
• Amebiasis most frequently involves the cecum and ascending colon, followed in order by the
sigmoid, rectum, and appendix.
• Cutaneous amoebiasis
• Direct infection from liver
• Granulomatous ulceration and granulomatous mass may occur in the peri-anal region.
• Characteristic feature of amoebic ulcer
• Flask shaped
• Undermined edge
• Amoebic liver abscess :
• In the tropics 2-10% of the individuals infected with E. histolytica suffer from hepatic complications
• Liver abscess is the most common extra-intestinal manifestation of amoebiasis.
• Common in :
Most common in right lobe liver/right posterior-superior region
Portal vein is in direct continuation with the right tributary.
• Pus in amoebic liver abscess is not due to suppuration, but is a mixture of sloughed liver tissue and
blood
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• Pus is chocolate coloured, classically called anchovy-sauce
• Abscess wall good for culture
• Pleuropulmonary infection is the most common complication.
• Most common cause of amoebic lung abscess is direct spread from liver
• Amoebic liver abscess ruptures most commonly into pleural cavity
2. Luminal amoebicides:
3. Tissue Amoebicides:
119. Leishmania
Epidemiology
• Location
• tropical and subtropical countries
• mostly a disease of the developing world
• Reservoir of Leishmaniasis in India in acute visceral leishmaniasis
Promastigote forms
Culture
Transmission
Clinical Manifestations
• Leishmania donovani
• Causes a visceral disease called Kala azar.
• Hepatosplenomegaly
• Immune-complex-mediated mesangio-proliferative glomerulonephritis seen
• Leishmania tropica:
• Causes Oriental sore (cutaneous leishmaniasis) On the skin
• Post kala azar dermal leishmaniasis:
• Leishmania brazilensis
• Espundia
• muco cutaneous leishmaniasis/nasopharyngeal leishmaniasis
Diagnosis
• Blood smear
• stained with Giemsa or Leishman's stains
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• Direct visualization of the amastigotes
• In aspirates of bone marrow, spleen, liver or lymph nodes, makes the diagnosis
• Aldehyde test
• Supportive hematological tests.
Treatment
Pharmacologic
Burning or incineration
122. Mucormycosis
Introduction:
Epidemiology
Risk factors
• acidosis
• diabetic ketoacidosis
• leukemia
• AIDS
• DM
• lymphomas
• Long-term desferroxamine therapy
• Immunosuppression due to steroids or cytoxic drugs
Associated conditions
Clinical Manifestations
Symptoms
• Intitially, the disease runs a subtle course with only fever and rhinorrhea.
• Later on, it invades the orbit and intracranial cavity:
• It has marked predilection for vascular invasion:
• leading to widespread thrombosis, tissue necrosis, and gangrene.
• Characteristic nasal finding:
• Dark necrotic turbinate
• Surrounded by pale mucosa blackish discharge and crusts.
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• M/C site is middle turbinate followed by middle meatus and septum.
Laboratory
Pharmacologic
123. Adenovirus
Classification
Morphology
• DNA virus
• double-stranded and linear
• non-enveloped
• Space vehicle (hexagonal shape) shaped
Disease conditions
• Serotype- 1,2,5,6
• MC in children with rhinitis
• ARD in military recruits
• serotypes 4,7,21
• Common cold/coryza:
• MC cause
• acute respiratory disease:
• Serotype 4,7
• in adult MC
• Follicular (swimming pool)conjunctivitis
• Serotypes- 3,7
• Epidemic keratoconjunctivitis(shipyard eye)
• Serotypes- 8,19,37
• gastroenteritis
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• Serotypes- 40,41
• Hemorrhagic cystitis
• Serotypes-11,21
• Pharyngoconjunctival fever
• Serotypes-3,7
Oncogenic virus:
124. Aspergillosis
Introduction
3. Invasive Aspergillosis
4. Allergic sinusitis
5. Aspergillosis in AIDS
6. Extrapulmonary
• Otomycosis
• Aspergillus Niger 90% cases
• Endophthalmitis
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• Satellite lesions in eye
In Atopic Individual
Histopathology
• Microscopically, the fungus may appear as a tangled mass within the cavity.
• The organisms are identified by their characteristic morphology—
• Thin septate hyphae with dichotomous branching at acute angles
• Stain positive for fungal stains such as PAS and silver impregnation technique.
• The wall of the cavity shows chronic inflammatory cells.
Treatment
125. Nocardia
Morphology
• Gram positive
• Show true branching both in culture and in stains from clinical lesions.
• Aerobic
Staining
Culture
Clinical Manifestations
Treatment
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• Trimethoprim-Sulfamethoxazole-
• DOC
126. DERMATOPHYTES
Introduction
Classification:
• Three genera:
• Trichophyton
• Causes black dot ring worm
• Microsporum
• Epidermophyton
Distribution:
• M. distortum
• Australia, USA
• Not in India
Morphology
• In lesions appear as :
• Hyphae
• Arthrospores
• On sabouraud's agar form :
• Septate hyphae
• Asexual spores (micro and macroconidia)
• Differentiation is based mainly on macroconidia.
Nail
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Microconidia Abundant Single Absent
(multicellular)
Arranged in clusters along
hyphae
Macroconidia Relatively scanty Single Groups of 2 or 3
Pencil/Cylindrical shaped
• Clinical Manifestation
• Treatment
• Topical antifungal agents
• Oral griseofulvin is DOC.
• 3 months duration for fingure nail dermatophytosis.
127. Blastomycosis
Mump Virus
• Paramyxovirus.
Source of infection
Incubation period
• 14-18 days
Clinical manifestation
Parotitis
Orchitis
Aseptic meningitis
Complications of mumps
• Sterlity
• Spontaneous abortion in about 27% of cases during the first trimester of pregnancy.
• Mild forms of meningitis.
• Oophoritis (inflammation of ovaries).
• Pancreatitis , manifesting as abdominal pain and vomiting
• Encephalitis, very rare
• Profound (91 dB or more) but rare sensorineural hearing loss, uni- or bilateral.
• Acute unilateral deafness occurs in about 0.005% of cases
• Thyroiditis, neuritis, hepatitis, myocarditis etc.
Mumps vaccine
129. Measles
Introduction
Virus
• A paramyxovirus
• Only one strain causes infection
• Nucleocapsid proteins
• Protect the genome RNA from nuclease digestion
• Recognize the location in the cell membrane for budding
Transmission
SAR
• Approximately 80%.
• Formula to Calculate SAR
• No. of exposed persons developing the disease within the range of incubation period/Total number
of exposed”susceptible” contacts*100
Incubation period
• An asymptomatic incubation period occurs nine to fourteen days from initial exposure
Infectivity
Isolation
• After the appearance of rash, prophylactic isolation of measles case is necessary for a minimum of 5
days
Clinical Manifestations
Prodromal/Pre-eruptive stage
• Koplik's spot
• A day or two before the appearance of rash
• Appear on the buccal mucosa opposite the first and second upper molars.
• Pathognomonic enanthem of measles.
Eruptive Stage
Complications
Warthin–Finkeldey cell :
Measles vaccine :
• Type:
• Live attenuated, lyophilized (Freeze dried) vaccine
• Route:
• Subcutaneous
• Age of administration in National Immunisation schedule (India):
• India started 2-dose vaccination strategy for measles
• 9 months (can be lowered to 6-9 months in epidemics & malnutrition)
• Second dose of measles is also given at 16-24 months.
• Diluent for Reconstitution:
• Distilled Water or sterile water
• Use within 1hr after reconstitution with diluent
• Side effect
• Measles (& MMR) vaccine can lead to Toxic Shock Syndrome
• Measles vaccine is contraindicated in pregnancy
• Measles vaccine also contains:
• Sorbitol and hydrolyzed gelatin as stabilizers
• Small amount of neomycin as preservative
• People with a history of an anaphylactic reaction to neomycin, gelatin or other components of the
vaccine should not be vaccinated
• In epidemics measles:
• Vaccine is to be given within 3 days of exposure
• Duration of Protection: Lifelong
• IP of vaccine-induced measles: 7 days
Immunoglobulin
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• Measles immunoglobulin is also available for post exposure prophylaxis.
• Non immunized pregnant women coming in contact with measles may be protected by:
• Intramuscular injection of 5ml of immune serum globulin within 3 days of exposure.
Elimination
• WHO defines elimination of measles as the absence of endemic measles for a period of 12 months
in the presence of adequate surveillance.
• One indicator of measles elimination is a sustained measles incidence < 1/100, 000 population.
• In 2005, the World Health Assembly set a goal:
• Achieving a 90% reduction in global measles mortality by 2010 as compared with level in 2000.
• WHO's measles elimination strategy comprises a three part vaccination strategy, i.e. :-
i) Catch-up
• One-time, nationwide vaccination campaign targeting usually all children aged 9 months to
• 14 years regardless of history of measles disease or vaccination status.
ii) Keep-up
• Routine services aimed at vaccinating more than 95% of each successive birth cohort.
iii) Follow-up
Epidemic of measles :
• Pear shaped, rounded anterior end, posterior end pointed (looks like monkey face)
• Bilaterally symmetrical:
• 2 nuclei, 2 axostyles, 4 pairs of flagella (2 anterior, 2 posterior, 2 ventral, and 2 caudal)
Infective form
Routes of transmission
• Feco-oral
• Ingestion of contaminated water – most important
• Ingestion of contaminated food
• Person to person – day care, nursing homes, mental asylums (poor hygiene)
• Sexual – sexually active homosexual males
Pathology
132. Giardiasis
Giardiasis
• Acute:
• Self-limiting infection
• Acute watery diarrhea
• Abdominal cramps
• Bloating
• Flatulence
• Stool is profuse & watery in earlier disease
• Frothy
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• Voluminous, foul-smelling & greasy(steatorrhoea) later
• Chronic
• Chronic diarrhea with malabsorption syndrome
• Steatorrhoea
• Chronic Recurrent intestinal giardiasis/Intractable diarrhea
• Common variable deficiency is associated with it.
• Hypogammaglobulinemia
• Reduction in all classes of immunoglobulins
• But sometimes only IgG is reduced.
• Traveller's diarrhea
Laboratory Diagnosis
Microscopy
Sting Test
Treatment
• Nitroimidazole derivatives –
• Metronidazole
• Tinidazole drugs of choice
Milk
Cryptococcus neoformans
Morphology
Serotypes
Culture:
Pathogenesis
• Capsule:
• Anti-phagocytic
• Phenoloxidase:
134. Cryptococcosis
Risk Factors
• Cryptococcosis is most often seen in immune-compromised patients with impaired T cell immunity
• AIDS
• Solid organ transplantation (Renal transplant)
Cryptococcal meningitis:
Laboratory diagnosis
Identification:
Detection of Antigen:
Treatment
• Cryptococcal meningitis :
• Treated for two weeks with intravenous Amphotericin B
135. Poliomyelitis
Clinical manifestation:
• Few suffer from minor illness, very few suffer from meningitis and less than 1% suffer from
major paralytic disease
1. Asymptomatic illness:
2. Abortive poliomyelitis:
4. Paralytic Poliomyelitis:
• Lab diagnosis:
• Specimen: nasal secretion, faecal samples, throat swab, CSF
• Electron Microscopy: virus detection
• Virus isolation from stool
• Prevention and control:
1. Vaccination
Dose Age
Complications of OPV
• In the course of their multiplication in vaccinated children, and rare cases of vaccine associated
paralytic polio have occurred in -
• Recipients of the vaccine
• Thier contacts
Types of VDPV:
• Poliovirus 1:
• Most common and virulent type.
• Frequently isolated from patients with poliomyelitis and causes epidemics
Mode of transmission
Reservoir of infection
• Man is the only reservoir. Most infections are subclinical and play a dominant role in spread of
infection.
• It is estimated that for every clinical case, there may be 1000 subclinical cases in children and 75 in
adults.
Period of communicability
Habitat
Morphology
Cultural characteristics
Antigenic Properties
Pathogenicity
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Haemophilus influenza b (Hib)
Treatment
Polio Epidemic
• An epidemic of polio is defined as 2 or more local cases caused by same virus type in any 4 week
period.
• So, it has following features -
Polio Free
• As of 25th Feb 2012 India was removed from the list of polio endemic countries by the WHO
• On 27th March 2014, the Regional Certification Commission of WHO certified South-East Asia
Region of WHO, which includes India, as polio free.
• Each region can consider certification only when all countries in the area demonstrate the absence
of wild poliovirus transmission for at least three consecutive years.
AFP Surveillance
• Ferments glucose and maltose with acid production is the differentiating feature of Neisseria
gonococcus from Neisseria meningitides
• Neisseria meningitides can penetrate normal cornea
• It is most common organism which can contaminates crowded army camps
• Lipopolysaccharide is responsible for the production of overwhelming septicemic shock
complicating bacteremia
• Most common cause of meningitis in children
• Meningitis with rash is seen.
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• Fulminant meningococcemia (purpura fulminans or Waterhouse - Friderichsen syndrome caused by
N meningitides
• A quadrivalent vaccine constituted by polysaccharides of serotypes A,C,Y and W-135 : for children
and adults
• Penicillin DOC for meningococcal infections
Morphology
• Gram negative
• Comma shaped
• Motile with a single polar flagellum → DarƟng or tumbling moƟlity
Biochemical reactions
Source:
Campylobacteriosis
1. Guillain-Barré Syndrome
2. Reactive arthritis
3. Reiter’s syndrome
Laboratory diagnosis:
Specimen:
141. Plasmodium
• Pre-erythrocytic schizogony
• Exo- erythrocytic schizogony
• Cause of relapse.
• This Phase is absent in P falciparum.
• Erythrocytic schizogony
• Gametogony
In RBCs :
Incubation period
Diarrheal Syndrome
Emetic Syndrome
Clinical features
• P. falciparum:
• Malignant tertian = Pernicious malaria
• The most virulent plasmodium species.
Falciparum Malaria
Recurrences in Malaria
1. Recrudescence –
2. Relapse
• The parasites reproduce in the cat's small intestine and form oocysts, which are thick-walled cysts
containing zygotes.
• Human, sheep, pig etc intermediate host.
Transmission
Laboratory Diagnosis
Thin films :
Schüffner's dots
Maurer's dot:
• Fine granular precipitates or irregular cytoplasmic particles present in red blood cells infected with
the trophozoites of Plasmodium falciparum
Immunochromatographic test
1. Pre-erythrocytic schizogony
• Drugs acting on this stage will prevent infection of RBC and clinical attack of malaria causal
prophylaxis.
• Drug are
• Proguanil & Tetracycline → for falciparum.
3. Gametogony
4. Exoerythrocytic schizogony
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• Primaquine is the only drug which acts on exoerythrocytic schizogony.
• Artemisinin derivatives are the drug of choice for any type of falciparum malaria
i)Uncomplicated
ii)Complicated/severe/cerebral
Chemoprophylaxis of malaria
• Chloroquine
• DOC for chemoprophylaxis in chloroquine sensitive P. falciparum areas.
• Chloroquine 300 to 310 mg once weekly, and Proguanil 200 mg once daily
• Atovaquone/Proguanil
• Used in areas with chloroquine or mefloquine-resistant P. falciparum.
• Doxycycline
• Used in areas with chloroquine or mefloquine-resistant P. falciparum.
• Mefloquine
• Used in areas with chloroquine-resistant P. falciparum
• Hydroxychloroquine
• Alternative to chloroquine in areas with chloroquine-sensitive P. falciparum
• Quinine + Clindamycin
• Or Atovaquone + Proguanil
• Nipah virus (NiV) infection is a newly emerging zoonosis that causes severe disease in both animals
and humans.
• Family: Paramyxoviridae
• Seen in India, outbreak 2001 West Bengal.
• Nipah virus is associated with epidemics of Encephalitis
Toxoplasma Gondi
• Most Cats Shed Oocytes in Feces only once in a lifetime for 1-2 weeks
• Oocytes Becomes infective only after 5 days (After Sporulation)
Important Definitions
• Sterilization: the process by which an article, surface or medium is freed of all living microorganisms
(vegetative or spore state)
• Antisepsis: prevention of infection, by inhibiting the growth of bacteria in wounds or tissues
1. Ethylene oxide.
• It is used to sterilize heat labile articles such as bedding, textiles, rubber, plastics, syringes,
disposable petri dishes, complex apparatus like heart-lung machine, respiratory and dental
equipments.
• Efficiency testing is done using Bacillus subtilis var niger.
2. Formaldehyde gas
3. Beta-propiolactone
Formaldehyde
• It is a high-level disinfectant
• Disinfectant for heat-sensitive equipment such as dialysis instruments, surgical instruments, suction
bottles, bronchoscopes, endoscopes, ear, nose, and throat instruments,spirometry tubing,
transducers, anesthesia and respiratory therapy equipment and reuse of laparoscopic disposable
plastic trocars .
• Concentrations -Solutions range in concentration from 2.4 – 3.4%.
Radiation
Dyes
Halogens
• Ethylene oxide
• Prophylene oxide
• Ozone
• Glutareldehyde
• Formaldehyde
• Halogen (sodium hypochlorite, Iodine,Hydrogen peroxide,phenol and cresol, Iodophore, chlorine)
• Peracetic acid
• P-propionolactone
• Chlorhexiding
150. Disinfectant
Disinfectants
• Examples are :-2% gluteraldehyde, 8% formaldehyde, 6-10% hydrogen peroxide and ethylene oxide
gas.
• Examples are :-0.5% iodine, 70-90% ethanol and isopropanol, chlorine compounds (hypochlorite),
some phenolic compounds and iodophor based disinfectants.
i) Rideal-Walker test
• In this, the disinfectant acts in the presence of organic matter (dried yeast or feces).
• Phenol is taken as standard
Group C Streptococci
• Group C beta hemolytic streptococci currently include S. dysgalactiae subsp. equisimilis and other
related strains
Group D Streptocci
• Include enterococci (e.g., Enterococcus faecalis and Enterococcus faecium) and nonenterococci (S.
bovis).
• Enterococci are members of normal flora of the colon.
• A beta hemolytic bacteria
• Resistant to vancomycin shows growth in 6.5% NaCI
• Non bile sensitive
• They can cause urinary, biliary and cardiovascular infections.
• There is a significant association between S. bovis bacteremia and endocarditis with carcinoma of
the colon and other colonic diseases.
Actinomyces
Characterized by
• Contiguous spread,
• Suppurative and granulomatous inflammation, and
• formation of multiple abscesses and
• sinus tracts that may discharge sulfur granules
Morphology
• Anaerobic
• Thin, branching (filamentous)
• Gram positive bacillus.
• Morphologically Actinomyces colonies form fungus-like branched networks of hyphae
• Microaerophilic, grow best anaerobically. VERY fastidious.
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Clinical manifestations:
Actinomycosis
Cervicofacial
Thoracic
• This is an indolent, slow process involving the pulmomonary parenchyma and pleural space.
Abdominal
• The inflammatory process is a chronic, localized, and is preceded by the breaking of the integrity of
the gastrointestinal mucosa by intestinal perforated
• The ileocecal region is involved most frequently
Pelvic
• This is observed in women who had prolonged use of IUD, and may also occur from extension of
intestinal infect
• Rare
Treatment
K. pneumoniae
Morphology
Predisposing Factors
• Chronic alcoholics
• Diabetics
• Chronic lung disease
Clinical Manifestations
Klebsiella Pneumonia
Diagnosis
Voges–Proskauer or VP is a test
Treatment
K. ozaenae
K. rhinoscleromatis
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• Causes rhinoscleroma
H. ducreyi
Morphology
Clinical Manifestations
Chancroid
Diagnosis
• Identification of the pathogen by means of microscopy and culturing are needed to confirm the
diagnosis.
• School of fish appearance or rail road track appearance
Morphology
• Spiral-shaped
• Gram-negative
• Motile bacterium with lopotrichous flagella, 5-6 flagella
• Microaerophilic.
Epidemology
Biochemical test
Culture
Diseases
Laboratory diagnosis
Noninvasive tests
1.Serology
• Detect an immune response by examining a blood sample for antibodies to the organism (ELISA).
5. Urease Test
Invasive testing
Treatment
1st line:Regimen 1
• 14 days
• PPI(proton pump inhibitors) BD
• Clarithromycin 500 mg BD
• Amoxicillin 19 BD (or Metronidazole 500 mg BD in penicillin allergic)
• PPI BD
• Amoxicillin 1g BD (days 1-5)
• Days 6-10 Clarithromycin 500 mg + Metronidazole 500 mg both BD
2nd line
Caused By
Introduction
• Transmitted by direct contact with infectious lesions often during play or group sleeping.
• This is enhanced by disruption of skin.
• Clinical manifestations
• Incubation period of yaws is 3-5 weeks.
A) Early yaws :-
iv) Hydroarthosis.
Treatment
• Penicillin
Pinta
Diagnosis
• Gene transfer refers to the process of genetic material (e.g. DNA) being sent and received among
two organisms-* Donor sends and recipient receives the genetic material.
• Conjugation
• Transduction
• Transformation.
a. Conjugation
• Mating of two bacterial cells, during which DNA is transferred from the donor to the recipient cell
• The mating process is controlled by anF (fertility) plasmid (F factor), which carries the genes for the
proteins required for conjugation.
• The role of plasmids in conjugation was first described by Lederberg and Tatum in E coli
• Plasmid may be R factor, which codes for transferrable multiple drug resistance.
b. Transduction
c. Transformation
158. Acanthamoeba
Acanthamoeba
Modes of transmission
C/Fs
Diagnosis:
Treatment
Naegleria fowleri
Clinical features
Diagnosis
Trypanosoma brucei
Host
Infective form
C/Fs
• Sleeping sickness
• Lymphadenopathy, particularly of the posterior triangle of the neck- Winter bottom sign
Trypanosoma cruzi
Transmission
• Transmitted to humans and other mammals by an insect vector, the blood-sucking insects of the
subfamily Triatominae (family Reduviidae) most commonly species belonging to the Triatoma,
Rhodnius, and Panstrongylus genera.
Host
• Zoonoses
• Leptospira affects wild and domestic animals worldwide.
• Man is an accidental host.
• Rats and small rodents are the main reservoirs of Leptospira.
• Korthof medium
Modes of transmission
1. Direct contact
• Transmission of leptospires may follow direct contact with urine, blood or tissue from an infected
animal.
2.Indirect contact
3. Droplet infection
Clinical features
1. Microscopic Demonstration
3. Serology
6.Molecular diagnosis-PCR
7. Molecular typing
Treatment of leptospirosis
162. Mycoplasma
• Mycoplasma are pleuromorphic smallest living organism, also known as Pleuropneumonia like
organism (PPLO).
• Medically important species are: Mycoplasma pneumoniae, M. hominis, M. genitalium
Morphology:
Diagnosis
Microscopy
Serological diagnosis
• PCR
Other test
• Raised ESR
Ureaplasma urealyticum
• Hydrolyzes urea
Genital infection
Treatment
TB complex
• M tuberculosis
• M africanum
• M bovis
Photochromogens
• M asiaticum
• M kansasii
• M marinum
• M simiae
Scotochromogens
• M flavescens
• M gordonae
• M scrofulaceum
• M szulgai
Nonchromogens
• M avium complex
• M celatum
• M haemophilum
• M gastri
• M genavense
• M malmoense
• M nonchromogenicum
• M shimoidei
• M terrae
• M trivale
• M ulcerans
• M xenopi
Rapid growers
• M abscessus
• M fortuitum group
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• M chelonae group
• M phlei
• M smegmatis
• M vaccae
Diseases
Mycobacterium marinum/M.balanei
• M. phlei
• M. smegmatis
• M. gordona
• M. paratuberculosis
M. Kansasii
Mycobacterium bovis
Mycobacterium ulcerans
164. Legionella
LEGIONELLA
Morphology
• Gram negative
Culture
Mode of transmissions :
1) Aerosolization
• Inhalation of aerosols produced by cooling towers, air conditioners and shower heads which act as
disseminators.
2) Aspiration
Source
• Water
Serotypes
Predisposing factors
C/F s
• Legionnaire disease
• Pontiac fever
Diagnosis
• Legionella is grown on complex media such as Buffered Charcoal Yeast Extract agar (BCYE) with
alpha ketoglutarate at pH 6.9, temp 35°C and 90% humidity..
Legionnaire's disease
Prevention
Morphology
Culture
• Obligate aerobe
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• Optimum temperature for growth is 37 degree and is able to grow at temperature as high as 42° C
• Colonies emit a distinctive, musty, mawkish, earthy or sweet grape-like odour or corn tocolike
odour.
• Cetrimide agar is a selective media.
Biochemical Reactions
Diseases
Respiratory infections
• Causes hospital acquired Gram negative bacteremias in immunocompromised patient and in severe
burns.
• Accounts for 25% of hospital acquired BSI caused by Gram negative bacilli.
Ear infections
• Meningitis
Endocarditis
Bone and joint infections
Gastrointestinal infections
• In immunocompromised host.
Diagnosis
NOTE:
Morphology
• Gram-negative
• Saftey pin appreance
• Pleomorphic
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• Most are motile under 30 degrees C. and non-motile at 37 degrees C
MACROSCOPIC APPEARANCE
Transmission
Disease
Bubonic plague
• Most common
• Human acts as dead end host
• Easily diagnosed by the presence of extremely swollen and tender lymph glands called “buboes”
that can grow to the size of an egg, and typically arise in the groin, neck and armpits.
• Absence of visible cellulitis
• Disease becomes evident 2-6 days after infection
• High fevers, chills, headache, and extreme exhaustion.
• Development of gangrene in the extremities, lending it the name “Black Death”.
Septicemic plague
• Necrosis
• Develops secondarily to bubonic plague, and is a result of direct invasion of the bloodstream
without involvement of the lymph nodes.
• Due to the lack of buboes, symptoms generally resemble the flu and make diagnosis difficult.
• In severe cases, seizure and shock can take place.
• Death rates for this form are 40% for treated cases and 100% for untreated cases.
Pneumonic plague
• The most serious form of infection is the which is 100% lethal if not treated within the first 24
hours.
• Man to man transmission.
Treatment
Misc.
Halophilic vibrios
V. parahaemolyticus
• Display a safety pin appearance due to the accumulation of dye at the poles of the cells
• It is the causative agent of food poisoning due to sea fish.
• Usual signs are abdominal pain, diarrhea, vomiting and fever.
V vulnificus
• Vechile- Shellyfish
• Acute gastroenteritis
• People may develop a blistering dermatitis sometimes mistaken for pemphigus or pemphigoid.
Morphology
• Gram-negative, nonmotile.
Disease in humans
• Infection typically produces cellulitis and/or abscesses at the site of the bite or scratch
• Usually 3 to 6 hours after inoculation
• Occasionally, the local infection can progress to necrotising fascitis, septic arthritis and
osteomyelitis.
Diagnosis
• Diagnosis is made on the basis of bacterial culture from infected tissues or secretions.
• Pasteurella grows readily on chocolate and sheep-blood agar media, but fails to grow on
MacConkey agar, the usual medium for Gram-negative bacteria.
Lyme disease
Stage 1
• Begins with the characteristic skin lesion, erythema migrans, at the site of the tick bite (~80-90% of
patients).
• Erythema migrans starts as a red papule at the site of the bite, which gradually expands to a round
lesion with red borders and partial central clearing.
Diagnosis
Introduction
• Relapsing fever is caused by spiral-shaped bacteria of the genus Borrelia and sub-species Relapsing
Fever Borrelia (RFB).
• Borrelia readily undergoes antigenic variations in vivo and this is believed to be the reason for the
occurrence of relapses in the disease
Clinical manifestations
• Severe for most tick-borne relapsing fever; headache, neck stiffness, arthralgia, myalgia,
ecchymosis, epistaxis, and petechiae.
• Complications include ARDS, decreased sensorium, myocarditis, hepatitis, abortion or stillborn and
death.
Treatment
• For decades, penicillins and tetracyclines have been the treatment of choice in relapsing fever.
Sporothrix schenckii
Traumatic implantation
• The conidia or hyphal fragments of S schenckii are introduced into the skin by trauma(rose or pulm
thorns/phagnum moss)
• Patients frequently recall a history of trauma associated with outdoor activities and plants.
C/Fs
Sporotrichosis
2) Pulmonary sporotrichosis
3) Disseminated sporotrichosis
Diagnosis
• In the clinical laboratory, round or cigar-shaped budding yeasts are seen in tissue specimens. In
culture at room temperature, hyphae occur bearing oval conidia in clusters at the tip of slender
conidiophores (resembling a daisy).
Coccidioides immitis
Clinical manifestations
Classification
• Enveloped
• Linear, double-stranded DNA virus
Thrombocytic purpura
Pneumonitis
CNS damage
Diagnosis
2.Labs
3. Histology
• A large cell containing a large basophilic intranuclear "owl's eye" and intracytoplasmic inclusion
bodies.
Drugs
• Gancyclovir
• Gancyclovir used intravitreally for retinitis
• Valganciclovir
Characteristics
• DNA
• double-stranded
• linear
• enveloped
Transmission
• Respiratory secretions
Pathogenesis
• Molecular biology remains latent in trigeminal and dorsal root ganglia reactivation due to
immunocompromised state or stress
Presentation
Chickenpox
Infectious period
• 70-90 %
• C/Fs - has two stages
1. Pre-eruptive stage
2. Eruptive stage
• Rash is symmetrical
Centripetal in distribution
• Rash is plemorphic, that is, all stages of rash (Papule, vesicle and crusts) may be seen
simultaneously.
• Old age
• Lymphoreticular malignancy. e.g., Hodgkin's disease
• HIV infection
Complications
• Meningeal irritation
• Pnemonia in adults
• Transverse myelitis
• Cutaneous dissemination
• Patient's with hodgkin's disease and non hodgkin's lymphoma are at greatest risk for progressive
hespes zoster.
• Bacterial superinfection(Most Common i children)
• Pneumonia
• Meningitis (rare complication)
• Encephalitis may be seen in children and immunosuppresion
• Reye syndrome
• Intrauterine complications in the fetus
• Blindness
• Cutaneous scarring in a dermatomal distribution
• Limb hypoplasia
Laboratory Diagnosis
A) Microscopy
B) Virus Isolation
C) Serology
Treatment
• Acyclovir
Vaccination
176. Coxsackievirus
Morphology
• Genus Enterovirus
Types
• The coxsackieviruses were subdivided into groups A and B based on their pathology in newborn
mice.
Clinical Manifestations
• Asymptomatic
• Mild fever
• Common cold
• Rashes
• Aseptic meningitis
Coxsackie A
• Herpangina
• Fever
• Sore throat
• Small vesicles on the back of the throat
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• Hand, foot, and mouth syndrome
1. Fever
2. Oral vesicles
3. Lesions on hands, feet, buttocks
4. Caused by coxsackie A16, A5, A10
Coxsackie B
Isolation
Classification
• Filovirus
Characteristics
• "filo"-viridae
• Category A bioterrorism agent
Incubation period
• 2-21 days.
• It kills up to 90% of people who are infected.
Diseases
• Hemorrhagic fever
Classification
• Virus
• DNA
• Non-enveloped
• Papovaviridae family.
• Human papillomavirus
Risk Factor
Presentation
Cutaneous warts
• Serotypes 1, 2, and 4
• Hands, fingers, and soles of feet
• Multiple papillomatosis most common manifestation in childrens.
• Serotypes 6 and 11
• Low risk HPV
Diagnosis
Vaccine
Two types
Efficacy
Recommended for
Administration
• The quadrivalent vaccine is administered intramuscularly as three separate doses, with second dose
given at 2months after the first dose and the third dose 6 months after the first dose.
• Cells Macrophages, Dendritic cells, NK cells, NK-T cells, Neutrophils, Eosinophils, mast cells,
basophils, epithelial cells.
• Complement components → Classical and alternaƟve pathway.
• Antimicrobial peptides Defensins, Cathelin, probiotics.
• Pattern recognition receptors.
• Cytokines.
• Natural killer cells/NK cells are a type of cytotoxic lymphocyte that constitutes a major component
of the innate immune system. they play a major role in the rejection of tumors and cells infected by
viruses. They kill cells by releasing small cytoplasmic granules of proteins called perforin and
granzyme that cause the target cell to die by apoptosis.
• Neutrophils and monocytes (the precursors of tissue macrophages) migrate from the blood into
inflammatory sites during innate immune responses. Macrophages and neutrophils are phagocytic
cells that engulf a microbial pathogen after it has been identified by the innate immune system.
• Conserved antigenic patterns in bacteria such as unmethylated CpG DNA, flagellin, lipid and
carbohydrate structures in the bacterial cell wall serve as danger signals to activate innate
immunity, resulting in local inflammation and the influx of the macrophages, neutrophils, and
dendritic cells.
Functions of AI include:
• Active memory
• Passive memory
Active immunity has immunological memory. Passive-active immunity is useful for the exposure of
Rabies, Hepatitis B, Varicella-zoster.
In some diseases passive immunization is often undertaken in conjunction with inactivated vaccine
products, to provide both:
The disease in which simultaneous active and passive immunization is used: Tetanus Diphtheria Rabies
Hepatitis B
In measles also, both active and passive immunization is used, but not simultaneously. Because the antibody
response to live attenuated measles vaccine is diminished in persons who receive immunoglobulin can currently.
So, the person passively immunized should be given a live measles vaccine 8-12 weeks later.
The duration of passive immunity is approximately equal to the half-life of the immunoglobulin
injected, which varies from disease to disease,
Example:7 days in case of anti-tetanus serum.
The main functions of the lymphoreticular system are the removal of senescent cells and production of immune
cells. The human body contains 1012 lymphocyte out of which 109 are renewed daily. Mature B and T cells before
they encounter antigen are called Naive cells.
1) T-lymphocytes
• Found in the parcortical area of lymph nodes and periarteriolar sheaths of the spleen.
• Antigen binds to the TCR [T cell receptor] which is responsible for signal 1.
• All lymphocyte contain CD-3 molecule which are involved in transduction of signal 1.
• Other surface molecules or co-receptors include CD 2, CD 4 or CD 8, CD 11a, CD 28. Antigen interaction
with T lymphocytes precipitates the release of lymphokines, substances that modulate other aspects of the
immune response., CD 40.
• CD 4 is expressed on 50% of T cells which help to produce immunoglobulins, while 30% expressed CD 8,
they are strict aginst virus infected cells
• All T cells express T cell receptors, and either CD4 o CD8.NOT BOTH.
• Antigen interaction with T lymphocytes precipitates the release of lymphokines, substances that modulate
other aspects of the immune response.
2) B-Lymphocytes
• ADCC lymphocyte
• NK cell- two types 1) LAK- lymphokine-activated killer cell 2) NK/T cells-
• Antibodies do not induce proliferation of NK cells. NK cells express CD3, CDI6 & CD56 and also but less
commonly CD2 & CD8.
4) phagocytic cells
• it is of two types
2) Microphages
These are polymorphonuclear leucocytes of blood-neutrophil, eosinophils and basophil, they do not have any role in
specific immune processes.
Dendritic cells
• Interdigitating dendritic
• Langerhans cells.
• Follicular dendritic cells.
1. MEFLOQUINE
2. ISONIAZID (INH)
3. HALOPERIDOL
• Involuntary movements of this hands, feet, lips, and tongue will increase initially as the
medication is decreased
• Haloperidol toxicity can cause Akathisia
• Long QT is seen as effect of overdosing of haloperidol.
• The most common side effect reported with treatment with haloperidol is Akathisia
• Depot preparations are available for Haloperidol.
• A week after the initiation of Haloperidol the patient shows be restlessness, fidgety, irritability and
cannot sit still at one place can be treated with beta-blockers.
• Acute drug dystonia shows abnormal movements like induced persistent deviation of neck on one
side is seen with haloperidol.
• Tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss
of consciousness for last 20 minutes after administration of haloperidol suggest acute dystonia.
• Hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia, high BP after administration
of haloperidol suggest Neuroleptic malignant syndrome.
• Drug treatment of schizophrenic is haloperidol.
• Treatment of morbid grief showing Preoccupation with the memory of deceased is Haloperidol.
• Effect of dopamine on kidney is blocked by Haloperidol.
• Extrapyramidal syndrome like side effects are seen in haloperidol.
4. DAPAGLIFLOZIN
DAPAGLIFLOZIN
6. TICLOPIDINE
7. GLYCERYL TRINITRATE
8. DIGOXIN
• Digoxin toxicity may result from the concurrent administration of digoxin with Amiodarone,
quinidine, verapamil, spironolactone, Furosemide, Hydrochlorothiazide.
• Digoxin toxicity is increased by Renal impairment, Hypercalcemia hypokalemia & Hypomagnesemia
9. ATROPINE
10. OCTREOTIDE
11. BROMOCRIPTINE
12. HALOTHANE
13. THIOPENTONE
• Fall in intracranial tension, decreases oxygen consumption of brain & decreases metabolic rate of
the brain are seen as an effect of thiopentone
• Dose of thiopentone is 2.5%
• Sodium carbonate is added to improve solubility of thiopentone.
• Thiopentone is Cerebro protective
• Thiopentone is contraindicated in porphyria
• Thiopentone on extravasation or intraarterial injection cause intense pain and even necrosis.
• Thiopentone is indicated in case of head injury.
• Thiopentone is indicated in increased intracranial tension.
• Thiopentone does not trigger malignant hyperthermia.
• Sodium Thiopentone is ultra short-acting due to rapid redistribution.
• Thiopentone is commonly used in narcoanalysis.
• Intravenous thiopentone produces rash, pain, spasm
• Intraarterial injection of thiopentone causes vasodilation, necrosis of vessel wall, hypotension
• Anaesthesia used in Duchenne muscular dystrophy for tendon lengthening procedure is induction
with intravenous thiopentone and N20; and halothane for maintenance.
• Thiopentone is highly distributed to body fat that is an anaesthetic agent lacking analgesic effect.
• Action of i. v. thiopentone is terminated by redistribution.
14. PROPOFOL
• Propofol intravenous induction agent is most suitable for day care surgery.
• Safe inducing agent in malignant hyperpyrexia is Propofol
• Propofol is associated with less residual impairment and low incidence of postoperative nausea
and vomiting.
• Propofol intravenous anaesthetic agent is highly protein bound & lipid soluble.
• Propofol is painful on injecting intravenously, because of oil preparations.
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• Propofol has no muscle relaxant property.
• Propofol undergoes hepatic metabolism.
• Propofol is safe in porphyria, anti-emetic effect, pleasant sedation & recovery.
• Propofol, Fentanyl, Isoflurane are most preferred for short daycare surgeries.
15. ISOFLURANE
16. SEVOFLURANE
17. FLUOXETINE
18. CLOZAPINE
• Clozapine is the drug of choice for the schizophrenic patient with poor oral absorption.
• Clozapine is indicated in a patient with schizophrenia & tardive dyskinesia.
• Least extrapyramidal side effects are seen in Clozapine.
• Clozapine may precipitate seizure & agranulocytosis.
• Clozapine should be discontinued if WBC (leukocyte) count <3000/mm3.
• Clozapine should not be used along with carbamazepine.
• Clozapine's action is more on D1 receptors than D2 receptors.
• Patient of schizophrenia on CPZ (chlorpromazine) develops auditory hallucination should be treated
with Clozapine.
• Clozapine is an antipsychotic drug with least extrapyramidal effects.
• Clozapine shows highest potential to cause metabolic syndrome.
19. LITHIUM
20. HEPARIN
21. PILOCARPINE
24. ACYCLOVIR
26. LINEZOLID
27. ZIDOVUDINE
• Zidovudine for mother (36 weeks) and child (6 weeks) therapy can be offered to reduce the chance
of transmission of HIV to the newborn.
• Zidovudine causes myopathy as a side effect.
• Severe hepatotoxicity associated with steatohepatitis, most likely a result of mitochondrial toxicity,
is being recognized with zidovudine.
• Zidovudine + Lamivudine + Indinavir for 4 weeks is the recommended regimen for post-exposure
prophylaxis of HIV Infection.
• Resistance to zidovudine develops due to mutations in reverse transcriptase.
• Zidovudine + Lamivudine + Nevirapine drugs are supplied free of cost to the government Hospital
by NACO.
• Co-administration of Indomethacin, Aspirin & Trimethoprim are not preferred with zidovudine.
28. CISPLATIN
30. TRASTUZUMAB
31. PYRAZINAMIDE
32. Clozapine
• Clozapine is the Drug of choice for schizophrenic patient with poor oral absorption.
• Resistant schizophrenia is indication for use of clozapine
• Agranulocytosis, seizure are common side effects of clozapine
• Drug of choice for the treatment of negative symptoms of schizophrenia is clozapine
• Clozapine has highest potential to cause metabolic syndrome
• Extrapyramidal side-effect least seen with Clozapine
33. RIFAMPICIN
34. ETHAMBUTOL
35. AMINOGLYCOSIDE
• Dots Plus regime consist of 6Km Ofx Eto Cs ZE + 18 Ofx Eto CsE
• To be termed as cured a patient who was initially smeared positive and completed treatment
should have a negative smear result on at least 2 occasions of which one should be at treatment
completion.
• ND2 regime – For sputum -ve pulmonary not seriously ill patients and extrapulmonary not seriously
ill patients – 12(HE)
• In DOTS continuation phase drugs are given in a multi-blister combi-pack.
• DOTS medication is to be taken in presence of a health worker
• Alternate day treatment is recommended in DOTS.
37. METRONIDAZOLE
38. KETOCONAZOLE
39. CHLORAMPHENICOL
• A young male presents with meningococcal meningitis and allergy to penicillin can be treated with
chloramphenicol.
• Chloramphenicol resistance in Pseudomonas aeruginosa is due to active efflux pumping out of drug.
• Gray baby syndrome is caused by Chloramphenicol.
40. AZITHROMYCIN
• A patient with discharge per vagina was evaluated and on endocervical biopsy, chlamydia was
found. Treatment to be given in this case is Azithromycin and contact tracing.
• A young boy presented with high fever shows clinical features suggestive of Legionnaires'
Disease. Treatment of choice is Azithromycin.
• The drug of choice to treat Chlamydia infection in pregnancy is Azithromycin.
• Mass treatment with azithromycin is indicated if the prevalence of trachoma follicles (TE) in 1-9
years population is more than 10%.
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• A 30-year-old male presents with pneumonia and diarrhoea five days after discharge from hospital.
The drug of choice for treating him is Azithromycin.
• 24 years old male complains of mild urethral mucoid discharge after sexual contact with a sex-
worker. Examination is normal. Drug used to treat such a patient is Azithromycin.
• Treatment of granuloma inguinale is Azithromycin.
41. SULPHONAMIDE
42. COTRIMOXAZOLE
43. DOXYCYCLINE
44. TETRACYCLINE
45. DAPSONE
46. PENICILLIN
48. AMOXICILLIN
49. CEPHALOSPORIN
• Positive edrophonium test is most sensitive test for diagnosis of myasthenia gravis.
• Neostigmine is a quaternary ammonium compound.
• Neostigmine antagonizes nondepolarizing blockade by decreasing acetylcholine breakdown at
motor end plate, preventing K+ efflux from cell & depolarization of motor end plate.
• Neostigmine helps in urinary retention.
• Neostigmine is given to reduce post operative paralytic ileus.
• Neostigmine is given to reduce effect of depolarising muscle relaxation.
• Donepezil is used in treatment of alzheimer dementia.
• Rivastigmine (cholinesterase inhibitor) should not be used with drugs that have cholinergic
antagonistic activity like tricyclic antidepressants (TCA) as combination is counterproductive.
• Neostigmine is used for reversing adverse effect of DTC + pancuronium.
• Shortest acting anticholinesterase is Edrophonium.
• Rivastigmine & Donepezil are drugs used predominantly in management of dementia.
• Muscarinic signs of OPC poisoning can be remembered as SLUDGE- BBB: Salivation, Lacrimation,
Urination, Defecation, Gastric upset, Emesis, Bronchospasm, Blurred vision (Miosis), Bradycardia.
• Delayed onset polyneuropathy after organophosphorous poisoning is seen after 2-4 weeks.
• Fatality rate of organophosphorous poisoning in India is 15-30%.
• In organophosphorous compound poisoning, organophosphorous compound is a
Phosphorylated enzyme irreversibly inhibit cholinesterase.
• Most specific test for organophosphorous poisoning is Plasma cholinestrase level.
• Organophosphate inhibits Esteratic site of AchEs.
• Antidote for organophosphorous poisoning is Atropine.
• Besides its properties of decreasing intraocular pressure, timolol is preferred in the treatment
of glaucoma because it Produces no miosis
• Drug of choice for open angle glaucoma Timolol
• Acetazolamide s contraindicated in sulfonamide hypersensitivity
• Brimonidine can cause drowsiness
• A patient with glaucoma is being treated with systemic beta blocker should not be
given Levobunolol
• Acute angle closure glaucoma first line treatment Iv mannitol
• Drug used in refractory glaucoma Alpha agonist
• Latanoprost used topically in glaucoma primarily acts by Increasing uveoscleral outflow
• Main MOA brimonidine in glaucoma Decreased aqueous secretion
• Drug kept as a last resort in the management of primary open angle glaucoma is Oral acetazolamide
• Selective alpha 2 agoinst used in glaucoma is Brimonidine
• Atropine should be avoided in angle closure glaucoma
• Pain in absolute glaucoma is best relieved by Retrobulbar injection of steroid
• Drug CONTRAINDICATED in glaucoma patients suffering from bronchial asthma is Timolol
• Combination of pilocarpine and epinephrine use in glaucoma treatment may inhibit Pigmented
pupillary cyst
• In primary angle-closure glaucoma pilocarpine lowers the intraocular pressure by its direct action
on the Sphincter pupillae muscle
• In primary open-angle glaucoma pilocarpine eye drops lowers the intraocular pressure by its direct
action on the Longitudinal fibres of the ciliary muscle
• In a hypertensive patient with glaucoma Dipivefrine is contraindicated
• Treatment of malignant glaucoma includes Topical atropine, IV mannitol & Vitreous aspiration
54. EPINEPHRINE
57. DOPAMINE
• The strategy for therapy for dopamine deficiency in the substantia nigra of individuals with
Parkinson’s disease is indicated by provision of metabolites in the tyrosine pathway.
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• Neurotransmitter related to schizophrenia pathology is dopamine.
• The efferent fiber bundle of the substantia nigra transmits dopamine to Corpus striatum.
• Dopamine is the major neurotransmitter in substantia nigra.
• Slow IPSP in autonomic is generated by dopamine.
• Adrenaline, noradrenaline and dopamine act through seven pass receptor.
• Dopamine shows positive ionotropic effect.
• Dopamine improves renal perfusion.
• Dopamine causes vasoconstriction.
• Effect of dopamine on kidney is blocked by Haloperidol.
• Dopamine is preferred in treatment of shock because of renal vasodilatory effect.
• Prolactin secretion will be inhibited by dopamine.
• Bromocriptine,Ropinerole & Pramipexole are dopaminergic agonists used for parkinsonism.
• Dopamine neurotransmitter is depleted in Parkinson's disease
• Drug most useful in cardiogenic shock is dopamine.
• Dopamine is preferred over dobutamne in treatment of renal shock because of renal vasodilatory
effect.
• Anti-psychotic drugs act through Dopamine D4 receptor blockade.
• Dopamine at 1-2 Microgram/ Kg/ min produces renal vasodilatation.
• Dopamine receptor with inhibitory action is D2.
• A drug administered through oral route undergo high first pass metabolism.
• High first pass metabolism causes for less bioavailability.
• High first pass metabolism is seen in Lignocaine, Propranolol & Salbutamol.
• Isosorbide mononitrate bypasses first pass metabolism.
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• Sublingual route escape first pass metabolism.
• Theophylline escape first pass metabolism.
• Action potentials on the alpha motor neuron release acetylcholine (Ach) from the axon terminal
• Cholinergic receptors on the muscle endplate are cation channels
• Alpha motor neurons excite, and Renshaw cells inhibit, the muscle endplate
• In Myasthenia gravis, antibodies are present against Nicotinic Receptor
• Nicotine receptor sites include Adrenal medulla, Skeletal muscle & Sympathetic ganglia
• Carbachol has maximum nicotinic effect
• Muscarinic antogonists Decrease gastric secretions, Decrease respiratory secretions & Fascilitates
AV conduction
• Oxybutynin acts by Muscarinic receptor inhibition
• D-tubocurarine is a skeletal muscle relaxant that acts by competitive inhibition of NM receptors at
neuron-muscular junction.
• Dry mouth during antidepressant therapy is caused by blockade of Muscarinic acetylcholine
receptors
• Bupropion is Nicotinic receptor antagonist
• Drug used for muscarinic symptoms seen in cobra envenomation is Neostigmine
• Acetylcholine acting on nicotinic receptors produces Contraction of skeletal muscle
• Nicotinic cholinergic receptors are ionic channel
• Varenicline acts by Partial nicotine receptor agonist
• Muscarinic cholinergic receptors are seen at Stomach, CNS , Glands
• Alpha 1a blocker used for BHP without any effect on blood pressure - Tamsulosin
• Dale's vasomotor reversal is due to Alpha blocker
• Prazosin, Indoramin & Idazoxan are alpha blocker
• Clonidine is Alpha 2 receptor agonist
• In a hypertensive patient with glaucoma, Alpha blocker is given
• Alpha-1 agonist used as Nasal decongestant
• Selective alpha 2 agonists used in glaucoma - Brimonidine.
• The presence of a noncompetitive inhibitor can Lead to a decrease in the observed Vmax
• A competitive inhibitor of an enzyme will Bind to the same site as the substrate
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• In competitive inhibition Vmax is unchanged but Km increased
• Disopropyl phosphorofluoridate (DFP) reacts with serine proteases irreversibly and therefore
is Non-competitive inhibitor
• In noncompetitive antagonism Km value decreased; V max decreased
• Atropine is useful in organophosphate poisoning because it is a competitive antagonist of
acetylcholine
• Non-competitive inhibitor of carbonic anhydrase is Acetazolamide
• Non-depolarizing muscle relaxants are Competitive inhibitor of acetylcholine
• Imatinib and suntinib are competitive inhibitors of tyrosine kinase
• If V max decrease to 80% due to an inhibitor and Km is same as before Non competitive type of
inhibition
• Cyanide affects respiratory chain by Non-competitive irreversible inhibition
• Substance which binds to substrate other than catalytic enzyme is Non-competitive inhibitor.
63. GLUCOCORTICOIDS
64. MINERALOCORTICOID
65. ASPIRIN
• At usual therapeutic doses (blood levels), expected effects of aspirin include efficacy greater than
acetaminophen as an anti-inflammatory agent.
• Aspirin is contraindicated in Warfarin.
• In low doses, aspirin inhibits cyclo-oxygenase.
• Important effects of aspirin include reduction of fever, prostaglandin synthesis in inflammed tissues
& Respiratory stimulation.
• Aspirin irreversibly inhibits platelets.
• Aspirin is useful in prevention of heart attack and stroke.
• Aspirin is contraindicated in Peptic ulcer.
• In aspirin poisoning most important step is Fluids.
• Aspirin and NSAIDS are most commonly involved in Anaphylactoid reaction.
• Aspirin hypersenstitivity is seen along with Nasal Polyposis.
• Mechanism of action of Aspirin in MI is Thromboxane A2 synthesis inhibition
• Low doses of aspirin used in myocardial infarction act by Inhibiting cyclooxygenase
• Antiplatelet action of aspirin is due to Decrease thromboxane A2 synthesis.
• Aspirin is associated with Reye's Syndrome.
• An elective surgery is to be done in a patient taking heavy doses of Aspirin. Management consists
of Stopping aspirin for 7 days and then do surgery
• A patient is on aspirin shows Prolonged BT
• Aspirin + Low molecular weight Heparin is recommended in a woman with Antiphospholipid
Antibodies and history of prior abortions / still birth.
• Low doses of aspirin therapy is essentially advised for IUGR, Post myocardinal infarction & Pre
ecclampsia.
• Aspirin reduces risk of TIA.
• Anti-inflammatory dose of aspirin is 3 - 6 g/d.
• Chemically aspirin is Acetyl salicylic acid.
• In patients with decompensated cirrhosis on diuretic therapy with tender gynaecomastia, the best
diuretic to substitute is Amiloride (10-40 mg/day) for spironolactone
• The usual maximum dose of furosemide and spironolactone in patients with cirrhosis and portal
hypertension is Furosemide 160 mg and spironolactone 400 mg
• Antiandrogen is the MOST important adverse reaction of spironolactone therapy
• Spironolactone, Eplerenone & Triamterene drugs act as potassium-sparing diuretics
• Triamterene is only slightly soluble and may precipitate in the urine, causing kidney stones.
• Spironolactone should NOT be given with ACE inhibitors
• Spironolactone alters cardiac mortality
• The primary site of action of triamterene and spironolactone is the Distal tubule and collecting
duct.
• Eplerenone & Spironolactone are Aldosterone antagonist
• Spironolactone is the first drug to be given for Cirrhotic edema
• Mainstay of treatment of Nephrogenic Diabetes Insipidus is Thiazide / Amiloride diuretics and salt
restriction
• Spironolactone is least commonly used in Hypertension
68. PARACETAMOL
69. PHENYTOIN
70. BENZODIAZEPINE
• Histamine causes Arteriolar dilatation, Increased permeability of venules & Constriction of large
arteries
• Histamine is found in Mast cells
• Histamine Increases gastric acid secretion
• The role of histamine in acute inflammation mediates increase in Related to arousal and blood
pressure,vascular permeability, chemotaxis, Release of pain causing substances
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• HCL secretion is stimulated by Histamine
• Increased permeability in acute inflammation is due to Histamine
• Vasoactive amines, involved in inflammation are Histamine
• H1 blockers are useful as Anti-allergic
• Pulmonary vasodilatation is caused by Histamine
• Triple response is due to Histamine
• In monoclonal antibody production, monoclonal cells are differentiated from Myeloma cell lines
• Bevacizumab is Monoclonal antibody against VEGF
• Herceptin (trastuzumab) prescribed in breast cancer is a monoclonal antibody produced by
injecting her-2 antigen
• Monoclonal antibody against VEGF is Bevacizumab
• The monoclonal antibody useful in the treatment of PNH is Eculizumab
• Monoclonal antibody Produced by hybridoma technology
• Monoclonal antibody Used for blood grouping
• Monoclonal antibody Requires in small quantity
• Cetuximab and rituximab are Chimeric monoclonal antibodies
• Cardiomyopathy is caused by Trastuzumab
• DENOSUMAB a monoclonal antibody against RANKL receptor is used in the treatment
of Osteoporosis
• HER2/neu overexpression in Ca breast Responds well to monoclonal antibodies
• Rituximab is an anti-cancer drug comes under monoclonal antibodies
• Rituximab is a Chimeric monoclonal antibody against CD-20 B cell antigen
• Most common side effect of Rituximab is infusion reaction
• Rituximab is First FDA drug approved for resistant lymphomas
Mechanism of action:
• Absence seizure
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• Myoclonic and atonic seizures
Interactions:
Adverse effects:
Treatment:
ANTI-THYROID DRUGS:
Propylthiouracil:
Carbimazole:
• Antagonize propylthiouracil.
• Plasma t1/2 : 6-10 hrs.
• 3 times more potent.
• Duration of action: 12-24 hrs.
• Major disadvantage:
• Active metabolite - Methimazole.
• Increased trans-placental & milk diffusion.
Effects in Pregnancy:
Congenital malformation:
Indications:
• Thyroid Storm:
• Thyrotoxicosis in Grave's disease & Toxic Nodular Goitre in pregnancy
Contraindications:
• In pregnancy
• Carbimazole:
• Hyperthyroid pregnant women.
• Causes Aplasia Cutis Congenita.
1. Hyperthyroidism in Pregnancy:
76. CYCLOSPORIN
CYCLOSPORIN
Adverse effects:
• Nephrotoxicity
• Post-transplant hypertension
• Hyperuricemia, hyperkalemia & hypomagnesemia
• Hirsutism
• Gum hyperplasia
• Tremor
• Seizures
Indicated in:
Drug interactions:
• Enhanced toxicity when given along with Vancomycin, Amphotericin B, & NSAIDS.
DOSE-RESPONSE CURVE
THERAPEUTIC WINDOW:
• Is the minimum dosage necessary for a patient to benefit from the main effects intended of a
specific drug.
TDM testing is not performed for whose drugs whose effect are easily measured.
ANTI-CHOLINERGIC DRUGS
ATROPINE:
DRUG DISTRIBUTION
1. Incretins:
Ex:
MOA:
• Little stimulatory effect on insulin secretion (at normoglycemic concentration) - Hence, GLP-1 has
lower risk of causing hypoglycemia.
• Other actions:
Suppress glucagon secretion.
Preserves islet cell integrity & decreases its apoptosis.
Delays gastric emptying causing reduced appetite
Properties of GLP-1:
Individual drugs –
Liraglutide -
Exenatide -
• Twice daily
• Dose adjustment needed (should be reduced).
3. DPP-4 Inhibitors:
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MOA:
Disadvantages:
MOA:
• SGLT-2 inhibitors act by inhibiting this transporter Causing glucosuria in diabetics causes
weight loss.
• Effective orally.
• Efficacy reduced in renal failure.
• Eg: Dapagliflozin & canagliflozin.
Dapagliflozin:
5. Dopamine D2 agonist:
Bromocriptine mesylate:
MOA:
3. Thiazolidinediones:
OPIOID ANTAGONISTS
OPIOID DRUGS
• Opioid drugs are substances obtained from crude extracts of Papaver somniferum (poppy plant).
• Main used as analgesic agents.
• Opioid receptors include, µ, κ and δ receptors.
• Pure
opioid includes Morphine, Methadone, Heroin, Hydromorphone, Oxymorphone, Pethidine, Codeine
, Hydrocodone & Oxycodone.
• Mixed agonist-antagonist drugs include Buprenorphine, Butorphanol, Nalbuphine, Pentazocine
& Tramadol.
• Opioid antagonists includes Naloxone, Naltrexone, Nalmefene & Naloxegol.
• Endogenous peptides include Endorphins, dynorphins, enkephalins & Nociceptin.
• Endorphins act on µ receptor; Dynorphins acts on κ receptor; Enkephalins acts on δ receptors.
• Morphine - Administered by oral, rectal, i.v., i.m., intrathecal or epidural routes.
• Fentanyl - Applied as transdermal patch; also administered by buccal transmucosal route.
• Butorphanol - Only opioid available in nasal formulation.
• Morphine acts on µ, κ and δ receptors.
• Morphine produce respiratory depression, cough suppression & miosis.
• Main feature for opioid poisoning diagnosis - Pinpoint pupil.
• Highly lipid soluble drugs include fentanyl, alfentanil & sufentanil.
• Fentanyl, alfentanil & sufentanil causes truncal rigidity on rapid i.v. infusion.
• Pure opioids peripherally cause increased heart rate, decreases BP & constipation.
• Alvimopan, a peripheral opioid antagonist, mainly used for paralytic ileus, because
of increased intrabiliary pressure, by constricting biliary smooth muscle.
• Morphine (i.v.) used in myocardial infarction, acute pulmonary edema & pre-anesthetic medication.
• Codeine, pholcodine, dextromethorphan & noscapine are effective cough suppressants.
• Loperamide & diphenoxylate used for non-infective diarrhea treatment.
ERECTILE DYSFUNCTION
• Nitric oxide (NO) increases cGMP levels (This most important step is metabolized by
phosphodiesterase) --> smooth muscles relaxation of corpora cavernosa --> Penile erection.
• Primary & most common cause for ED is psychological.
ANTI-OBESITY DRUGS
• Arcuate nucleus in mediobasal hypothalamus is the main integrating center for feeding &
regulation of body weight.
• 5-HT2 activation causes weight loss.
• Drugs targeting 5-HT2 receptor includes mainly Lorcaserin, which is a selective
5HT2c agonist which decreases appetite.
• Orlistat is used as an anti-obesity drug, which mainly acts by inhibiting gastrointestinal lipases.
ANTI-SMOKING DRUGS
• Nicotine replacement therapy is available in all forms like chewing gum, lozenges, patch, except
tablets.
• Bupropion (along with Varenicline & Nicotine replacement therapy) is a USFDA approved first-line
agent for pharmacotherapy in smoking cessation.
• Nicotine replacement therapy includes transdermal patch, gum, lozenges, oral inhaler & nasal
spray.
• Varenicline is a selective partial agonist at Alpha4-Beta2 Nicotinic A-Choline receptor, that is
believed to mediate nicotine dependence.
• Bupropion is a nicotinic receptor antagonist.
• Bupropion/amfebutamone is used both for atypical antidepressant & smoking cessation aid.
• Bupropion acts as a norepinephrine & dopamine reuptake inhibitor (NDRI), and alpha3 beta4-
nicotinic receptor antagonist.
• Bupropion is used in prophylaxis of nicotine addiction.
• Bupropion/Amfebutamone decreases nicotine craving.
• Bupropion/Amfebutamone shows increased efficacy when combined with nicotine patch.
• Mecamylamine is a nicotine antagonist, used as an anti-smoking drug.
• Nortryptyline is an active metabolite of amitriptyline, used as an anti-smoking drug.
• Drugs used for treating BHP include Selective α1-blockers & 5-α reductase inhibitors.
• α-adrenoceptor blockade results in smooth muscle relaxation in neck of urinary bladder & prostatic
urethra, reduces dynamic obstruction, increases urinary flow rate & causes complete bladder
emptying in BHP patients.
• Selective α1-blockers relieves dynamic obstruction & provides rapid symptomatic relief in BHP.
• Selective α1-blockers afford faster (within 2 weeks) & greater symptomatic relief (than finasteride).
• Selective α1-blockers relieves voiding symptoms (hesitancy, narrowing of stream, dribbling &
increased residual urine) effectively.
• Selective α1-blockers does not affect prostate size.
• Selective α1-blockers includes prazosin, terazosin, silodosin, doxazosin & alfuzosin.
• Selective α1-blockers are DOC for BHP.
• DOC for BHP cases with hypertension is Prazosin/Doxazosin.
• DOC for BHP cases without hypertension -Tamsulosin.
• Prazosin blocks α1 receptors in bladder trigone & prostatic smooth muscle --> Improves urine flow
& reduces residual urine in bladder.
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• Tamsulosin & Silodosin acts by selectively inhibiting α1A receptor (α1 subtype) present in prostate.
• Tamsulosin & Silodosin has reduced propensity to cause postural hypotension, hence preferred for
treating BHP.
• 5-α reductase inhibitors like Finasteride & dutasteride.
• 5-α reductase enzyme converts DHT to testosterone.
• 5-α reductase inhibitors block 5-α reductase enzyme, conversion of dihydrotestosterone to
testosterone is blocked --> reduced DHT production --> Prostate gland growth is controlled.
• 5-α reductase inhibitors treats BHP by arresting growth/reducing prostate size.
• 5-α reductase inhibitors are used for relieving static component of urinary obstruction in BHP.
• Finasteride is 5α-reductase antagonist, mainly type II.
• Finasteride inhibits conversion of testosterone to dihydrotestosterone & reduces prostate volume.
• Finasteride reduces serum & prostatic concentrations of dihydrotestosterone --> prostatic volume
decrease & urine flow rate increases, hence useful for BHP treatment.
• Finasteride exhibits delayed action; hence, takes >3 months to exert its beneficial effect.
90. THALIDOMIDE
THALIDOMIDE
• Thalidomide tragedy is a serious adverse effect happened in the 1960s, on using the drug as a
sedative & anti-emetic drug for morning sickness.
• Thalidomide was banned due to teratogenic effects (phocomelia).
• Thalidomide has been re-introduced & marketed recently for anticancer drug in multiple myeloma
& melanoma.
• Though thalidomide has teratogenic effects, it also possesses anti-cancer properties,
immunomodulatory & anti-angiogenic characteristics.
• Thalidomide acts by inhibiting angiogenesis.
• Two enantiomers of thalidomide (R & S), are inter-convertible within body.
• Thalidomide are indicated for multiple myelomas at initial diagnosis,its relapsed/refractory states,
erythema nodosum leprosum & skin manifestations of SLE.
• Thalidomide is used in steroid-resistant type-2 lepra reaction.
• Daily dosage of thalidomide for controlling ENL is 200-300 mg.
• Major adverse effects of thalidomide includes, teratogenicity, peripheral neuropathy, sedation &
constipation in cancer patients.
• Thalidomide causes congenital abnormalities particularly phocomelia (defect in development of
long bones).
• Immunomodulatory derivatives of thalidomide are called IMiDs.
• Lenalidomide is an ImiD's, which is more potent & non-teratogenic derivative.
• Lenalidomide is approved as first-line therapy for multiple myeloma, combined
with dexamethasone & bortezomib.
• Lenalidomide is approved recently for mantle cell lymphoma.
• Lenalidomide can cause peripheral sensory neuropathy.
TRICYCLIC ANTIDEPRESSANTS
• Revisions in JNC 8 guidelines include first-line drugs as Thiazide, ACE inhibitors, ARBs & calcium
channel blockers (CCBs).
• Beta-blockers are no longer considered as first-line drugs, according to JNC 8 guidelines for
hypertension.
• ACE inhibitors/ARBs are first choice drugs in patients with CKD irrespective of ethnic backgrounds.
• For African descent patients without CKD, calcium channel blockers or thiazides are preferred.
• Goal for all patients < 60 years, BP should be < 140/90 mmHg, irrespective of presence or absence
of diabetes (DM) or chronic kidney disease (CKD).
• Goal for elderly > 60 years without CKD or DM or both, BP is targeted at < 150/90 mm/Hg.
• Goal for elderly > 60 years with CKD or DM or both, BP is targeted at < 140/90 mmHg.
• First-line therapy for pulmonary hypertension treatment includes oral calcium channel
blockers (including amlodipine, diltiazem & nifedipine), only if patients respond to intravenous
vasodilators.
• First-line therapy for pulmonary hypertension treatment mainly depends upon function & patient's
status if patients don't respond to intravenous vasodilators.
• Patient with WHO Class 2 symptoms are treated using phosphodiesterase inhibitors
(Sildenafil/tadalafil) & Endothelin receptor blockers (Bosentan/ambrisentan).
• Patient with WHO Class 3 symptoms are treated using prostacyclin analogs particularly
epoprostenol intravenously, iloprost by inhalation & beraprost/treprostinil subcutaneously.
• Patient with WHO Class 4 symptoms are treated with epoprostenol or iloprost, as sole agent
therapies.
• Pulmonary transplantation has high operative mortality (around 20–25%).
• Bosentan & sitaxentan are useful in treating pulmonary hypertension, which is a non-specific
antagonist of endothelin receptors, both ETA & ETB.
• Phosphoramidon is a non-specific inhibitor of endothelin converting enzyme, which is useful for
treating pulmonary hypertension.
• PGI2 analogs, particularly with vasodilator action is preferred for treating pulmonary hypertension
like epoprostenol & longer acting PGI2 analog Treprostinil.
• Soluble guanylate cyclase (sGC) stimulator like Riociguat is specifically indicated
for persistent/recurrent chronic thromboembolic pulmonary hypertension.
ANTI-DYSLIPIDEMIC DRUGS
• First line anti-dyslipidemic drugs are statins, bile acid binding resins & intestinal cholesterol
absorption inhibitors.
• Second line anti-dyslipidemic drugs are fibrates & niacin.
• Statins act by inhibiting HMG CoA reductase enzyme competitively.
• HMG CoA reductase catalyzes in cholesterol biosynthesis, mainly conversion of HMG CoA to
mevalonate.
• Rate-limiting step in cholesterol biosynthesis is conversion of HMG CoA to mevalonate, catalyzed
by HMG CoA reductase.
• Statins decrease cholesterol synthesis in liver, by inhibiting HMG CoA reductase enzyme.
• Statins decrease bile acids & steroid hormones synthesis.
• Statins are most powerful LDL lowering agents.
• Statins decrease TG, IDL & VLDL & increases HDL slightly.
• Statins have no effect on lipoprotein.
• Statins mainly pravastatin decreases plasma fibrinogen levels.
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• Statins exhibit pleiotropic effects like antioxidant, anti-inflammatory & anti-proliferative properties.
• Pitavastatin, rosuvastatin, atorvastatin, fluvastatin & lovastatin are drugs included under statins.
• Pravastatin approved for children ≥ 8 years.
• Major adverse effect of statins includes Myopathy & hepatotoxicity.
• Pravastatin is safer with regard to causing myopathy.
• Statins are first-line drugs for type IIa, type IIb & secondary hyperlipoproteinemia.
• Long-acting statins are Rosuvastatin (t1/2 - 19 hours) & Atorvastatin (t1/2 - 14 hours).
• Rosuvastatin with t1/2 19 hours is the longest acting statin.
• Activity of HMG CoA reductase maximum at night, hence most statins are administered at night.
• Long-acting drugs like Rosuvastatin & Atorvastatin are administrated any time of day, due to their
longer half-life.
• All statins absorbed orally, maximum with fluvastatin.
• Lovastatin & simvastatin are administered as prodrugs & have extensive first-pass metabolism.
• Pravastatin, fluvastatin, atorvastatin & rosuvastatin are administered as active drugs.
• All statins are metabolized extensively by hepatic microsomal enzymes, except pravastatin.
• Pravastatin metabolized by sulfation (non-microsomal).
• Most potent statin is Pravastatin; Least potent statin is lovastatin.
• Ezetimibe is an intestinal cholesterol absorption inhibitor.
• Ezetimibe acts by inhibiting NPC1L1 transporter, involved in intestinal absorption of cholesterol.
• Intestinal cholesterol absorption inhibitor like Ezetimibe indicated in type IIa & IIb
hyperlipoproteinemia.
• Bile acid binding resins bind to bile acids in intestinal lumen Decreases its reabsorption results
in more excretion via feces.
• Bile acid binding resins are indicated only for type IIa disorder.
• Drugs included under bile acid binding resins cholestyramine, colestipol & colesevelam.
• Fibric acid derivatives act by activating LPL by activating nuclear receptor, PPARα (peroxisome
proliferator-activated receptor alpha).
• Fibric acid derivatives reduces TG (contained in VLDL), increases HDL & reduces plasma fibrinogen
level.
• Drugs included under fibric acid derivatives are Clofibrate, gemfibrozil, fenofibrate, bezafibrate.
• Fenofibrate is prodrug with longest half-life.
• Fenofibrate has maximum LDL cholesterol-lowering action & are uricosuric.
• DOC in hypertriglyceridemia (type III & IV) is Fenofibrate.
• Nicotinic acid acts by inhibiting lipolysis in adipose tissue.
• Main effects of nicotinic acid increase HDL cholesterol, decrease LDL cholesterol, VLDL
triglycerides, lipoprotein (a) & fibrinogen.
• Among all hypolipidemic drugs, nicotinic acid is maximum HDL increasing property.
• Due to maximum HDL increasing property, Nicotinic acid is useful in patients having increased risk
of CAD.
• Except for type-I disorders, nicotinic acid is useful in type IIb, III & IV disorders.
• Main limiting feature of nicotinic acid is cutaneous flushing & pruritis.
• Probucol is an anti-dyslipidemic drug useful for its antioxidant action.
• Probucol inhibits LDL oxidation resulting in reducing both HDL & LDL cholesterol levels.
• Gugulipid causes modest reduction of LDL & slight increase of HDL.
PLASMA EXPANDERS
TREATMENT OF OSTEOPOROSIS
• Drugs used for treating osteoporosis are bisphosphonates, selective estrogen receptor modulators
(SERM), Teriparatide, Denosumab, Osteoprotegerin, Cinacalcet, Strontium
ranelate, Calcium, Gallium nitrate & Calcitonin.
• Bisphosphonates exhibit inhibitory effect on osteoclast-mediated bone resorption.
• Bisphosphonates cause osteoclast-mediated bone resorption, by accelerating osteoclastic
apoptosis & by suppressing differentiation of osteoclast precursors to mature osteoclasts.
• Least potent bisphosphonates are 1st generation drugs like medronate, clodronate & etidronate.
• Longest half-life of bisphosphonate in bone is with alendronate for almost 10 years.
• 3rd generation bisphosphonate drugs like risedronate & zoledronate are the most potent agents.
• Bisphosphonates are used in treatment of post-menopausal & steroid-induced osteoporosis.
• Pamidronate & zoledronate, by i.v route is preferred for treating hypercalcemia of malignancy.
• Distinctive toxicity of bisphosphonates is esophageal irritation & ulceration.
• Bisphosphonates are not taken by mouth & advised not to lie down, for at least half an hour.
• 1st generation bisphosphonate results in osteomalacia.
FIBRINOLYTIC DRUGS
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• Fibrinolytic drugs are also referred as “thrombolytics”.
• Fibrinolytic drugs are drugs activating plasminogen to form plasmin & helping thrombus lysis.
• Plasmin is generated from plasminogen, by tissue plasminogen activator (tPA).
• tPA selectively activates fibrin-bound plasminogen in thrombus.
• Bleeding is the major adverse effect of fibrinolytic, mainly due to lysis of physiological thrombi &
excessive circulating plasmin.
• Fibrinolytic drugs are indicated for treatment of acute myocardial infarction (Stemi) - Administered
i.v. within 12 hours preferably within 1st 3-6 hours.
• Absolute contraindications for fibrinolytic drugs include,
• History of non-hemorrhagic stroke within the past year/at any time,
• Marked hypertension (systolic >180 and/or diastolic > 110mm Hg),
• Active internal bleeding (excluding menses).
• Relative contraindications for fibrinolytic drugs include,
• Current use of anticoagulants (INR≥ 2),
• Recent (>2weeks) invasive or surgical procedure,
• Prolonged (> 10 min.) cardiopulmonary resuscitation,
• Known bleeding diathesis,
• Pregnancy,
• Hemorrhagic diabetic retinopathy,
• Active peptic ulcer disease,
• History of severe hypertension.
• Specific antidotes for fibrinolytic drug overdose are Epsilon aminocaproic acid (EACA) &
tranexaemic acid.
• Streptokinase, anistreplase urokinase, alteplase, reteplase & tenecteplase are some of the
important fibrinolytic drugs.
• Streptokinase, anistreplase & urokinase activate bound fibrin as well as circulating plasminogen.
• Reteplase, alteplase & tenecteplase are fibrin-specific drugs.
• Streptokinase activates fibrin-bound as well as circulating plasminogen.
• Unlike other plasminogen activators, streptokinase does not directly convert plasminogen to
plasmin instead forms complex with plasminogen.
• Streptokinase is antigenic in nature, causing allergic reactions.
• Anistreplase is formed by combining streptokinase with Lys-plasminogen.
• Urokinase directly converts plasminogen to plasmin.
• Streptokinase & Urokinase are contraindicated in intracranial malignancy.
• Fibrinolytic drug affecting both free & circulating plasmin is urokinase.
• Alteplase, reteplase & tenecteplase are recombinant tPA.
• Recombinant tPA is more efficacious than streptokinase.
• Reteplase & tenecteplase are longest acting tPA & are referred as "bolus fibrinolytic”.
• Calcium channel blockers block L-type of voltage-gated calcium channels present in blood vessels &
heart.
• CCB's causes vasodilation by inhibits calcium channels & reduces frequency of Ca+ channels
opening.
• CCB’s reduces cardiac activity including heart rate, AV conduction & contractility.
• Dihydropyridine (DHP) group of CCB drugs are referred to as peripherally acting CCB's.
• Strong cardio-depressant activity is mainly exhibited by verapamil & diltiazem (verapamil >
diltiazem).
• CCB's are indicated for both classical & variant angina, mainly verapamil, diltiazem & long acting
DHPs.
• DOC for hypertensive patients with migraine is calcium channel blocker.
• Flunarizine is weak CCB used for prophylaxis of migraine.
• CCB's are used in hypertensive patients with PVD (Raynaud’s phenomena).
• CCB's are contraindicated in sick sinus syndrome, as it causes reflex tachycardia.
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• Short-acting DHPs like nifedipine accentuates angina symptoms, by causing tachycardia
& precipitates acute anginal attack.
• Nifedipine causes hyperglycemia by decreasing insulin release.
• CCB’s along with β-blockers are contraindicated.
• Nifedipine shows marked tachycardia.
• Long-acting CCB's like Amlodipine will show less tachycardiac effects.
• CCB's causes urinary bladder relaxation, resulting in voiding difficulty in elderly.
• CCB's increases plasma digoxin concentration, by decreasing its excretion.
• Verapamil shows maximum cardio-depressant action.
• Verapamil exhibits maximum effect on cardiac conduction.
• Verapamil increases PR interval.
• CCB with maximum plasma protein-bound nature is verapamil.
• Verapamil has racemic mixture of two enantiomers with different pharmacokinetic &
pharmacodynamic properties.
• Verapamil is used for treatment of angina, PSVT, hypertension & hypertrophic obstructive
cardiomyopathy (HOCM).
• Among CCB's, dihydropyridine drugs are safer in pregnancy.
• Nifedipine has predominant peripheral action.
• Nifedipine by increases angina risk by increasing heart rate & thus cardiac work.
• Nifedipine interferes with anesthesia.
• Mostly Nifedipine & beta-blocker are given together, to overcome nifedipine's increased
sympathetic activity.
• Nifedipine is banned for sublingual usage for hypertensive emergencies, due to increased risk of MI
& mortality.
• Nifedipine is also used for achalasia cardia.
• Longest acting parenteral CCB is Nicardipine.
• DOC for hypertensive emergencies is Nicardipine.
• Nimodipine is shortest acting CCB's with relatively cerebro-selective vasodilating nature.
• Nimodipine is used for reversal of compensatory vasoconstriction after subarachnoid hemorrhage.
• Clevidipine is an ultrashort-acting DHP.
• Clevidipine is recently approved for hypertensive emergencies.
• Amlodipine is DOC for managing asthmatic patient with hypertension.
• Rebound hypertension is seen with Amlodipine.
ANTI-PLATELET DRUGS
Forensic Medicine
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1. Criminal Procedure Codes
• A married woman died in unnatural conditions within 5 years of her marriage. Her parents
complained of frequent demand of dowry. Her autopsy will be conducted under Sec. 176 CrPC.
• Under section 53 CrPC, police can ask the doctor to examine without the accused person's consent.
• Sec. 176 CrPC is related to Magistrate inquest.
• Cognizable offence comes under 2(c) section of CrPC.
• Doctor suspects homicide poisoning. He needs to inform police under Section 39 CrPC.
• 412 CrPC is related to reasons to be recorded.
• A case of suspected homicide comes to a doctor. He is supposed to inform police under section 39
of CrPC.
2. Lead poisoning
3. Postmortem Caloricity
4. IPC
5. INQUEST
6. CONSENT
• Explaining to the patient the nature of his disease, the proposed treatment or procedure, the
alternative procedure, the risks and benefits involved in both the proposed and alternative
procedure, the relative chances of success or failure of both procedures
• In cases of emergency consent is not necessary
• In criminal cases, the victim cannot be examined without his/her consent
• The minimum age for giving consent for medical termination of pregnancy is 18 years
• Assistant surgeon working in a CHC and a rape convict is brought to him by the police constable.
The constable has a letter from the sub inspector of police from the concerned area requesting you
to do a potency test and forensic examination of the accused. The accused refused to give consent
for the examination and any further tests. A reasonable amount of force should be used if needed
and examine the accused.
• A person who has been arrested on charges of rape is brought to you. No requests for potency
test/forensic examination has been produced by the police constable but the arrested person asks
you to examine him and take evidences as he is innocent then Examining the person and collecting
informations and samples after getting the consent is the best scenario
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• If the government has made it compulsory for any vaccination of an epidemic strainof infection at
the earliest so as to check the spread of the disease then vaccination mustbe done even if the
person refuses & threats to sue the doctor
• Minimum age for giving consent for organ donation in India is 18 years
• Form of acceptable consent include Informing the patient the nature of his disease, the proposed
treatment or procedure, the alternative procedure, the risks and benefits involved in both the
proposed and alternative procedure, the relative chances of success or failure of both procedures
• Form of acceptable consent includes information that In cases of emergency consent is not
necessary
• Form of acceptable consent include information that In criminal cases, the victim cannot be
examined without his/her consent.
• A school teacher gives consent for treating a child who becomes sick during a picnic away from
home town. This type of consent is known as Loco Parentis
• Consent can only be valid if it is given by a person who is sane and has attained maturity, ie. age of
18 yrs
• For sterilization of a married person, consent of both spouse, i.e. husband and wife is required
• In criminal cases, the victim cannot be examined without his/her consent.
• Informed consent includes All information should be given about treatment options
• Informed consent includes Any treatment option better than the treatment being provided should
be told
• Informed consent includes All disclosure should be done in a language that the patient can
understand
• A patient of head injury, has no relatives & requires urgent cranial decompression; Doctor
should Operate without formal consent
• 20 years old young female comes to a male gynaecologist for pelvic examination Implied consent is
used
• For MTP consent is taken from Wife only
• Consent from guardian/husband for MTP is required if Female is below 17 years of age
• Termination of pregnancy up to 20 weeks can be done by medical practitioner without consulting
specialist
• Female can give consent for sex if she is above 16 years
• Examining the patient without consent amounts to Assault
• Consent for examination in a psychiatric patient is given by Guardian
• A doctor while examining the patient without consent in an emergency is protected underSec. 92
IPC
• A doctor has to do an urgent operation on an unconscious patient to save his life. But there are no
relatives to take consent. He goes ahead without obtaining consent from anyone; he is using the
principle of Doctrine of implied consent
• Consent is required for Pathological autopsy
• Blanket consent is consent taken At the time of admission to do any surgery
• Minimum age to give consent for organ donation for therapeutic purposes is 18 yrs
• A valid consent is Obtained in presence of two witnesses
• A valid consent Should not be obtained with force, fear or fraud
• True information to be given freely in A valid consent
• According to MCI act, medical education granted by Indian universities comes under Schedule I of
MCI act
• Medical qualifications awarded by institutions outside India and recognized by MCI are registered
in Second schedule of Indian Medical Council Act 1956
• Disciplinary control over Registered Medical Practitioners is under State Medical Council
• Indian council of medical research is presided over by Union health minister
• Professional death sentence is given by State Medical Council
• As per MCI, minimum period for which a doctor should preserve his patient's record 3 years
• Schedule-3 of MCI includes Diploma of CPS
11. EUTHANASIA
12. EXHUMATION
• Corpus delicti means Proof of occurrence of crime or Essence of crime or body of offence
14. Drowning
Atypical drowning
1. Dry drowning:
• On contact with water, especially cold water, there results intense laryngospasm
• So that water does not enter the lungs.
• Death is due to asphyxia because of laryngospasm
• Asphyxia.
• Myocardial anoxia.
• Ventricular fibrillation.
• Vagal inhibition.
• Laryngeal spasm.
• Exhaustion.
• Secondary injuries.( for eg., head injuries)
Eyes
SKIN
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• Washer woman’s hands and feet are seen after 48 to 72 hours
• Where the skin of the palms and soles becomes beached, wrinkled and saddened.
• Weeds, grass, plants, mud or stones in tightly clenched hand
• Due to cadaveric spasm
• Strongly suggest that the person was alive when drowned, as it indicates the struggle of person for
life
Froth:
Lungs
• Paltauf’s hemorrhage.
• The lungs show large subpleural haemorrhages
• Produced due to rupture of the intra alveolar partitions beneath the pleura.
• More prominent over the lower lobes and interlobar surfaces.
• The lungs are ballooned up, edematous, heavy and boggy.
• Emphysema aquosum
• On cut section crepitus like feeling is present due to entrapment of water.
• In saltwater drowning, lungs are much more edematous than fresh water drowning and appear
purple.
• Soft jelly like
• No crepitus
Ear
• Water may also be detected from middle ear resulting from violent respiratory
excursions( conclusion post mortem finding .
Diatom Test
• Most samples of the water contain microscopic unicellular algae or plankton called diatoms.
• These diatoms possess silicaceous cell membranes and vary from size 10 to 80 microns.
Gettler Test
• Caliber of a rifled gun is calculated by distance between two diagonally opposite lands
• Cartridge case of shotgun has percussion (detonator) cap at the base of rim and top wad (retaining
cardboard) at top.
• Wad is responsible for separation, sealing, optimal pressurization & lubrication but not for fatal
injuries
• The killing range of a military rifle is about is 300 yards.
• Choking is the constricting device present at the muzzle end of the shotgun
• Air rifle & air pistol release shots or pellets (skirted) which are propelled by compressed air /gas
• The effective range of shot gun is 30 -40 yards
• The spread of pellets from a fully choked barrel is given below:
• 10 meter - 25 cm
• 15 meter - 35 cm
• 20 meter - 45 cm
• 30 meter - 75 cm
• Shotgun does not contain use bullet.
• In a firearm injury, there is burning, blackening, tattooing around the wound, along with the cherry
red colour of the surrounding tissues and is cruciate in shape, the injury is close shot injury.
• Stellate wound is produced with firearm in contact shot.
• In a firearm injury, blackening seen around the entry wound is due to smoke
• Tattooing in entry wound of a firearm injury is due to gunpowder.
• The skull was burst open, charring and cherry red colouration in the track inside. Range of the shot
is contact shot.
• 'Rat hole' appearance of entry wound of firearm is seen in near range of shotgun.
• In firearm entry wound, arrangement of abrasion collar, dirt collar and tattooing from inside to
outside: Dirt collar, abrasion collar, tattooing
• Abrasion collar is seen in entry wound
• Bullet entry wound, for bullet entering at acute angle is identified by oval shape of abrasion collar
• Harrison-Gilroy test can detect gunshot residue
• Bullet entry wound in skull
• Punched in hole in outer table
• Inner table shows bevelling surface
• Wound is funnel-shaped with the funnel opening in the direction in which the bullet is travelling
• exit wound of a bullet
• Bevelled
• Everted
• No COHb
• DERMAL NITRATE TEST ( PARAFFIN TEST ) and helps to detect gunpowder residue from suspects
hand.
• The Harrison & Gilroy test can also be used
• Kennedy Phenomenon: Medico-legal evaluation of firearm injury made difficult by surgical suturing
or alteration.
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21. Firearm: Identification of Weapon
22. Fingerprint
23. Laceration
• Normally, pus formation occurs in about 48 hours, but in a lacerated wound it occurs slightly
earlier.(24-48 hours)
• Lacerated wound appears as incised wound in which of the following sites-scalp, Tibial shin,
iliac crest, Zygomatic bone and forehead.
• Spilt laceration resembles Incised wound.
• Laceration is an open wound, tearing of the skin and subcutaneous tissue
• "Lacerated" wound has irregular margin
• Tissue bridges are seen in laceration
• In a lacerated wound, the hair bulb is crushed
• Lacerations produced without excessive skin crushing may have relatively regular sharp margins.
• Split" laceration is seen in blunt perpendicular impact
• Flaying is seen in avulsion type of lacerated wound
• ALKYL PHOSPHATES
• ARYL PHOSPHATES
• HETP
• TEPP (Tetron)
• OMPA
• Dimefox
• Isopestox
• Malathion (Kill bug; Bugsolin)
• Sulfotepp
• Demeton
• Trichlorfon
Pathophysiology
MUSCARINIC MANIFESTATIONS
• Salivation
• Lacrimation
• Urination
• Defaecation
• Distress
• Emesis
• Diaphoresis, diarrhoea,
• Miosis
• Bronchorrhea, bronchospasm
• C.V.S: Bradycardia, hypotension
• Ciliary Body: Blurred vision
• Bladder : Urinary incontinence
• Restlessness, emotional lability, headache, tremor, drowsiness, confusion, slurred speech, ataxia,
generalised weakness, coma, convulsion, depression of respiration and CVS centres
Severe poisoning:
DIAGNOSIS
TREATMENT
Nonoccupational Exposure
Mechanism of Action
• Binds to sulfhydryl groups as well as to phosphoryl, carboxyl, amide, and amine functional groups.
Chronic Exposure
General symptoms
• Excessive sweating,tachycardia,irritability,anorexia,photophobia
• insomnia
• Tremors
• Paresthesias, decreased tendon reflex and weakness
• Skin
• Painful pinkish red discoloration of the extremities
• Rash may be urticarial, vesicular and hemorrhagic
• Hyperkeratotic induration of palms soles and face
Chelation
Nuclear Sexing
Davidson Bodies
Y- Chromosomes
• The ‘Y’ Chromosomes present in males are fluroscent for the dye Quinacrine dihydrochloride.
Intersex States
Gonadal dysgenesis
a. Klinefelter’s syndrome
• Anatomical structure in male, but the nuclear sexing is female (chromatin positive).
• Barr bodies present
• The chromosomal pattern is 47XXY
• Testes are small & firm in consistency, aspermia, No semen, Hyalinised testis (histologically).
b.Turner’s syndrome
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• Anatomical structure is female nuclear sexing is male (chromatin negative).
• Barr bodies absent
• The chromosomal pattern is 45 XO
True hermaphroditism
• A rare condition,wherein external genitalia may be of both sexes, but internally there is presence of
both testes & ovaries and ovotestes
Pseudohermaphroditism
a.Male pseudohermaphroditism:
• Nuclear sex XY, sex organs & sexual characteristic of female form
b.Female pseudohermaphroditism:
• Nuclear sex XX, sex organs & sexual characteristic of male form
ACCURACY OF SEXING….KROGMAN
PELVIS………………..95%
SKULL…………………90%
LONG BONES………..80%
Male Female
• Skull
Male Female
• Mandible:
• Seen in female mandible i.e., ramus with smaller breath, angle of body of mandible obtuse, ramus
inverted,and chin (symphysis mentis) rounded
Vertebral Column
Male Female
Height of a children:
• At birth 50cm,at 6months 60cm,at 1year 70cm, at 2years 8Ocm,at 3years 90cm,and at 4 years 100
cm.
• At 4 years height becomes double than birth.(100 cm)
Criminal responsibility
Judicial punishment
• Juvenile offender-
• BELOW 18 yrs
Consent
• Sec 87 IPC- child < 18 yrs cannot give valid consent( implied or expressed) to suffer any harm which
may result from an act not intended or not known to cause death or grievous hurt. E.g. wrestling
contest
Rape
Attainment of majority
• 18 yrs
Employment
Infanticide
Rule of Hasse
• Rule of Hasse is used to determine the age of fetus from crown to heel length in cm.
• During first five months, Length in cm = (Age in months)2
• After age of >5 months, Age in months = (Length in cm)/5
• The lack of cartilage and the easy foldability (lack of recoil are evident in the ear of premature
infant at 26 weeks.
• Prominence of the labia minora in a premature female infant represents the gestational age of
aprox 28 weeks.
• Heart is fully developed at 3 month age of intrauterine life
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31. Age Determination- Teeth
• Attrition
• Periodontosis
• Secondary dentin
• Cementum apposition
• Root resorption
• Root transparency
• Among the criteria transparency of the root is considered to be the single most important one in
age determination.
• Mirror test:Mirror held in front of nose does not show vapors and blurring
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Suspended Animation
• It is a condition in which the vital functions of the body are at such a low level that they cannot be
appreciated by clinical examination
Apparent death
Early changes
Changes In Eye
• Brownish discolouration of the sclera due to cellular debris and dust-Tache noire
Changes in Skin
Postmortem Lividity
• It gives the information about the position of the body at the time of death
• Time since death can be estimated
Time of Onset :
Duration
Pattern
Late Changes
• Decomposition / Putrefaction.
BACTERIAL ACTION
CHARACTERISTIC FEATURES
COLOUR CHANGES
APPEARANCE OF MAGGOTS
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• Maggots are seen on the dead body after 2-3 days
• 2-4 days in rainy season
INTERNALLY
• Larynx, trachea > stomach, intestine > spleen, liver> brain, lungs > heart > kidney, bladder >
uterus/prostate > bone
• Amongst the soft tissues uterus in female and prostate in males are last to undergo putrefaction, as
uterus and prostate resist putrefaction. Otherwise bones are last to undergo putrefaction, overall
LIVER
• Adipocere is most commonly seen in the body immersed in water or in damp, warm environment
with lack of air.
• It is also called saponification
• Modification of putrefaction
• Body has an offensive sweet smell
• Hydrolisation of fatty tissue into fatty acids.
• Bacterial fat splitting enzymes and moisture are essential – Lecithinase.
• Cl. welchii bacteria helpful in adipocere formation
• It is usually formed first in the subcutaneous tissues of cheeks, breasts, buttocks, and abdomen.
38. Summon
SUBPOENA (SUMMONS)
Section
DEFINITION
• Subpoena is defined as a legal document compelling the attendance of a witness on a particular day
and time in the court of law under penalty.
• No conduct money is paid to the doctor in criminal cases
• Conduct money is paid to expert witness with summons from civil court
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39. Medical Evidence
Documentary
• Medical certificate
• Medico-legal reports
• Dying declaration
Medical Certificates:
• Documentary evidence
• Issuing false medical certificate is punishable under section 197IPC.
Dying declaration:
• It is a written or oral statement of a person, who is dying as a result of some unlawful act, relating
to the material facts of cause of his death.
• Magistrate should be called to record the declaration (if there is time).
• Doctor should certify his mental state and consciousness before recording(compos mentis).
Dying Deposition
• It is the statement of a person on oath, recorded by the magistrate in the presence of the accused
or his lawyer, who is allowed to cross-examine the witness.
• More importance in court then dying declaration
Witnesses
Types
• Common witness
• Expert witness
Hostile witness:
• One who is supposed to have some interest or motive for concealing part of the truth, or for giving
completely false evidence.
• IPC -191
Perjury
Record of Evidence
• Oath is declaration required by law, which is compulsory and hold the witness responsible for the
consequences of his evidence.
Cross-Examination
Conduct money
• It is money paid in some legal systems to a person under the compulsion of a summons to witness/
subpoena to pay for their expenses to attend in court.
• Conduct money is paid to expert witness with summons from civil court
• In civil cases, conduct money is decided by judge
41. Embalming
42. Contusion/Bruise-Types
Types of contusion
1. Petechial haemorrhages
2. Intradermal bruises
• A 'negative image' of the profile of the impacting instrument is produced i.e. a 'patterned injury
• E.g tyre marks in a road traffic collision
3.Tramline bruises
• Appears as a pale linear central area lined on either side by linear bruising
4. Fingertip/pad bruises
• Where an assailant has forcefully gripped a person, for example around the neck (e.g. during
attempted manual strangulation) or arms etc, one may see small discoid or ovoid bruises in a
cluster.
6.Migratory or Ectopic or Percolated contusions: injury at one site, contusion at a remote site due to
gravitation of blood
• Fracture of floor of anterior cranial fossa - bruising around eye (black eye or spectacle hematoma)
• Battle’s sign (named after William Henry Battle) – bruising visible behind and below the ear at the
mastoid process, caused by the gravitational accumulation of blood from a basilar skull fracture
• ‘Racoon/ panda eyes’ – Bruising of the lax soft tissues around the eyes caused by skull base
fractures
Note: Artificial bruises can be caused by juice of marking nut, calotropis or plumbago rosea
44. Abrasion
Types of abrasions
1.Scratch abrasion
2.Graze abrasion
3. Pressure abrasion
4. Impact abrasions
Patterned abrasion
• lmpact abrasion or pressure abrasion, which show pattern of the object (causing injury) are called
patterned abrasion.
• Examples are pattern of cycle chain, pattern of whip, pattern of teeth ond nails,Pattern of tyre,
pattern of string in hanging and strangulation (ligature mark), pattern of head
light/bumper/radiator in vehicles occident, and pottern of porallel lines in (railwoy line pattern)
blow with a stick.
Antemortem Abrasions
Incised wounds
Features:
Medico-Legal importance
Homicidal
• Sparrow foot marks are multiple punctate lacerations on face, produced due to shattering of
windscreen glass
• Whiplash injury:
• Acute hyperflexion followed by hyperextension of neck due to violent acceleration or
deceleration force applied to (front seat) passenger
• Fracture not common
• Paresthesia and chronic pain
• Seat belt injury is chance fracture, causes laceration of mesenteries and rupture of small intestine.
• Ladder tear Multiple transverse intimal tears in aorta, adjacent to main rupture
• Motorcyclist fracture: Hinge fracture of base of skull, dividing it into anterior and posterior half
• Ring fracture of skull base separating the rim of foramen magnum from rest of the base.
• Overall, the most common site is leg 85%, followed by head (50-80%) > arms > pelvis > chest
orabdomen > neck and spine
Bumper fracture
• After the primary impact, the victim is then again thrown back over the vehicle, causing further
injuries.
3) Secondary injuries:
• Injuries due to contact with ground include abrasion and bruises over the face, hand, hips and legs,
and laceration over the bony prominence
4.) Rolling/Runover (degloving injuries) : Caused by wheel of vehicle or rolling over the victim. Children
are oftenly involved.
• Contrecoup means that the lesion is present in an area opposite the side of impact.
• It is caused when moving head is suddenly decelerated by hitting a firm surface
• Straight or curved fracture lines, which may radiate from a depressed region
• ‘Hinge’ fractures occur when the linear fracture passes across the middle cranial fossa, separating
the skull base into 2 halves, and may be caused by a heavy blow to the side of the head (e.g. in
motorcycle accidents).
2. Ring
6. Elevated fracture
8.Gutter fracture
• When a part thickness of bone is removed (fracture involves only the outer table of skull), e.g.
glancing (oblique) bullet wounds in firearm injury
• The doctor who is certifying an injury report should keep in mind the Penal provisions (as below)
required by police to book the case.
• Â Simple injury: IPC Section 323.
• Â Simple injury caused by dangerous weapons: IPC Section 324.
• Â Grievous injury: IPC Section 325.
• Â Grievous injury caused by dangerous weapons: IPC Section 326.
• Â Dangerous injury: IPC Section 307.
• Â Injury likely to cause death: IPC Section 304.
• Â Injury sufficient to cause death: IPC Section 302.
• Â Causing hurt by means of poison: IPC Section 328.
Sec 302 IPC Punishment for murder (upto death sentence/life imprisonment with fine)
Sec 304 IPC Punishment for culpible homicide not amounting murder.
Sec 304-A IPC: Causing death by negligence (Sec 304-8 IPC is related to dowry death)
sec 319. Hurt: Whoever causes bodily pain, disease or infirmity to any person is said to cause hurt.
Section 320 of The Indian Penal Code – Grievous hurt, it has 8 categories.
52. Inquest
1. POLICE INQUEST:
• Conducted by an officer in charge of a police station. It’s usually conducted by an officer of the rank of sub
inspector of police. The police officer making the inquest is known as investigating officer (I.O.).
• Police inquest is conducted under S.174 of Cr PC if the police officer in charge receives information that a
person has committed suicide, or has been killed by another or by an animal or by machinery or by an
accident, or has died under circumstances raising a reasonable suspicion that some other person has
committed an offence.
• Before the inquest is done by police it should be informed to the executive magistrate of the area. The
inquest report prepared by the police is known as Panchnama.
• In case of any doubt regarding the cause of death or in case of any unnatural the body of deceased is sent by
investigating officer for autopsy to the concerned medical officer with the inquest report.
• On refusing to give answer questions, person can be punished under Sec. 179 IPC with imprisonment upto 6
months and/ or fine of Rs. 1000/.
• This is empowered by a district magistrate, sub- divisional magistrate or any executive magistrate especially
empowered by the state government such as collector, deputy collector or Tahsildar.
• In case of any death a magistrate may conduct an inquest instead of or in addition to the police inquest
(S.176, Cr.P.C.).
• Magistrate inquest is conducted in case of
1. Death in prison
2. Death in police custody
3. while under police interrogation
4. Death due to police firing
5. Death in a psychiatric hospital
6. Dowry deaths
7. Exhumation (S.174(4) and 176, S.CrP.C)
• Section 304-A of the Indian Penal Code, 1860 [IPC] prescribes punishment for death/ 2 years of
imprisonment with fine or both due to rash or negligent conduct of a person. It is under this section that
doctors or other medical practitioners have generally been proceeded against under criminal law.
• "Section 304-A deals with criminal negligence. Criminal negligence occurs when the doctor shows gross lack
of competence or inaction, gross recklessness or wanton indifference to the patient's safety, or gross
negligence in the selection and application of remedies. It involves an extreme departure from the ordinary
standard of care."
sections 52, 80, 81, 83, 88, 90, 91, 92 304-A, 337 and 338 contain the law of medical malpractice in India.
Sec. 88 in the Chapter on General Exceptions provides exemption for acts not intended to cause death,
done by consent in good faith for person's benefit.
Sec. 92 provides for exemption for acts done in good faith for the benefit of a person without his consent
though the acts cause harm to a person and that person has not consented to suffer such harm.
• In India, Sections 126 to 129 of the Indian Evidence Act, 1872 deal with privileged that is attached to
professional communication between a legal adviser and the client
• Section 126 and 128 mention circumstances under which the legal adviser can give evidence of such
professional communication
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• Section 127 provides that interpreters, clerks or servants of legal adviser are restrained similarly.
• Section 129 says when a legal adviser can be compelled to disclose the confidential communication which
has taken place between him and his client..
• Section 126 states that no barrister, attorney, pleader or Vakil shall at any time be permitted to
• exception to the general rule of professional secrecy between doctor and patient. Example are:-
2. As compulsor duty: Every doctor has to give details of birth, death and communicable disease.
3. As a social duty: Ifhealth ofa patient can cause danger to society, e.g
• The three key factors required to identify skeletal remains are age, sex and race
• The cranium is the only reliable bone and, even then, can only tell general category as below:
• Mongoloid: wider cheekbones, square shaped skull, rounded apertures, concave incisors, width between
eyes greatest
• Negro: Narrow elongated skull, squared orbit, rounded nasal aperture, more prominent ridges, wider nasal
opening
• Caucasian: Rounded skull, elongated nasal aperture, triangular palate
• Cephalic index: Cephalic index is defined as the index of breadth of skull
• CI = width ÷ length x 100 or CI = (Left/Right) ÷ (Front/Back) x 100.
• Dolico-cephalic: 70-75.(aryans, negroes).
• Mesati-cephalic: 75-80. (europe, chinese).
• Brachy-cephalic: 80-85. (mongoloids).
• Four carpal bones are present at age 4
Hydrocution or immersion syndrome refers to sudden death in water due to vagal inhibition as a result of:
mechanical causes of asphyxia which can cause violent asphyxial death. These mechanicai causes
can be divided into
• hanging,
• strangulation,
• suffocation,
• drowning
Complete hanging:
• When the whole body is suspended from the ligature material and no portion of the body is
touching the ground.
Partial hanging:
• As the name suggests, the body is partially suspended, the toe or feet or either part of the body
touching the ground.
• The deceased may be in kneeling down position, sitting position etc.
• the weight of the head is where the constricting force comes from.
Typical hanging:
• Where the ligature runs from the midline, above the thyroid cartilage.
• symmetrically upwards on both sides of the neck(judicial hanging), to the occipital region.
• The knot is placed over the central part of the back of neck.
Atypical hanging: The knot is anywhere other than the central part of the back of neck.
Combined asphyxia and cerebral venous congestion is the most common cause of death.
Introduction
Lynching
It is homicidal hanging in which a suspect, accused or eneffiy is hanged by a rope from a tree by
the mob. Name is derived from William Lynch, a white captain in USA, who used to order hanging of
blacks (negroes) on the spot without trial..
It was practiced in tribal part of India and some southern states of America for sexual crimes or to
take revenge.
Masochism:
Transvestism.
• Transvestism is the practice of dressing and acting in a style or manner traditionally associated with
the opposite sex.
• In some cultures, transvestism is practiced for religious, traditional or ceremonial reasons.
• Partial asphyxia causes cerebral distrubances with feeling of sexual gratification.
• The impaired consciousness caused by pressure on carotid vessels or partial obstruction of air
passages may lead to hallucinations of an erotic nature.
63. Suffocation
Smothering:
• Asphlxia is caused by mechanical occlusion of external air passage, i.e. entry of air to lungs is
prevented by closure of nose and mouth.
• Lips, gums, tongue, inner side of nose may show bruising or lacerations.
• Asphyxial signs (congestion, cyanosis, petechiae) are severe except when the head and face is
enclosed in plastic bag.
Chocking:
• Asphyxia caused by mechanical occlusion of internal air passage, i.e. obstruction of respiratory
passages (glottis, larynx, trachea, bronchi etc.)
Gagging:
• It is chocking by preventing air entry through mouth and nostril by filling piece of cloth in the
mouth.
Burking:
• It is defined as tissue injury due to application of heat in any form to the external or internal body
surfaces.
• Section 324 & 326 I.P.C. specifies any ‘hurt’ or ‘grievous hurt’ which is caused by ‘fire or any heated
substance’ or ‘corrosive’ or ‘explosive substance’ is punishable more severely in comparison to
unspecified means.
Dupuytren classified burns into six degrees, which can be merged into three degree by Wilson.
(A) Wilson’s Classification (merged) : can be categorized into 3 types depending upon body layer involved.
• The affected part is erythematous (red) and blister formation, there is capillary dilatation and
transudation of fluid into the tissue causing swelling.
• Repair is complete without scar formation. These are painful burns'.
• When deeper tissues below skin are involved viz. subcutaneous tissues, muscles and bones etc.
• These are relatively less painful owing to destruction of nerve endings and heal with scar and
contracture formation.
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• Disfigurement and loss of function chiefly when near a joint.
Introduction,
• It is most important parameter which affects the prognosis in case if burn injury. To estimate the
body surface area involved,
• Rule of Nines” given by Alexander Wallace is practiced clinically for calculating the amount of fluid
i.e. “ration” to be given to injured adult.
• TOTAL= 100%
• Rule of five’’ may be more appropriate. For calculating percentage of body surface area involved in
children in practice.
• For calculating percentage in case of scattered burn injuries ‘Palm rule’ has been found handy.
According to it the surface area of the palm of victim is approximately 1% of total body surface area
• Genitals constitute 0% up to 9 years of age and head forms the largest area in children.
• Area of palm (palmar surface), as a general rule, constitutes about l% of surface area both
in adult and children.
• The nasal and oral cavities may show presence of carbon soot and are inflamed.
• There is increased carbory-hemoglobin which gives cherry red colour to post mortem lividity.
• Presence of carbon particles (soot) in respiratory passages and elevated level of carboxy-
hemoglobin confirms that victim was alive when the burn occurred, i.e. ant-mortem burn.
• Laryngeal edema which is caused by passage of hot gases into respiratory tract.
• Raised carboxyhaemoglobin level in the blood; exceeding 10%. Chain smokers may develop blood
level upto 8%-10%; therefore it needs careful interpretation in such cases.
• Various levels of cyanide is found in blood depending upon the materials burning in fire. But
the levels are less than 0.3% mg (normal is zero.
• Presence of intact nerves, blood vessels and connective tissue in the floor of rupture.
• Absence of bleeding in the wound, Irregular matgins, Absence of bruising or other vital
reactions in margin.
1) Microchemical tests :
Florence test:
Barberio's test:
2) Enzyme tests: Since spermatozoa contain gram positive protein, the presence of spermatozoa will be
confirmed by microscopic appearance of purple bodies
3) Ammonium molybdate test: lt gives deep yellow colour, due to presence of phosphorus.
D) UV light:
• Invisible, softened and dry semen stains of the clothes can be rendered distinct by the
filtered UV light which produces bluish fluorescence.
69. Hair: Examination, Importance, & difference between Human Hair Vs. Animal Hair
4) Crimes: Hair or fibers found at the scene on weapons or clothes helps in identification of
accused.
5) Hit and run case: When specimens of hair removed from various parts of the motor car are sent
by authorities for comparison with victim's hair.
INTRODUCTION:
• Insanity is an old term used loosely to denote any mental disorder or mental illness. The Indian Penal Code
employs the term unsoundness of mind while referring to insanity.
• Lucid interval is the period of sanity (sound mind) in an insane person, i.e. period in course of mental
illness when there is complete cessation of manifestations of insanity.
• During this period he is quite normal and can make valid will, sell/purchase property, give valid
evidence and is legally responsible for his deeds.
• Patient is kept under observation for l0 days which can be extended upto maximum 30 days.
In law, criminal responsibility means liability to punishment for the crimes committed.
Also that a person who is proved to be insane is not responsible for his actions, as he is devoid of free will,
intelligence and knowledge in relation to his acts.
It states that an accused person is not legally responsible, if it is clearly proved that at the time of
committing the crime, person was suffering from such a defect of reason from abnormality of mind that he
didn’t know the nature and quality of act he was doing or that what he was doing was wrong i.e. a person is
not responsible if he is not of sound mind (section 84 IPC).
2) Doctrine of partial responsibility: suffering from some weakness or aberration of mind (though not
completely insane).
3) Durhan rule: Accused is not responsible for the act, if his act resulted from mental disease or defect.
4) Currens rule: A person is not responsible if at the time of committing the crime, he did
not have the capacity to regulate his conduct according to the requirments of law as a result of his mental
disease or defect.
Introduction
In some cases newly married girls are abused, harassed, cruelly treated and tortured by the
husband, in-laws and their relatives for or in connection with any demand for dowry. In extreme
cases, the woman is killed by burning or some other method. Law in relation to dowry death are:
• Whoever commits dowry death shall be punished with imprisonment for a term ten years which
may extend to imprisonment for life.
Law prescribing punishment for causing cruelty to a married women (Sec.498A, IPC).
• Husband or (his any) relative will be tried under section 498A, IPC for causing cruelty to a
married woman.
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• Punishment includes imprisonment which may extend upto 3 years and fine.
Section 174 (3) CrPC : Autopsy is compulsory in all cases of unnatural death of a female within 7
years of marriage (i.e.dowry death) or if she is less than 30 years of age (Note : Section 174 CrPC
allows police inquest for any case).
Section 176, CrPC: Authorize magistrate inquest for investigation of dowry death.
Section 113 A' IEA : Deals with presumption as to abetment (encouragement) of suicide by a married
woman due to cruelty by husband or his relatives.
Dowry Prohibition act, if any person gives or takes or abets the giving or taking dowry is
punishable with imprisonment for a term which shall not be less than 5 years and with a fine which
shall not be less than 15000 rupees or the amount of the value of such dowry, whichever is more.
Pathology
1. Pulmonary Tuberculosis
• The most common hematologic finding associated with pulmonary tuberculosis is Mild anemia,
leukocytosis,thrombocytosis with slightly elevated ESR
• Reactivation tuberculosis is almost exclusively a disease of the lungs
• Epitheloid cells in tuberculosis act as Secretory cells
• Pleural effusion is seen in two-thirds of cases of primary pulmonary tuberculosis
• Fibrocasseous lesion is seen in primary pulmonary tuberculosis
• Phlyctenular conjunctivitis is seen in primary pulmonary tuberculosis
• Primary pulmonary tuberculosis Shows Consolidation & pulmonary fibrosis
• Primary Tuberculosis most commonly involves Lungs
• Most commonly involved organ in congenital tuberculosis is lung
• A man presents with fever, wt loss and cough; Mantoux reads an induration of 17 x 19 mm: Sputum
cytology is negative for AFB shows pulmonary tuberculosis infection
• Secondary pulmonary tuberculosis usually involves Apex of lungs
• Ghon's focus is seen in primary pulmonary tuberculosis
• Paratracheal lymphadenopathy is seen in primary pulmonary tuberculosis
• Primary pulmonary tuberculosis Heal spontaneously by fibrosis
• Reactivation of pulmonary tuberculosis always occur at Apex of the upper lobe
• Cavitation of the lungs is a feature of secondary pulmonary tuberculosis
2. Genital Tuberculosis
• Mycobacterium can be grown from menstrual blood in TB patient showing pelvic inflammation
• In patient with infertility hysterosalpingography reveals 'Bead – like' fallopian tube & clubbing of
ampulla is suggestive of genital tuberculosis
• Most common site of genital tuberculosis is Fallopian tube
• Perforation of the uterus while doing endometrial biopsy in a case of suspeccted genital
tuberculosis can be treated by Laparascopy & Immediate laparotomy
• The commonest type of genital tuberculosis is Endosalpingitis
• Blood stream is the commonest method of spread of genital tuberculosis
• Primary focus is most often in the lung
• The commonest complication of pregnancy after complete treatment of genital tuberculosis
is Ectopic pregnancy
3. Genitourinary Tuberculosis
4. Gastrointestinal Tuberculosis
5. Skeletal Tuberculosis
6. TUBERCULOUS MENINGITIS
• Loss of appetite cough followed by neck rigidity with increased protein level of CSF than normal &
lymphocytosis is suggestive of TB meningitis.
• Chronic headaches accompanied by chronic mild nuchal rigidity with Cerebrospinal fluid sampling
showing a chronic inflammatory infiltrate with lymphocytes, plasma cells, macrophages, and
fibroblasts is suggestive of Mycobacterium Tuberculosis infection
• Raised intracranial tension in the form of vomiting and altered sensorium & CT scan showing basal
exudates and hydrocephalus is suggestive of TB meningitis
• CSF findings in tubercular meningitis include:
• Elevated opening pressure
• High leukocyte count ( 1000/microl) predominantly lymphocytes
• Increased protein (100 - 800/mg/dl)
• Low glucose
• AFB seen on direct smear of CSF
• In tuberculous meningitis, the exudates tends to be most severe At the base of the brain
• C.S.F. cell count in tubercular meningitis varies between 100-1000
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• Hemiplegia, quadriplegia, monoplegia, Cranial nerve palsies, Cerebral infarction, Ptosis,
Decerebrate Rigidity, Tremors, Decorticate Rigidity, Midline cerebellar syndromes, Cerebellar
Hemispheric Lesions are the neurological complications of tuberculosis meningitis
• Most common cause of adrenal insufficiency in India is Tuberculosis
• Characteristic finding in CT scan of patient with tubercular meningitis is Exudates seen in basal
cistern
7. TUBERCULOSIS OF SKIN
• A farmer with a single warty lesion on leg may be suggestive of Tuberculosis verrucosa cutis.
• Tuberculids are seen in Lichen scrofulososum.
• Lichen scrofulosorum is an extending eruption of small follicular papules characterized by
involvement of the sweat glands and hair follicles by causing noncaseating epithelioid
granulomas in young persons with underlying TB.
• Anatomist's warts/ Prosector's warts/ Verruca necrogenica are the synonyms of tuberculosis
verrucosa cutis.
• In miliary TB the granulomas are of size 1-2 mm.
• Cryptic type miliary TB usually affects elderly patients.
• Choroid tubercles are the pathognomonic finding in miliary TB.
• Miliary TB & Tuberculosis verrucosa cutis is a form of Post-primary TB infection.
• Lupus vulgari is the most common type of cutaneous T.B.
• Apple Jelly nodule at root of nose is the characteristic finding of Lupus vulgaris.
• Gradually progressive plaque on a buttock with of 15 cm in diameter, annular in shape, with
crusting and induration at the periphery and scarring at the center, is suggestive of lupus vulgaris.
• Miliary Tuberculosis occur following primary infection and secondary reactivation
• Sputum microscopy is usually negative & Montoux test is negative in 20-30% in Miliary
Tuberculosis
• Systemic miliary TB occurs when spread occurs via Arterial.
9. TYPHOID
11. APOPTOSIS
• Parvovirus B19 has been associated with transient aplastic crises in persons with sickle cell disease.
• Target cells, Jaundice, Reticulocytosis, Sickle cells, Howell Jolly bodies are seen in Sickle cell Anemia.
• Sickle cell anemia leads to resistance towards P.Falciparum.
• In Sickle cell disease, single nucleotide change results in change of Glutamine to Valine.
• Sticky patch in sickle cell disease results from replacement of a polar residue (Glutamate) with a
non-polar residue (Valine) at the 6th position of the beta chain.
• RFLP results from a single base change in Sickle cell disease.
• HbS confers resistance against malaria in heterozygotes in Sickle cell disease.
• Hydroxyurea is used in sickle cell anemia.
• IV regional anesthesia is contraindicated in a young boy with sickle cell trait.
• Sickle cell disease is inherited as Autosomal recessive.
• In Sickle Cell Anaemia defect is in beta chain.
• Replacement of glutamate by valine in β-chain of HbA is the primary defect which leads to sickle
cell anemia.
• Sickle cell trait patient does not have manifestations as that of Sickle cell disease, because 50% HbS
is required for occurrence of sickling.
• 0 and 100% is the chances of having children with sickle cell disease and sickle cell trait respectively
in a mother diagnosed to have sickle cell disease, her husband is normal.
• If both parents are sickle cell anemia patients then the likelyhood of offsprings having the disease
is 100%.
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• The decrease in size of the spleen is most likely related to infarction in a 6-month-old child with
sickle cell anemia having a chronically enlarged spleen and by 5 years of age, the child's spleen is no
longer palpable.
• Polymerase chain reaction with allele-specific oligonucleotide hybridization, Southern blot
analysis, DNA sequencing can be used to detect the point mutation in the beta globin gene that
causes sickle cell anemia.
• Decreased Solubility is the cause of sickling of RBC in sickle cell disease.
• Recrrrent infections - Most common cause of death in Sickle cell anemia.
• There is a positive correlation between HBS and polymerization of HBS in Sickle cell anemia.
• Patients require frequent blood transfusions in Sickle cell anemia.
• Patients usually presents after the age of 6 months in Sickle cell Anemia.
• In sickle cell anemia hemoglobin electrophoresis shows HbF, HbS, HbA2.
• PAH, Fish vertebra, Leukocytosis, Cardiomegaly is seen in Sickle cell anemia.
• The mechanism of increased susceptibility of Pneumococcal infection in patients with sickle cell
anemia is Splenic dysfunction.
• In sickle cell anaemia, the defect can be explained as having arisen from base substitution in DNA.
• Sickle cell anemia is the clinical manifestation of homozygous genes for an abnormal haemoglobin
molecule.
• The event responsible for the mutation in the B chain in Sickle cell anemia is Point mutation.
• Condom or Diaphragm is the safest contraceptive method for a woman with sickle-cell anaemia .
• Sickle cell anemia is commonly seen in black and R.B.C. size is altered.
• HbS concentration, HbA, pH are the factors affecting Sickling.
• Number of bands found in sickle cell trait is 2.
• Autosplenectomy in sickle cell anaemia is due thrombosis and infarction.
• Crew haircut appearance in X-ray skull and Gandy gamma bodies are seen in sickle-cell anaemia .
• Sickle cell disease causes extravascular hemolysis.
• Bone pain is the commonest presentation of sickle cell anemia.
• Salmonellosis is most common in sickle cell anemia.
• Vertebra plana, Bone infarct, Marrow hyperplasia, 'H' shaped vertebra are radiological features of
Sickle cell anemia.
• Splenectomy is indicated in Sickle cell anemia.
• Dactylitis, Pulmonary hypertension, Decreased osmotic fragility, Necrotizing pappilitis, pituitary
apoplexy, Persistent priapism is seen in Sickle cell anemia.
• 'Sea-Fan' retina is seen in SLE and Sickle cell disease.
• Splenomegaly may be a feature of Sickle cell anemia but Hepatosplenomegaly is not a feature.
• Sickle cell anemia is a non-metabolic cause of abdominal pain.
• Missense mutation occurs in Sickle cell disease.
• Peak incidence is less than 3 years of age in Letterer Siwe disease type of Langerhans cell
histiocytosis.
• Langerhans cell histiocytosis is radiosensitive.
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• Diffuse form of Langerhans cell histiocytosis is known as Letterer Siwe disease.
• Langerhans cell histiocytosis produces a seborrheic dermatitis-like lesion in an infant.
• CD 1a is a marker of Langerhans cell histiocytosis.
• The nuclei of Langerhans giants' cells are arranged around the periphery.
• Localised Langerhans cells histiocytosis affecting head & neck is called Eosinophilic Granuloma.
• X-bodies called Birbeck granules are characteristically seen in Langerhan's cell granulomatosis.
• The histologic hallmark of Langerhans cells is Birbeck granules.
• Langerhans histiocytosis can be associated with diabetes insipidus.
• Hand Schuller Christian disease, Eosinophilic granuloma, Letterer Siwe disease are the types of
Langerhan's cell histiocytosis.
• Langerhans cells belong to Antigen presenting cells.
• During angiogenesis recruitment of pericytes and periendothelial cells is due to Angiopoietins, TGF
& PDGF.
• Fibrosis is due to TGF Beta.
• Actions of TGF: Anti-inflammatory ,Proliferation of fibrous tissue , Inhibition of metalloproteinases .
• Anaphylaxis is not an action of TGF.
17. HEMPHILIA
19. THALASSEMIA
• Oral deferiprone is the most appropriate drug used for chelation therapy in beta-thalassemia
major.
• Splenomegaly, target cells on peripheral smear, microcytic hypochromic anaemia are seen
in thalassemia major.
• Hb-A2 estimation will be diagnostically helpful in a case of beta thalassemia trait.
• Hb-H disease is a form of alpha thalassemia.
• Intracorpuscular hemolytic anemia is seen in Thalassemia
• Defect leading to thalassemia lies in Haemoglobin.
• Thalassemia occurs due to Splicing mutation.
• In Beta thalassemia, there is decrease in beta chain & increase in alpha chain.
• A2 concentration in thalassemia trait is >3.5
• The investigation done to establish the diagnosis of thalassemia is Hb-electrophoresis.
• NESTROFT test is used in screening of Thalassemia.
• In α-thalassemia, there is no α-chain
• Thalassemia gives protection against malaria.
• Bone marrow iron is increased in Thalassemia.
• Decrease in osmotic fragility cause hemolysis in Thalassemia.
• Test for beta-thalassemia trait is HbA2
• Hair on end appearance is seen in X-ray skull in Thalassemia.
• Hepatosplenomegaly and edema all over body of new born leading to death is diagnosed to have α-
thalassemia
• Splenectomy is least useful in Thalasemia major
• Normal levels of free Erythrocyte Protoporphyrin with hypochromic microcytic anemia, seen
in Thalassemia
• Haptaglobin levels are decreased in Thalasemia
• Thalassemia is inherited as Autosomal recessive
• In alpha-thalassemia trait,electrophoresis shows Normal HbF and normal HbA2
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• Defect in Snurps causes thalassemia
• Sebaceous cysts are mostly found on the face, neck, back, scrotum, or torso.
• Cocks peculiar tumor is actually a complication of sebaceous cyst.
• Chalazion is a sebaceous cyst.
• Best investigation when there is clinical suspicion of pulmonary embolism in a patient is Multi
detector CT angiography
• Hampton's hump is seen in chest X-ray in Pulmonary embolism.
• Test results that confirm or exclude pulmonary embolism are Perfusion scan & CT pulmonary
angiogram
• Hampton's hump, Westermark sign & Fleischner sign are radiological sign present in a young lady
with symptoms suggestive of pulmonary embolism.
• The anticoagulant effect of heparin in pulmonary embolism would be most appropriately assessed
by Activated partial thromboplastin time.
• Treatment of choice for acute pulmonary embolism with right ventricular hypokinesis and
compromised cardiac output but normal blood pressure is Thrombolytic agent.
• Obesity, Malignancy & Protein S deficiency may predispose to pulmonary embolism
• In acute pulmonary embolism, Sinus tachycardia is the most frequent ECG finding
• Activation of juxtapulmonary-capillary receptors during pulmonary embolism causes Tachypnea
• The most common source of pulmonary embolism is Large veins of lower limb.
• D-dimer is the most sensitive test for Pulmonary embolism
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• In pulmonary embolism, findings in perfusion scan are perfusion segmental defect with normal lung
scan & radiography.
• Best method to diagnose pulmonary embolism Pulmonary angiography
• Gold standard for diagnosing pulmonary embolism Ventilation-perfusion scan
• The sequence of symptoms in pulmonary embolism is Dyspnea, pain, haemoptysis
• In pulmonary embolism, fibrinolytic therapy is responsible for risk of haemorrhage
• A patient undergoing surgery suddenly develops hypotension, the monitor shows that end-tidal
CO2 has decreased abruptly by 155 mm Hg. Diagnosis - Pulmonary embolism
• The most common cause of preventable Hospital Death is Pulmonary embolism
• ECG pattern seen in pulmonary embolism is S1Q3T3.
• Advatage of Zinc treatment in wilson disease is that it's Nontoxic, Produces a negative copper
balance by blocking intestinal absorption of copper, induces hepatic metallothionein synthesis,
which sequesters additional toxic copper
• In wilson disease patients with hepatic decompensation the disease severity is assessed using Nazer
prognostic index.
• DOC in Wilson disease with Neurologic/Psychiatric manifestation is Tetrathiomolybdate and zinc
• Low ceruloplasmin is the diagnostic feature of wilson's disease
• Siblings of the diagnosed patient with Wilson disease will be having 25% risk of Wilson disease
• Free copper level is increased in the body however Serum copper level is usually lower than normal
in wilsons disease
• Due to the large amount of copper released into blood stream in wilson disease anemia occurs
• Kayser-Fleischer ring will be present in Almost 100 % proportion of patients with neurologic
manifestations of wilson disease
• The gold standard for the diagnosis of Wilson disease is Liver biopsy with quantitative copper assay
• In a patient with wilson disease related compensated cirrhosis, without evidence of neurologic or
psychiatric symptoms the best treatment option is Zinc
• Commonest cutaneous eruption in Systemic Lupus Erythmatosus is Erythema of light exposed area
• Criteria for diagnosis of systemic lupus erythematosus includes Photosensitivity, Malar rash ,Discoid
rash
• 22% of patients with disseminated discoid lupus erythematosus develops SLE
• Anti Ro autoantibodies is most suggestive of subacute cutaneous lupus erythematosus
• High titers of Anti dsDNA are considered to be highly specific for Systemic lupus erythematosus
• Neonatal lupus erythematosus (NLE) is characterized by Cutaneous lesions, Heart block
& Thrombocytopenia
• Libman-Sacks endocarditis may develop with systemic lupus erythematosus
• Woman with systemic lupus erythematosus (SLE) and chronic renal failure develops anemia
because of IgG directed against red blood cells
• There may be an increase in spontaneous abortions and prematurity in patient with SLE planning
for pregnancy
• Diffuse proliferative is the most common histological type of nephritis seen in systemic lupus
erythematosus (SLE)
• Children born to mothers with systemic lupus erythematosis are likely to have Complete heart
block
• Characteristic feature of SLE is Polyserositis
• Autoimmune Hematolytic Anemia & Anti-ds DNA are seen in SLE
• In SLE, characteristic kidney lesion is Wire loop lesions
• Indications of steroids in SLE are Endocarditis
• SLE is Type III hypersensitivity reaction
• Onion skin spleen is seen in SLE
• Normal CRP with elevated ESR seen in SLE
• Skin biopsy of SLE patient using RTC labeled human IgG antiserum shows deposition of irregular
particles at dermoepidermal junction. This means there is presence of Immune complex deposits
• SLE is can cause both cicatricial as well as noncicatrical alopecia
• Band test is done in SLE
• According to WHO, membranous glomerulonephritis seen in SLE, is Class V
• Hypertrophy is an increase in the size of cells resulting in increase in the size of the organ and there
is no change in the number of cells.
• Hypertrophy examples- Physiologic -
a) Enlarged size of uterus in pregnancy, breast tissue in puberty & pregnancy is an example of hypertrophy
as well as hyperplasia.
• Hyperplasia- Hyperplasia is an increase in the number of cells but there is no change in the size of
tissue.
Epithelial-
a) Squamous- Uterine endocervix in prolapsed uterus & old age, Bronchus in chronic smoker.
• Hypoxia is the most common cause of cell injury which is caused due to ischemia.
• ATP depletion to 5- 10 % of normal levels will induce cell injury.
• Decreased generation of cellular ATP— it occurs in both reversible & irreversible cell injury.
• Intracellular lactic acidosis results in nuclear clumping as there is decrease intracellular pH and
glycogen by anaerobic glycolysis.
• Failure of sodium- potassium pump (Na+- K+ ATPase) resulting in cell swelling (Hydropic swelling).
• Failure of calcium pump by increased sodium level where excess of calcium will move into the cell
resulting in deposition of phospholipase & cell swelling.
• Due to hypoxia, ribosomes detach from endoplasmic reticulum & golgi apparatus which degrades
into monosomes leading to decrease in protein synthesis.
• Plasma membrane alterations in the form of blebbing & loss of microvilli.
• Myelin figures derived from damage of the membranes (whorls of lamellate phospholipid and
calcium)
• Mitochondrial swelling & small amorphous densities within mitochondria.
• Irreversible cell injury has two phenomenon consistently- Inability to reverse mitochondria
dysfunction.
• Mitochondria damage results in formation of large flocculent mitochondrial densities.
• Increased calcium influx activates phospholipase cell membrane damage.
• Karyolysis- decreased basophilia due to dissolution of nucleus.
• Lysosomal membranes are damaged lysosomal hydrolytic enzymes leakage.
• Coagulative necrosis-
• It effects- heart, kidney, spleen (except brain).
• Underlying tissue architecture is preserved.
• Coagulative necrosis is characteristics of infarcts in all solid organs (mainly heart).
• Hallmark of coagulative necrosis is conversion of normal cells into their tombstones.
• The cell injury causes denaturation of protein.
• Liquefactive necrosis- Examples are- Infarct brain and abscess cavity.
• Caseous necrosis- It is found in the centre of foci of tuberculous infections & histoplasmosis.
• It has features of both coagulative & liquefactive necrosis.
• Fat necrosis- Mesentric fat necrosis due to acute pancreatitis as there is liberation of pancreatitic
lipases resulting in necrosis of pancreas & peritoneal cavity.
• Traumatic fat necrosis of the breast.
• The released fatty acids combined with calcium gives a chalky white appearance.
• Fibrinoid necrosis- Fibrinoid necrosis is a special form of necrosis in immune reactions in which
antigen and antibodies are deposited on the walls of arteries.
• It is seen in vasculitis & malignant hypertension.
• Seen in sarcoidosis.
31. Necroptosis
• Necroptosis- It is a programmed cell death without caspase (cysteine- aspartic proteases) activation.
• Pyroptosis- It is a caspase (caspase 1 & 11) dependent programmed cell death.
• Free radical occurs by- Oxidation- reduction reactions- examples are
• Antioxidant mechanism-
• Two categories-
a) Non- Enzymatic-
i) Catalase
ii) Superoxide dismutase (SOD)- SOD1 protects brain causing amytrophic lateral sclerosis.
• Autophagy refers self eating (lysosomal digestion) of cell’s own components during nutrient deprivation.
• Macrophage- specific deletion of Atgs- 5 (autophagy related genes- Ag) increases susceptibiltiy to
Tuberculosis.
2. Protein-
Disorder associated with misfolded/ unfolded proteins are alzeheimer’s disease, Huntington disease and
parkinson’s disease.
3. Water
Intracellular water accumulations are known as cloudy swelling.
4. Pigment
a) Lipofuschin-
Also known as wear and tear pigment/ aging pigment.
It is perinuclear brown pigment.
• b) Melanin-
Detected by Fontana masson staining.
• c) Hemosiderin-
Detected by Perl’s Prussian blue staining.
• Color of hemosiderin is brown
• Pathological calcification starts in mitochondria or microsomal vesicles except for kidney where it starts at
basement membrane.
• Dystrophic calcification- Deposition of calcium salts in dead and degenerated tissues and has normal calcium
level.
• Calcification in degenerated tissues- Artheromas
• Metastatic calcification- Deposition of calcium salts in normal tissues associated with deranged calcium
metabolism & hypercalcaemia.
• Mestatic calcification- Excessive absorption of calcium from gut-
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i) Hypervitaminosis D
• Site of metastatic calcification are- lungs (most common), kidney, stomach, blood vessels, cornea
• Most widely accepted theory for ageing is – “free radical mediated damage”.
a) Vasodilation
Transmigration-
• Leucocyte moving towards sites of infection or injury along a chemical gradient by a process called
chemotaxis (unidirectional).
• Agents can be-
a) LTB4
b) IL8
Phagocytosis
• Normal human cells are protected from phagocytosis due to presence f N- acetylgalactosamine or
terminal sialic acid.
• Opsonisation is when phagocytosis is enhanced as microorganisms are coated with specific proteins
ie. Opsonins from the serum.
• Main opsonins present are-
b) C3b opsonin
c) Lectins
Engulfment-
I) Vasoactive amines-
i) Myeloperoxidase (MPO)
ii) Cathepsin
• i) Lactoferrin
• ii) Lysozyme
• iii) Type IV collagenase
• iv) Vitamin B12 binding proteins
• Involved in chemotaxis
• Contains gelatinase
a) Interleukines
i) IL1- fever
TNF- α- acute inflammatory, septic & shock, systemic inflammatory response syndrome & cachexia.
VI) Chemokines
1. Complement system-
• Complement system functions- C3a, C5a, C4a (anaphylatoxins) activates mast cells & basophils
which releases histamine. (inflammation)
• Actions-
• C3b is an opsonin (opsonisation)
• C5a is chemotactic for leukocytes.
• Membrane attack complex (MAC) (C5b- C9) is a lipid dissolving agent (cell lysis)
2. Kinin system
3. Clotting system
• Factor XIIa initiates the cascade of clotting system resulting in fibrinogen formation.
• Clotting activates fibrinolytic system.
• Infiltration with mononuclear cells includes- macrophages (most important), lymphocytes and
plasma cells.
• Tissue destruction or necrosis- Hallmark of chronic inflammation by activated macrophages.
• Repair- healing by fibrous & collagen takes place.
• Fever
• Leucocytosis
Pathogenesis-
Composition of granuloma-
• Epitheloid cells
• Multinucelated giant cells
• Lymphoid cells
Types of granuloma-
• Immunological granuloma
Systemic effects-
• Neovascularization (angiogenesis)
• Fibrogenesis
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• Non specific inflammation
• Scar tissue & adult skin - Type I collagen
• Early granulation tissue- Type I & III collagen
Types of cells-
• Self renewal
• Asymmetric replication (stochastic differentiation)
• At canals of Hering
• Forms bipotent progenitor called oval cells.
d) Skeletal muscle
e) Cornea
f) Bone marrow
• Pluripotent
• Marrow stromal cells
g) Brain
• Secondary intention-
• Initial hemorrhage
• Inflammatory phase
• Epithelial changes
• Granulation tissue
• Wound contraction- is most prominent seen in wound healing.
• Presence of infection
• Infection
• Deficient scar formation
• Hypertrophied scar
• Keloid formation
Wound Strength-
i) Hematoma formation
c) Remodelling
• Osteoblast & osteoclast removes necrotic content, which results in remodelling of the united bone
end into compact bone.
CVC lung- Alveoli contains hemosiderin laden macrophages (heart failure cells)
CVC liver-
CVC spleen-
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• Hyperplasia of reticuloendothelial cells.
• Gamna gandy bodies are seen.
• AL fibril protein is derived from lambda (λ) light chain (twice more common) than kappa (κ).
• Seen in plasma cell dyscrasias & primarily systemic amyloidosis.
2. AA protein-
3. Aβ amyloid-
• Amyloid P component
1. Primary amyloidosis
4. Hereditary Amyloidosis-
1. Senile cardiac
• Biochemical type- ATTR
• Associated disorder- senility (senile cardiac amyloidosis)
• Precursor proteins- Transthyretin
2. Senile cerebral
3. Endocrine
DIAGNOSIS OF AMYLOIDOSIS-
• Most common & best site for biopsy is abdominal fat aspiration.
• Congo red staining-
1. Amyloidosis of kidneys-
2. Amyloidosis of spleen-
• It has 2 patterns-
a) Sago pattern-
b) Lardaceous spleen-
• Amyloidosis involving splenic sinuses, extending to splenic pulp with formation of large, sheet like
deposits.
3. Amyloidosis of Liver-
4. Amyloidosis of Heart-
54. Haematopoiesis
• Romanowsky technique used for staining & a stain for iron assess the reticuloendothelial stores of
iron.
• Most common site for bone marrow biopsy-
Sites of Haemotopoeisis-
55. Erythropoiesis
Erythroid series-
• It is non- nucleated.
• Reticulocytes counted by vital staining from new methylene blue or brilliant cresyl blue.
• Reticulocytes- 1- 2 days in marrow.
• 1-2 days circulate in the peripheral blood before maturing in the spleen.
IRON METABOLISM
• Heme iron enters mucosal cells and non heme iron is first reduced to ferrous iron and then
absorbed in duodenum.
• Then, it is transported inside enterocytes via apical transport called DMT1 (divalent metal
transporter 1).
• Absorbed iron transported to basememnt membrane which requires ferroprotein & Hephaestin for
conversion of ferrous to ferric form.
• Finally ferric iron will be utilized for maturation of erythroid precursors.
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• DMT1 also facilitates uptake of cadium & lead.
Iron excretion-
Clinical Features-
Lab findings-
b) Erythropoiesis- micronormoblasts
c) Iron staining on bone marrow aspirate shows decrease iron stores (Prussian blue reaction)
• Biochemical findings-
b) TIBC increase
TREATMENT
• Sideroblastic anaemia is a group of disorder in which erythroid precursor in the bone marrow show
characteristic ‘ringed sideroblastic’.
• Siderocytes are erythrocytes & sideroblasts are normoblasts.
• Siderocytes contains granules of non- heme iron.
• Granules are positive with Prussian blue reaction & Romanowsky dyes called Pappenheimer bodies.
a) Secondary- Drugs, chemical & toxins (Isoniazid- antituberculous drugs & pyridoxine antagonist).
Lab findings-
Hereditary spherocytosis-
• It is a common autosomal dominant inheritance disorder in which red cell membrane is abnormal.
• RBC lifespan is decreased to 10- 20 days.
• Decreased reticulocyte count is a feature aplastic crisis caused by parvovirus B-19 infection.
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Pathogenesis-
Clinical Features-
• Splenomegaly
• Jaundice
• Pigment gallstone
Lab findings-
• Reticulocytosis
• Abnormality of erythrocytes formed microspherocytes.
• MCHC increased
• Osmotic fragility increased (main diagnostic test)
• Autohemolysis test increases & corrected by glucose.
• Direct Coomb’s test is negative.
• Spherocytosis.
Pathogenesis-
• In G6PD deficient cells oxidant will denature globin of haemoglobin to form Heinz bodies.
• To detect Heinz bodies stain, crystal violet is used.
Clinical features-
Lab findings-
ENT
1. CSF Rhinorrhoea
• Discharge is clear, watery, appears suddenly in a gush of drops when bending forward (tea pot sign)
or straining
• Uncontrollable and cannot be sniffed back
• Glucose content > 30mg/dI (nasal discharge - < 10 mg/dl)
• β2 transferrin is specific for CSF (absent in nasal discharge)
• Olfactory slit – cribriform plate of Ethmoid Bone (most common site)In traumatic CSF leak, CSF and
blood are mixed – double ring sign or target sign
• Immediate Management - Antibiotics and Observation
• Persistent Case Treated surgically by nasal endoscopy or intracranial route
• CSF Rhinorrhea Occurs in fracture of maxilla in Le Fort type II and type III. (as cribriform plate is
injured here) and also in nasal fracture class Ill
• The entire pinna (except its lobule and outer part of external acoustic canal) is made up of a
framework of a single piece of yellow elastic cartilage
• Pinna develops from the cleft of 1st and 2nd pharyngeal arch
• Ear pinna develops from Ectoderm
• Skin over the pinna is closely adherent to the perichondrium on the lateral surface while it is loosely
attached on the medial surface.
• Greater auricular nerve(C2C3)-Supplies Major Part of Pinna
• Sensory nerve supply of pinna is Mandibular nerve
• Cauliflower ear (boxer's ear, wrestler's ear)
• Is an acquired deformity of the outer ear.
• In this injury, the ear can shrivel up and fold in on itself and appear pale, giving it a cauliflower-like
appearance, hence the term cauliflower ear.
• Wrestlers, boxers and martial artists in particular are susceptible to this type of injury.
• When the ear is struck and a blood clot develops under the skin, or the skin is sheared from the
cartilage, the connection of the skin to the cartilage is disrupted.
4. Otosclerosis / Otospongiosis
• Most often the otosclerotic focus involves stapes, leading to stapes fixation and CHL
• Family history present, Autosomal dominant
• Age 20-30 yrs
• Females affected twice more than males.
• Stapedial otosclerosis causing stapes fixation and CHL is the most common variety
• Cochlear otosclerosis – causes SNHL, Otosclerosis tinnitus
• Fissula ante fenestrum - in front of oval window is the site of predilection (anterior focus)
• Hearing loss – painless progressive bilateral CHL
• Paracusis willisi - hears better in noisy surroundings
• Membrane – normal and mobile
• Schwartz sign – reddish hue seen on the promontory through TM, which indicates active focus
• TFTs- negative Rinne, Weber lateralized to the ear with greater hearing loss
• The tympanogram is Type AS
• In some cases a dip in the bone conduction curve appear at 2000Hz which disappears after
successful stapedectomy (Carhart's notch)
• Gene’s test and Gelle's test identifies Otosclerosis
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• The prosthesis used in the surgical treatment are Teflon (M/C used)
5. Septoplasty
• Deviation of the nasal septum with partial or complete unilateral or bilateral obstruction of airflow
• Persistent or recurrent epistaxis
• Evidence of sinusitis secondary to septal deviation
• Headaches secondary to septal deviation and contact points
• Anatomic obstruction that makes indicated sinus procedure difficult to perform efficiently
• Obstructive sleep apnea
• As an approach to transseptal transsphenoidal approach to pituitary fossa
Tissue sparing procedure where septa' deviation is corrected by minimal resection of cartilage and bone
Secondary Atrophic rhinitis are due to Specific infections, such as syphilis, lupus,
leprosy, and rhinoscleroma.
• The disease is mostly seen in females and tends to appear during puberty.
• There is foul smell from the nose making the patient a social outcast though patient himself is
unaware of the smell due to marked anosmia (merciful anosmia).
7. Vasomotor Rhinitis
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VASOMOTOR RHINITIS
8. Meniere's disease
Origin
• in the internal auditory canal from the inferior or superior portion of the vestibular nerve
• 80% of all Cerebello-pontine angle tumors
• 10% of all intracranial tumors
• Benign encapsulated, extremely slow growing tumors
• Bilateral tumors seen in neurofibromatosis type 2 (NF2), a syndrome resulting from a chromosome
22 mutation.
• Tumors almost always arise from the Schwann cells of the vestibular division of VIII nerve
Cochleovestibular symptoms
Cranial nerves
Investigations
Treatment -
10. Rhinoscleroma
Cause:
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• Chronic granulomatous disease caused by Gram negative bacillus called Klebsiella rhinoscleromatis
(Frisch bacillus)
• Rhinoscleroma may be found in all age groups, but typically young adults 20–30 years old are most
frequently affected.
• Airborne transmission combined with poor hygiene, crowded living conditions, and poor nutrition
contributes to its spread.
• Subdermal infiltration of the lower part of external nose and upper lip giving a woody feel
• Miculicz' cells (macrophages containing large amounts of bacteria-filled vacuoles)
and Russell bodies (spherical structures found in the cytoplasm of plasma cells and also seen in
multiple myeloma)
Clinical symptoms:
Diagnosed by:
14. Otoslerosis
Otosclerosis is characterized by abnormal removal of mature dense otic capsule bone by osteoclasts, and
replacement with the woven bone of greater thickness, cellularity, and vascularity.
When disease involves the annular ligament of the oval window and stapes footplate, a conductive hearing
loss (CHL) occurs which is slowly progressive, usually bilateral and asymmetric.
The hallmark of bone conduction thresholds in otosclerosis is the Carhart notch which is as a result from
the disruption of normal ossicular resonance, approximately at 2000 Hz. One of the earliest signs of
otosclerosis is an abnormal acoustic reflex.
Carharts notch
• Its most distinctive feature is conductive hearing loss, but sensorineural hearing loss and vertigo are
also common;
• tinnitus is infrequent due to Cochlear Otosclerosis,increased vascularity in lesion or conductive
deafness
• Paracusis Willis refers to improved hearing with background noise. It is seen in patients with
otosclerosis.
• Otosclerosis is suggested by a positive family history(50% have family history)
• a tendency toward onset at an earlier age,
• the presence of conductive hearing loss, or
• bilateral symmetric auditory impairment.
• Females are more commonly affected than males.
• Whites are affected more than negroes.
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• Age = most common between 20-30 years and is rare before 10 and after 40 years.
• Deafness is increased by pregnancy, menopause, trauma and major operations.
• Viruses like measles virus have also been associated with it.
• Stapes footplate—Shows a rice grain / biscuit type appearance
• Blue mantles are seen histopathologically.
Gene's Test
In this test, BC (bone conduction) is tested and at the same time Siegle's speculum compresses the air in
the meatus.
In normal individuals hearing is reduced after this; i.e. Gelles test is positive; but in stapes fixation,
sound is not affected. i.e Gelles test is negative.
FINDINGS IN OTOSCLEROSIS
Symptoms of otosclerosis
• Hearing loss :- Bilateral conductive deafness which is painless and progressive with insidious onset.
In cochlear otosclerosis sensorineural hearing loss also occurs along with conductive deafness.
• Paracusis willissii :- An otosclerotic patient hears better in noisy than quiet surroundings.
• Tinnitus :- More common in cochlear otosclerosis.
• Speech :- Monotonous, well modulated soft speech.
• Vertigo :- is uncommon.
Signs in otosclerosis
• As otosclerotic patients have conductive deafness, the tuning fork tests results will be as follows :?
• Rinnes :- Negative
• Webers :- Lateralized to the ear with greater conductive loss.
• Absolute bone conduction (ABC) :- Normal (can be decreased in cochlear otosclerosis).
• Gelles test :- No change in the hearing through bone conduction when air pressure of ear canal is
increased by Siegle's speculum.
Audiometry in otosclerosis
• Shows loss of air conduction, more for lower frequencies with characteristic rising pattern. Bone
conduction is normal. However in some cases, there is a dip in bone conduction curve which is
maximum at 2000 Hz (2 KHz) and is called the Carhart's notch.
2) Impedance audiometry
i) Tympanometry
• Patient with early disease may show type A tympanogram (because middle ear areation is not
affected) Progressive stapes fixation results in classical As type tympanogram.
• It is one of the earliest sign of otosclerosis and precedes the development of airbone gap. In early
stage, diphasic on-off pattern is seen in which there is a brief increase in compliance at the onset
and at the termination, stimulus occurs. This is pathognomonic of otosclerosis. In later stage the
reflex is absent.
• Treatment with a combination of sodium fluoride, calcium gluconate, and vitamin D may be
effective. If not, surgical stapedectomy/stapedotomy/fenestration should be considered.
• Otomycosis is most commonly caused by Aspergillus Fungus and then Candida fungus.
• Patients with diabetes are susceptible to otitis externa.
• Findings of Otits externa:ear pain, pruritus, and discharge. On examination, the ear canal is
erythematous and edematous. Tenderness to manipulation of the external ear present.
• Exacerbating factors of Otits externa include: Warm humid climates, swimming, frequent hair
washing (especially if in the bath), and insertion of foreign bodies can introduce bacterial infection
and cause local trauma to the ear canal, making infection more likely. Prolonged use of hearing aids
may also predispose to infection.
• Most common cause of otitis externa is Pseudomonas Aeruginosa ans Staphylococcus Aureus.
• External otitis/Diffuse otitis externa is also known as Telephonists ear.
• Otitis externa haemorrhagica is most commonly caused by influenza virus and is characterised by
formation of haemorrhagic bullae on the tympanic membrane.
17. Pinna
• Malignant Otitis externa-Ear pain and drainage in an elderly diabetic patient must raise concern
about malignant external otitis.It is associated with tenderness in the pinna and swelling and
inflammation of the external auditory meatus.Granulation tissue may be present in the external
auditory canal.This infection is almost always caused by P. aeruginosa.
• Other features -Facial palsy, not responding to antibiotics, increased uptake on technetium bone
scan.
• Severe Hearing Loss is absent.ESR is used for follow-up.
• Antibiotic of Choice-Antipseudomonal penicillin or cephalosporin (3rd generation piperacillin or
ceftazidime) with an aminoglycoside/fluoroquinolone
• Length of external auditory canal is 24 mm.
• Use of Isotretinoin may lead to teratogenic effects like Cleft lip,Cleft Palate and Agenesis of the
External ear canal.
• Corrective surgery for a new born with microtia is usually performed at 5-7 years of age.
• Mechanical stimulation of ear canal while cleansing it can cause stimulation of the auricular
branch of vagus nerve and may induce cough.
• The cartilaginous part of external auditory canal has 2 deficiencies - the "fissures of
santorini" through which infections can pass from external ear to parotid and vice versa.
• Mac Even's Triangle is formed by Posterosuperior segment of bony external auditory
canal,Temporal line(Suprameatal crest) and Tangent drawn to the external auditory meatus to
Suprameatal Crest.
• External Auditory canal is formed from first pharyngeal groove/Cleft.
• Keratosis Obturans occurs due to defective epithelial migration from the tympanic membrane to
posterior meatal wall, which results in collection of pearly white desquamated epithelial debris with
cholesterol in deep meatus.
• Lateral wall of Mastoid Antrum is related to External Auditory Canal.
• Exostosis of External Auditory canal occurs due to recurrent proplonged cold water exposure.
• Most common site of perforation of tympanic membrane in ASOM is Anterior inferior quadrant.
• Rupture of an ear drum may occur at the noise level above 160 dB.
• Use of nitrous oxide is contraindicated during Tympanic Membrane Grafting Surgery.
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• The torture method involving simultaneous beating of both ears with palms of hand, resulting in
rupture of tympanic membrane is called Telefono.
• Uses of of Siegel's Speculum during Ear Examination are Magnification ,Assessment of movement
of the tympanic membrane, As applicator for the powdered antibiotic of ear and to suck out middle
ear secretions in patients with chronic serous ottitis media.
• In a case of conductive hearing loss of 55 db with normal cochlera reserve,due to accident,with
normal tympanic membrane,the tympanogram would show Ad type of Curve.It occurs due to
Ossicular Discontinuity.
• Maximum hearing loss occur when there is ossicular interruption with intact tympanic membrane
(54dB).
• Glomus Tumor-Otoscopy shows a red reflex through intact tympanic membrane. “Pulsation sign” is
positive, progressive deafness and pulsatile tinnitus
• Handle of Malleus is attached to the center of the tympanic membrane.
• The presence of conductive type of hearing loss, dull tympanic membrane and type B
tympanogram suggests the presence of fluid in middle ear cavity or serous otitis media.
• Serous otitis media in an older individual should raise the suspicion of nasopharyngeal malignancy.
The presence of enlarged lymph nodes adds to the suspicion.
• Tympanic membrane develops from all the three germinal layers-represents all the 3 components
of the embryonic disc.
• Auriculotemporal nerve is one of the nerves providing sensation to the tympanic membrane.
• The treatment of traumatic rupture of tympanic membrane is no active treatment.
• Normal consciousness and blood in the tympanic membrane may be found in a case of Basilar
fracture due to head injury.
• Normal colour of tympanic membrane is pearly white.
• The most mobile part of the tympanic membrane is peripheral part.
• Pars flaccida of the tympanic membrane is also called Shrapnell's membrane.
• The distance between tympanic membrane and medial wall of middle ear at the level of center is 2
mm.
• Surface area of tympanic membrane is 90 mm2.
• The effective diameter of the tympanic membrane is 45 mm2.
• Lever ratio of tympanic membrane is 1.3-1.
• The hearing loss after rupture of tympanic membrane is 10-40 db.
• Chalky white tympanic membrane is seen in Tympanosclerosis.
• Features of moderately retracted tympanic membrane : Handle of malleus appearance
foreshortened ,Cone of light is absent or interrupted , Lateral process of malleus becomes more
prominent,Non prominent Umbo.
• Bluish tympanic membrane is seen in Glue ear(Secretory Otitis Media).
• Myringoplasty is plastic repair of Tympanic membrane,done with Operating Microscope.
• Procedure of surgical opening in Tympanic Membrane is Myringotomy.
• Tympanoplasty is eradication of middle ear disease with reconstruction of tympanic membrane &
ossicles.
• Thin painless otorrhoea, multiple perforations of the tympanic membrane and failure to respond to
antimicrobial treatment is characteristic of Tubercular Otitis Media.
• Areas of spontaneously healed tympanic membrane are called Dimeric.
• The auditory tube connects the nasopharynx with the anterior wall of the Middle ear.
• Tests for Eustachian Tube Patency are Valsalva test,Methylene blue test,Sonotubometry,Politzer
test,Toynbee test,Frenzel maneuver,Catheterization,Inflation - Deflation test.
• Cholesteatoma invading Eustachian tube is an indication for Radical Mastoidectomy.
• Eustachian tube opens behind the level of inferior turbinate.
• Cartilaginous part of auditory tube is inferior to Sphenopetrosal Synchondrosis.
• The length of Eustachian tube is 36 mm.
• Inner 2/3rd part is Cartilaginous and outer 1/3rd part is Bony of the Eustachian Tube.
• Tensor Veli Palatini and Levator veli palatini muscle causes opening of Eustachian Tube during
Swallowing,yawning,sneezing.
• Higher elastin content in adults in Eustachian Tube.
• Eustachian Tube develops from the first and second pharyngeal arch.
• Otoscopic findings of Eustachian tube dysfunction are Malleus is easily visible,Lusterless tympanic
membrane,No movement of the tympanic membrane on siegel's method,distorted light image on
the anterior quadrant of tympanic membrane.
• Common cause of eustachian diseases is Adenoids.
• Throat infection causes Ear infection through Eustachian Tube.
• Patency of Eustachian Tube is closed and communication of middle ear with ET is obliterated during
Radical Mastoidectomy.
• Eustachian tube gets blocked if pressure difference is more than 90 mm.
• Structures seen on posterior Rhinoscopy are Both choanae ,Posterior end of nasal septum ,Opening
of Eustachian Tube,Posterior end of superior/tube middle and inferior turbinates,Fossa of
Rosenmuller,Torus Tubarius, Adenoids ,Roof and posterior wall and nasopharynx.
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• Ostmann's pad of fat- helps the Eustachian tube closed at pharyngeal end.
23. Labyrinth
• Paget's Disease may present with abnormality at upper tibia,Hip and Back pain,Sensorineural
Hearing loss,Elevated Alkaline Phosphatase,Ivory Vertebra and Cotton Wool Spots in Skull X Ray.
• Basilar Migraine presents with intermittent headache in association with tinnitus,vertigo and
hearing loss.
• Ramsay Hunt Syndrome may present with facial palsy ,facial pain ,vesicles on the canal and
pinna,vertigo and sensor neural hearing loss .
• Exposure to noise above 160dB can cause permanent loss of hearing.
• The diagnosis of classic alport syndrome is based on X-linked inheritance of hematuria,
sensorineural hearing loss, and lenticonus
• Psycho-acoustic index of loudness is indicated by the term 'Phon'.
• In chidren suffering from meningitis,sensorineural hearing loss may occur despite prompt initiation
of appropriate antimicrobial therapy.
• Ossicular disruption with intact tymnpanic membrane causes maximum hearing loss.
• After rupture of tympanic membrane, the hearing loss is 10-40 dB.
• Permanent privation of the hearing of either ear comes under grievous injury .
• Commonest cause of hearing loss in children is Chronic secretory otitis media.
• The hearing loss when the patient fails to understand normal speech, but can understand shouted
or amplified speech would be severe hearing loss.
• Cause of unilateral conductive hearing loss in a patient with history of head injury with tympanic
membrane normal and mobile would be Ossicular Chain Discontinuity.
• Otosclerosis-Family history positive,Bilateral hearing loss,type As Tympanogram,PTA -bone
conduction hearing loss with an apparent bone conduction hearing loss at 2000 Hz,hearing might
worsen during pregnancy
• Tuning fork frequency used most commonly in the ENT clinic is of 512Hz.
• Weber’s test best elicited by placing tuning fork on the middle of the patient’s forehead and he is
asked to say in which ear he hears the sound better.
• Tuning fork tests used to differentiate hearing loss are:Rinne’s test,Weber test,Absolute bone
conduction (ABC) test,Schwabach’s test,Bing test,Gelle’s test.
• False Negative Rinne's Test:
• When a patient has unilateral sensori-neural deafness in the test ear, the bone conduction stimulus
may be perceived by the opposite ear. Hence it can be interpreted as Rinne's Negative.
• In such cases,Weber's test will be lateralised to the normal ear thus confirming false negative
Rinne's result. The above can also be avoided by giving a masking sound to the non-test ear.
• Frequency of tuning fork commonly used for performing Rinne's test is 512Hz.
• The most preferred and commonly used is 512 Hz frequency tuning fork because it is better felt.
• Negative Rinne's test for 256 Hz tuning fork indicates a minimum air-bone gap of 15dB.
28. Audiometry
• Type of Tympanogram in a patient with conductive hearing loss of 55 dB due to head trauma is
Type-Ad(as it occurs in Ossicular Discontiniuty).
• Impedance Audiometry is done by pressure changes in Middle ear.
• Type of Tympanogram in a patient with Otosclerosis is Type As.
• Secretory otitis media is diagnosed by Impedance Audiometry.
• Impedance denotes disease of Ossicles.
• Most common cause of Type B tympanogram in an old aged patient with neck nodes is
Nasopharyngeal Carcinoma.
30. Tympanoplasty
32. BERA
• Intermittent brief vertigo with occasional drop attacks, ataxia, visual loss, double vision and
confusion: Vertebrobasilar insufficiency.
• Vertigo is defined as subjective sense of imbalance
• Epley's Maneuvre is used in the treatment of BPPV.
• Most likely diagnosis in an adolescent female with a positive family history having occipital
headache which is intermittent in episode and associated with tinnitus, vertigo,ataxia and hearing
loss is Basilar Migraine.
• Vertigo with sensorineural hearing loss, facial weakness,appearance of vesicles on the canal and
pinna and loss of taste sensation:Ramsay hunt syndrome.
• Vertigo, tinnitus, headache and visual disturbances due to hyperviscosity,Systolic
hypertension,Aquagenic pruritus:Polycythemia rubra vera.
• Most possible diagnosis in a patient on total parenteral nutrition for 20 days presenting with
weakness, vertigo and convulsions is Hypomagnesemia.
• Postitional vertigo is due to stimulation of Posterior Semicircular Canal.
• Vestibular Exercises is the treatment for Benign Positional vertigo
• In BPPV,patients display nystagmus and the symptoms that can be reproduced by head movement.
• In addition, the symptoms show latency, fatigability and habituation.
• Ocular features like Chronic granulomatous anterior uveitis, posterior uveitis ,etc,Neurological
lesions like meningism, encephalopathy, tinnitis, vertigo and deafness and Cutaneous lesions
likealopecia, poliosis and vitiligo may be present in Vogt-Koyanagi Harada syndrome.
• Antiemetic Phenothiazine with labrynthine suppressant activity used for vertigo is
Prochlorperazine.
• Tullio phenomenon is a condition where the subject gets attack of vertigo/dizziness by loud sounds.
35. Nystagmus
• Nystagmus that occurs when the patient looks straight is Optokinetic Nystagmus.
• Nystagmus is absent in a brain stem dead patient.
• A patient has a right homonymous hemian-opia with saccadic pursuit movements and defective
optokinetic nystagmus.The lesion is most likely to be in the Parietal lobe.
• Cerebellar hemisphere is the site of lesion in unilateral past pointing nystagmus.
• In caloric test,Cold stimulation causes nystagmus towards opposite side while warm stimulation
causes Nystagmus towards same side.
• Spontaneous vertical nystagmus is seen in the lesion of Midbrain/Medulla.
• Central Nystagmus changes the direction,with no fatiguability,no latency and does not disappears
on visaul fixation.
• Peripheral Nystagmus has fixed direction,latency and fatiguability present and disappears on Visual
Fixation.
• Cochlear problems is associated with hearing loss and not nystagmus.
• In destructive lesions eg. trauma to labyrinth, the nystagmus is towards the opposite side.
• Stimulation of posterior semicircular canal produces Torsional vertical nystagmus.
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• Miners nystagmus is of Rotatory type.
• Illuminated frenzel galsses are useful for abolishing fixation and thus revealing peripheral vestibular
nystagmus
• Cochlear malformation is a surgical challenge but not a contraindication for cochlear implantation.
• Use of nitrous oxide is contraindicated in Cochlear Implant Surgery.
• In Cochlear implants, the electrodes are most commonly placed at Cochlea.
• Auditory Nerve should be intact for Cochlear Implantation.
• Patients of profound binaural SNHL-PTA of 70 dB or more(with non functional cochlear hair cells)
who have intact auditory nerve functions and show little or no benefit from hearing aids are the
candidate for Cochlear Implant surgery.
• Facial recess is a suprapyramidal recess,middle ear can be approached through it and important in
Cochlear Implant Surgery.
• Minimum age for Cochlear Implant Surgery is 1 year
• Electrode is kept in Scala Tympani in Cochlear Implant surgery.
• In cochlear implants, electrodes are most commonly placed through Round window.
• Switch on of Cochlear Implant is done after 3 weeks.
• Pre-op investigation before a Cochlear Implant is placed:HRCT Temporal Bone and Complete
Audiological Examination.MRI may be needed.
• Receiver/Stimulator and Electrode array are the part of internal component of cochlear implant,
which are fitted inside the body.
37. Mastoidectomy
• Operation of choice for a patient having Attic cholesteatoma of ear with lateral sinus
thrombophlebitis is Canal Wall Down Mastoidectomy.
• Iatrogenic traumatic facial nerve palsy is most commonly caused during Mastoidectomy.
• Schwartz operation is Cortical Mastoidectomy.
• Radical mastoidectomy is done for Attico-Antral Cholesteatoma.
• Coalescent Mastoiditis is an indication for cortical mastoidectomy.
• Incus and head of malleus,lateral attic wall ,posterior meatal wall are removed in a Modified
Radical Mastoidectomy in a patient with Cholesteatoma.
• Cholesteatoma invading eustachian tube is an indication for Radical Mastoidectomy.
• The treatment of choice for atticoantral variety of chronic suppurative otitis media is Modified
radical Mastoidectomy.
• Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma
is Modified Radical Mastoidectomy.
• Treatment of cholesteatoma with facial paresis in child is Immediate Mastoidectomy
• Communication between middle ear and Eustachian tube is obliterated in Radical mastoidectomy.
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• Treatment of middle ear malignancy includes Excision of petrous part of temporal bone
and Modified radical mastoidectomy.
• Treatment of middle ear papilloma is Tympanomastoidectomy.
• Treatment for postauricular subperiosteal abscess is Antibiotics along with drainage of abscess and
cortical mastoidectomy.
• In chronic secretory otitis media(also known as Glue ear), the treatment of choice is Myringotomy
with ventilation tube insertion
• Glue ear is a painless condition.
• Glue ear is also known as Chronic Secretory Otits Media.
• During follow up of a case of acute otitis media, a 6 year old child found to have glue ear with no
symptoms.
• Commonest cause of hearing loss in children is Chronic secretory otitis media.
• Cause of U/L secretory otitis media in an adult is Nasopharyngeal Carcinoma.
• Acute non suppurative otitis media in adults is due to Malignancy.
• Secretory otitis media is diagnosed by Impedance Audiometry.
• Bluish tympanic membrane is seen in Glue ear.
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• Effusion is sterile in Otits media with effusion.
• Type-B Tympanogram is seen in Otits media with effusion.
• Otitis media with effusion is also known as Serous Otitis Media or Mucoid Otitis Media.
• Patients with Wegener's Granulomatosis may present with Secretory Otitis Media
• Characteristic triad of Wegener's granutomatosis is vasculitis of the upper respiratory tract (serious
otitis media and epistaxis), vasculitis of the lower respiratory tract (hemoptysis) and vasculitis of
the kidney (proteinuria).
• Watchful waiting is recommended without immediate use of antibiotics for children with
uncomplicated otitis media with effusion.
• Conducting hearing loss with intact tympanic membrane occurs in Glue Ear.
• Treatment of choice in a patient presenting with mouth breathing, recurrent serous otitis media
and adenoid facies is Adenoidectomy.
• Most common site of perforation of tympanic membrane in ASOM is Anterior inferior quadrant.
• Most common extra-cranial complication of ASOM is Subperiosteal abscess.
• 95% of all cases of invasive disease (epiglottitis, meningitis) due to H. influenzae are caused by type
b organisms that possess a polyribitol phosphate capsule. Otitis media is generally not caused by
type b organisms.
• Streptococcus Pneumoniae is the most common cause of Acute otitis media in children.
• Infection of middle ear can spread to CNS through Cochlear Aqueduct.
• The quadrant for a myringotomy in a case of acute suppurative otitis media is Postero-inferior as it
is easily accessible,damage to ossicular chain does not occur and damage to chorda tympani is
avoided
• Most frequently ASOM resolves without sequelae.
• Cart Wheel sign is seen in ASOM.
• Acute suppurative otitis media is treated using Erythromycin,Penicillin or Cephalosporin.
• Pulsatile otorrhoea is seen in ASOM.
• Light house sign is seen in ASOM.
• Inadequate antibiotic treatment of acute suppurative otitis media may lead to Secretory Otitis
Media.
• Most common complication of acute otitis media in children is Mastoiditis.
• Incomplete resolution despite antibiotics when drum remains full and bulging is an indication for
Myringotomy in a case of ASOM.
• Light house sign in seen in ASOM in stage of Suppuration.
41. CSOM
• Presence of delta sign on contrast enhanced CT SCAN suggests presence of Lateral Sinus
thrombophlebitis.
• Operation of choice in a patient with Attic cholesteatoma of ear with lateral sinus thromboplebitis
would be Canal Wall Down Mastoidectomy.
• Griesinger's sign is seen in Lateral Sinus Thrombosis.
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• Lateral sinus thrombosis is associated Greisinger sign, Lily-Crowe sign and positive Tobey Ayer test.
• Atrophic laryngitis or Laryngitis sicca is characterized by atrophy of laryngeal mucosa and crust
formation,often seen in women and is associated with atrophic rhinitis and pharyngitis.
• Etiology in a patient with long standing nasal obstruction to develop secondary atrophic rhinitis can
be long standing purulent Sinusitis.
• Atrophic rhinitis may occur due to Chronic sinusitis ,Nasal deformity ,Strong hereditary factors.
• Merciful anosmia is seen in Atrophic Rhinitis.
• Cause of nasal obstruction in Atrophic rhinitis is Crusting.
• Organisms is known to cause Atrophic Rhinitis are Coccobacillus ozaena, Diphtheroid bacillus,
Kiebsiella ozaenae,Bordettela bronchiseptica,Pasteurella multocida, P. vulgaris, E. coli
,Staphylococcus ,Streptococcus.
• Atrophic rhinitis is not associated with the chronic use of nasal drops and is uncommon in males
and not associated with Diabetes.
• Young's operation is done for Atrophic Rhinitis.
• Pott’s puffy tumor is a complication of frontal sinusitis due to osteomyelitis of frontal bone .
• The probable diagnosis in a patient with history of running nose and pain over medial aspect of the
eye presenting with sudden onset of high grade fever, prostration, chemosis, proptosis and diplopia
on lateral gaze with congestion of the optic disc would be Cavernous Sinus Thrombosis.
• Complications of acute sinusitis are Orbital cellulitis,Pott's puffy tumor and Conjunctival chemosis.
• Orbital cellulitis may occur as a complication of Parasinusitis, Faciomaxillary trauma,Endoscopic
sinus surgery.
• Frontal lobe abscess may be associated with fever,papilloedema,Personality changes and headache.
• The diagnostic criteria for allergic fungal sinusitis (AFS) are the presence of characteristic allergic
mucin, type I hypersensitivity (eosinophilic-lymphocytic inflammation), absence of fungal invasion,
immuno-compromised individuals and radiological confirmation (areas of high attenuation on CT
scan).
• Type 1 and Type 3 Allergic reaction is seen in patients with Allergic fungal sinusitis.
• Causative organism in a diabetic with orbital cellulitis and maxillary sinusitis showing hyaline,
narrow, septate and irregular branching hyphae with invasion of the blood vessels on microscopy
would be Aspergillus.
• Mucormycosis has a predilection for vascular invasion.
• Orbital mucormycosis may occur as a complication of Diabetic Ketoacidosis.
• Amphoterecin B IV is used for invasive fungal sinusitis.
50. Tonsillectomy
• Coblation intracapsular tonsillectomy utilizes a thin layer of ionized sodium to ablate tissues.
• Tonsillectomy is contraindicated in Polio Epidemic.
• Tonsillectomy is recommended if number of acute infections in a year exceed 3 years.
• Recurrent throat infections, peritonsillar abcess, tonsillitis causing febrile seizures, hypertrophy of
tonsils causing sleep apnoea or speech interference and any suspicion of malignancy are absolute
indications for tonsillectomy.
• Secondary Haemorrhage after tonsillectomy usually presents between the 5th to 10th
postoperative day.
• Torrential bleed during tonsillectomy is due to Paratonsillar vein.
51. Quinsy
• Adenoidectomy with grommet insertion is treatment of choice for Serous otitis media in children .
• Best line of management in a patient presenting with mouth breathing, recurrent serous otitis
media and adenoid facies is Adenoidectomy.
• Treatment of a child with recurrent URTI with mouth breathing and failure to grow with high
arched palate and impaired hearing is Grommet insertion with Adenoidectomy and tonsillectomy
(to remove the causative factor).
• Common cause of eustachian diseases is due to Adenoids.
• Next step of management in a child has adenoidectomy done but has effusion in middle ear is
Grommet insertion.
• Regarding adenoids ,there is failure to thrive,high arched palate and mouth breathing is seen.
• The inner Waldeyer's group of lymph nodes constitutes of Tonsils, Lingual tonsils ,Adenoids.
• Indication for Adenoidectomy in children include Recurrent respiratory tract infections, Chronic
serous otitis media and Multiple adenoids.
• Torticollis can occur as a complication of adenoidectomy due to ligamentous laxity secondary to
inflammatory process following adenoidectomy.
• In a patient with hypertrophied adenoids, the voice abnormality that is seen is Rhinolalia Clausa.
• Complications of adenoidectomy include Retro pharyngeal abscess,Velopharyngeal insufficiency
and Grisel syndrome.
• Adenoidectomy results in hypernasality of speech.
• CT scan is not routinely preferred to assess Adenoid size.
54. Epistaxis
55. Tracheostomy
• Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner
cannula.
• In emergency tracheostomy the following structures are damaged: Isthmus of the thyroid,Thyroid
ima and Inferior thyroid vein.
• High tracheostomy is indicated in Carcinoma of Larynx.
• Cardiac tamponade,Uncomplicated Bronchial Asthma,Pneumothorax is not an indication for
tracheostomy.
• Mid tracheostomy is done over 3rd and 4th tracheal rings.
• In Pediatric tracheostomy,most common early complication is subcutaneous emphysema and 3rd &
4th tracheal rings are incised.
• Indications of Tracheostomy are Flail chest,Head injury,Tetanus,Tracheal stenosis,Bilateral vocal
cord palsy,Foreign body larynx,Emphysema,Bronchiectosis,Atelectasis.
• For foreign body causing sudden choking, most appropriate first line of management is Heimlich
maneuver.
• Heimlich manoeuver is done to remove upper airway obstruction by foreign body.
• Advantage of fibreoptic bronchoscopy over rigid bronchoscopy is Good View.
• The treatment of choice for airway foreign bodies is prompt endoscopic removal with a
Bronchoscope
• In child, foreign body in lung is removed by rigid bronchoscopy.
• Commonest sign of intrabronchial foreign body in children is Cough.
• A 4-year child presents with a history of hoarseness, croupy cough and aphonia, the child has
dyspnoea with wheezing. The most probable diagnosis is Laryngeal foreign body.
• In erect posture commonest site of foreign body is in Right posterior basal bronchus.
• Foreign body aspiration in supine position commonly affects Apical part of right lower lobe.
• A foreign body completely obstructing the right main bronchus causes decreased Ventilation-
perfusion ratio.
• Palpatory thud audible slap is seen in Tracheal foreign body.
• During autopsy, foreign body is found in respiratory tract; manner of death is Accident.
• CSF rhinorrhea immediate management is wait & watch for 7 days + antibiotics.
• CSF Rhinorrhea is usually due to fracture of cribriform plate which is a part of Ethmoid.
• CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of
blood with an outer ring or halo. Blood alone does not produce a ring.
• CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in
CSF Rhinorrhea.
• Most probable diagnosis in a patient brought to the emergency department following head trauma
who is conscious and complaining of fluid coming out of his nostrils without having running nose
before the traumais CSF Rhinorrhea.
• Nasal intubation is contra indicated in CSF Rhinorrhea.
• CSF rhinorrhea is seen in Le Fort II and Le Fort III Maxillary fracture and Nasoethmoid fracture.
• CSF rhinorrhea occurs due to break in cribriform plate and contains glucose.
• CSF rhinorrhea is diagnosed by Beta-2 transferrin.
• Management of persistent cases of CSF rhinorrhea is Endoscopic repair.
• CSF rhinorrhea is diagnosed by Glucose estimation,Halo sign,Immunoelectrophoresis.
• Laryngotracheobronchitis is the most probable diagnosis in a 4 year old boy, with three days history
of upper respiratory tract infection presenting with stridor, which decreases on lying down.
• Laryngotracheobronchitis is caused most commonly by Parainflueza Virus.
• Seal barking like croupy cough is a feature of laryngotracheobronchitis .
• Management of Croup includes Oxygen inhalation and Hydration.
• Steeple sign is seen in Croup.
• On postmortem examination, contusion of neck muscles is seen along with fracture of hyoid bone.
The most probable cause of death is Throttling.
• Fracture of hyoid bone is indicative of Hanging or Strangulation or Throttling
• Hyoid bone fracture does not occur in Choking.
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• Outward displacement of fractured hyoid bone is seen in Hanging.
• Hyoid bone fracture most common occurs in Manual strangulation(Throttling)
• Le Forte II facial fracture implies Fracture running through zygomatic process of the maxilla, floor of
orbit, root of nose on both the sides.
• Craniofacial dissociation is seen in Le Fort 3 fracture.
• CSF Rhinorrhea Occurs in fracture of maxilla in Le Fort type II and type III (as cribriform plate is
injured here) and also in naso-ethmoid fracture
• Bone commonly fractured in facial injuries is Nasal Bones.
• Most common site for fracture mandible is Condyle.
• LeFort's fracture would include Maxilla,Zygoma and Nasal Bones,
• Tripod fracture is the name given for Zygomatic fracture.
• Pyramidal fracture of maxilla is Le Fort-2
• Most probable diagnosis in a patient presenting with Browns sign and a Mass in ear on touch
bleeding heavily is Glomus jugulare tumour
• Pulsatile Tinnitus in ear is due to Glomus jugulare tumour
• Rising sun sign is seen in Glomus juglare
• 9th and 10th cranial nerve may be involved in Glomus juglare.
• Probable diagnosis in a middle aged female presenting with progressive deafness(conductive in
nature) and tinnitus and Otoscopy shows a red reflex through intact tympanic membrane with
Pulsation sign”positive is Glomus Jugulare Tumor.
• Glomus Jugulare is the most common benign neoplasm of middle ear.
• Glomus tumor is a benign tumor, therefore lymph node metastats is not present.
• Glomus cells may be seen in Carotid body tumor.
66. Layngomalacia
• A patient has carcinoma of right tongue on its lateral border of anterior 2/3rd, with lymph node of
size 4 cm in level 3 on left side of the neck, stage of disease is N2.
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• In carcinoma base of tongue pain is refered to the ear through Glossopharyngeal nerve.
• A patient with carcinoma of tongue is found to have lymph nodes in the lower neck. The treatment
of choice for the lymph nodes is Radical neck dissection.
• Radiotherapy is used for which stage-I cancer -Anterior 2/3rd of Tongue.
• A patient presented with a 1 x 1.5 cms growth on the lateral border of the tongue. The treatment
indicated would be Laser ablation.
• Carcinomatous ulcers are painless but may become painful in advanced stages, with extension into
surrounding tissues.
• Commonest site of carcinoma tongue is Anterior 2/3 of Lateral borders
• Carcinoma tongue less than 2 cm is treated by Excision
• Tobacco chewing is a risk factor for Tongue Carcinoma.
• Lymph node invovlement occurs in case of Tongue Carcinoma.
• 60 year old man presents with an ulcer on lateral margin of tongue also complains of ear pain, most
probable diagnosis is Carcinomatous Ulcer.
• Tongue carcinoma is usually Radio-sensitive.
• Posterior tongue most commonly metastasizes to cervical lymph nodes.
• Referred pain in the ear is commonly from Carcinoma of Tongue.
• Most common histological type of carcinoma of tongue is Squamous cell carcinoma.
• Ohngren's line that divides maxillary sinus into superolateral and inferomedial zone is related
to Maxillary cancer.
• Early maxillary carcinoma presents as Bleeding per nose.
• First lymph node involved in maxillary carcinoma is Submandibular.
• In Maxillary carcinoma of a 60 year old patient involving anterolateral part of maxilla, the preferred
treatment is Radiotherapy followed by total/extended maxillectomy.
• The most likely diagnosis in a patient having lower third molar extracted due to dental caries and
then developed high fever and pain and on examination, tonsil deviated medially and there was
swelling in upper one-third of sternocleidomastoid muscle is Parapharyngeal Abscess.
• Retropharyngeal abscess is confined to one side of the midline and presents with dysphagia &
difficulty in breathing.
• Retropharyngeal abscess can be palpable per orally by pressing the finger on posterior pharyngeal
wall.
• Retropharyngeal Abscess may present with High fever and hoarseness of voice.
• Post-styloid space of parapharyngeal space contains cranial nerve IX ,XII and Lymph nodes.
• Retropharyngeal abscess lies anterior to the prevertebral fascia.
• Parapharyngeal space is also known as Lateral pharyngeal space.
• The medial bulging of pharynx is seen in Pharyngomaxillary abscess.
• Trismus in parapharyngeal abscess is due to spasm of Medial Pterygoid muscle.
• Most common cause of chronic retropharyngeal abscess is caries of cervical spine.
• Chronic retropharyngeal abscess is associated with tuberculosis of spine and suppuration of
Rouviere lymph node.
• Retropharyngeal abscess may present with swelling on posterolateral wall of the pharynx.
• Cadaveric position of vocal cords is seen in Bilateral recurrent and superior laryngeal nerve palsy.
• The voice is not affected in unilateral abductor palsy.
• Recurrent laryngeal nerve palsy and External branch of superior laryngeal nerve palsy may occur as
a complication of hemithyroidectomy surgery.
• In complete bilateral palsy of recurrent laryngeal nerves,there is preservation of speech with severe
stridor and dyspnea.
• Twenty-four hours following partial thyroidectomy where the inferior thyroid artery was also
ligated (tied off), the patient now spoke with a hoarse voice (whisper), and had difficulty in
breathing.Recurrent Laryngeal Nerve is injured in this case.
• Recurrent Laryngeal Nerve injury most commonly leads to vocal cord paralysis.
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• Damage to the internal laryngeal nerve results in anaesthesia of the larynx.
• Thyroid Ca causes laryngeal paralysis due to Recurrent Laryngeal nerve palsy.
• Vocal cord palsy in thyroid surgery is due to injury to Recurrent Laryngeal nerve.
• Bilateral Recurrent laryngeal nerve injury may lead to respiratory distress after Thyroid Surgery.
• Hoarseness secondary to bronchogenic carcinoma is usually due to extension of the tumour into
Left Recurrent laryngeal nerve.
• Posterior crioarytenoid , Lateral cricoarytenoid ,Thyroarytenoid. muscles of larynx are affected in a
casr of Recurrent Laryngeal nerve palsy.
• Laryngeal carcinoma especially glottic can cause U/L or B/L Vocal Cord paralysis .
• Vocal nodule does not cause vocal cord palsy.
• Thyroid surgery ,Thyroid malignancy,Cancer cervical oesophagus are the causes of Bilateral
Recurrent laryngeal nerve palsy.
• Throid surgery is the most common cause of B/L recurrent laryngeal paralysis.
• Most dangerous lesion of vocal cords is bilateral abductor paralysis (Bilateral RLN palsy).
• Injury to superior laryngeal nerve causes Loss of timbre of voice.
• Paralysis of recurrent laryngeal nerve is common on Left side
• A child able to breathe and suckle at the same time due to high placed larynx.
• 29-year-old male with episodic abdominal pain and stress-induced edema of the lips, the tongue,
and occasionally the larynx is likely to have low functional or absolute levels of C1 esterase
inhibitor.
• The most probable diagnosis in a man taking peanut and developing stridor, neck swelling, tongue
swelling and hoarseness of voice is Angioneurotic Edema.
• C1 esterase inhibitor deficiency is causative in a patient presenting with history of episodic painful
edema of face and larynx.
• Laryngopharyngeal reflux is the cause of pseudosulcus in the larynx in an alcoholic presenting with
globus sensation in throat, cough and hoarseness.
• Scleroma of larynx is caused by Klebsiella,Subglottic stenosis is a common complication,Treatment
may include steroids.
• Larynx is the most common site in respiratory tract for amyloidosis.
• Epiglottis is the most common site in larynx for sarcoidosis.
• Reflux laryngitis produces subglottic stenosis and Ca larynx.
• A patient with burns die within 24 hours. Physical burn injury to the airways above the larynx could
be the most probable cause.
• Vocal nodule is also known as screamer's node and occur at junction of ant. 1/3rd and post. 2/3rd
of vocal cords.
• Reinke's space is situated in edges of True vocal cord.
• Chronic irritation of vocal cords due to misuse of voice, heavy smoking, chronic sinusitis and
laryngopharyngeal reflux are likely to be associated in Reinke's Edema.
• In Reinke’s edema hoarseness is the common symptom.
• In Reinke's edema, bilateral symmetrical swelling of the membranous part of the vocal cords is
present.
• In Reinke's edema,Polypoid degeneration of vocal cords is due to oedema of the subepithelial
space.
• The most important cause for contact ulcer in vocal cords is Voice abuse.
• Contact ulcer can be caused by intubation injury, adductor dysphonia.
• Contact ulcer can be caused/aggravated by acid reflux
• Vocal process is the site for contact ulcer formation.
• Kiss ulcer of larynx is due to Vocal Abuse.
• Ethmoidal polyp can cause bilateral nasal obstruction and loss of taste.
• Rhinorrhea may be present with Ethmoidal polyp.
• Ethmoidal polyp may be associated with Cystic Fibrosis.
• All polypi should be subjected to histology,especially in old age patient as a simple nasal poylp in an
old patient may masquerade a malignancy underneath.
• On examination, smooth, glistening, grape-like masses which are pale in color are seen in case of
Ethmoidal polyp.
• A patient with Ethmoidal polyp may present with is a history of asthma and allergies.
• Ethmoidal polyp is not associated with epistaxis.
• Ethmoidal polyp typically occurs in middle aged individuals and not in the first decade of life.
• Recurrent polyps are seen in Ethmoidal polyp.
• Epinephrine,Corticosteroids and Antihistamines is the medical treatment of multiple ,bilateral nasal
polyp.
• Extranasal ethmoidectomy should be done in a patient who presents with an Ethmoidal polyp,6
months later after undergoing polypectomy for Ethmoidal polyp.
• "Bernoulli's theorem" explains Nasal Polyp.
• Multiple nasal polyp in children should guide the clinician to search for underlying Mucoviscidosis.
• Aspirin-sensitive asthma is associated with Nasal Polyp.
• Most common nasal mass is polyp.
• Nasal Steroids may be given post-operatively to prevent recurrence in a case of Ethmoidal polyp.
85. Laryngocele
86. Rhinosleroma
87. Rhinosporidiosis
88. FESS
Ophthalmology
1. ACANTHAMOEBA KERATITIS
• Acanthamoeba does NOT depend upon a human host for the completion of its life-cycle.
• Acanthamoeba keratitis is Seen in contact lenses users.
2. INTERSTITIAL KERATITIS
4. KERATOPLASTY
• Cornea should be removed from cadaveric donors within 6 hrs after death (Golden Period).
• Short term storage (upto 48 hours) – whole globe is stored at 4°C in a moist chamber.
• Intermediate storage (upto 2 weeks) - in Mc Carey Kaufmann medium.
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• Long term storage (upto 35 days) – organ culture method or cryopreservation at minus 70°C.
• The cornea graft with graft diameter b/w 7 & 8.5 mm has more chances of survival.
• Deep anterior lamellar keratoplasty is indicated in Superficial corneal opacities.
• Endothelial cell loss in donor tissue of Descemet stripping endothelial keratolplasty is nearly 36%.
5. STAPHYLOMA
6. RETINITIS PIGMENTOSA
7. KERATOCONUS
• Non-inflammatory bilateral ecstatic condition of cornea with Protrusion of anterior cornea and
characterized paraxia/stromal thinning
• Progressive myopia, regular and irregular astigmatism
• Munson's sign – bulging of lower lid on downward gaze
• Placido disc – irregular circles
• Fleischer's ring at the base of cone due to iron deposition
• Acute corneal hydrops due to rupture of Descemet's membrane (especially in Down syndrome)
• Spectacles, rigid gas permeable contact lenses, intacs (intracorneal ring segments)
• Late stages – Deep anterior lamellar keratoplasty or Penetrating keratoplasty
9. Sympathetic ophthalmitis
• Giant cells located within the choroid ,T lymphocytes & Eosinophils are the histopathologic features
of sympathetic ophthalmia
• Dalen Fuch's nodules are seen in Sympathetic ophthalmia
• If a person shows impaired vision of eye after few weeks of gun shot injury to another eye this is
suggestive of Sympathetic ophthalmia
• Sympathetic ophthalmitis affects both eye because Uveal pigment act as allergen which inturn
induce plastic uveitis in the sound eye.
• Common features between sympathetic ophthalmitis and Vogt Kanayagi Harada syndrome
is Autoimmune etiology & Uveitis
• In sympathetic ophthalmitis first sign is Presence of KP's.
• The earliest symptom of sympathetic ophthalmitis is Photophobia
• Sympathetic ophthalmitis develops 3 wks-12 wks after trauma
• Structure commonly involved in sympathetic ophthalmia is Iris and ciliary body
• Sympathetic ophthalmitis or ophthalmia almost always results from a penetrating wound
• Clinically in the non-injured eye, sympathetic ophthalmitis may manifest as Acute plastic
iridocyclitis,Neuroretinitis,Choroiditis
• Refsum's disease is a rare genetic disorder due to deficiency of phytanate alpha oxidase.
• Combination of retinitis pigmentosa and ichthyosis is seen in Refsum's syndrome.
• Ichthysis is caused by Refsum's syndrome.
• Refsum's syndrome is associated with Retinitis pigmentosa.
13. GLAUCOMA
• Double arcuate or ring shaped scotoma in glucoma develops when two arcuate scotomas join.
• Most common cause of neovascular glaucoma Diabetes
• Pupil in acute congestive glaucoma Vertically oval & semidilated
• Patient with open angle glaucoma of myopia, complains of blurring of vision on administration of
pilocarpine due to Small pupil
• Pseudophakia is a cause of secondary angle closure glaucoma
• Hundred day glaucoma is associated with CRVO
• Neovascular glaucoma is caused by CRVO, CRAO, Diabetes mellitus
• Tears of the iris sphincter and ciliary body is seen in angle recession glaucoma
• Angle recession more than 180 degree in angle recession glaucoma
• Secondary open angle glaucoma can occur in angle recession glaucoma
• Frequent change in presbyopic correction is seen in open angle glaucoma
• open angle glaucoma is most common with Open anterior chamber angle
• In angle closure glaucoma Small cornea, shallower Anterior chamber & Short axial length of eyeball
are the anatomical changes seen
• Angle closure glaucoma may be associated with Hypermetropia
• Most common etiolopathogenetic cause of glaucoma is Decreased outflow
• Intractable secondary glaucoma is seen in Diffuse iris melanoma
• Congenital glaucoma presents as Photophobia
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• First sign seen in open-angle glaucoma is Extension above blind spot
• The most reliable provocative test for angle-closure glaucoma is Dark room test
• In haemolytic glaucoma the mechanisms are Siderosis of trabeculae,Deposition of haemosiderin
& RBC clogging the trabecular
• Secondary glaucoma following corneal perforation is due to Peripheral anterior synechiae
• The earliest change in glaucoma is Baring of the blind spot
• In chronic simple glaucoma the most common field defect is Baring of blind spot
• Inverse glaucoma occurs in Spherophakia
• The walls of the orbit which are removed in the two wall decompression for proptosis of thyroid
ophthalmopathy include part of Orbital floor and medial wall
• Occurrence of diplopia, dysphagia, dysarthria, blurring of vision and muscle weakness could be due
to Botulism
• Muscle mostly affected in thyroid ophthalmopathy is Inferior rectus
• Earliest symptom of thyroid ophthalmopathy is Lid retraction
• Most common cause of proptosis in adults is Thyroid Ophthalmopathy
• Sign of thyroid ophthalmopathy are Van Graefe's sign , Dalrymple's sign & Joffroy's sing
• Most common ocular movement affected in thyroid ophthalmopathy Elevation
22. ASTIGMATISM
• Astigmatism is defined as refractory error wherein refraction varies along different meridians.
• Astigmatism is due to irregularity of curvature of cornea.
• Astigmatism is considered to be Spherical abberation.
• In simple astigmatism, foci of image formed on One on retina, other behind the retina.
• Regular stigmatism → Principal meridians are pendicular
• Irregular astigmatism → Principal meridians are not perpendicular.
• Lens used to treat astigmatism Cylindrical lens.
24. APHAKIA
• The typical signs of aphakia are deep anterior chamber, iridodonesis (tremulousness of iris) and a
dark pupillary reflex.
• Most common cause of aphakia is surgical removal of cataractous lens.
• In aphakia purkinje images absent are 3rd & 4th.
• Treatment of choice for Aphakia is IOL.
• The ideal rehabilitation for aphakia is Posterior chamber intraocular lens.
27. CONJUNCTIVITIS
28. TRACHOMA
PTERYGIUM
PINGUECULA
• Corneal dystrophies are degenerations that are usually Primary and bilateral.
Marginal crystalline
dystrophy of Bietti
Epithelial basement Lattice dystrophy is the most Fuch’s Endothelial
membrane dystrophy is common Stromal Corneal Dystrophy is the most
the most common dystrophy. common
Anterior Corneal Posterior/Lattice
Dystrophy Lattice Type I is the Dystrophy
commonest type of
dystrophy.
Endothelial corneal
Dystrophy is the least
common of the classical
stromal dystrophies
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33. BLOW-OUT FRACTURES
LACRIMAL APPARATUS
TEAR
2. Mucin deficiency:
• Xeropthalmia
• conjunctival scarring (Stevens- Johnson syndrome, Trachoma)
3. Lipid deficiency:
• Bell's palsy
• Exposure keratitis
• Pterygium
• Central part of macula appears as a red spot, whenever there is retinal edema.
• This is because, vascular choroid shins through the very thin area of retina at this area.
Idiopathic condition
Ophthalmoscopic findings:
Diagnosis:
2. Smoke-stack pattern:
TREATMENT
• When left alone, central serous retinopathy heals spontaneously within 4-12 weeks, with full
recovery of vision in 90% of patients.
• Reassurance is the only treatment required in majority of the cases.
• Most common early feature of diabetic retinopathy Dot and blot hemorrhages.
• Earliest feature of Diabetic Retinopathy is Microaneurysms.
• Diabetic retinopathy is characterized by Hard exudates, dot haemorrhages , microaneurysm, Flame
shaped haemorrhages & soft exudates.
• Sudden loss of vision in patient with diabetic retinopathy is due to Vitreous defects.
• Commonest cause of loss of vision in non-proliferative diabetic retinopathy is Macular edema.
• Diabetic retinopathy is treated by Strict glycemic control, Panphotococagulation, Antihypertensive.
• Diabetic retinopathy, most likely present with NIDDM with 2 years duration.
• Cotton wool spots in diabetic retinopathy are due to Retinal edema.
• Diabetic retinopathy is related to Duration of disease.
39. PAPILLOEDEMA
1. Demyelinating disorders
2. Viral infection
• Measles
• Mumps
• Chicken pox
• Whooping cough
• Glandular fever
3. Metabolic/Nutritional deficiency:
4. Toxic ambylopia
• Quinine
• Chloroquine
• Ethambutol
• Isoniazid
• Digitalis (digoxin)
• Methyl alcohol
• Unilateral
• Profound vision loss (major symptom)
• Mononuclear sudden, progressive & profound loss of vision
• Pain behind the eyeball, particularly in retrobulbar neuritis which there is pain on eye movements.
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• Visually evoked response (VER) shows reduced amplitude & delayed transmission time.
SIGNS
1. Clinical signs:
TREATMENT
• Intraocular part: 1 mm
• Intraorbital part: 25 - 30 mm
• Intracanalicular part: 5 - 9 mm
• Intracranial part: 10 - 16 mm
• Optic atrophy (partial, descending) – occurs in lesions of chiasma, optic tract and geniculate body
• Optic atrophy does not occur in lesions of optic radiations and visual cortex
• Intraocular part: 1 mm
• Intraorbital part: 25 - 30 mm
• Intracanalicular part: 5 - 9 mm
• Intracranial part: 10 - 16 mm
• Optic atrophy (partial, descending) – occurs in lesions of chiasma, optic tract and geniculate body
• Optic atrophy does not occur in lesions of optic radiations and visual cortex
1. Pseudoisochromatic charts
• Ishihara plates mainly to screen congenital protan & deuterons (i.e red & green defects)
6. Nagel’s anomaloscope
1. Cohort Study
2. Asbestosis
3. Odd's Ratio
• In a study done to establish Smoking as a risk factor for a disease, 30 out of 50 smokers developed
the disease while 10 out of 50 non-smokers developed the disease. Odd's ratio is 6
• Odds ratio is related to Relative risk
• Odds = Probability/(1-probability)
• Using case control study only odds ratio can be calculated.
• Association can be measured by odds ratio
• In a case control study, the most characteristic feature is odd's ratio
• Odds ration is designated as ad/bc
• Proportion of children underweight, Proportion of population using biomass fuel & Tuberculosis
morbity and mortality are part of MDG
• According to Millennium development goals Targets to be achieved by 2015
• In Millennium Development Goals (MDGs),3 out of 8 goals are health related
• Millennium development goals aim to reduce MMR by 3/4
• Eradication of extreme poverty, Global partnership for development, Sustainability of the
environment, Reducing child mortality comes under Millennium Development Goals (MDGs)
• Total number of goals in the Millennium Development Goals are 8
• MDG was adopted by UN 2000
• Reduce by 2/3" the tinder five mortality by year 1990-2015 MDG
• Number of children orphaned by HIV/AIDS, Prevalence and death rates of tuberculosis
& Prevalence and death rates of malaria comes under indicators of goal 6 of Millennium
Development Goal
• In Target 10 of Goal 7 of Millennium Development Goal, “access” to an improved water source
mean Availability of at least 20L water / person/ day from a source within 1 km of dwelling
• Millennium developmental goal for HIV/ AIDS is 6
7. ICEBERG PHENOMENON
• Infectious disease showing iceberg phenomenon are Rubella, Influenza, Polio, Japanese
encephalitis, Mumps , Hepatitis A and B & Diphtheria
• An infectious disease shows iceberg phenomenon. That means it has More subclinical case
• Demarcation line in iceberg disease is between Apparent and inapparent cases
• According to the concept of iceberg phenomenon of disease It includes sub-clinical cases, carriers
& It constitutes undiagnosed reservoir of infection
• Iceberg phenomenon differentiates Apparent and inapparent
Meningococcal vaccine:
• The vaccine for meningococcal meningitis is ineffective in children < 2 years old .
• Vaccines are available for group A, C, Y and W-125. There is no group B vaccine available at present.
• Meningococcal vaccines should be stored at 2-8° C.
• Vaccine for meningococcal meningitis should be routinely given to young adolescents.
• Bivalent meningococcal vaccine is is AC.
Rabies:
• Recombinant glycoprotein vaccines (Subunit vaccines) for Rabies are still in experimental Stage.
• Following rabies vaccines are commercially available : Killed sheep brain vaccine, Human diploid cell
vaccine , Vero continous cell vaccine.
• Recommended vaccines for rabies is HDCV.
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• Chick fibroblast anti-rabies vaccine has been recommended by WH.
• Neurological complications following Rabies vaccine is common with Semple Vaccine.
• Fixed virus is used to produe rabies vaccine.
• In rabies, human diploid cell culture vaccine for post-exposure vaccination is given on 0, 3, 7, 14, 28
then booster dose 90 days.
• Schedule of intradermal rabies vaccine is 8-0-4-0-1-1.
• Number of doses of HDCV vaccine required for preexposure prophylaxis is 3.
• Site for injection of cell culture rabies vaccine is Deltoid.
• It an cause adverse effects in persons with allergy to egg ,
Rota virus:
Hepatitis B:
• Risk of HIV transmission is not seen with plasma derived hepatitis B vaccine.
• Hepatitis B vaccine should be given as per which schedule at 0,1,6 months.
• Hepatitis B vaccine is a killed 'inactivated' vaccine
Live vaccines:
• Live Vaccines should be avoided in the long-term follow-up of a renal transplant recipient on
ciclosporin.
• Two live vaccines can be administered simultaneously..
• Booster doses are not required when live vaccines are administered.
• Single dose of live vaccine gives life long immunity.Live vaccine contains both major and minor
antigens.
• Live, attenuated virus and live bacterial vaccines generally are contraindicated during pregnancy.
• Minimum interval between 2 live vaccine immunization is 4 weeks.
BCG vaccine :
Polio vaccines:
• Two types of vaccines are used throughout the world :?Inactivated (salk) polio vaccine (IPV)
and Oral (sabin) polio vaccine (OPV)
• In OPV, the vaccine potency is stabilized with molar magnesium chloride or sucrose..
• IPV:Given in 4 doses,Being an inactivated vaccine, it can be given to immunosuppressed individuals,
e.g. AIDS patients,Produces circulatory antibody,Does not require stringent refrigeration,Not
effective in an epidemic,Does not provide Immunity against paralytic and wild strains ,It prevents
paralysis,Easily transported,Oral polio can be given as booster.
• Trivalent oral polio vaccine contains:
DPT vaccine:
Measles:
• Usually there is no preservative in measles vaccine, though it may contain very small amounts of
Kanamycin, neomycin or erythromycin..
• Measles vaccine given to contact of measles case exerts protective effect within 7 days.
• In measeles vaccine can be given within- 6 months.
• MMR is a type of live attenuated vaccine.
• Can cause TSS.
• Contraindicated in neomycin allergic patients.
• In epidemics measles vaccine is to be given within 3days of exposure.
• Encephalopathy can occur as complication
• It is a live vaccine.
• OKA strain is used to produce vaccine for Chicken Pox.
Cholera Vaccine:
• It is WC-r BS.
• Oral cholera vaccine is effective for 3 years.
Typhoid:
The Vi polysaccharide vaccine can be co-administered with other vaccines relevant for international
travelers.
Refrigerator:
• Deep freezers are used for making ice packs and to store OPV and measles vaccines.
• Vaccines which must be stored in cold part but never allowed to freeze are: typhoid, DPT, Tetanus
toxoid, DT, BCG, and diluents.
• Polyvalent snake vaccines contains immunoglobins against : Naja naja , Daboia rusellii , Bungarus
caeruleus.
• Bivalent HPV vaccine contains types 16,18.
• Mumps vaacine efficacy is 95%..
• Hepatitis A:
• Both live and inactivated for Hepatitis A.
• Recomended at age of 12 months.
• 2 dose of killed vaccine 6 months apart.
• 1 dose of live vaccine
• Intramuscular is is the route of administration of avian influenza vaccine.
• Children should receive Influenza vaccine at 2 doses at one month interval with one booster dose
later.
• Fundamental aspects of disaster management include disaster mitigation, disaster preparedness,
and disaster response.
• Rehabilitation,reconstruction and response are is seen in recovery phase after disaster.
• Vaccines recommended in disasters
• Following vaccines are recommendedVaccination against typhoid and cholera is not recommended.
1) Children < 10 years :- DPT, inactivated polio (IPV), H.influenzae type b (Hib), hepatitis B, pneumococcal
conjugate vaccine (PCV), measles-mumps-rubella (MMR), varicella vaccine, influenza, hepatitis A and
rotavirus.
• Hydrological disasters (i.e. floods, tsunamis) are associated with causing maximum death toll.
• Control room is is the nodal centre for disaster management.
• Disease common in Post-disaster Phase
• Gastroenteritis (MC) ,Acute respiratory tract infections (Pneumonia) , Leptospirosis ,Rickettsiosis
,Rabies ,Equine encephalitis.
• The 4 triage categories (with corresponding color codes), in precedence, are:
• Black indicates dead,
• Red indicates that the patient needs immediate attention,
• Green indicates that a patient has only minor injuries.
• Yellow signals medium priority
• A natural disaster is a major adverse event resulting from natural processes of the Earth; examples
include floods, volcanic eruptions, earthquakes, tsunamis, and other geologic processes.
• Accidental radioactive gas leak from factory is most commonly a result of human or mechanical
error and thus not a natural disaster.
9. Disaster Management
• Following vaccines are recommendedVaccination against typhoid and cholera is not recommended.
• Children < 10 years:- DPT, inactivated polio (IPV), H.influenzae type b (Hib), hepatitis B,
pneumococcal conjugate vaccine (PCV), measles-mumps-rubella (MMR), varicella
vaccine, influenza, hepatitis A and rotavirus.
• Children and adolescents (11-18 years):- Tetanus, diphtheria, pertussis, meningococcal conjugate
vaccine (MCV), Influenza.
• Adults (>18 years):- Tetanus, diphtheria, pertussis, pneumococcal polysaccharide vaccine (PPSV23),
and influenza.
• Hydrological disasters (i.e. floods, tsunamis) are associated with causing maximum death toll.
• Control room is is the nodal centre for disaster management.
• Time interval between invasion of the infection agent and appearance of first sign or symptom is
Incubation period.
• Incubation period is useful for : -
• Tracing the source of infection and contacts.
• Period of surveillance or quarantine
• Immunization
• Identification of point source or propagated epidemics
• Estimating the prognosis of a disease.
• As a rule, infectious diseases are not communicable during the incubation period, but there are
exceptions, for example, measles, chickenpox, whooping cough (pertusis) and hepatitis A are
communicable during the later part of incubation period.
• Epidemiological studies is carried for a period of twice the incubation period.
• Characteristic of a point source epidemic is that all cases develop within one incubation period.
• Prognosis of a disease can be given by- Incubation Period.
• In control of communicable diseases, the period of quarantine in respect of a disease is determined
by Incubation period.
• Incubation period of new disease determined by?Generation time.
• Leprosy is not targeted for global eradication because of Long incubation period.
• Shortest incubation period is seen in: Influenza.
• Incubation period of influenza is 18-72 hours.
• Incubation period of swine flu is 1-3 days.
• Incubation period of rubella is 2-3 weeks.
• Incubation period of typhoid is 3-20 days.
• The incubation period of yellow fever is 3-6 days.
• Incubation period of Hepatitis A is 2 to 4 weeks.
• Incubation period of staphylococcus aurues food poisoning is 1-6 hours.
• Incubation period of Cholera: few hours upto 5 days
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• Shortest incubation period is for food poisoning from Bacillus Cereus.
• Following are used as proxy measures for incubation period: Latent period ,Serial interval ,
Generation time.
• Incubation period of plasmodium vivax is 10-14 days.
• Incubation period of chancroid is < 7 days.
• Incubation period of Diptheria is 2-5 days.
• The usual incubation period of pertusis is 7-14 days.
• Incubation period of syphilis is 10-90 days.
• Incubation period of measles is 10 days.
• Average incubation period of AIDS is 10 years.
• Incubation period of gonorrhoea is 2-8 days.
• In leptospirosis, the incubation period ranges from 2 to 20 days.
• In rabies,Incubation period depends on the site of bite,number of bites,animal species.
• Incubation period of HBV is 45 to 180 days.
• There is long incubation period in prion disease.
• Incubation period of scabies is 4 weeks.
• The limitation of movement of well persons or animals exposed to communicable diseases for a
period usually not longer than the longest incubation period is known as Quarantine.
It consists of:
As per the World Health Organisation guidelines, iodine deficiency disorders are endemic in a community if
the prevalence of goiter in school age children in more than 5 %. The world health organisation day is 7th
April.
The headquarters of UNESCO is in Paris,WHO- Geneva. UNICEF- New york, FAO- Rome.
UNDP is an international agency which works for Development or human & natural resources in a country
.
World Bank :
• Sickness benefit under the ESI act consists of periodical cash payment to an insured person in case
of sickness. The benefit is payable for a maximum period of 91 days in any continuous period of 365
days, the daily rate being about 505 of daily wages.
• Under the ESI act, an insured woman is entitled to maternity benefit for 12 weeks in case of
confinement, 6 weeks for miscarriage, 30 days for sickness arising out of confinement.
• The Employees State Insurance (ESI) Act act passed in 1948
• Educational institutions are also included under ESI scope.But it is included only in some states and
there should be 20 or more employed persons
• ESI act does not cover railway
• The scheme is run by contribution by employees and employers and grants from central and state
governments?
• Employers contribution → 4.75% of total wages bills
• Employee contribution → 1.75% of total wages bills
• The state government's share of expenditure on medical care is '/8 of total cost of medical care.
• Clinical trials
• Risk factor trials
• Trial of etiological agents
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• Preventive trials
• Cessation experiment
• Evaluation of health services
In a neonate with inadequate breast milk intake the weight loss is more than 8-10%.
• Other signs of inadequate breast milk intake are: Less than six noticeably wet diapers per 24 h by
day 3–4 ,Less than four stools per day by day 3–4 ,Nursing less than eight times per 24 h.
•
• The protective effects of breast milk are known to be associated with IgA antibodies.
• Most common immunoglobulin secreted by mother in milk and colostrum is IgA.
• Para amino benzoic acid of breast milk prevent the infection of Plasmodium Vivax.
• Breast milk contains several antiinfective factors -
• Antibodies secretory IgA, IgM
• Lysozyme
• Antistaphylococcal factor
• Specific inhibitory substances against viral infections.
• Lactoferrin Inhibits growth of E. coli.
• Bile stimulated lipase kills entamoeba histolytica and Giardia lamblia.
• Bifidus factor -4 Inhibits growth of E. coli
• Para-amino-benzoic acid (PABA) - Provides protection against malaria
• Phagocytic macrophages and lymphoid cells
Under normal conditions breast milk production reaches a maximum when the baby is around 4 - 6
months.
Colostrum:
• Compared with mature milk, colostrum contains more minerals and amino acids. It also has more
protein, much of which is globulin, but less sugar and fat.
• It also contains antibodies, and its content of immunoglobulin A (IgA) offers the newborn
protection against enteric pathogens.
• Other host resistance factors found in colostrum and milk include complement, macrophages,
lymphocytes, lactoferrin, lactoperoxidase, and lysozymes.
Milk ejection occurs in response to a surge of oxytocin, which induces a contractile response in the smooth
muscle surrounding the gland ductules.
Cow Milk:
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• Whey protein constitutes 80% of the protein in human milk, while the main protein in cow's milk is
casein.
• Has more K+ and Na' than infant formula feeds.
• Has more protein than breast milk.
• Compared with Cow's milk, mothers milk has more lactose.
• Human milk has less fat, less protein, more carbohydrates and less calcium, in comparison to cow
milk .
• Cow's milk contains 3.2 % proteins.
• Percentage of lactose in human milk is 7.0 gm.
• Calcium in human milk is 35 mg/dl
• Hind milk is richer in fat.
Breast milk:
16. Sampling
Stratified Sampling.
• The method in which the sample is taken from each predefined strata of society is called Stratified
Sampling.
Systemic sampling:
Random Sampling:
• Quota sampling
• Volunteer sampling
• Convenience sampling
• Snowball sampling
In multistaged sampling,
• For a survey a village is divided into 5 lanes then each lane is sampled randomly is an example of
Stratified Random Sampling.
• In stratified random sampling, the population is divided into strata.
• Type of sampling, if random sample is taken from a characteristic population, eg. Hindus, Muslims,
Christians etc
Cluster sampling:
• it is a two-stage sampling.
• it is cheaper than other methods of sampling
• it has the disadvantage of higher sampling error.
• Children surveyed in cluster sampling for coverage of national immunization programme is 30
cluster of 7 children.
• A region is divided into 50 villages for the purpose of a survey. 10 villages are then selected
randomly for the purpose of a study. This type of sampling is termed as Cluster Sampling.
• Cluster sampling is cost effective.
• Is a Rapid and simple method.
• It is a type of probability sample.
• The sample size may vary according to study design.
• Estimation of percentage of children immunized in community as per WHO is to be done by Cluster
Sampling.
• In the WHO recommended EPI Cluster sampling for assessing primary immunization coverage, the
age group of children to be surveyed is 12-23 months.
• Design Effect' is associated
• Snowball sampling is used for hidden population
17. ASHA
ASHA(Accredited Social Health Activist) is the central component of the National Rural Health Mission
(NRHM):
1. Process Indicators:
2. Outcome Indicators:
3. Impact Indicators:
• The National Rural Health Mission (NRHM) was launched on 12th April 2005
• INcludes
• Reduction in IMR and MMR by 50% from existing levels in 7 years
• Integrating vertical Health and Family Welfare programmes at National, State, Block, and District
levels.
• Accredited Social Health Activists (ASHA)-Recruitment & training
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• formulation of state and district health programme
• Promotion of Rogi Kalyan Samiti
• NRHM aims at mainstreaming the Indian systems of medicine to facilitate healthcare
• Including posting of anaesthetists in CHC
• Integrated Management of Neonatal and Childhood Illness (IMNCI) includes
• Diarrhea, Malaria, Malnutrition, ARI (Pneumonia, Otitis media), Measles.
19. Lathyrism
Lathyrism
Toxin
• In a certain population, there were 4050 births in the last one year. There were 50 still births. 50
infants died within 7 days whereas 150 died within the first 28 days. Neonatal mortality rate is 50.
• Perinatal conditions like low birth weight is the commonest cause of IMR (20%). It is followed by
acute respiratory infection (19%), Diarrhoea (15%). Underlying malnutrition is present in 46% in
India.
• The socioeconomic status of community is best indicated by IMR.
• Maternal mortality rate:
• The numerator of the rate includes the total number of female deaths due to complications of
pregnancy, childbirth or within 42 days of delivery from puerperal causes in a particular area during
a given year.
• The denominator includes the total number of live births in a particular area during a particular
year and not the number of stillbirths and abortions.
• Perinatal Mortality rate includes: still borns and death within 7 days of birth.
c. Where (a) and (b) are not available body length (crown-heel) at at last 35 cm . should be used.
IMR = Number of deaths of children less than 1 year of age in a year X 1000/number of live births in the
same year.
• The maternal mortality rate is the number of maternal deaths due to childbearing per 100,000 live
births.
• The crude death rate is the total number of deaths per year per 1000 people
• Infant Mortality Rate for Japan is 3.
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• Mortality rates are taken into account while calculating Net Reproduction Rate.
• For international comparisons, perinatal mortality rate is calculated as late fetal deaths (28 weeks
gestation or more) plus early neonatal deaths (first week) [weighing over 1 kg at birth] in a year
per 1,000 live births [weighing over 1 kg at birth].
• Least neonatal mortality is recorded in Kerala.
• Proportional Mortality rate:It is defined as "number of deaths due to a particular cause (or in
specific age group) per 100 total deaths".
• Best indicator for burden of disease is Proportional mortality rate.
• Positive mortality indicator is Life Expectancy.
• In MCH programme, best indicator for mother and child health is IMR.
Multifactorial causation
Web of causation
• It is the action taken prior to onset of disease, which removes the possibility that a disease will ever
occur.
• Modes of Intervention:
• Health Promotion:
• Health Education, Environmental modifications, Nutritional interventions, Lifestyle & behavioural
changes
• Specific Protection:
• Example
• Immunization
• Installation of sanitary latrines
• Provision of safe water
• Use of mosquito net
• Health education (cancer education) and specific protection (radiation protection) are primary
levels of prevention..
• Wearing a seatbelt will not prevent the collision but may lessen its effects. Thus it is secondary level
of prevention.
• Modes of Intervention:
• Early Diagnosis
• Treatment
• It is an important level of prevention for diseases like Tuberculosis, Leprosy and STDs.
• Examples
• Breast self exam
• Total mastectomy for breast cancer
• Cervical pap smear checking
• Modes of Intervention:
• Disability Limitation:
• It 'prevents the transition of disease from impairment to handicap'.
• Rehabilitation
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• Examples
• Tendon transplant in leprosy
• Physiotherapy in residual polio myelitisProvision of spectacles for refractive errors
ii) Knowledge (expected years of schooling (Earlier Adult literacy rate) and mean years of schooling,
i.e. Gross enrolment ratio)
iii) Income GNI per capita (Earlier it was real GDP per capita in purchasing power parity in US
dollars)
• Epidemic dropsy is a condition caused by consumption of mustard oil contaminated with argemone
oil
• Active component of Argemone Mexicana is Sanguinarine.
Clinical features:
• To ensure availability and accessibility of minimum mental health care for all in the foreseeable
future, particularly to the most vulnerable and underprivileged sections of population
• To encourage application of mental health knowledge in general health care and in the social
development'.
• To promote community participation in the mental health services development7
• Provisions of voluntary admission and admission on the reception orders were retained.
• Role of Police and Magistrate to deal with cases of wandering mentally ill.
• Guardianship and Management of properties of mentally ill.
• Provisions of penalties in case of breach of provisions of the Act
JSY
• JSY is an abbreviation for Janani Suraksha Yojana. It is a new initiative by the RCH - phase II
(Reproductive and Child Health programme) which began from 1st April, 2005.
• Under Janani suraksha yojana Scheme, amount of financial incentive to ASHA per institutional
delivery in low performing state is 200 Rs.
• Benefit is awarded upto 2 live births.
• Janani Suraksha Yojana is applicable to poor women of low performing states for all births.
• The practices for preventing neonatal tetanus under JSY include clean hands, clean delivery
surface, clean cord care i.e. clean blade for cutting cord, clean cord tie and no application on cord
stump.
Essential Components
• A herd immunity of over 70% is considered necessary to prevent epidemic spread, but some believe
that the critical level may be as high as 90%.
• Herd immunity refers to group protection beyond what is afforded by the protection of immunized
individuals
• It is affected by :
• The presence and distribution of alternative animal hosts
• Depends on clinical and subclinical cases
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• Influenced by immunization
• In the case of tetanus, it does not protect the individual
• Herd immunity can be achieved by immunizing a population with a vaccine that interrupts
transmission
• The live virus in the vaccine can replicate in the immunized person and spread to other members of
the population
• The vaccine must prevent transmission of the virus as well as prevent disease.
Diptheria 85%
Measles 92-94%
Mumps 75-86%
Pertussis 92-94%
Polio 80-86%
Rubella 80-85%
31. Isolation
• "Isolation separates those who are already ill or infected from those who are not for the period of
communicability".
• For which diseases isolation is beneficial?
• Isolation has a distinctive value in the control of some infectious diseases, e.g.,
• diphtheria, cholera, streptococcal respiratory disease, pneumonic plague.
• Isolation is strictly recommended for pneumonic plague
• In some diseases where there is a large component of subclinical infection and carrier state, even
the most rigid isolation will not prevent the spread of disease, e.g.
• polio, hepatitis and typhoid fever.
31. Isolation
• "Isolation separates those who are already ill or infected from those who are not for the period of
communicability".
• For which diseases isolation is beneficial?
• Isolation has a distinctive value in the control of some infectious diseases, e.g.,
• diphtheria, cholera, streptococcal respiratory disease, pneumonic plague.
• Isolation is strictly recommended for pneumonic plague
Measles From the onset of catarrhal stage through 3rd day of rash
German None , except that women in the first trimester or sexually active, non-
measles immune women in childbearing years not using contraceptive measures
should not be exposed.
Cholera, 3 days after tetracyclines started, until 48 hours of antibiotics (or
diphtheria negative cultures after treatment)
Salmonellosis 3
Hepatitis 3 weeks
A
• 'Quarantine' (meaning "40 Days') is the restriction of activities of apparently healthy persons who
have been exposed to a case of communicable disease during its period of communicability
• It applies to those who have been exposed to a contagious disease but who may or may not
become ill.
• Quarantine was first applied for plague
• Quarantine period for yellow fever: 6 days (maximum IP)
• Quarantine period of cholera 5 days
• Quarantine currently has been 'replaced with active surveillance
• Absolute quarantine
• Restriction of movement for maximum incubation period.
• Modified quarantine
• A selective partial limitation of freedom of movement, such as the exclusion of children from
school.
33. Epidemic
Definition:
• Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is
normally expected in that population in that area.
Types Of Epidemic:
B. Propagated Epidemic.
Sex ratio
• Child sex ratio is defined as females (0-6 years age) per 1000 males (0-6 years age).
• Sex ratio at birth in India is 914.
35. Literacy
• It was decided in 1991 census to use the term literacy rate for the population > 7 years
• A person is deemed as literate if he or she can read and write with understanding in any language
• Was introduced in a large scale in 1960s under the chief ministership of K. Kamraj Nadar in Tamil
Nadu.
• The meal supply should provide at least one-third of the total energy requirement, and half of the
protein need.
36. Crude Birth Rate, Crude Death Rate And Growth Rate
• CRUDE means it include all causes and all ages - It is independent of age of population
Denominator
Growth rate
Skin
1. Pityriasis Versicolor
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• The skin patches often fluoresce an apple green in long-wave UVR (Wood's light).
• Ketoconazole shampoo to wash the affected areas once daily for 5 days
• Caused by yeast-like micro-organism Pityrosporum ovale (orbiculare) or Malessezia furfur
2. Tinea capitis
3. Dermatitis herpetiformis
4. Acrodermatitis enteropathica
• Autosomal recessive
• Inherited form of zinc deficiency
• Triad of
• Acral dermatitis (face, hands, feet, anogenital area)
• Alopecia
• Diarrhea
• Treatment
• Requires lifelong zinc supplementation
5. Dermatomyositis
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• Groton's sign is seen in Dermatomyositis
• Heliotrope rash is seen in Dermatomyositis
• Gottrens papules, Helitrope rash & Mechanics hand is seen in Dermatomyositis
• Perifascicular atropy of muscle fibres is seen in Dermatomyositis
• A 40 year old woman presented with a 8 month history of erythema and swelling of the periorbital
region & papules & plaques on the dorsolateral aspect of forearms & knuckles with ragged cuticles.
There was no muscle weakness is diagnosed to have dermatomyositis
6. ELECTROCONVULSIVE THERAPY
• ECT operates a modulation of serum Brain derived neurotrophic factor levels in drug resistant
depressed patients.
• There is no absolute contraindication for ECT
• Mainly used for the treatment of major depressive disorder
• Pheochromocytoma is a relative contraindication
7. Vitiligo
8. URTICARIA
9. ERYTHEMA MULTIFORME
• The most clinically significant skin eruption associated with M. pneumoniae infection is Erythema
multiforme major
• After taking sulphonamide group of drugs, one patient developed certain oral lesions of Erythema
multiforme
• Erythema multiforme lesions consist of vesicles, ruptured to form ulcers covered with
pseudomembrane.
• While touching, the lesions of Erythema multiforme bleed easily with Hemorrhagic crusts on lips
and other skin .
• Commonest etiology among infection of erythema multiforme is Viral
• In Erythema multiforme Target lesions are seen
• Erythema multiforme Involves face and neck regions
• Erythema multiform shows Sign of internal malignancy
• Erythema multiforme is most commonly caused by idiopathy
• The portion of the skin that serves as a barrier to water loss is the Epidermis
• Melanoblast cells appear in basal layer of epidermis during 3rd month of intrauterine life
• Lymphatics are found in Dermis of skin
• Stratum corneum is underdeveloped in the VLBW infants in the initial 7 days
• Normal turnover time of epidermis (skin doubling time) is 4 weeks
• Function of the epidermis layer of the skin provides a waterproof barrier and creates our skin tone.
• Haascheiben cells in epidermis are responsible for Touch
• Dead layer of epidermis is Stratum corneum
• Skin and facia of great toe drains into Vertical group of superficial inguinal lymph nodes
• It has been calculated that a human adult has about 1012 bacteria on the skin
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• Density of bacterial population at most sites is between 100-1000 per square cm.
12. IMPETIGO
15. Icthyosis
18. Pellagra
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• Pellagra is characterized by classical triad of 3Ds :-Diarrhea,Dermatitis,Dementia.
• Pellagra is due to deficiency of Niacin.
• In South India pellagra is reported in population eating Jowar.
• Pellagra in jowar eating population is due to excess of Leucine.
• Patient presenting with pellagra, parkinsonism, convulsions, anemia and kidney stones has
deficiency of Pyridoxal Phosphate.
• Development of pellagra like skin lesion in carcinoid syndrome is due to inadequate conversion of
Tryptophan to Niacin.
• A 10 year old child is suspected of having pellagra because of chronic symptoms including diarrhea,
a red scaly rash, and mild cerebellar ataxia. However, his diet is not deficient in protein and he
appears to be ingesting adequate amounts of niacin. A sister has a similar problem. Chemical
analysis of his urine demonstrates large amounts of free amino acids. Hartnup's Disease is the most
probable diagnosis.
• Consumption of maize may aggravate Pellagra. As some strains of maize contains excess of Leucine
which interferes in the conversion of Tryptophan into Niacin.
• Casal's paint necklace is caused by Pellagra.
• Photosensitive dermatitis are Psoriasis, Pellagra, Pemphigus, SLE, Congenital erythropoietic
porphyria
19. Chancroid
22. Leprosy
25. Impetigo
• A 3 year old child is seen by a pediatrician because he has developed multiple isolated lesions on his
face and neck. Physical examination reveals many lesions up to 4 cm in diameter with golden crusts,
while in other sites small blisters and weeping areas are seen.Impetigo is the most likely diagnosis.
• Impetigo contagiosa may be caused by Staphylococcus aureus (most common) or Group A beta
hemolytic streptococci or by both.
• Bullous impetigo caused by S. aureus mostly
• Impetigo may predispose to glomerulonephritis.
• Impetigo does not produce scar on healing.
• Commonest skin infection in children is Impetigo Contagiosa.
• 'Honey colored' crusts are characteristic of Impetigo.
• Impetigo is a contagious bacterial infection.
• Impetigo is a pyoderma.
• Treatment for impetigo is Dicloxacillin.
• Pigment production by staphylococcus aureus occurs in Bullous Impetigo.
• Nikolsky's sign is seen in Bullous Impetigo.
27. Dermatitis
• A combination therapy with steroids and Dapsone is used in generalised Lichen Planus.
• LP is characterized by shiny, violaceous, flat-topped polygonal papules which retain the skin lines.
• Wickham’s striae are white lines which traverse the surface of the papules.
• A focal increase in thickness of the granular layer and infiltrate corresponds to the presence of
Wickham’s striae.
• Mouth lesions are seen in Lichen Planus.
• Skin, hair and oral mucosa commonly involved in Lichen Planus.
• Features of Lichen planus are Pruritus, Purple, Papule
• Max. Joseph's space is a histopatho-logical feature of Lichen Planus.
• Civatte bodies are found in Lichen Planus.
• Following is seen in a case of Leprosy:Basal cell degeneration; Colloid bodies seen; Epidermal
hyperplasia in chronic cases.
• A young lady presents with lacy lesions in oral cavity and genitals, and her proximal nail fold has
extended onto the nail bed. Lichen Planus is the likely diagnosis.
• A 30 year old male present with pruritic flat-topped polygonal, shiny violaceous papules with
flexural distribution. the most likely diagnosis is Lichen Planus.
• Lymphatic infiltration in supradermal layer is seen in Lichen Planus.
• Lichen Planus may be associated with Hepatitis C.
• Topical Steroids are the mainstay of therapy in Lichen Planus.
• Spontaneous remissions may be seen in 6month to 2years.
• Characterstic nail finding in lichen planus is Pterygium.
• Most characteristic Feature of lichen planus is Wickham Striae.
• The most characteristic finding In lichen planus is Basal Cell Degeneration.
• Nail deformity commonly seen in lichen planus are Pterygium,Longitudnal grooves,Oncholysis.
• Wood's lamp is not used for diagnosing Lichen Planus.
• Lichen planopilaris,Lichen hypertrophica, Lichen pigmentosa are the types of Lichen Planus.
• Lichen scrofulosorum is a type of cutaneous TB, not the lichen planus.
• Koebner phenomenon may be seen in Lichen Planus.
• The role of Lichen Planus in predisposing Squamous cell carcinoma of Oral cavity is uncertain.
31. Psoriasis
34. Rosacea
• An 76 year lady had a history of a red facial rash suffered venous eczema of legs. She was treated
for acne rosacea by her GP. On examination, she had bluish pigmentation on both the legs.
Minocycline is likely to have caused this.
• A 40-year-old woman presents with a 2-year history of erythematous papulopustular lesions on the
convexities of the face. There is a background of erythema and telangiectasia. The most likely
diagnosis in the patient is Rosacea.
35. Acne
37. Alopecia
• Rapid, diffuse, excessive hair loss after 3 months of pregnancy is due to Telogen Effluvium.
• An 8-yrs-old male presents with multiple patches of alopecia and severe pruritus. A bright blue-
green fluorescence is seen on examination of the scalp with a wood lamp. Pathogen most likely
responsible is Microsporum Canis.
• Pitting of nails can be seen in Alopecia Areata.
Psychiatry
2. OBSESSIVE-COMPULSIVE DISORDER
3. Phobia
• The woman who cannot urinate in a restroom because of embarrassment is probably suffering
from social phobia.
• Agoraphobia is a disorder characterized by Avoidance of situations in which it occurs ,Presence of
panic symptoms, Avoidance of being outside alone
• Phobia is neurosis
• Commonest type of phobia seen in clinical practice is Agoraphobia
• Displacement is the defense mechanism in phobia
• Patient of contamination phobia was asked by therapist to follow behind and touch everything he
touches in patients house Therapist kept talking quietly & calmly all the time .This procedure is
called modelling
• Systemic de-sensitization therapy is used for phobia
• In Agoraphobia behavioural therapy is helpful
• Thanatophobia – fear of death
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• Claustro phobia- Fear of closed spaces
• Acrophobia – fear of high places.
• Definitive treatment of all types of phobias is behavioural therapy
• Systemic desensitization,Psychodynamic therapy,Exposure therapy are the method of
treating Agoraphobia
• SSRI is first line treatment for Panic disorder, Social phobia, Post traumatic stress disorder
6. PANIC DISORDER
• Sudden onset breathlessness, anxiety, palpitation & feeling of impending doom suggest panic
attacks
• Patient showing Chest pain, sweating, restlessness, dyspnoea, and palpitation which
is asymptomatic with supportive measures is diagnosed to have panic disorder
• Patient afraid of dying, experiencing chest pain, a sensation of choking, nausea, and tingling
sensations, face is flushed and sweating, high pulse and respirations rate but 15 minutes later
symptoms are dissipating & normal ECG suggest Panic disorder
• Behaviour therapy is useful in panic disorder
• Panic attack is Acute anxiety
• Panic attack is associated with a disturbance in Serotonin, GABA,Dopamine, CCK, pentagastrin
• SSRI is first line treatment for panic disorder
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• Agoraphobia associated with panic disorder
• Muscle tension,Irritability,Restlessness but not Fear of impedending doom are seen in general
anxiety disorder
• Lithium is not used in treatment of general anxiety disorder
• SSRIs are not effective in treatment of general anxiety disorder
8. Psychosexual Phases
9. Sexual Perversions
• Repeated episodes of excessive eating followed by purging by use of laxatives is seen in Bulimia
nervosa
• Anorexia nervosa can be differentiated from bulimia by Peculiars patterns of food handing
• The main differnce between anorexia nervosa and bulimia nervosa depends on weight
• Bilateral parotid enlargement with repeated episodes of uncontrolled eating is seen in Bulimia
nervosa
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11. REM Sleep
• Brain is very active but muscles are virtually paralyzed in REM sleep
• Irregular breathing,depressed Muscle tone in the body ,active dreaming are seen in REM sleep
• Disturbances in sleep due to depression are associated with Decreased REM (rapid eye movement)
latency
• Bruxism is not seen in REM sleep
• Neurotransmitter For REM sleep is acetylcholine
• REM sleep Shows ? rhytm on EEG
• The condition known as REM sleep is Referred to as paradoxical sleep.
• Nightmare is seen in REM sleep
• Growth hormone secretion is decreased by REM sleep
12. Schizophrenia
• Good prognosis in schizophrenia is indicated by Late Onset ,Catatonic features ,Pyknic Built ,No
Family history, Acute onset ,Emotions are preserved ,Type I
• Subtle involuntary movements of hands, feet, lips, and tongue on decreasing the dose of
haloperidol is increase initially as the medication is decreased
• Resistant,negative symptoms & Refractory Schizophrenia is an indication for the use of Clozapine
• Drugs used in the treatment of schizophrenia have in common their ability to Block dopamine
receptors in the brain
• In Schizophrenia treated with CPZ (chlorpromazine) if develops auditory hallucination again should
be given Clozapine
• After the initiation of haloperidol if the patient shows be restlessness, fidgety, irritability and
cannot sit still at one place should be treated with betablocker
• Schizophrenia patient treated with Clozapine medication may develope purposeless involuntary
facial and limb movements, constant chewing and puffing of cheeks
• Bad prognostic indicator of Schizophrenia are Family history ,Poor Prognostic Factors,Younger age
of onset ,Disorganized type,Asthenic built,Chronic type,Blunting of affect or atypical Feature
Present,Type II
• Common Drugs used in schizophrenia include Chlorpromazine,Haloperidol,Olanzapine
• BY ERIK.H.ERICKSON (1963)
• Erik Erikson was a follower of Sigmund Freud who broke with his teacher over the fundamental
point of what motivates or drives human behavior.
• For Freud it was biology or more specifically the biological instincts of life and aggression.
• His developmental theory of the "Eight Stages of Man" was unique in that it covered the entire
lifespan rather than childhood and adolescent development.
• In Piaget's theory of cognitive development 'out of sight, out of mind' and 'here and now' is seen
in Sensory-motor stage
• Concrete thinking stage of cognitive development is 5-10 years
18. AUTISM
• Developed Isolated area of talent ,No attribution of Parental attitude and behavior
& delayed Emergence of speech and social smile is often suggestive of childhood autism
• A 5-year-old boy with normal motor skills has severe language delay, shows no interest in
interacting with other children or with adults, and spends a lot of time spinning around. The most
likely diagnosis for this child is Infantile autism
• A 3 year old child presents with developmental delayed in speech. He has difficulty in
communication and social interactions. His teachers and parents are worried that he is not making
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any friends. He is observed to have unusual routines and repetitive activities is diagnosed to have
autism.
• The parents of a 4-year-old girl Mili is worried that she is isolating herself from people. She seems
to be deeply involved in her own games and keeping her toys in a particular order. She does not
speak full sentences yet. All other developmental milestones were normal. She does not leave
parents when she is taken out to a party or shopping. She finds it difficult to concentrate on reading
and has not managed to write alphabets is diagnosed to have autism.
• A 6-year-old boy is observed to be peculiar by his teacher. Children attempt to play with him but his
response is to either ignore them or get angry at their advances. This response in someone with
autism might best be described as Lack of social reciprocity.
• Autism Starts before 2-3 years of age
• Autism is Social and language communication problem
• A student justifying his bad marks in an examination saying that the teacher did not give him the
marks that he deserve because he does not like him, is an example of Projection defence
mechanism.
• Anticipation & Altruism is a mature defence mechanism
• Ego's defence mechanism "Undoing" is typically seen in Obsessive compulsive neurosis
• One of the important defence mechanism is Repression
• Projection, Undoing,Conversion & Reaction formation are defence mechanisms of ego
• Defence mechanism in OCD Repression,Undoing & Displacement
Radiology
1. Frontal Sinus
• Caldwell view is the best method to see frontal sinus in patients with recurrent frontal sinusitis
• Frontal sinus drain into Middle meatus
• Most superior sinus in the face is Frontal sinus
2. PET Scan
3. MRI Scan
4. CT Scan
• Most sensitive and specific investigation for screening of Renovascular hypertension is Spiral CT
Angiography.
• Investigation of choice for juvenile nasoangiofibroma is Contrast enhanced CT Scan.
• CECT is the investigation of choice in a patient with blunt abdominal trauma with hematuria.
• Presence of calcification on an intracranial lesion is best made out by CT Scan
• Initial Investigation of choice of subarachnoid hemorrhage is CT Scan.
• Trauma to spleen in a stable patient is best diagnosed by CT scan.
• Endoscopic sinus surgery prerequisite is CT scan of PNS.
• Investigation of choice for Acute pancreatitis is CT Scan.
• IOC for ureteric stone with acute colic is Non Contrast CT scan.
• IOC for interstitial lung disease is CT scan.
• Investigation of choice for bronchiectasis is CT scan.
• IOC for pleural effusion is CECT.
• Best diagnosis of pancreatic cancer (head) is by CT scan.
• About non contrast CT scan in head injury:
• Extra dural haematomas are usually lens shaped.
• Acute subdural hematoma appears as crescent shadow of increased density.
• Subarachnoid haemorrhage appears as areas of increased density in basilar cisterns.
• In a patient with renal cell carcinoma with a thrombus in the IVCrenal vein, CT scan is the best for
diagnosis.
• In a case of Cushing's Syndrome,Adrenal CT scan distinguishes adrenal tumour from cortical
hyperplasia.
• Most diagnostic of pulmonary embolism in a high-risk case is Multidetector CT angiography
• Investigation of choice for small intestine tumor: CT scan with contrast.
• Investigation of choice for vascular ring around airway is CT scan.
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• Investigation of choice for a lesion of temporal bone is CT scan.
• Slip ring technology is useful for CT scan.
• Preferred imaging modality for choanal atresia is CT scan.
• Most reliable test for spinal tuberculosis is CT guided Biopsy.
• NCCT head is the investigation of choice for evaluation of acute head injury.
5. USG
• To detect a 4 mm nodule in the pancreas, the investigation of your choice would be Endoscopic
USG.
• USG examination of an 8 weeks pregnant female shows a gestational sac with absent fetal parts.
The diagnosis is Blighted Ovum.
• Basanti, a 28yrs aged female with a history of 6 weeks of amenorrhea presents with pain in
abdomen; USG shows fluid in pouch of douglas. Aspiration yields dark colour blood that fails to clot.
Most probable diagnosis is Ruptured Ectopic Pregnancy.
• Young lady presents with acute abdominal pain and history of 1 1/2 months amenorrhoea. On USG
examination there is collection of fluid in the pouch of douglas and empty gestational sac. Diagnosis
is Ectopic Pregnancy.
• USG sign of fetal death:Heart beat absent; and Spalding sign.
• Contrast used in USG is Sonavist.
• USG is sensitive in Gall Stone,Blunt abdominal trauma.
• Piezoelectric crystals are made use of that is safe from radiation also,in USG.
• Midline hypoechoic mass with dilated lateral ventricles (on USG), bruit on auscultation,
hydrocephalus and high output cardiac failure in neonates/ infants is diagnostic of vein of galen
malformation.
• Ultrasonography is the investigation of choice to confirm diagnose of hypertrophic pyloric stenosis
with accuracy > 95% (approching almost 100%). USG visualizes thickened and elongated pyloric
canal. USG criteria for diagnosis include >16 mm pyloric length and >4mm pyloric muscle wall
thickness.
• Thickened gall bladder wall in USG seen in? Acute cholecystitis ,Mucosal thickening, Cholesterosis.
• Features of cholecystitis on USG : Thick fibrosed gallbladder wall , Stone impacted at neck of gall
bladder , Perigallbladder halo.
• Focal and diffuse thickening of gall bladder wall with high amplitude reflections and 'comet tail'
artifacts on USG suggest the diagnosis of Adenomyomatosis.
• Ectopic pregnacny, characteristic finding in USG is absence of gestational sac in uterus.
• Most accurate assessment of gestational age by USG is done by Crown Rump Length.
• 20 yr old man with progressive proptosis which increases on bending forward. It is compressible
and has no bruit or thrill. USG showed "hyperintense" mass with shadowing of mass. The diagnosis
is Orbital Varix.
• Ultrasound is the first radiological investigation done to evaluate obstructive or any jaundice. It is
both sensitive and specific for diagnosing gallbladder stones and biliary tract dilatation..
• USG is very sensitive for ascites.USG can detect as little as 100 ml of peritoneal fluid.
7. ERCP,MRCP,HIDA Scan
• Biliary radionuclide scanning (HIDA scan) may be of help in the atypical case. Lack of filling of the
gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of acute
cholecystitis, is highly sensitive and specific for acute cholecystitis. A normal HIDA scan excludes
acute cholecystitis.
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• Best screening method for Mirizzi syndrome is: ERCP.
• Risk factors for post-ERCP pancreatitis are minor papilla sphincterotomy, sphincter of Oddi
dysfunction, prior history of post-ERCP pancreatitis, age 2 contrast injections into the pancreatic
duct..
• Elective ERCP with sphincterotomy is considered in patients with persistent / incipient biliary
obstruction, those who are poor candidates for cholecystectomy, and for those in whom there is
strong suspicion for bile duct stones after cholecystectomy. ERCP with stent placement is indicated
for pancreatic ductal disruptions..
• Urgent ERCP is indicated in patients who have severe acute biliary pancreatitis with cholangitis.
• ERCP in pancreatitis is done to know about Gall Stones.
• Magnetic resonance cholangio pancreatography (MRCP) is a non - invasive alternative to evaluate
biliary tree.It is used to obtain the image.
• Best investigation for acute cholecystitis is HIDA Scan.
• ERCP is the gold standard for diagnosing CBD stones..
• ERCP, sphincterotomy and balloon clearance is now the standard treatment for stone in the
common bile duct.
• ERCP may provide direct diagnosis of the distal CBD pathology and may be therapeutic as well for a
CBD stone or stricture..
• 5 days after CBD surgery there is a small leak. ERCP and Stenting will be the best T/t.
• ERCP is the most sensitive test for detecting pancreatic cancer but CT scan is the inv. of choice.
• Most common complication after ERCP is Acute pancreatitis.
• Best investigation for diagnosis of ampullary gall stone with obstructive jaundice is ERCP.
• Chain of lakes appearance on ERCP is seen in Chronic Relapsing Pancreatitis.
• On HIDA scan. gall bladder is not visualized.
• Magnetic resonance cholangiopancreatography (MRCP) is not a cause of Acute pancreatitis.
• Principle of MRCP:Use of heavily T2-weighted image without contrast to create the three
dimensional image of the biliary tree using MIP algorithm.
• A 3-month-old child with history of passage of clay colored stools and dark yellow urine since one
month was given steroids and ursodeoxycholic acid. On further investigation, he was found to have
direct bilirubin of 6 mg%. HIDA Scan is the most sensitive investigation for the diagnosis of above-
mentioned condition.
9. Barium Studies
11. Radiation
Causes include:
• Pneumonia
• Inhalation of toxins - such as chlorine, mustard gas, smoke
• Circulating toxins - such as histamine, septicaemia
• Disseminated intravascular coagulation
• Intravenous drug use like heroin
• heart failure:
• X-ray tubes produce x-ray by accelerating electrons to high energies (PG1 04, MP 01). The x-ray
tube filament (cathode) is heated to incandescense so that it emits electrons (liPn'r 9°' TN 9°) by
thermoionic emmision. A high voltage is applied between filament (cathode) and target (anode) so
that the electrons are attracted towards anode and the electrons from the filament are accelerated
away from the negatively charged filament to positively charged target. When the electrons hit the
anode (the target), x-rays are produced. These x-rays are used to take all conventional radiography
(plane x-ray) and computed tomograph (CT).
• You should know that these x-rays are photon. When electron strikes it produces photon by either
of two mechanisms:?
• Simple radiography : - When we use the term x-ray in radiology, it usually means simple
radiography. It is also called plane x-ray. In simple radiography an x-ray beam is passed through the
patient to a photographic plate (x-ray plate).
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16. New imaging techniques in USG
Ultrasound:
Ultrasonography
• The patient is injected with a small amount of radioactive material such as 600 MBq of technetium-
99m-MDP and then scanned with a gamma camera, a device sensitive to the radiation emitted by
the injected material.
• Two-dimensional projections of scintigraphy may be enough, but in order to view small lesions (less
than 1 cm) especially in the spine, single photon emission computed tomography (SPECT) imaging
technique may be required. About half of the radioactive material is localized by the bones. The
more active the bone turnover, the more radioactive material will be seen.
• Not all tumors are easily seen on the bone scan.
• Some lesions, especially lytic (destructive) ones, require positron emission tomography (PET)
• he nucleide then undergoes a nuclear reaction with the localized release of substantial amount of
energy and kills the tagged cancer cells but does not damage the surrounding untagged normal
cells.
• At present moderated neutron beams from nuclear reactors are used but there is ongoing work in
developing high current particle accelerator to produce low energy thermal or epithermal beams
for BNCT.
20. RADIOTHERAPY
• The postoperative radiotherapy in Willm's tumor is started within 10 days of surgery. Delay in
starting RT beyond 10 days leads to tumor cell repopulation and increase in relapse rate.
• Indication of RT in Willim's tumor are:
3.Metastatic disease
• Cytotoxic drugs and radiation cause cellular damage which leads to release of 5-HT from intestine
and activation of emetogenic 5-HT3 receptors. Therefore, 5-HT3 receptor antagonists (e.g.
ondenstron) are the DOC for this condition.
• Cisplatin is the most common culprit causing chemotherapy induced nausea and vomiting.
• Drugs used to treat chemotherapy induced nausea and vomiting are:
• Cisplatin can induce vomiting within 24 hours or after 2 days. DOC for the early vomiting is
ondensetron while for delayed vomiting is aprepitant (substant P antagonist).
• 1-122
• Radioactive isotopes that are used in treatment of cancer are
• Cesium; b i.e. Cobalt
• Which of the following radioactive isotopes is not used for brachytherapy:
• Iodine -131
• Which of the following radioisotopes is commonly used as a source for external beam radiotherapy
in the treatment of cancer patients
• Cobalt - 60
• Which of the following chemicals or isotopes is used in cardiac ventriculography?
• 99m Technitium is used as an isotope in Cardiac Ventriculography. It is a medical imaging technique
used to detemine the cardiac functions. Ejection fraction, stroke volume and cardiac output can be
measured by the procedure. Gallium is used to find out places where inflammation is present.
Most common radio-isotopes used as a source for external beam radiotherapy in the treatment of
cancer:
• Cobalt 60 is commonly used as a source for external beam radiotherapy in the treatment of cancer
patients
Anaesthesia
• Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the
area of distribution of ulnar nerve
• Pneumothorax is a common complication of brachial plexus nerve block
• Persistent paresthesia of forearm is due to injury to the peripheral nerve seen as complication of
axillary nerve block
2. Epidural anaesthesia
• Lower Segment Caesarean section (LSCS) can be carried out under Combined Spinal Epidural
anaesthesia
• In pregnant patients with mitral stenosis, mitral regurgitation, aortic stenosis or aortic regurgitation
epidural anaesthesia is the preferred route during labour.
• 2% concentration of lignocaine is used in epidural anaesthesia
• Epidural anaesthesia in pregnancy is Given through Epidural space
• Epidural anaesthesia in pregnancy Decreased venous return,Bladder
distension,Hypotension,Nausea & Hypotension
• Hypopnoea, Total spinal analgesia, Urinary retention are the complications of Epidural anaesthesia
in pregnancy
• T10 – S5 level of block outside dura is desired for painless delivery by epidural anaesthesia
• Epidural anaesthesia is preferred over spinal anaesthesia because of Prolonged duration of effect
4. INTUBATION
• Submental intubation is the choice in a patient with Le-fort II, Le-fort III, & naso-ethmoid fracture
• Difficult oral intubation may be associated with Receding lower jaw, Poor mobility of mandible
& Protruding upper incisor tooth
• Mallampatti classification is used for Inspection of oral cavity before intubation
• Blind nasal intubation is indicated in TM joint ankylosis, Impossible laryngoscopy & CSF otorrhea
• In severe maxillofacial trauma with low Sp02 the immediate management is Orotracheal
intubation
• Merits of nasotracheal intubation is Good oral hygiene
• Miller's sign, TMJ ankylosis & Micrognathia are related to difficult intubation
• An anaesthetist is using Mallampati classification for Inspection of oral cavity before intubation
• TM joint ankylosis, Impossible laryngoscopy & CSF otorrhea are indication for blind nasal
intubation
• Indication for endotracheal intubation are Pulmonary toilet, Maintenance of a patent airway & To
provide positive pressure ventilation
• RTA leading to ribs fracture producing flial chest and respiratory distress is managed with IPPV with
oral intubation
• During intubation of a child, type of endotracheal tube and blade of laryngoscope is Uncuffed tube
with straight blade
• A child presented in the casuality with fever, unconcous & papilloedema should be Intubated
• Endotracheal intubation reduces normal anatomical dead space
• Laryngea Mast Airway Intubation can be done
• During laryngoscopy and endo-tracheal intubation Flexion of the neck, Extension of Head at the
atlanto-occipital joint & In a straight blade laryngoscope, the epiglottis is lifted by the tip are the
maneuver to be performed
• Nasal intubation is contra indicated in CSF Rhinorrhea
• Both Oral and Nasal intubation are Acute Tracheo - Laryngo - bronchitis
• Intubation dose of pancuronium is 0.08 mg/Kg
5. LARYNGOSCOPY
6. MALIGNANT HYPERTHERMIA
7. ETOMIDATE
8. KETAMINE
9. NITROUS OXIDE
10. XENON
• In Patient with mitral stenosis, & liver compromise Xenon inhalational agent is preferred
• Rapid induction and recovery is seen in Xenon
• Xenon have Low potency
• Xenon is Non explosive
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• Minimal cardiovascular side effects is seen with Xenon
• Xenon inhibits Ca. pump and low blood gas solubility
• Xenon acts through NMDA receptors
11. FENTANYL
• A patient after undergoing thoracotomy complains of severe pain. He can be managed by I.V
fentanyl
• Chest wall rigidly is the common side effects is seen with fentanyl
• A 25 year old overweight female was given fentanyl-pancuronium anesthesia for surgery. After
surgery and extubation she was observed to have limited movement of the upper body and chest
wall in the recovery room. She was conscious and alert but voluntary respiratory effort was limited.
Her blood pressure and heart rate were normal. The likely diagnosis is Incomplete reversal of
pancuronium
• Propofol, fentanyl, isoflurane are the most preferred for short day care surgeries
• Drug used for Epidural Analgesic is Fentanyl
• Management of chronic pain includes Epidural fentanyl
12. Ether
13. LIGNOCAINE
• To provide anesthesia to a patient in the third stage of labor, an obstetrician palpates the ischial
spine transvaginally, then injects a local anesthetic. Injection of anesthetic at this approximate
location will most likely block Pudendal nerve
• A patient with external hemorrhoids develops pain while passing stools. The nerve mediating this
pain is Pudendal nerve
• Pudendal Nerve Block Involve S2S3S4
Internal Medicine
Abnormalities:
• Tricuspid stenosis
• Cardiac tamponade
• Tricuspid stenosis
2. Pseudohypoparathyroidism
PSEUDOHYPOPARATHYROIDISM
3. Cluster Headache
Symptoms:
4. Ataxia telengiectasia
ATAXIA TELANGIECTASIA
• Gene involved – ATM gene on chromosome 11 which encodes Atm protein kinase, a member of
phosphatidyl inositol 3-kinase family.
• Only phacomatotic hereditary condition transmitted in the autosomal recessive mode, where
combined immunodeficiency is associated with cerebellar ataxia, telangiectasia, ovarian dysgenesis
& chromosomal abnormalities.
• Presents in the first decade of life with progressive telangiectatic lesions and ataxia & chorio-
athetoid movements associated with deficits in cerebellar function and nystagmus
5. Friedrich's Ataxia
FRIEDREICH'S ATAXIA
6. Rhabdomyolysis
RHABDOMYOLYSIS
Causes:
Complications:
• Myoglobinuria
• Acute Renal Failure
• The most common variant of Non-Hodgkin's Lymphoma in India is Diffuse Large B cell Lymphoma.
• Immunophenotype of Diffuse Large B Cell Lymphoma:
• They will demonstrate markers of mature B lymphocytes as well as germinal centre markers- CD 19-
CD 20 - CD 10- BCL-6- slg- BCL-2 (see in 10% to 20% associated with t(14:18)).
• Incidence of Diffuse Large B Cell lymphoma is more common in males.
• Most common extranodal site for non - hodkin's lymphoma is Stomach.
• 60-80% of intestinal lymphomas are B cell lymphomas, mostly diffuse large B cell type of Non
Hodgkin's lymphoma of the distal small intestine and especially in the ileo-cecal region
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• Most common ocular lymphoma is B Cell Non Hodgkin's Lymphoma.
• B cell lymphoma, Burkit lymphoma, Non Hodgkin's lymphoma, mantle cell lymphoma are common
in orbit.
• The paraneoplastic hypercalcemia in lymphoma is due to ectopic production of 1,25
dihydroxyvitamin D.
• 5 year survival rate of Diffuse large B cell lymphoma is 46%.
• Cytogenic Abnormality associated with Diffuse Large B Cell Lymphoma is t(3;-)(q27;-)t(17;-)(p13;-).
• Oncogene associated with Large B Cell Lymphoma is BCL-6,p53.
• Working formulation in staging of non-hodgkins lymphoma is based on Morphology of Cells.
• Follicular cell lymphoma falls under the low grade non-Hodgbkins lymphoma .
• Lymphomas with a follicular histological pattern have a longer survival than those of diffuse
pattern.
• Diffuse small, mixed , as well as large cell Lymphoma falls in the Intermediate form of Non-
Hodgkin's Lymphoma.
• The classification proposed by the International Lymphoma Study Group for non-Hodgkin's
lymphoma is known as REAL Classification.
• The IPI (International Prognostic Index) score system is calculated by the sum of the presence or
absence of 5 variables :age ≥ 65 y, performance status ≥ 2, elevated lactate dehydrogenase (LDH),
Ann Arbor stage III or IV, and ≥2 extranodal sites of disease.
• Distinction between a poorly differentiated carcinoma and a lymphoma can be made by
immunoperoxidase staining of the tumour tissue with antibodies directed against Cytokeratin.
• Immunohistochemical stains is used for the diagnosis of lymphomas is CD45 (leucocyte common
antigen).
• Ritumixab is used in the treatment of B-cell lymphomas: Low grade lymphomas, mantle cell
lymphomas, relapsed aggressive B cell lymphomas, CLL;SLE and Rheumatoid Arthritis.
8. Lucid Interval
• Serum analysis yields elevated ALT, HBsAg, Anti-HBc, HBeAg, and bilirubin in active
chronic hepatitis B
• DNA polymerase,Ig M anti-HBc antibody, HBsAg (+) is a marker of acute hepatitis B infection
• Liver biopsy in acute hepatitis due to hepatitis B virus is likely to show ballooning degeneration,
Councilman body or acidophil body, dropout necrosis, and bridging necrosis
• The incidence of chronic carrier state in liver disease is due to hepatitis B infection.
• The patterns of glomerular injury in HBV related chronic liver disease shows Membranous
nephropathy, Minimal change nephropathy, Mesangial proliferative
glomerulonephritis, Membranoproliferative glomerulonephritisIgA nephropathy
• Most widely accepted mechanism associated with nephropathy in chronic HBV patients
is Deposition of immune complex particles attributed to viral antigens and host antibodies
• Adult infection is usually symptomatic in chronic hepatitis B
• 90 % chance for chronic infection if HBV infection occur at birth
• Mild chronic hepatitis B has 5 year survival 97 %
• Complications of acute HBV include Fulminant hepatitis, Cirrhosis,Hepatocellular
carcinoma, Chronic hepatitis, Gianotti - crosti syndrome, Glomerulonephritis, Essential mixed
cryoglobulinemia, Polyarteritis nodosa (PAN), Hepatocellular carcinoma
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• Best means of giving hepatitis B vaccine is Intramuscular deltoid
• Ground glass hepatocytes are seen in HBV chronic infection
• Increased SGPT & SGOT with HBs Ag antigen positive HBe Ag antigen negative and anti-HBe
antibody positive shows chronic active hepatitis is diagnosed as HBV precore mutant
• Marker of level of liver injury in cases of hepatitis B is HBV DNA
• Hepatitis B associated with Polyarteritis nodosa
• Hepatitis B vaccine should be given as per which schedule 0,1,6 months
• Antiviral therapy with interferon is indicated in patients with active viral replication (is HBV DNA)
and elevated ALT levels
• Extrahepatic Manifestations of Hepatitis B include Aplastic Anemia ,Cryoglobulinaemia, Diabetes
mellitus, Dermatomyositis-like syndrome ,Gianotti- Crosti syndrome, Glomerulonephritis, Guillain-
Barre syndrome, Myasthenia gravis, Pericarditis and myocarditis, Pancreatitis, Peripheral
Neuropathy, Polyarteritis Nodosa ,Polyarthritis, Polymyalgia rheumatica, Polymyositis, Porphyria
cutanea tarda ,Psychosis, Raynaud's syndrome, Serum sickness like illness, Splenomegaly and lymph
node enlargement, Skin alterations, Thrombopenic. purpura ,Thyroiditis ,Urticaria
• Positive HBs Ag with Other serological tests for hepatitis negative & normal liver enzymes are
suggestive of inactive HBV carrier
• Amenorrhea, anorexia, weight loss and with milk discharge from the nipples are seen in Anorexia
nervosa
• Leukopenia, Amenorrhea, Self induced vomiting are seen in Anorexia nervosa
• Increased commitment to work ,Distortion of body image,Body weight < 85% of the predicted are
seen in Anorexia nervosa
• Weight loss,Dehydration,Mood changes are commonly seen in Anorexia nervosa
• Physical findings in anorexia nervosa are Emaciation, Hypotension, Bradycardia ,Hypothermia, Skin
dryness and flakiness, Lanugo ,Peripheral edema, Petechiae on extremities ,Sallow complexion
,Salivary gland hypertrophy, Dental enamel erosion, Osteoporosis ,Russell's sign ,Scars and calluses
on the back of the hand, Amenorrhea ,Mood changes
• Increase in free fatty acids,ketone bodies & Decrease in glycogen is seen within 24 hrs of starvation
in a 19-year-old patient with Anorexia Nervosa
• Hypophosphatemia and cardiorespiratory failure are the dangerous adverse effect of this type of
re-feeding in Anorexia Nervosa
• Anorexia Nervosa with euthyroid sick syndrome shows Low T3, Low T4, increased rT3, Normal TSH
• Anorexia nervosa can be differentiated from bulimia by Peculiars patterns of food handing
• Main difference between anorexia nervosa and bulimia nervosa lies in Weight
• In anorexia nervosa Bulimia may be seeen in 50% cases
• In anorexia nervosa Decreased FSH levels is seen
• BMI index is higher than normal Population in anorexia nervosa
• Malabsorption Syndrome is most common cause of anorexia nervosa
• Rail-road calcification in the brain are found characteristically in Sturge weber syndrome.
• The most probable diagnosis in a child who has got a vascular plaque like lesion over the lateral
aspect of forehead mainly involving ophthalmic and maxillary division of trigeminal nerve. which
has remained unchanged since birth and he is also on valproate for seizure disorder is Sturge weber
syndrome.
• A neonate has a large, purplish, slightly raised lesion on the skin of the forehead near the temporal
area. As the child grows, the lesion grows as well and becomes increasingly prominent. This lesion
may be a component of Sturge weber syndrome.
• Mental retardation(60% cases), Seizure (upto 85 % cases) and Rail road track appearance is seen in
Sturge Weber Syndrome.
• Diffuse choroidal hemangioma may be seen in upto 40% of the cases in Sturge Weber Syndrome.
• Sturge Weber Syndrome is characterised by nevus flammeus.
• Sturge Weber's syndrome is associated with ,Seizures,Hemiatrophy of cerebral cortex and Gyriform
calcification in brain.
• The most likely diagnosis is a case of intractable convulsions mental defect and facial nevus
is Sturge weber syndrome..
• Pheochromocytoma is associated with following familial syndromes :
• MEN syndrome type 2A & type 2B ,Von Recklinghausen (Neurofibromatosis type I) ,Von Hippel
lindau syndrome, Sturge weber Syndrome, Familial paraganliomas 1,2, & 3.
• Sturge Weber Syndrome is not associated with brain tumors.
• Large haemangioma of lid and cheek along with glaucoma is seen in Sturge Weber Syndrome.
• In Respiratory and metabolic acidosis ABG analysis show: pH 7.2,↑ PaC02, ↓HC03
• Reading of ABG analysis as ↓ PaCO2, Normal PaO2 and pH 7.5 shows Respiratory alkalosis
• Use of Intraarterial cannula in major surgery for Sample for ABG
• ABG revealing pH- 7.5, PCO2 24 mmHg, PO2 88 mm of Hg with excessive hyperventilation treated
for Respiratory alkalosis
• Alcoholic presents with psychosis and memory loss is suggestive of Wernicke’s Korsakoff psychosis
• Opthalmoplegia, ataxia, Psychosis are features of Wernicke's Korsakoff Syndrome
• Mammilary body,Thalamus & Hippocampus are affected in Wernicke's Korsakoff Syndrome
• Thalamus is responsible for the amnestic defect in Wernicke's Korsakoff syndrome
• Wernicke-Korsakoff's syndrome is due to the deficiency of thiamine
22. AML
• Age of onset between 2-8 years,female, Early pre-B cell,Initial WBC count less than 50000
& Hyperdiploidy are good prognostic factor
• t(9:22), t(8:14), t(4:11),t (12 : 21) translocation shows bad prognosis
• Presence of mediastinal mass shows bad prognosis
• Tumor marker for primary hepatocellular carcinoma are Alpha feto protein, PIVKA-
2, Neurotensin,Vit B12 binding globulin
• Yttrium 90 microspheres are used in treatment of hepatocellular carcinoma
• Liver transplantation offers the only chance of cure in those with unresectable case of
hepatocellular carcinoma
• High incidence in East Africa and South east Asia with worldwide incidence parallels the prevalence
of hepatitis B of hepatocellular carcinoma
29. Hyperparathyroidism
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• Secondary hyperparathyroidism is seen in Chronic renal failure, Vitamin D deficiency, Medullary
carcinoid syndrome & Malabsorption syndrome
• Adenoma is the most common surgically repairable cause of hyperparathyroidism
• Characteristic subperiosteal bone resorption in Hyperparathyroidism is best seen at Radial border
of middle phalanx
• MEN 1 is characterized by symptoms of hyperparathyroidism, tumor in pancreas, adrenal cortical
hyperplasia, pituitary adenomas, islet cell tumor with cutaneous angiofibromas
• Subperiosteal resorption and thickness of skull is increased in hyperparathyroidism
• Salt and pepper appearance of the skull on Xray is seen in hyperparathyroidism
• Chronic thiazide therapy causes persistent hypercalcemia due to hyperparathyroidism
• Brown’s tumour is seen in hyperparathyroidism
• Primary hyperparathyroidism, phaeochromocytoma may be associated with Medullary carcinoma
of the thyroid
• Treatment of choice for primary hyperparathyroidism secondary to parathyroid hyperplasia
is Removal of all glands leaving 50 mg of tissue as remnant
• Ca++↑ P04 ↓ is seen in hyperparathyroidism
• Secondary hyperparathyroidism due to Vitamin D deficiency shows Hypophosphatemia
• Hyperparathyroidism can cause nephrocalcinosis
• Tertiary hyperparathyroidism is Secondary hyperparathyroidism with chief cell adenoma
• Superior rib notching is/are caused by Hyperparathyroidism
• The symptoms of Hyperparathyroidism include Constipation , muscle weakness ,Anorexia ,weight
loss, Polydipsia & polyuri
• Subcutaneous Calcifications are seen in Hyperparathyroidism
• Peptic ulcer is associated with Primary hyperparathyroidism
• The initial treatment of choice for secondary hyperparathyroidism in renal osteodystrophy
is Phosphate binder
• The commonest cause of primary hyperparathyroidism is Solitary adenoma of parathyroid
• Secondary hyperparathyroidism causes rugger jersy spine in known case of chronic renal failure
• Tufting of the terminal phalanges is seen in hyperparathyroidism
• Floating teeth is seen in hyperparathyroidism
• Absence of lamina dura seen in hyperparathyroidism
• CPPD crystals are seen in hyperparathyroidism
• Osteitis fibrosa cystica is seen with hyperparathyroidism
30. Cystinosis
• Patient presenting with pellagra, parkinsonism, convulsions, anemia and kidney stones has
deficiency of Pyridoxal phosphate
• Tyrosine Hydroxylase enzymes is believed to be deficient in Parkinsonism
• Mangnese (Mn) is associated with secondary Parkinsonisms
• Hypokinesia, Rigidity & Static tremors are seen in Parkinsonism
• Dinesh, a 56 yr aged man presents with complaints of slowness of movements, postural instability,
tremors, rigidity and memory loss. Most likely diagnosis is Parkinsonism
• Subthalamic Nucleus is the most commonly used site for Transcranial Magnetic Stimulation to
reduce frequency of Parkinsonism symptoms
• Parkinsonism like features are evident in surviving patients of CO poisoning
• Deep brain stimulation used in treatment of Parkinsonism
• Drug abuser presents with fever , weight loss, hypertension, nodular skin rash, and peripheral
neuropathy showing ESR is 100 mm/L, and RBC casts are seen on urinalysis is suffering
from Polyarteritis nodosa
• Palpable purpura are seen in Polyarteritis nodosa
• Fibrinoid necrosis may be observed in Polyarteritis nodosa
• Loss of appetite, nausea and vomiting, and fatigue with confirm diagnosis of hepatitis B & icteric 2
shows vulnerable to the development of Polyarteritis nodosa
• Polyarteritis nodosa is a necrotizing vasculitis of small and medium-sized muscular arteries
• Involvement of the renal and visceral arteries is characteristic of Polyarteritis nodosa
• Granulomas, significant eosinophilia, and are not observed in Polyarteritis nodosa
• Patient with Severe abdominal pain with Guaiac test on stool demonstrates occult blood is taken to
exploratory laparotomy, at which a small area of infarcted small bowel is found and surgically
removedHistologic studies on the removed section of bowel demonstrate a recent thrombus
occluding a small muscular artery. The adjacent vessel wall shows fibrinoid necrosis with a mixed
inflammatory infiltrate containing neutrophils, eosinophils, and mononuclear cells is diagnosed to
have Polyarteritis nodosa
• Polyarteritis nodosa poses the greatest risk for development of pre-eclampsia
• Digital gangrene , palpable peripheral pulses is suggestive of Polyarteritis nodosa
• In polyarteritis nodosa, aneurysms are seen in Kidney, Liver & Pancreas
• Neuropathy is seen in polyarteritis nodosa
• Hepatitis B associated with polyarteritis nodosa
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• Fibrinoid necorsis with neutrophilic infiltration is seen in PAN
• Most common causeof renal artery stenosis in children in India is Takayasu Aortoarteritis
• Takayasu arteritis commonly effects Renal arteries
• Takayasu arteritis are associated with granulomatous pathology
• Most common cause of renovascular hypertension in children in India is Takayasu Aortoarteritis
• Aortic arch syndrome is also known as Takayasu Aortoarteritis
• Takayasu Aortoarteritis is Large vessel vasculitis
• Takayasu Aortoarteritis is Pulseless disease
• Takayasu's arteritis predispoase to Aortic dissection
• A young female presents with diminished pulses in the upper limb and hypertension. The most
likely diagnosis is Takayasu's arteritis
• Reversed Coarctation is seen in Takayasu Arteritis
• Takayasu arteritis mainly affects Subclavian artery
• Renal artery stenosis may occur in Takayasu arteritis
• Blood pressure difference between left and right limbs in Takayasu arteritis
• Takayasu arteritis Shows Strongly positive mantoux
• After trauma, hypovolemic shock can be due to Pelvic fracture, Blunt trauma to abdominal viscera
or Hemothorax
• 6 months old child is brought with vomiting & diarrhea. RR-45/min, HR-130/min, SBP-85 mm of Hg.
Capillary refilling time is 4 secs. Diagnosis is Early compensated hypovolemic shock
• Heart is spared from vasoconstriction during hypovolemic shock
• Features of hypovolemic shock are Oliguria, Low B.P & Acidosis
• Most common cause of death due to burns in early period is hypovolemic shock
• Hypovolemic shock after blunt trauma of the abdomen with splenic tear should undergo immediate
surgery
• The most serious complication of a pelvic fracture is hypovolemic shock
• Most common form of shock is hypovolemic shock
• In hypovolemic shock Constriction of capacitance vessels & arterioles in the skin with Decrease in
cardiac output is seen
• Hemorrhage leads to hypovolemic shock
• In cardiacshock BP < 90 mm of Hg
• Drug of choice for cardiogenic shock is Dopamine
• The Reynold's pentad of fever, jaundice, right upper quadrant pain, septic shock and mental status
change in typical of Cholangitis
• Endotoxin causes Septic shock
• Peripheral resistance is decreased in Septic shock
• Veno constriction, Direct toxic endothelial injury & Activation of complement are pathogenetic
mechanisms operate in septic shock
• Septic shock in children 1st response is TC.O. due to vasodilatation
• Hypotension is a late sign in Septic shock in children
• The most important cause of the death in septic shock is Cardiac
• Renal failure in patients with septic shock occurs primarily from Acute tubular mecrosis
• Warm periphery is noticed in Septic shock
• Septic shock is due to Lipopolysaccharide
• Diagnostic criterion for infective endocarditis includes Rheumatoid factor, Positive blood culture
& Positive ECG
• Infective endocarditis due to pseudomonas is most commonly seen with Intravenous drug abuse of
pentazocin
• Patient with Rapidly progressive malaise, fever, and chills,subungual splinter hemorrhages and a
systolic murmur Leading to death due to MI may be suffering from Acute infective endocarditis
• IE have most friable vegetation
• Staphylococcus aureus is the most common cause of acute infective endocarditis
• In a hospital cardiac care unit, there are three patients with different cardiac conditions: a 52 year
old man with dilated cardiomyopathy, an 18 year old girl with mitral valve prolapse, and a 30 year
old man with infective endocarditis of the mitral valve. Risk of systemic thromboembolism is the
common feature seen
• Tricuspid valve is most likely to be involved by infective endocarditis following a septic abortion
• Salmonella typhi is least likely to cause infective endocarditis
• ASD is the least common cause of infective endocarditis
• Blood culturefor staph. aureus is positive in Infective endocarditis
• A patient of RHD developed infective endocarditis after dental extraction. Most likely organism
causing this is Streptococcus viridans
• The group of organism HACEK , causing infective endocarditis include Haemophilus, Actionobacillus
& Eikenella
• Infective endocarditis is common in MR & AR
• Non-sterile vegetations are seen in Infective endocarditis
• In Infective endocarditis cause due to I.V. drug abuse is Candida is a common cause
• Staphylococeus aureus is commonest organism for IE in I.V. drug abuse
• Myocardial ring abscess, MI & Focal and diffuse glomerulonephritis are complication of infective
endocarditis
• In Infective endocarditis vegetation are friable and easily detachable from the cardiac valves
• In infective endocarditis Roth spots, Osiers nodes & Glomerulonephritis are immune mediated
• Diagnostic criterion for Infective Endocarditis include Positive Echocardiogram, Positive Blood
culture & Positive Rheumatoid Factor
• Infective endocarditis is commonly seen in Small VSD, Tetralogy of fallot & TDA
• Roth's spots are seen in Infective endocarditis
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• Myocardial abscess, Vegetations along cusps & Perforation of cusp are the feature of Infective
endocarditis
• Acute Infective Endocarditis with abscess formation is most commonly associated
with Staphylococcus
• 3 culture sets separated by at-least 1 hour over 24 hours is recommended for culture sampling in
Infective Endocarditis
• Antiboiotic Prophylaxis for infective endocarditis is indicated in Coarctation of aorta
• Infective endocarditis after tooth extraction is probably due to Streptococcus viridans
• Pregnant patient will be benefited by having a forceps-assisted vaginal delivery at the time of
delivery in case of MS
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• Features of Mitral stenosis on X-ray are Double contour of right border,Pulmonary
hemosiderosis,Straightening of left heart border, Lifting of left main bronchus ,Posterior
displacement of esophagus on barium swallow& Splaying of carinal angle
• In Patient with mitral stenosis with some liver compromise Xenon inhalational agent is preferred
for surgery
• In Pregnant patient with H/o MS & MR for normal delivery best analgesia is Epidural anaesthesia
• In Pregnant patient with mitral stenosis class II and Rheumatic heart disease Give Prophylactic
antibiotics, Apply Outlet forceps in 2nd stage of labor & Give iv furosemide at delivery of placenta
• In Pregnant patient with mitral stenosis class II and Rheumatic heart disease Methergin at delivery
is contraindicated
• Surgical correction of mitral stenosis during pregnancy is ideally done at14 weeks
• A case of severe mitral stenosis is associated with Pulsatile liver, Atrial fibrillation & Increase in the
length of murmur
• A patient known to have mitral stenosis and atrial fibrillation, presents with acute onset of
weakness in the left upper limb which recovered completely in two weeks. The most likely
diagnosis is Ischemic stroke
• Most common heart disease associated with pregnancy is Mitral stenosis
• Surgery for mitral stenosis during pregnancy is ideally done at 14 weeks
• During pregnancy corrective cardiac surgery is commonly indicated in Mitral stenosis
• In a diastolic murmur in mitral area with ECG showing mitral valve orifice to be 0.8 cm2. The cause
of her murmur is Severe mitral stenosis
• Loud S1 in Mitral stenosis is seen in Prolonged flow through mitral valve
• Kerley B lines seen in Mitral stenosis
• A 25 year old primigravide with mitral stenosis and mitral regurgitation is under labor. She wants
normal delivery which would be the best way to provide analgesia in this lady Neuraxialblockde
analgesia
• Mid-diastolic Murmur with presystolic accentuation is typically seen in Mitral stenosis
• A wide and notched P wave is typically seen in MS
• Mitral stenosis is associated with Right ventricular hypertrophy
• Pulsatile liver, Atrial fibrillation & prolonged murmur is seen as severity of mitral stenosis increases
• Severity of mitral stenosis is assessed by Length of murmur & S2-OS gap
• MC cause of morbidity and mortality late in the course of mitral stenosis Recurrent pulmonary
emboli
• Austin Flint Murmur is commonly mistaken for the murmur of Mitral stenosis
• An old lady with mitral stenosis underwent hysterectomy for uterine fibroid and died after
developing pulmonary edema. The order of cause of death in international certificate is Pulmonary
edema, hysterectomy, mitral stenosis
• A wide and notched P wave is typically seen in MS
• Heart sounds heard in chronic mitral stenosis is Mid diastolic murmur, Opening snap & Loud S I
ETIOLOGY-
CLINICAL FEATURES-
DIAGNOSIS-
TREATMENT
ETIOLOGY
Clinical features-
TREATMENT-
54. Thyrotoxicosis
TREATMENT-
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• Antithyroid drugs- thionamides (Carbimazole for child, pregnancy), methimazole, Propylthiouracil
(pregnancy- preferred)
• Thyroidectomy
• Radioiodine
• Propranolol (? blockers)used for adrenergic symptoms
• Thyroid storm or thyrotoxic crisis is rare and is a life threatening exacerbation of hyperthyroidism.
ETIOLOGY
TREATMENT-
Definition
Pathophysiology:
Organism Responsible
• Reactive arthritis (ReA) is most commonly triggered by Shigella (usually flexneri > sonnei, boydii,
dysenteriae) > Chlamydia trachomatis, Salmonell, Yersinia (enterocolitica, pseudotuberculosis),
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Campylobacter jejuni > Clostridium difficile, Campylobacter coli, toxic E.coli > Ureoplasma
ureallyticum, Mycoplasma genitalium > Chlamydia pneumoniae URTI
• Adolescents and young men are most likely to acquire reactive arthritis after they have urethritis.
Clinical features:
• The arthritis is most commonly asymmetric and frequently involves the large weight-bearing joints
(chiefly the knee and ankle)
• The mucocutaneous lesions may include balanitis, stomatitis, and keratoderma blennorrhagicum,
indistinguishable from pustular psoriasis.
• The Characteristic skin lesions- Keratoderma Blenorrhagica, consist ofvesicles that become
hyperkeratotic, ultimately forming a crust before disappearing. These are seen in palms and soles
57. HYPOKALEMIA
• Hypokalemia
Associated with:
• Diuretics
• Thiazide,
• Bumetanide,
• Furosemide,
• Ethacrynic acid
• Theophylline intoxication,
• Cortisol,
• Villous adenoma of colon etc.
• ECG changes of hypokalemia:
• ST segment depression,
• Increased U wave amplitude etc.
• Hypokalemic Metabolic Alkalosis with Hypercalciuria in a patient with normal blood pressure
suggests a diagnosis of Bartter Syndrome.
• Hypokalemic metabolic alkalosis with normal blood pressure may be seen in both Banter Syndrome
and Gitelman's Syndrome. Presence of Nephrocalcinosis from Increased Urinary excretion of
Calcium is typically seen in Bartter's
• Syndrome and distinguishes Bartter's Syndrome from Gitelman's Syndrome (Decreased Urinary
Calcium Excretion). Liddle's Syndrome also causes Hypokalemic metabolic alkalosis but this disorder
is typically associated with Hypertension (Blood Pressure is elevated)
Presentation Diagnosis
Hypokalemic Metabolic alkalosis with Liddle's Syndrome
Hypertension
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Hypokalemic Metabolic Alkalosis without Banner Syndrome (Increased Urinary Ca
Hypertension Excretion)
MUST KNOW:
• Unlike HbS, HbA does not contain any sticky patch, but it does have a binding site for the sticky
patch of HbS.
• Thus it can bind to HbS through its receptor site but this binding cannot extend the polymer
because HbA does not contain any sticky patch to promote binding to still another hemoglobin
molecule.
• So HbA interferes with the polymerisation and aggreation of HbS and reduces the intensity of sickle
cell anemia.
59. sarcoidosis
• Parotid enlargement is a classic feature of sarcoidosis and bilateral involvement is the rule
• Neurological disease is reported in 5-10% of patients with sarcoidosis
• Facial nerve palsy is the single most common neurological manifestation of sarcoidosis seen in up
to 50% of patients with Neurosarcoidosis.
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• Angiotensin converting enzyme (ACE) levels are raised in sarcoidosis
60. KWASHIORKOR
CLINICAL FEATURES-
LAB DIAGNOSIS-
61. Marasmus
• Marasmus is a state in which all body fat stored has been exhausted due to starvation without
systemic inflammation.
CLINICAL FEATURES
• Growth retardation
• Loss of subcutaneous fat
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• Wasting of muscles
• Infections
• Chronic diarrhea
• Vocarious appetite
• Monkey facies
• Baggy pant appearance
• Weight loss
LAB DIAGNOSIS
62. Hypothyroidism
• Neonatal hypothyroidism is due to thyroid gland dysgenesis, inborn errors of thyroid hormone
synthesis.
CLINICAL FEATURES
• Common symptoms- tiredeness, weakness, dry skin, cold extremities, weight gain, hoarse voice,
growth retardation.
• CVS- Bradycardia, peripheral oedema
• Nervous system- carpel tunnel syndrome, paresthesia,mental retardation, large anterior
fontanelle
• Menorrhagia, delayed puberty
• Puffy face, hands and legs, protruded tongue
• TREATMENT-Levothyroxine
• Subacute causes- viral infection, silent thyroiditis, mycobacteria infection, drug induced
(amiodarone)
• Chronic- autoimmunity (Hashimoto’s thyroiditis, Riedel’s thyroiditis, parasitic infection, traumatic.
• Subacute thyroiditis also termed as de Quervain’s thyroiditis, granulomatous thyroiditis or viral
thyroiditis.
• High ESR
• During initial phase of follicular destruction, radioactive uptake is low
• Decreased T3 & T4 and TSH increased.
• Histology- MULTINUCLEATED GIANT CELLS.
• Painless thyroiditis or silent thyroiditis occurs with underlying autoimmune thyroid disease
(subacute thyroiditis).
• Postpartum thyroiditis occurs with subacute thyroiditis in women 3-6 months after pregnancy.
• The risk of of recurrence in subsequent pregnancy is 70%.
• Thyrotoxicosis lasting 2-4 weeks followed by hypothyroidism for 4-12 weeks.
• Thyroid function may be normal after 1 year.
• Blind loop syndrome or stagnant bowel syndrome is bacterial proliferation due to functional stasis
or anatomic stasis.
CLINICAL FEATURES
67. Scleroderma
69. Hyperphosphatemia
ETIOLOGY-
a) Renal insufficiency
b) Hypoparathyroidism
c) Parathyroid suspension
d) Pseudohypoparathyroidism
e) Acromegaly
CLINICAL FEATURES
Surgery
1. Hypospadias
• Immediate onset paralysis due to fracture of mastoid (temporal bone) requires surgery
(decompression, re-anastomosis or cable nerve graft).
• In Facial nerve is injury during parotid surgery Best management would be immediate repair
• Treatment of choice for CSOM with vertigo and facial nerve palsy is immediate mastoid exploration
• Crocodile tears Occurs due to improper regeneration of facial nerve
3. Thyroglossal Cyst
• CT can fairly accurately determine the size of the fracture and its relationship to the orbital soft
tissues
• Blow out fracture of the orbit, most commonly leads to fracture of Posteromedial floor of orbit
• Restriction of lateral and upward gaze of eyeball and diplopia with enophthalmos following history
of trauma is suggestive of blow out fracture
• Diplopia, 'Tear drop" sign , Positive forced duction test & enopthalmous are signs of blow out
fracture
• Eye opening , Motor response, Verbal response are used for gradation of coma in Glasgow coma
scale
• Glasgow coma scale score for head injury, eye opening seen with painful stimulus, localize pain
and inappropriate verbal response is 10
• Glasgow coma scale is the best prognostic factor in a case of head injury
• According to the Glasgow Coma Scale (GCS), a verbal score of 1 indicates No response
• Glasgow Coma Scale score in a conscious person is 15
• Glasgow coma scale Ranges from 3 – 15
• Glasgow coma scale are Less than 7 is classified as coma
• Glasgow coma scale More than 9 excludes coma
• Mild head injury is having Glasgow coma scale of 10-15
• Low score in Glasgow coma scale indicates deteriorating brain function
• According to the Glasgow Coma Scale (GCS), a verbal score of 1 indicates No response
• A person with 'Inappropriate speech' evaluated by the 'Glasgow Coma Scale' will have a verbal
score of 3
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• Glasgow coma scale in death is 3
6. Cleft Lip
• Cleft of the upper lip that extends upward toward the left nostril and left anterior cleft of the
primary palate just deep to the cleft lip. These defects are most likely due to a failure of Maxillary
process to fuse the medial nasal process
• Isolated cleft lip and palate is Multifactorial
• Cleft lip, cleft palate, polydactyly, microcephaly with holoprosencephaly, ectodermal scalp defect is
seen in Trisomy 13
• Repair of cleft lip should be undertaken at 10 weeks
• Millard repair is used for treatment of Cleft lip
• A midline cleft lip is present when there is failure of fusion between Medial nasal processes
• Drug likely to be consumed by the mother causing cleft lip is Isotretinoin
• Commonest type of cleft lip is Combined with cleft palate
• In cleft lip operation all the stitches are removed on 4th day
• Unilateral clefts are most common on Left side
• Le Mesurier's method,Tennison's method, Millard's method are used in cleft lip surgery
• Unilateral cleft lip is associated with Posterior displacement of alar cartilage
7. Cellulitis
8. Zenkers diverticulum
9. Sigmoid Volvulus
• Ovarian mass in x-ray pelvis showing a radio-opaque shadow suggest Dermoid cyst
• Dermoid cyst of ovary is teratoma Frequently undergo torsion
• Most common ovarian tumour in pregnancy is Dermoid cyst
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• Dermoid cyst of ovary contains derivatives from all 3 germ layers Endoderm,Mesoderm & Ectoderm
• Dermoid cyst is Commonly more than 10 cm
• Dermoid cyst Has sebaceous material
• Dermoid cyst diagnosed during pregnancy should be removed surgically at 14-16 week
• Dermoid cyst are commonly seen in skull
• Most common orbital cyst in children is dermoid cyst
13. Cholelithiasis
• Solitary gall stone 1.5 cm in size without symptoms can be treated with Cholecystectomy if it
develops biliary colic
• Mercedes Benz sign is seen in Gall stone
• Gall stones in children is caused by Chronic hemolytic disease (sickle cell anemia,
spherocytosis),Obesity & Prematurity with complicated medical or surgical course
• Open cholecystectomy for cholelithiasis is considered a clean contaminated wound
• History of epigastric pain radiating to back along with an enlarged (edematous) pancreas revealing
cholelithiasis on ultrasonography suggests a diagnosis of Acute Pancreatitis.
• Illeo cecal junction is the most common site of intestinal obstruction caused by a gall stone
• Radio-opaque stones is a contraindication for medical management of Gall stones
• Cholelithiasis is particularly seen in association with Somatostatinoma malignancy
• Gall stones in hemolytic anaemia are Pigmented
• Childhood cholelithiasis is seen in Neimann Pick's disease
• Investigation of choice for gall stone is USG
• The commonest site of obstruction in Gall stone ileus is Distal ileum
• The treatment of gall stone ileus is Removal of obstruction
• Gall stones is More common in female
• Coronary artery disease with asymptomatic gall bladder stones should not be treated with
surgery
• Indication for medical treatment in gall stone is stone size less than15mm
• Ursodeoxycholic acid is Gall stone dissolving drug
• Enlarged right hemi-scrotum with a mass that appears to be originating at the level of the external
inguinal ring. With the patient completely relaxed, the physician is able to reduce the mass by
pushing it back through the external inguinal ring. With the mass reduced, the physician instructs
the patient to perform a Valsalva maneuver, upon which a protrusion is felt at the external inguinal
ring. Once the mass is reduced, the testicle appears normal in size and consistency, this is
suggestive of inguinal hernia
• Direct inguinal hernia swelling is doughy in consistency , dull on percussion & reducible but
reduction is difficult towards the end is suggestive of Epiplocele
• Pain could indicate obstruction in inguinal hernia
• Family history of inguinal hernia,Weight lifter,COPD are the risk factors for inguinal hernia
• Sup. Inguinal ring is an opening in external oblique aponeurosis
• Indirect inguinal hernia lies Lateral to inferior epigastric vessels
• For differentiating Inguinal hernia and femoral hernia the landmark will be Pubic tubercle
• Bubonocele: in this case the hernia is limited in the inguinal canal.
• In children, if inguinal (indirect) hernia is present in one side, then processus vaginalis is intact on
other side
• Direct hernia is less likely to undergo strangulation
• Hernia on Rt side is more common than Lt side
• In case of female commonest hernia is Indirect inguinal hernia
• Aspiration of the sac for diagnosis,X-ray abdomen,USG abdomen are not done in case of obstructed
inguinal hernia
• Truss cannot prevent progression of Sliding type of inguinal hernia
• Transillumination distinguishes indirect inguinal hernia from hydrocele
• Most common type of hernia is indirect inguinal hernia
• Incompletely descended testis Early repositioning can preserve function,It may lead to sterility, if
bilateral & May be associated with indirect inguinal hernia
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15. TREATMENT OF INGUINAL HERNIA
• During surgical repair of hernia, the sac of a strangulated inguinal hernia should be opened
at Fundus
• Congenital hydrocele is treated by herniotomy
• Hernia in children is treated with herniotomy
• Absorbable mesh should not be used for surgery
• Surgery can be done using laparoscopy
• A pt. operated for direct inguinal hernia developed anethesia at the root of the penis and adjacent
part of the scrotum the nerve likely to be injured is Ilioinguinal nerve
• During repair of indirect inguinal hernia, while releasing the constriction at the deep inguinal ring,
the surgeon takes care not to damage Inferior epigastric arterySpermatic cord
• Most important step in the repair of an indirect inguinal hernia is Narrowing of the internal ring
• Well’s operation,Lahaul’s operation,Ripstein’s sling operation are abdominal procedure for rectal
prolapse
• A young male patient presents with complete rectal prolapse. The surgery of choice is Abdominal
Rectopexy
• Chronic dysentery, abdominal pain, and rectal prolapse in children is caused by Trichuris trichura
• Treatment of rectal prolapse in childhood is Thiersch wiring
• Delorme's Procedure is used for Rectal prolapse
• Blunt injury abdomen, patient was hemodynamically stable, next investigation is X-ray abdomen
• Blunt injury of abdomen by RTA with established Airway & stable respiration , Blood collection for
cross matching & IV fluid adminisration is the next line of management
• In Renal injury following blunt injury to abdomen management will include Diagnostic peritoneal
lavage,IVP,Exploratory laparotomy
• Preferred incision for abdominal exploration in Blunt injury abdomen is Always Midline incision
• Blunt injury abdomen, patient was hemodynamically stable, next investigation is FAST
• Non-specific gas pattern in bowel and an air-fluid level in LUQ seen in Abdominal radiograph after
Splenectomy is suggestive of Subphrenic abscess
• Subphrenic abscess is toxemia
• Complain of right hypochondrial pain with plain chest x ray showing elevated right hemidiaphragm
is seen in Subphrenic abscess
22. Varicocele
23. Ureterocele
24. Hydrocele
• Adenocarcinoma with invasion of muscular layer is treated with Wedge hepatic resection with
lymph node dissection
• Patients with solitary hepatic metastases without clinical or radiographic evidence of additional
tumor involvement is treated with partial liver resection.
• Hepatic resection is done in hydatid disease of liver
• The minimum amount of normal perfused liver parenchyma to be left intact when a hepatic
resection is planned is 20%
26. Cholecystectomy
27. Splenectomy
• Ligation of inferior thyroid artery during thyroidectomy is done maximally away from the gland
• Thyroxine can be given in Papillary thyroid carcinoma
• After thyroidectomy for medullary carcinoma of thyroid recurrence of tumour can be determined
by Carcinoembryonic antigen
• Marker for follow-up of patient undergone total thyroidectomy for papillary carcinoma of thyroid
is Thyroglobulin
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• In treatment of papillary carcinoma thyroid, radioiodine destroys the neoplastic cells predominantly
by ri rays
• A female presented with severe secretory diarrhea and the thyroid carcinoma can be treated
by Surgery only.
• Complications of total thyroidectomy is Hypercalcaemia
• The drug used in the management of medullary carcinoma thyroid is Cabozantinib
• A 27-year-old female presented with long-standing nodule in right lobe of size 2 cm x 2 cm and
underwent right hemithyroidectomy. Histopathological findings are suggestive of Papillary
carcinoma
• Direct Pressure and Elevation is the first treatment of choice in a case of rupture of varicose veins
at the ankle
• Varicose veins is associated with migratory thrombophlebitis
• Sclerotherapy for varicose vein is contraindicated in Deep vein Thrombosis
• Pulsatile varicose veins in lower limbs is seen in Klippel trenaunay syndrome
• After the division of testicular vein for treatment of varicose vein, venous drainage of testes is
by Cremasteric veins
• Varicose veins are seen in DVT & AV fistula
• Most commonly varicose veins are seen with Long saphenous vein
• 5% oily phenol is an appropriate sclerosant for venous sclerotherapy.
• Surgery in varicose veins is NOT attempted in presence ofDeep vein thrombosis
• A pt presented with pulsating varicose veins of the lower limb. Most probable diagnosis is Klippel
Trenaunay syndrome
• Injection sclerotherapy for varicose veins is by using phenol
• Commonest complication of varicose vein stripping is Ecchymosis
• Pulsating varicose vein in a young adult is due to Arteriovenous fistula
• An operated case of varicose veins has a recurrence rate of About 10%
• Operations for varicose veins are best accomplished by Stripping
• Gold standard diagnostic test in varicose veins is Duplex imaging
• Trendelenburg's operation is done for Varicose veins
• Investigation of choice for varicose veins Duplex ultrasound imaging
• Arteriovenous fistula, Deep venous thrombosis & Pregnancy may cause varicose veins
• Drug used for sclerotherapy of varicose veins are Polidocanol, Sodium tetradecyl
sulfate, Ethanolamine Oleate,
• Perthe's test, Tourniquet test & Trendelenberg test are done for varicose veins
• Patient presents with varicose vein with sapheno-femoral incompetence and normal perforator can
be managed with Endovascular stripping, Sapheno-femoral flush ligation & Saphenofemoral flush
ligation with striping
• Choledochal Cyst is associated with anomalous junction of the pancreatic and biliary duct.
• Surgical removal is the treatment of choice in a case of Choledochal Cyst.
• Choledochal cyst if ruptures ,can cause biliary peritonitis.
• Type I is the most common.
• In case of choledochal cyst, side-to-side choledochoduodenostomy is NOT recommended because
of the risk of recurrent cholangitis.
• Conjugated hyperbilirubinemia in infancy may be seen in Choledochal Cyst.
• Choledochal Cyst presents with Pain, lump and progressive jaundice.
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• Saccular diverticulum of extrahepatic bile duct in choledochal cyst is classified as Type-II.
• Choledochal Cyst may predispose to Cholangiocarcinoma.
36. Laproscopy
• Mode of treatment for achalasia is associated with high rate of recurrence : Botulinum toxin.
• Progressive Dysphagia,Regurgitant vomitting is a presenting problem.
• Dilated and Tortuous Esophagus is seen in Achalasia Cardia.
• The cause is degeneration of ganglion cells of auerbach's myenteric plexus.
• Treatment includes heller’s cardiomyotomy, forceful dilation by pneumatic balloon, repeated
injection botulinum toxins and drugs improving motility of esophagus.
• Esophagectomy is not a treatment modality for achalasia cardia.
• Barium swallow shows a dilated esophagus with tapering narrowing in the terminal end of
esophagus, described as ‘BIRD BEAK’ appearance.
• Fluoroscopy shows loss of normal peristalsis in the lower third of the esophagus..
• Dysphagia equal for both solid and liquid from the very onset suggests motor disorder i.e achalasia
and diffuse esophageal spasm.
• The characteristic esophageal manometry finding in achalasia cardia is Impaired lower esophageal
sphincter relaxation and absent peristalsis.
• It is believed that cause of ganglion cell degeneration in achalasia is an autoimmune process
attributable to a latent infection with human herpes simplex virus 1 combined with genetic
susceptibility.
• The malignancy which is a close mimicker of achalasia is Carcinoma of gastric fundus.
• The most sensitive diagnostic evaluation for achalasia cardia is Esophageal Manometry.
• The pharmacologic agents used in Achalasia are:
1. Nitrates
2. Calcium channel blockers
3. Botulinum toxin
4. Sildenafil- phosphodiesterase inhibitors, effectively decrease LES pressure.
• In pneumatic dilatation for the treatment of achalasia, the cylindrical balloon dilator is dilated upto
3-4 cm.
• Achalasia is associated with increased risk of Squamous Cell carcinoma of Esophagus.
• Uniform dilation of esophagus is seen in Achalasia Cardia.
• Elevated resting LES tone is seen in Achalasia.
• A 40-year-old female patient presented with dysphagia to both liquids and solids and regurgitation
for 3 months. The dysphagia was non-progressive.Achalasia cardia is the most likely diagnosis.
• 'Pencil tip' deformity is seen in Achalasia Cardia.
• Heller's operation treatment of choice in Achalasia Cardia.
• Radiologic feature suggestive of Achalasia cardia is? Absence of gastric air bubble , Air fluid level
in mediastinum ,Sigmoid esophagus.
• Maximum dilatation of esophagus occurs in Achalasia Cardia.
• Amyl nitrite inhalation is used to distinguish patients of achalasia from those with pseudoachalasia.
38. Gastritis
• Increased production of macrocytic red blood cells would mostly likely be associated with chronic
gastritis (Type A) resulting from autoimmune destruction of parietal cells.
• A patient of peptic ulcer disease, when investigated endoscopically showed chronic antral gastritis.
Warthin Starry Stain will be able to stain the specimen.
• Type B gastritis:It is called as antral predominant gastritis as antrum is involved predominantly.
However, it is misnomer as the inflammatory process may progress to body and fundus and causing
pangastritis.
• Autoimmune gastritis is less common of the two forms and is characterized by :- Presence of
antibodies against parietal cells and intrinsic factor and Involvement of body and fundus with
sparing of antrum.
• Endoscopic biopsy from a case of H.pylori related duodenal ulcer is most likely to reveal Antral
predominant Gastritis.
• Atrophic Gastritis is a predisposing factors for gastric carcinoma.
• Erosive gastritis commonly occurs at Body and Fundus.
• H. pylori causes Type B gastritis.
• Most important side effect of aspirin is Gastritis.
• Regarding congenital hypertrophic pyloric stenosis of infancy : It most commonly occurs in first
born male child,It usually presents at 2 to 4 weeks of life,Baby is hungry soon after vomiting,Non
bilious Vomitting.
• The classical electrolyte abnormality associated withpyloric stenosis is hypokalemic, hypochloremic
metabolic alkalosis, presumably due to ongoing gastric acid loss from vomiting. Paradoxical
acidurea is sometimes noted (with progressive Hypokalemia and hypovolemia) because the kidney
excretes protons in exchange of sodium in an attempt to conserve fluid".
• A 3 week old patient presenting with vomiting and failure to thrive is found to have pyloric
stenosis. Correction of electrolyte disturbances should be the next step of management.
• Drug which can cause Hypertrophic Pyloric stenosis is Erythromycin.
• Most characteristic feature of congenital hypertrophic pyloric stenosis:The pyloric tumour is best
felt during feeding.
• Treatment of choice is Finney’s pyloroplasty in Hypertrophic Pyloric Stenosis.
• Clinical features of pyloric stenosis in infants are Abdominal lump , Constipation , Weight Loss.
• The vomiting in pyloric stenosis may or may not be projectile, however non bilious vomiting after
feed is the characteristic feature.
• Peristalsis is seen from left to right across the upper abdomen in Hypertrophic Pyloric Stenosis.
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• A 6 year old boy presenting with palpable abdominal mass in the epigastrium. (There is no bile in
vomitus).The clinical diagnosis is Pyloric Stenosis.
• The traditional Ramstedt procedure is performed through a short transverse skin incision in a case
of Hypertrophic Pyloric Stenosis.
• A 10 days old neonate is posted for pyloric stenosis in surgery. The investigation report shows a
serum calcium level of 6 mg/dL. The information which you would like to know before you
supplement calcium to this neonate is Serum Protein.
• Ultrasonography is the investigation of choice to confirm diagnose of hypertrophic pyloric stenosis
with accuracy > 95% (approching almost 100%). USG visualizes thickened and elongated pyloric
canal. USG criteria for diagnosis include >16 mm pyloric length and >4mm pyloric muscle wall
thickness. Gastric residues are low b/o recurrent emesis.
• Xray feature of Pyloric Stenosis is Single bubble appearance.
• A robust male baby with vigorous feeding and immediate vomiting at 2 months of age. Most
probable diagnosis is Congenital Hypertrophic Pyloric Stenosis.
• Dilated Stomach with minimal gas is seen in Pyloric Stenosis.
• In congenital pyloric stenosis the defect usually lies in -Circular muscle fibres in antrum.
• String sign is seen in: Crohn's disease ,TB of the ileocaecal region , Idiopathic hypertrophic pyloric
stenosis.
40. Hemorrhoid
• The pathology in ulcerative colitis typically involves distortion of crypt architecture, inflammation of
crypts (cryptitis), frank crypt abscess, and hemorrhage or inflammatory cells in the lamina propria.
• Crohn's disease is frequently associated with "skip lesions," discontinuous areas of active disease in
the colon and small intestine with intervening segments that appear normal.
• Pseudopolyps are more commonly found in ulcerative colitis than Crohn's disease.
• For patients of ulcerative colitis associated with primary sclerosing cholangitis :They may develop
biliary cirrhosis , may have raised alkaline phosphatase ,increased risk of hilar Cholangiocarcinoma.
• Ulcerative Colitis is associated with:
• Dermatologic: Erythema nodosum ,Pyoderma gangrenosum
• Rheumatologic: Peripheral arthritis, Ankylosing spondylitis, Sacroiliitis
• Ocular:Conjunctivitis ,Anterior uveitis/iritis ,Episcleritis
• Hepatobiliary: Hepatic steatosis ,Fatty liver ,Cholelithiasi ,Primary sclerosing cholangitis
• Urologic: Calculi ,Ileal bladder fistulas
• Metabolic bone disorders
Thromboembolic disorders.
• Ulcerative colitis (UC) is a chronic inflammatory condition causing continuous mucosal
inflammation of the colon without granulomas on biopsy, affecting the rectum and a variable
extent of the colon in continuity, characterised by relapsing and remitting course.
• Distal colitis with respect to ulcerative colitis refers to Left sided colon distal to splenic flexure is
only involved.
• Parameters of truelove witts criteria : Bloody stools/day ,Pulse, Temperature, Haemoglobin, ESR,
CRP.
• In clinical practice, ‘remission’ mean a stool frequency ≤3/day with no bleeding and no urgency.
Sigmoidoscopy to confirm mucosal healing is generally unnecessary.
• Steroid refractory ulcerative colitis is said to be present in a patients who have active disease
despite Prednisolone up to 0.75 mg/kg/day over a period of 4 weeks.
• Baron Endoscopic scores for ulcerative colitis
• Score 0: Normal: matt mucosa, ramifying vascular pattern clearly visible, no spontaneous bleeding,
no bleeding to light touch
• Score 1: Abnormal, but non-haemorrhagic: appearances between 0 and 2
• Score 2: Moderately hemorrhagic: bleeding to light touch, but no spontaneous bleeding seen ahead
of the instrument on initial inspection
• Score 3: Severely haemorrhagic: spontaneous bleeding seen ahead of instrument at initial
inspection and bleeds to light touch.
• Occasional severe constipation is seen in ulcerative colitis patients with Proctitis.
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• Pancolitis and Pseudopolyps may be seen in Ulcerative Colitis.
• Ulcerative colitis involves the rectum and extends proximally in a retrograde fashion to involve the
entire colon (pancolitis) in more severe cases.
• Malabsorption may be seen in ulcerative colitis.
• Sulfasalazine is used in ulcerative colitis.
• Pyoderma gangrenosum is seen in Ulcerative Colitis.
• Rx of choice in case of chronic ulcerative colitis is Proctocolectomy with Ileo-Anal Anastomosis.
• Surgical treatment of Ulcerative Colitis :Done in cases where medical treatment fails & Pouch
surgery done.
• Complications of ulcerative colitis : Perforation ,Toxic megacolon, Carcinoma.
• As the inflammation is purely mucosal in ulcerative colitis, strictures are highly uncommon. Any
stricture diagnosed in a patient with ulcerative colitis is presumed to be malignant until proven
otherwise.
• Ulcerative colitis involves mucosa and superficial submucosa with deeper layers unaffected except
in fulminant disease.
• Pt with recurrent diarrhoea, pseudopolyp, lead pipe appearance on Ba enema has Ulcerative Colitis.
• Risk of Malignancy in Ulcerative Colitis is more in :Onset in childhood ; Extensive involvement of
colon,Takes atleast 10 years to develop,Associated with dysplasia of the rest of the colon.
• Primary sclerosing cholangitis is the most serious extraintestinal manifestation of ulcerative colitis
and it does not resolve with colectomy.
• Most common post operative complication of ileo anal pouch anastomosis in ulcerative colitis is
Pouchitis.
• Sulphonamide is used for the treatment of ulcerative colitis is Salazopyrin,Sulfasalazine.
• Procedure of choice in ulcerative colitis with acute perforation is Total Colectomy with Ileostomy.
• Best treatment for Remission of Acute ulcerative colitis is Prednisolone.
• A 20 year old male presents with mucus and repeated gastrointestinal bleeding. Patient is positive
for ANCA. The most likely diagnosis is Ulcerative Colitis.
• A 25 year old male presents with a history of chronic diarrhea. Pathological examination
reveals cryp. titis and crypt abscesses. The likely diagnosis is Ulcerative Colitis.
• 5-amino salicylic acid is drug of choice for ulcerative colitis.
• Methotrexate has not been shown to be effective for treating active ulcerative colitis or for
maintaining remission.
• Malignant potential is seen in both ulcerative colitis and Crohn's disease, but ulcerative colitis is a
more important risk factor than Crohn's.
• First radiological sign of ulcerative colitis is loss of Haustrations.
• Pipe stem colon is seen in Ulcerative Colitis.
• Agents that may be used for treatment of ulcerative colitis
• 5-ASA
• Glucocorticoids
• Azathioprine and 6 mercaptopurine
• Cyclosporine or TNF alpha therapy (Infliximab).
• Tacrolimus
45. Diverticulosis
46. Appendicitis
• During an operation for presumed appendicitis, the patient appendix is found to be markedly
thickened and feels rubbery to firm. The serosa is edematous and inflamed and the mesentery is
thickened with fat growing about the bowel circumference. Most likely diagnosis is Ileal Crohn’s
disesase.
• In a case of retrocecal appendicitis ,extension movement aggravates pain.
• A female who underwent laproscopic appendicectomy for acute appendicitis, on post op. day 2
bumped her nose on to a table. She developed difficulty in breathing and examination showed a
swelling in the anterior part of the nasal septum. Next line of management is Incision and Drainage.
49. Peritonitis
• Primary peritonitis is more common in females because ostia of Fallopian tubes communicate with
abdominal cavity.
• A posteriorly perforating ulcer in the pyloric antrum of stomach is most likely to produce initial
localized peritonitis or abscess formation in Omental Bursa(lesser sac).
• A patient with abdominal injury presents to the emergency department with signs of peritonitis and
shock. His airway and breathing were secured and IV fluids were started with 2 large bore cannulas.
The next line of management should be Exploratory Laparotomy under general Anesthesia.
• Apart from Escherichia coli,Bacteroides is the other most common organism implicated in acute
suppurative bacterial peritonitis.
• A 23-year-old man is admitted to the hospital through the emergency department with probable
appendicitis. He has been having right lower quadrant abdominal pain for several days, which has
been becoming increasingly worse. His temperature 39.2 C (102.6 F), blood pressure is 80/40 mm
Hg, Pulse is 120/min, and Respiratory rate is 35/min. The abdomen is rigid with guarding. Multiple
petechiae and purpura are present, and the patient is oozing blood from his oral mucosa. According
to the patient's wife, he has not had bleeding problems in the past. The fact the abdomen is rigid
with guarding suggests Peritonitis.
• Meconium peritonitis is an aseptic peritonitis which can occur in late intrauterine life, during birth
or just after delivery.It occurs due to intestinal perforation usually as a result of some form of
neonatal intestinal obstruction.
• Total parenteral nutrition is the management of choice in a patient presenting with peritonitis and
massive contamination because of duodenal leak.
• Prophylaxis against spontaneous bacterial peritonitis ( SBP) in case of cirrhosis with ascites is
indicated in prior history of SBP.
• The characteristic ascitic fluid findings in the setting of secondary bacterial peritonitis are Ascitic
fluid PMN > 250 cells/mm 3 with at least two of the following criteria
2. LDH greater than the upper limit of the normal of the serum
• In patients with SBP, along with cefotaxime albumin infusion is indicated in the setting , when
• Primary bacterial peritonitis (PBP) occurs most commonly in conjunction with cirrhosis . Other
conditions which may cause PBP are Metastatic malignant disease, Postnecrotic cirrhosis, Chronic
active hepatitis, Acute viral hepatitis, Congestive heart failure, Systemic lupus erythematosus
Lymphedema.
• PBP is commonly present with fever, but it can present without any symptoms too.
• Most common infection in a child nephrotic syndrome is spontaneous bacterial peritonitis.
• Most common cause of peritonitis in adult male is perforated Appendix.
• Primary peritonitis with pneumococcus is associated with Nephrotic Syndrome.
• Early surgery is indicated in Biliary and Typhoid Peritonitis.
• Most common cause of generalised peritonitis in a 40 year old adult male is Duodenal ulcer
perforation.
• Intra-abdominal calcificaition in a plane X-ray abdomen is most often seen in Meconium
Peritonitis.Plain X-ray abdomen of this condition reveals calcification on liver and spleen.
• Meconium peritonitis should always be considered when a baby is born with tense abdomen.
• Systemic complications of peritonitis Bacteraemic/endotoxic shock Bronchopneumonia/respiratory
failure,Renal failure,Bone marrow suppression ,Multisystem failure.
• A 25 years old female presents with pyrexia for ten days, develops acute pain in periumblical region
spreading all over the abdomen. Typhoid enteric perforation and peritonitis would be the most
likely cause.
• Spontaneous peritonitis in cirrhosis patients; the polymorphonuclear cells are more than 200
cells/cumm.
• About preoperative optimization for perforation peritonitis:Patients may require large volume of
crystalloid infusion,Hypovolemia and sepsis contribute to tissue underperfusion,Base deficit >6 is
marker of significant metabolic acidosis.
• The most common intraperitoneal abscess following peritonitis is Pelvic.
• Paralytic ileus is caused by Peritonitis.
• Diffuse peritonitis in acute appendicitis is caused due t early rupture of Appendix.(within 24 hours).
• A patient was on long term antibiotic therapy for peritonitis. During the course of treatment, he
develops mucus diarrhea. Most likely cause of diarrhea is antibiotic associated diarrhea.
• In a case of Acute peritonitis,CT scan may aid in the diagnosis and Upright films shows free air
under the diaphragm.
51. AMPUTATION
52. AMELOBLASTOMA
53. RANULA
54. HYDRONEPHROSIS
• Presence of hydronephrosis in staging of carcinoma cervix denotes FIGO disease Stage III-B
• In follow up of BPH, most important indication of surgery is Bilateral hydronephrosis
• Whitaker test is done for diagnosing hydronephrosis
• IOC in Posterior urethral valves of newborn with hydronephrosis is Micturating Cystourethrogram
• Hydronephrosis with dilated renal pelvis and cortical thinning with a normal ureter treated
with Pyeloplasty
• Micturating cysto urethrogram shows bilateral Grade IV vesicoureteral reflux with Ultrasound
abdomen showing bilateral hydronephrosis is suggested for Ureteric re-implantation
• Recurrent E.coli infection with Hydroureter and Hydronephrosis as U/S finding & Micturating cysto
- urethrogam shows filling defect in urinary bladder are suggestive of Ureterocele
• Rim sign in IVP is seen in Hydronephrosis
• Bilateral impacted ureteric stones with hydronephrosis & RBCs with pus cells in urine should be
imediately treated with stent drainage
• Inadvertent surgical occlusion of the ureter leads to Complete renal atrophy & Hydronephrosis
• Unilateral hydronephrosis is due to Carcinoma of prostate
• During investigation of hydronephrosis, isotope renogram is useful mainly in Distinguishing
between non-obstructed system
• In follow up of BPH, most important indication of surgery is Bilateral hydronephrosis
• Catheterization with Foley catheter is mandatory for acute urinary retention with bilateral
hydronephrosis .Spontaneous voiding may return, but a catheter should be left indwelling for 3
days while detruson tone returns
• History of recurrent ureteric calculi presented with fever treated with Right-sided nephrectomy
suggest diagnosis of Chronic pyelonephritis with hydronephrosis
• Intra uterine hydronephrosis of 32-34 weeks-management Require serial USG and other associated
anomalies
Surgery
Radiation therapy
• it may produce unpredictable results and has obvious potential side effects including neoplastic
degeneration; and has high recurrance rate when used alone.
Pressure application
Topical retinoids
b) Back
c) Shoulder
d) Earlobes
Also know
• It is a fungal infection.
58. FELON
• Boerhaave syndrome is a barogenic injury resulting from a sharp increase in the intraluminal
pressure against a closed cricopharyngeus.
• Perforation typically occurs at the weakest point in the esophagus, usually in the left lower
esophagus below the diaphragm in adults, whereas in very young patients, the perforation is
usually into the right pleural cavity.
61. CHOLANGIOCARCINOMA
• Whipple's triad includes symptoms of hypoglycaemia, low blood glucose measured at the time of
symptoms and symptoms resolved on correction of hypoglycemia
• Insulinomas are a 13 cell endocrinal tumour of the pancreas.
• The symptoms are produced due to excessive secretion of insulin causing hypoglycemia
• Most of the insulinomas are solitary and benign.
• Only about 10-15 % of insulinomas are malignant. (Keep in mind that all other endocrine tumours
of pancreas are usually malignant).
• Cyanocobalamine (Vitamin B12) deficiency is the most common deficiency in patients with short
bowel syndrome associated with loss of ileum (Heal resection) since vitamin B12 is absorbed only in
the ileum
• Short Bowel Syndrome may be associated with deficiency offal-soluble vitamins (Vitamin A, D, E
and K) and water soluble Vitamin B12 (when ileum is resected / non functional).
• The most common deficiency is determined essentially by the specific segment of the small
intestine (jejunum or ileum) that is resected / non functional
• Short bowel syndrome is characterized by increased gastrin levels (hypergastrinemia) due to
reduced small intestinal catabolism of gastrin
• Short bowel syndrome is a condition in which extensive resection of the small bowel results in
malabsorption, fluid and electrolyte loss and malnutrition. Short bowel syndrome can occur at any
age from neonates through the elderly. Patients present with diarrhea, steatorrhea, increase in
renal calcium oxalate calculi and cholesterol gallstones.
• Etiology: In neonates can result from jejunoileal atresia, gastrochisis, omphalocele and necrotizing
enterocolitis (bowel is resected). In adults it occur after bowel resection secondary to trauma,
chrons disease and mesenteric vascular disease. Following resection of the small intestine, the
residual intestine undergoes adaptation of both structure and function that may last for up to 6–12
months.
70. VOLVULUS
Volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel
obstruction. The most common sites of volvulus am the sigmoid colon and cecum.
Volvulus of other portions of the alimentary tract, such as the stomach, gallbladder, small bowel,
splenic flexure, and transverse colon, are rare
• previous surgery
• pregnancy
• malrotation
• obstructing lesion of the left colon
• Cecocolic volvulus affects a younger age group (late 50s) than sigmoid volvulus (60s & 70s).
• X-ray picture
• dilated cecum usually occupying the left upper quadrant.
Volvulus neonatorum
• o The fetal alimentary canal returns from the extraembryonic coelom into the abdomen at 8-10
weeks, and the bowel undergoes rotation and fixation at certain points by the attachment of its
mesentery to the posterior abdominal wall.
• o When the process is incomplete or deviates from the normal plan, the result is malfixation or
malrotation.
• o Commonly, the normal oblique attachment of the mesentery from duodenojejunal flexure of the
caecum is absent, and the small bowel is attached to the posterior abdominal wall by a narrow stalk
based around superior mesenteric vessels. The caecum is undescended, i.e., situated in the right
hypochondrium and abnormally fixed by peritoneal bands running laterally across the second part
of duodenum.
• o The poorly attached small bowel undergoes volvulus around the axis of the 'universal mesentery',
which is twisted so that the flow of blood is cut off, producing a strangulating obstruction of the
small bowel. This typically occurs in the newborn, hence the term Volvulus neonatorum'. The
terminal ileum and caecum are drawn into the volvulus and are wrapped around the stalk of the
mesentery in two or three tight coils.
Clinical feature
• o A young infant, previously healthy, starts bile-stained vomiting during the first few days of the
live. Abdomen is
• soft and non-distended; however, abdominal distension may occur which is limited to upper
abdomen (epigastrium). o No obstruction may occur in the first day or two after birth and
meconium may be passed normally. Then, with
• variable suddenness, bowel actions cease with onset of obstruction.
• o The signs vary, depending on the degree of intestinal obstruction versus ischemia. When
strangulation occurs there are signs of schock, especially pallor and a vague mass of congested
bowel may be palpable in the centre of abdomen. Blood or blood-tinged mucus may be passed
rectally.
• o Ischemia may result in gangrene and perforation.
Investigations
1. Unless there are obvious signs of gangrene or peritonitis, the initial management of sigmoid volvulus
is resuscitation followed by endoscopic decompression (by using rigid proctosigmoidoscopy or
flexible sigmoidoscopy or colonoscopy) ; a rectal tube is inserted and kept to maintain
decompression. Endoscopic decompression is contraindicated if there is evidence of strangulation or
perforation.
2. Although endoscopic decompression is successful in majority of patients, recurrence rate is quite
high. Therefore elective sigmoid colectomy is performed as the definitive procedure after the
patient is stabilized and adequate bowel preparation done.
3. Emergency laparotomy is performed if strangulation or perforation is suspected or if attempts of
endoscopic decompression fail
4. A volvulus is the twisting strangulation of an intestinal segment around an axis which is formed by
an axis or an adhesion.
5. Ascaris infection is acquired by ingestion of the eggs, usually from contaminated soil.
• The ingested eggs hatch in the duodenum to produce larvae, which cross the small intestinal wall to
enter the bloodstream.
• They then pass through the heart to lodge in the lungs.
• They leave the lung capillary bed to enter the airspaces.
• They then ascend the bronchial tree into the oropharynx, where they are again swallowed.
• This time, they return to the small intestine where they develop into mature worms that can live in
the host for up to two years.
• A gravid female worm may produce up to 250,000 eggs daily, which are shed in stool.
• The passage of the larvae through the lungs often produces cough and/or wheezing, and may, in
severe cases, produce fever, dyspnea, fleeting patchy pulmonary infiltrates (Loeffler pneumonitis
with prominent eosinophilia), and rarely hemoptysis.
• Passage through the heart is usually asymptomatic, as the larvae are small.
• A single adult worm, but not usually larval forms, can migrate into the biliary tree, leading to biliary
colic, cholangitis, or gallstone formation; obstructive jaundice uncommonly occurs.
• The pancreas and stomach are not common sites for complications of ascariasis.
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1. Plain Xray abdomen finding in Sigmoid Volvulus
1. Characteristic bent inner tube or coffee bean appearance with convexity of loop lying in the right
upper quadrant (opposite to the site of obstruction)
2. Contrast study (gastrografin enema) - bird beak appearance i.e. narrowing at the site of voivulus.
B) Decreasing inflammation
• Decreasing inflammation may be indicated in patients who are about to undergo major intestinal
surgery, as this is thought to be an important contributing factor to POI.
• Nonsteroidal anti-inflammatory (NSAIDs) agents can be used in conjunction with opioid analgesics
for their dual effects on pain control and inflammatory inhibition.
D) Alternative medications
• Bisacodyl administration versus placebo twice daily starting on postoperative day 1, patients who
received bisacodyl had significantly earlier bowel movements than those who received placebo (25
h v. 56 h), but further studies are needed to assess the effect of laxatives on POI.
• Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal obstruction in
infants and children. Causes of paralytic ileus may include:
• Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels)
• Complications of intra-abdominal surgery
• Decreased blood supply to the abdominal area (mesenteric artery ischemia)
• Injury to the abdominal blood supply
• Intra-abdominal infection
• Kidney or lung disease
• Use of certain medications, especially narcotics
Management:
• Postoperative - a degree of ileus usually occurs after any abdominal procedure and is self-limiting,
with a variable duration of 24-72 hrs. Post op ileus may be prolonged in the presence of
hypoproteinemia or metabolic abnromality.
Paralytic ileus is a state in which there is failure of transmission of peristaltic waves
secondary to neuromuscular failure.
The resultant stasis leads to accumulation of fluid and gas within the bowel with
associated distention, vomiting, absent or diminished bowel sounds and absolute
constipation.
Radiological picture shows dilated gas filled bowel loops with multiple air-fluid level.
The picture is similar to mechanical small bowel obstruction; the only differentiating point
is presence of gas in colon and rectum in paralytic ileus.
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• Other clinical differentiating features of paralytic ileus from mechanical small bowel obstruction
are.
1) Pain - Pain is colicky in mechanical obstruction. Pain is not a feature of paralytic ileus and if present
is a steady, diffuse pain.
2) Bowel sounds - Bowel sounds are hypoactive or absent in paralytic ileus in contrast to hyperactive
bowel sounds in mechanical obstruction.
• Vaginal drainage of a pelvic abscess (posterior colpotomy) is indicated when a pelvic abscess
extends into the pouch of Douglas.
• Portal hypertensive gastropathy (PHG) is the ectatic blood vessels in the proximal gastric body and
cardia causing oozing of the blood.
• Less severe grades of PHG appear as a mosaic or snakeskin pattern and are not associated with
bleeding.
• Severe PHG with diffuse bleeding is treated by β-adrenergic receptor blockers or possibly with
placement of a TIPS or surgical portacaval shunt.
• The best treatment is liver transplantation
• Classification of Portal Hypertensive Gastropathy
• Tyrosine kinase inhibitors imatinib and sunitinib are approved for the treatment of Gastrointestinal
Stromal Tumors (GIST)
79. LYMPHOMA
• Burkitt's lymphoma is a tumor of mature B cells that express surface IgM, CD19, CD20, CD10, and
BCL6, a phenotype consistent with a germinal center B-cell origin.
• Unlike other tumors of germinal center origin, Burkitt lymphoma almost always fails to express the
antiapoptotic protein BCL2
• Burkitt's lymphoma is a B-cell lymphoma
• As this a tumor of mature B-cells it expresses IgM, CD 19, CD20, CD 10 and BCL 6 a phenotype
consistent with a B-cell origin.
• However, unlike other tumors of germinal center origin, Burkitt lymphoma almost always fails to
express the antiapoptotic protein BCL-2.
• All forms of Burkitt lymphoma are associated with translocations of c-Myc gene on chromosome 8.
• The usual translocation is t (8 : 14).
• Other less common translocations are t (2 : 8) and t (8 : 22).
• Most of the patients in United States with Burkitt's lymphoma present with peripheral
lymphadenopathy or an intro abdominal mass.
• The disease is typically rapidly progressive and has a propensity to metastasize to CNS.
• Chemotherapy is the treatment of choice in Burkitt's Lymphoma.
• Burkitt's Lymphoma was one of the first cancers shown to be curable by chemotherapy.
• Mantle cell lymphoma is a type of non-hodgkin lymphoma characterized by presence of tumor cells
which closely resemble the normal mantle zone of B-cells that surround germinal centers.
• Immunophenotype of mantle cell lymphoma
• Mantle cell lymphoma is neoplasm of B cells.
• Therefore it expresses B cell marker :
• CD19,CD20
• Surface immunoglobulin heavy chain (IgM and IgD).
• Either /c or X light chain.
• As the tumor cells are derived from Mantle zone, they are positive for B cell marker of mantle zone
i.e., CD-5.
• Mantle cell lymphoma is CD23 negative, this feature distinguish it from chronic lymphocytic
leukemia (CLL) which is positive for both CD5 and CD23.
• The other characteristic marker of mantle cell lymphoma is cycline DI.
Cytogenetic abnormalities.
• Mantle cell lymphoma is associated with an 11 : 14 translocation involving the IgH locus on
chromosome 14 and the cyclin DI locus on chromosome 11.
• This leads to increased expression of cyclin D 1, which promotes GI to S phase progression during
the cell cycle.
• 65 years old man with splenomegaly, lymphodenopathy CD-23 negative and CD-5 positive B-cell
suggest the diagnosis of mantle cell lymphoma.
Histological type
Epstein-Barr Virus
Clinical Features:
Diagnosis:
Treatment:
Purpura
Leukopenia
Cryoglobulinemia
• he stomach is the most frequent extranodal site for lymphomas. Microscopically, the vast majority
of gastric lymphoid tumors are non-Hodgkins lymphomas of B cell origin, Hodgkins ds involving the
stomach is extremely uncommon."
• Most patients notice the reddish discoloration of the surface of the eyeball (conjunctiva).
• As the tumor enlarges, patients seek medical attention.
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• Conjunctival lymphomas can become large enough to displace the eyeball, and restrict eye
movement. Eye movement restriction can cause diplopia (double-vision).
• If the tumor extends behind the eyeball, it can be pushed forward (proptosis). Rarely, and if large
enough, orbital lymphoma can press on the optic nerve and cause loss of vision.
• If discovered early, prompt treatment offers the best chance for recovery of vision.
• n 1964, researchers at the National Cancer Institute developed the first combination chemotherapy
that cured a number of patients who had relapsed following a standard radiation therapy regimen.
This drug combination was called MOPP and was, for a long time, the standard treatment for
Hodgkin's disease:
• Mustargen (mechlorethamine, nitrogen mustard)
• Oncovin (Vincristine, VCR)
• Procarbazine (Matulane)
• Prednisone (Deltasone, Orasone)
• MOPP has been mostly replaced by another combination chemotherapy called ABVD (Adriamycin,
Bleomycin, Vinblastine, Dacarbazine), which is now the standard chemotherapy regimen for
Hodgkin's disease.
• However, MOPP may be used if there are lung or heart conditions present or allergies to any of the
medications in the ABVD combination. Additionally, 30% to 40% of people will relapse after
treatment with ABVD, which will require 'salvage' treatment with MOPP.
• VAD combination chemotherapy is used for multiple myeloma and CHOP combination
chemotherapy is used for B cell chronic lymphoid leukemia
• Reed-Sternberg cells (also known as lacunar histiocytes for certain types) are different giant cells
found on light microscopy in biopsies from individuals with Hodgkin's lymphoma (aka Hodgkin's
disease; a type of lymphoma), and certain other disorders. They are usually derived from B
lymphocytes.
• nvolvement of another organ (kidney) by Gi lymhonlma of duodenojejunal flexure classifies it as a
stage IV lymphoma.
Acute Myoblastic t(8; 21), t(9;22) +8, 7-, 5-, 7q, 5q?
Leukemia (AML)
Acute Monocytic Leukemia t(9; 11), t(11; ?
23)
Acute Promyelocytic t(15; 17)
leukemia (M3)
Acute lymphoblastic t(4; 11), t(9; t(8; 14) 20q?
leukemia (ALL) 22),
Chronic lymphocytic +12
leukemia (CLL)
Erythroleukemia - 7q-, 5q?
Polycythemia Rubravera - 20q?
• The treatment of choice for Burkitt's Lymphoma is chemotherapy and not Radiotherapy.
• 'Burkitt's lymphoma responds well to short term high dose chemotherapy. Treatment of Burkitt's
lymphoma in both children and adults should begin within 48 hours of diagnosis and involves the
use of intensive combination chemotherapy regimens' – Harrisons
• Burkitt's Lymphoma is a B cell lymphoma
• Burkitt's Lymphoma are tumors of mature B cells – Robbins 7th/677
• t (8;14) translocation is the most common translocation in Burkitt's Lymphoma Burkitt's
lymphomas are associated with translocation of the c-MYC gene on chromosome 8. Translocation
• t (8; 14)
• t (8; 22)
• t (2; 8)
• Burkitt's Lymphoma may present with an abdominal mass
• The disease is rapidly progressive and has a propensity to metastasize to CNS, prophylactic therapy
to CNS is therefore mandatory.
• Burkitt's Lymphoma is the most rapidly progressive human tumor
• Burkitt's Lymphoma is typically associated with Epstein Barr virus (EBV).
• EBV is associated with upto 95% of cases of Endemic Burkitt's Lymphoma.
• EBV is associated with approximately 30% of cases of Sporadic Burkitt's Lymphoma and Immune
Deficiency associated Burkitt's Lymphoma.
• Infectious Agents Associated with the Development of Lymphoid Malignancies
Lymphoid Malignancy
• Thu-kites lymphoma
• Post–organ transplant lymphoma
• Primary CNS diffuse large B cell lymphoma
• Hodgkin's disease
• Extranodal NK/T cell lymphoma, nasal type
• Adult T cell leukemia/lymphoma
• Diffuse large B cell lymphoma
• 8111-kW's lymphoma
• Lymphoplasmacytic lymphoma
• Gastric MALT lymphoma
• Primary effusion lymphoma
• Multicentric Castleman's disease
• CNS, central nervous system; HIV, human immunodeficiency virus; HTLV. human T cell
lymphotropic virus; MALT, mucosaassociated lymphoid tissue; NK, natural killer
• Primary Effusion Lymphoma (PEL) is a rare variant of Immunoblastic Lymphomas seen primarily in
HIV infected patients.
• Primary Effusion Lymphoma (PEL) is a rare variant of Immunoblastic Lymphomas seen primarily in
HIV infected patients
• 'Two variants of Immunoblastic Lymphomas seen primarily in HIV infected patients are Primary
Effusion Lymphoma(PEL) and its solid variant Plasmacvtic lymphoma of the oral cavity'
• Centroblastic Lymphoma and Anaplastic Lymphomas are variants of Diffuse Large B call Lymphomas
and are distinct entities from I mmunoblastic Lymphomas
• Morphologic Variants of Diffuse Large B Cell Lymphomas ( DLBCL)
• Centroblastic
• Immunoblastic
• Anaplastic
• The most common variant of Non-Hodgkin's Lymphoma in India is Diffuse Large B cell Lymphoma
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• Diffuse Large B cell Lymphoma is also the most common variant of Non-Hodgkin's Lymphoma in the
United States (Western Data)
• 'The majority of Non-Hodgkin's Lymphoma (NHL) in India are B-cell Lymphomas (around 80
percent). The distribution of Non-Hodgkin's Lymphoma (NHL) subtypes in India shows important
differences with those from the rest of the world. Diffuse large B-cell lymphoma remains the most
common form of NHL as in Western Data. However, Follicular lymphoma and mantle-cell
lymphoma are less common in India compared to Europe and the USA. T cell Lymphomas account
for approximately 16 percent of all NHL. T-cell lvmphohlastic lymphoma and anaplastic large T/null
cell lymphoma are more prevalent in India. Peripheral T-cell lymphomas and T/NK-cell lymphomas
of nasal and nasal types, which are common in many other Asian countries, are less prevalent.'
• Working formulation of NHL for clinical usage is as follows:
• Low grade
Small lymphocytic Q
Follicular, predominantly small cleaved cell Q
Follicular, mixed, small cleaved and large cell. Q
• Intermediate grade
Follicular predominantly large cell Q
Diffuse small cleaved cell
Diffuse mixed small and large cell.
Diffuse large cell.
• High grade
Large cell immunoblastic Q
Lymphoblastic Q
Small non cleaved cell.
• Note that all varieties of diffuse fall in the intermediate grade category only.
• International prognostic index' does not include Hemoglobin and Albumin as prognostic factors.
• Prognostic Factors according to International Prognostic Index for NHL
V. Hodgkins LF mphoma
• Classical subtypes
• Nodular sclerosis - Mixed cellularity
• Lymphocyte-rich
• Lymphocyte depletion Lymphocyte predominance
Restrictive
• Laparoscopic adjustable gastric banding (LAGB)
• Sleeve gastrectomy (SG)
• Vertical banded gastroplasty (VBG)
Malabsorptive
• Biliopancreatic diversion (BPD)
• Jejunoileal bypass (JIB)
• In orthotropic liver transplantaion, the bile duct between recipent and donor liver are repaired in
end to end fasion or else Roux en Y choledochojejunostomy.
• Biliary atresia is an indication for Liver transplantation in children while primary Biliary Cirrhosis,
Sclerosing cholangitis and Hematochromatosis an established indications for Liver transplantation
in adults
Children
• Biliary atresia
• Neonatal hepatitis
• Congenital hepatic fibrosis
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• Alagille's disease"
• Byler's disease
• a 1 -Antitrypsin deficiency
• Inherited disorders of metabolism
• Wilson's disease
• Tyrosinemia
• Glycogen storage diseases
• Lysosomal storage diseases
• Protoporphyria
• Crigler-Najjar disease type I
• Familial hypercholesterolemia
• Primary hyperoxaluria type I
• Hemophilia
Aduts
Children
Biliary atresia Primary biliary cirrhosis
Neonatal hepatitis Secondary biliary cirrhosis
Congenital hepatic fibrosis Primary sclerosing cholangitis
Alagille's disease Autoimmune hepatitis
Byler's disease Caroli's disease
al- antitrypsin deficiency Cryptogenic cirrhosis
Inherited disorders of metabolism Chronic hepatitis with cirrhosis
Wilson's disease Hepatic vein thrombosis
Tyrosinemia Fulminant hepatitis
Glycogen storage diseases Alcoholic cirrhosis
Lysosomal storage diseases Chronic viral hepatitis
Protoporphyria Primary hepatocellular malignancies
Crigler-Najjar disease type I Hepatic adenomas
Familial hypercholesterolemia Nonalcoholic steatohepatitis
Primary hyperoxaluria type I Familial amyloid polyneuropathy
Hemophilia
• Gallstone impacts in the wall causing pressure necrosis which further gets adherent to the CBD wall
• Occasionally leads to a cholecystocholedochal fistula
Management:
88. Pseudocyst
• Most common cause of pancreatic pseudocyst is Pancreatitis (90%). The second most common
cause is trauma (10%).
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• The complication least likely to occur in a pseudocyst of the pancreas is Carcinomatous change
• Commonest complication of pancreatic pseudocyst ?
• Infection
• "Other than pain, infection is the most common complication" - Maingot's 10/e, p 1929
• Other complications are:
• Obstruction of GIT
• Hemorrhage
• Rupture
• Pseudoanetoysm - splenic artery is most frequently involved.
• Percutaneous aspiration is preferred only in cases of infected cyst and abcesses, other wise internal
drainage is the t/t of choice.
• Epigastric mass is the main symptom of pseudocyst.
• Increased level of amylase is usually elevated with pancreatic pseudocysts.
A feeding tube jejunostomy is strongly advised during major foregut, or hepatic operation, during a
major trauma laparotomy, after pancreatic surgery; or in nutritionally bankrupt patients." - Essentials
of General Surgery by Lawrence 4/e p80.
GI tract surrounding pancreas (stomach, duodenum) undergoes paralytic ileus after a major
pancreatic surgery, thus oral feeding and feeding gastrostomy are not used.
A feeding jejunostomy would be ideal route after a major pancreatic surgery and is strongly
recommended.
• "Pseudocysts occur in up to 10% of patients with acute pancreatitis, and in 20 to 38% of patients
with chronic pancreatitis, and thus, they comprise the most common complication of chronic
pancreatitis."
• Areas of ductal dilatation alternating with areas of ductal stenosis are common finding in alcoholic
patients who have severe chronic pancreatitis.
• This type of duct obstruction cannot be relieved by a sphincteroplasty because of multiple areas of
stenosis along the duct.
• Although total pancreatectomy would be a beneficial approach, mortality and morbidity rate with
this procedure are extremely high.
• Thus the procedure of choice in this pt. is side to side pancreaticojejunostomy in which the duct is
opened longitudinally through the chain of lakes. A Roux-en-Y limb of jejunum should then be
brought up for anastomosis with the opened pancreas in side-to-side fashion
• he patient most likely has a pancreatic pseudocyst, which is a complication of pancreatitis.
Pancreatic pseudocyst is not a true cyst; it is lined by granulation tissue and collagen.
90. INSULINOMA
• Xylose test is used in the diagnosis of malabsorption due to intestinal mucosal disease. This test is
not used for the diagnosis of Insulinomas
• Fasting blood glucose, C- peptide levels and Insulin Glucose Ratio are all used in the diagnosis of
Insulinomas.
Diagnosis of Insulinomas
• 6,uU/m1 when blood glucose in < 40 mg/dl " align="left" height="40" width="237">Serum insulin
levels (fasting)
• Serum glucose levels (fasting)
• Serum C- peptide levels (Elevated)
• Serum proinsulin levels (Elevated)
• Insulin / Glucose Ratio (> 0.3)
• Plasma fl-Hydroxybulyrate (Decreased)
• The most reliable test is a fast upto 72 hours with serum glucose, C-peptide and insulin levels
measurements every 4-8 hours
• The Gold standard test for diagnosis of Insulinoma is a supervised '72 hour fast' test
• Diagnosis of lnsulinoma requires demonstration of inappropriately high levels of plasma Insulin (
and C- peptide) in the presence of documented hypoglycemia (Achieved by 72 hour fast test).
• Most common symptoms are due to the effect of hypoglycemia on the central nervous system
(Neuroglycemic Symptoms)
• Confusion
• Headache
• Disorientation
• Visual difficulties
• Irrational behavior (even coma)
• Tremor
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• Palpitation
• The most important examination is intraoperative ultrasound, which can identify a pancreatic
tumor in nearly all cases. It is more sensitive than any preoperative test." - CSDT
• nsulinomas invariably occur only in the pancreas, distributed equally in the pancreatic head, body
and tail".
• Harrison 17/e
• Insulinomas are a cell endocrinal tumur of the pancreas.
• Insulinomas are the most common pancreatic endocrine neoplasms.
• The symptoms are produced due to excessive secretion of insulin causing hypoglycemia
• Most of the insulinomas are solitary and benign,
• Only about 10-15% of insulinomas are malignant. (keep in mind that all other endocrine tumours of
pancreas are usually malignant).
• Symptoms of insulinoma ?
• The most common symptom is due to the effect of hypoglycemia on the central nervous system. -
These symptoms are - confusion, disorientation, visual difficulties, irrational behaviour, coma
• Other symptoms are due to increased secretion of catecholamines which includes sweating, tremor
and palpitations.
• Classic diagnostic criteria is - Whipple's triad
• Signs and symptoms of hypoglycemia during fasting.
• Blood glucose below 2.8 mmol/L (50mg/d1) during symptomatic episodes.
• Relief of symptoms by intravenous administration of Glucose.
• The most useful diagnostic test and the only one indicated in almost all patients is demonstration of
fasting hypoglycemia in the presence of inappropriately high level of insulin.
• The patient is fasted for 72 hrs or till the symptoms of hypoglycemia develop.
• When hypoglycemia develops, serum level of insulin is measured. A ratio of plasma insulin to
glucose > 0.3 is diagnostic.
• Localization of the tumour
• Once the diagnosis has been made, localization of the tumour is must for surgery.
• The most important examination for localization of tumour is intraoperative ultrasound, which can
indentify pancreatic tumour in all cases.
• It is more sensitive than any other method
• Other important methods of localization ?
• High resolution CT and MRI.
• Endoscopic ultrasound examination of pancreas.
• Selective arteriography
• T/T - Surgical excision is the t/t of choice ?
• Since most insulinomas are benign simple enucleation is done.
• "The most reliable test to diagnose insulinoma is a fast up to 72 h with serum glucose, C-peptide,
and insulin measurements every 4-8 h."—Harrison
• An insulinoma is an endocrine tumor of the pancreas derived from beta cells that ectopically
secretes insulin, which results in hypoglycemia.
• The clinical symptoms are because of.the effects of hypoglycaemia (sweating, tremor, palpitations,
confusion, headache, disorientation, visual difficulties, irrational behavior, or even coma)
91. urolithiasis
• Which one of the following gastrointestinal disorders predisposes to urolithiasis -short bowel
syndrome.
• A 45-year-old male with history of recurrent ureteric calculi presented with fever. Right-sided
nephrectomy was performed. Gross view and histology have been provided.the diagnosis will be
uteric calculi.
• Scrotal Wall becomes red, edematous , shiny and become adherent to epididymis
• Orchitis without epididymitis is seen in SYPHILIS
• In differential diagnosis of epididymo-orchitis & torsion it is important that Elevation of testis in
epididymo orchitis relieves pain
• Acute tuberculous epididymitis – thickened vas
• The Main Complication is testicular atrophy which may cause infertility (if B/L)
• Doxycycline for Chlamydial infection, Plenty of fluids, scrotal support and analgesics
• Meconium stooling is seen in 90 percent of newborns within the first 24 hours, and most of the rest
within 36 hours.
• Patient with leakage of fluid and meconium stained liquor at 34 weeks of gestation is suffering from
preterm premature rupture of membrane (PROM)
• Meconium is excreted by a new born till 3 day
• Saffron coloured meconium is seen in post maturity
• Meconium aspiration syndrome occurs when infants take meconium into their lungs during or
before delivery.
• Meconium stained liquor (amniotic fluid) with respiratory distress soon after birth suggests the
diagnosis of meconium aspiration syndrome
• Complications: Persistent pulmonary hypertension
• Obstructive emphysema can occur as a result of passage of meconium in utero
• Chest X-ray: bilateral heterogeneous opacities (patchy infiltrates), coarse streaking of both lung
fields, areas of hyper expansion, atelectasis and air leak, increased AP diameter, flattening of
diaphragm
• Management: IV fluids, ventilator support,oxygen,Antibiotics
3. Kwashiorkor
4. Phenylketonuria
• In Phenylketonuria the main aim of first line therapy is Limiting the substrate for deficient enzyme
• Microcephaly, blue eyes, fair skin, and mental retardation in a 4 year old girl with a positive ferric
chloride test is indicative of Phenylketonuria
• A child brought with seizures and impairment of development is diagnosed having phenylketonuria.
Restriction of substrate of the deficient enzyme in the diet is the initial line of treatment in this
child
• The primary deficiency in the disease phenylketonuria occurs in the synthesis of Tyrosine
• Phenylketonuria is detected by Guthrie test
• Incomplete oxidation of phenylpyruvic acid results in Phenylketonuria
• Mousy odour urine is seen in Phenylketonuria
• Enzyme deficient in phenylketonuria is Phenylalanine hydroxylase
• In phenylketonuria FeCl3 test with urine gives green color
• Severe mental retardation,Enamel hypoplasia & Vomiting in early infancy is seen
in Phenylketonuria
• Brain damage in phenylketonuria is due to accumulation of Phenylalanine
• Phenylketonuria is Autosomal recessive disorder
• Newborn with an early onset of dyspnea with chest retractions, expiratory grunting and cyanosis
following an uneventful normal preterm labor. On examination no cardiac murmurs are heard and
the lungs appear clear. On a plain X-ray there is evidence of prominent pulmonary vascular
markings and fluid lines in the fissures. The cyanosis improves with minimal oxygen. The most
probable diagnosis is Transient tachypnea of the newborn
• Transient Tachypnea of New born (TTN) is due to delayed clearance of lung fluids
• X – ray may show prominent vascular markings with prominent interlobar fissure
• A diabetic female at 39 weeks of gestation delivered a baby by elective cesarean section. Soon after
birth the baby developed respiratory distress. Chest X-ray shows opacity in right middle lobe
fissure. The diagnosis is Transient Tachypnea of New born (TTN)
• Transient tachypnea of new born (TTN) is commonly seen in Elective caesarean section
• Onset of respiratory distress is immediately after birth and it rarely lasts beyond 48 hrs
• Respiratory rate in a 2 month old, to label it tachypnea is 60
7. SHORT STATURE
• Characteristic of XO chromosomal defect are Short stature, Webbed necked & Infertility
• Characteristic of Noonan syndrome are anti-mongoloid slant, pulmonary stenosis, short stature and
undescended testis.
• 45 X karyotype is seen in female with short stature, wide spread nipples and primary amenorrhoea
• The most common cause of short stature is Constitutional
• Height more than 3.5 SD below the mean for chronologic age is seen in pathologic short stature in
a child
• Growth rate more than 2 SD below the mean for chronologic age is seen in pathologic short stature
in a child
• Height more than 2 SD below the target height when corrected for midparental height is seen
in pathologic short stature in a child
• Thyroid Dyshormonogenesis shows short stature, lethargy, & constipation with goiter & low T4 and
elevated TSH
• Mentally retarded, has short stature, gait disturbance, squint and proximal spasticity in the lower
limbs with a swelling in front of the neck which moves with deglutition arising due to a low intake
of iodine less than 25microg/d is diagnosed to have neurologic cretinism
• Short stature is seen in Maternal deprivation syndrome & Hypothyroidism
• Short stature, secondary to growth hormone deficiency is associated with Normal body proportion.
• Recurrent attacks of polyurea, short stature, Serum Creatinine - 6 mg%, HCO3 - 16 meq, Na - 134,
K+ 4.2 & USG showing bilateral small kidneys is diagnosed as Nephronophthisis
• Short limbs compared to trunk & short stature is seen in critinism
• Growth retardation and propensity to hypoglycemia,short stature, micropenis, increased fat and
high-pitched voice is most appropriately diagnosed with Growth hormone deficiency
• Short stature, secondary to growth hormone deficeincy is associated with Normal body proportion
• A child presents with antimongoloid slant, pulmonary stenosis, short stature and undescended
testis is showing symptoms of Noonan syndrome
• High risk pregnancy Short stature primi
• Bone age corresponds to chronological age in Familial short stature
• Webbing of neck, short stature, increased carrying angle, low posterior hair line, primary
amenorrhea and short fourth metacarpal are characteristics of Turner syndrome
8. DEVELOPMENTAL MILESTONES
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• Milestones during the first year of life is Social smile, Head control, Sits up The correct sequence in
the developmental & Crawls
• The sequence and time of attainment of milestones may vary among individual children
• Development always proceeds in a cephalocaudal sequence
• Presence of primitive reflexes is essential for attaining voluntary actions
• Mirror play developmental milestones is first to happen
• Moro's Reflex is not present from 3 months
• Motor function develops and differentiates early in a term newborn
• The milestones achieved at 13 months in children are Index finger approach, Walking & Single
words
• Mental retardation can be proved if delayed milestones and slow or retarded growth seen upto 18
yr
• Object permanence milestone develop at 9 months
9. PRIMITIVE REFLEXES
• Neonatal sepsis is associated with an increased risk of neurologic damage in a jaundiced newborn
• Most common cause of Neonatal sepsis in hospital in India is Klebsiella
• Preterni babies are predisposed to Neonatal sepsis
• Late initiation of breast feeding is a predisposition for Neonatal sepsis
• Premature rupture of membranes predisposes to Neonatal sepsis
• Early Neonatal sepsis is due to organism in maternal genital tract
• Environmental factors cause late Neonatal sepsis
• Least observed laboratory finding in Neonatal Sepsis is Neutrophilia
• Neonatal sepsis and meningitis most common cause Streptococcus agalactacea
• Early neonatal sepsis occurs within (hours) 72
• Necrotizing enterocolitis is complication of formula fed baby over human milk fed baby
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• Peritoneal drainage by putting drains in the flanks is the treatment of choice for low birth weight
preterm baby showing clinical features of necrotizing enterocolitis with perforation
• Probiotics have been found beneficial for use in Necrotizing enterocolitis
• Prematurity is considered the MOST important risk factor for necrotizing enterocolitis
• A preterm baby with Patent ductus arteriosus may show Necrotizing enterocolitis
• Pneumatosis intestinalis is diagnostic of Necrotizing enterocolitis
• Neonatal Necrotizing enterocolitis is characterized by Abdominal distension,Metabolic
acidosis, Pneumoperitoneum & Decreased bowel sounds
• A premature neonate on top feeding develop abdominal destension and bleeding per rectum with
acute Upper RTI is diagnosed to have Necrotizing enterocolitis
• A neonate is suspected to be suffering from necrotizing enterocolitis (NEC). On further examination
and investigation, he is diagnosed to be Bell's stage I NEC. The management of choice would
be Conservative management with IV fluids and antibiotics
• A newborn infant showing multiple hemorrhagic, cutaneous lesions and does not respond to sound
stimuli with periventricular calcifications in CT is most likely caused by Cytomegalovirus
• Late onset hemorrhagic disease of newborn is characterized by Onset at 4-12 week of
age, Intracranial hemorrhage
• Intramuscular vitamin K prophylaxis at birth has a protective role in hemorrhagic disease of
newborn
• Thrombin time is abnormal in classic hemorrhagic disease of newborn
• Biliary atresia can predispose late onset Hemorrhagic disease of newborn (HDN)
• Warfarin therapy is associated with late onset Hemorrhagic disease of newborn (HDN)
• Case of hemorrhagic disease of newborn bleed on 2nd day is associated with factor 2, 7, 9, 10
14. PHOTOTHERAPY
• About 50% of affected infants have moderately severe neonatal jaundice is hereditary
spherocytosis
• Neonatal Jaundice first time appears in the 3rd week by Galactossemia, Hypothyroidism & Breast
milk Jaundice
• Defective hepatic conjugation is seen in Neonatal jaundice
• Hypothyroidism, Jaundice due to breast milk & Galactosemia are cause for neonatal jaundice
manifesting for the first time in the second week
• G6PD deficiency is Associated with neonatal jaundice
• Neutrophils play a crucial role in the pathogenesis of alveolar-capillary damage in adult respiratory
distress syndrome (ARDS)
• Air bronchogram in chest x-ray favour the diagnosis of respiratory distress syndrome (RDS) in new
born
• Respiratory distress syndrome can be diagnosed prenatally by determining Lecithin / Sphingomyelin
ratio as RDS is caused by deficiency of surfactant
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• Respiratory distress syndrome in premature infants is due to inadequate secretion
of Dipalmitoylphosphatidylcholine
• To prevent Respiratory Distress Syndrome dexamethasone injection is given to a lady of 32 weeks
pregnancy
• Hyaline membranes and collapsed alveoli is most likely be observed in the lung during an autopsy
of a 2 week old infant who died of neonatal respiratory distress syndrome
• Respiratory distress syndrome in the newborn is commonly associated with Diabetic
pregnancy, Prematurity & Following an elective cesarean section
• Hyaline membrane disease shows FRC below the closing volume
• In hyaline membrane disease the pathology in the lung consists of Fibrin
• Respiratory distress syndrome in infants is seen in Babies of diabetics & Premature rupture of
membrane
• The clinical sign of hyaline membrane disease generally first appears In the first 6 hours of life
• Intercostal retraction & RR > 60/ min are signs of neonatal respiratory distress syndrome
• A 31 week pregnant lady delivers a child. In 4 hrs baby develops dyspnoea and cyanosis. X-ray chest
shows ground glass appearance. The diagnosis Hyaline membrane disease
• X-ray appearance in hyaline membrane disease can be Homogenous ground glass
appearance, Reticulonodular shadow or normal x-ray
• Granulomatous appearance of lung with air bronchogram in neonates represents Hyaline
membrane disease
• Phosphatidyl glycerol estimation is a reliable method of diagnosis Phosphatidyl glycerol estimation
is a reliable method of diagnosis
• The dose of betamethasone in prenatal to prevent respiratory distress syndrome is 12 mg every 24
hours
• Failure to initiate and maintain spontaneous respiration following birth is clinically k/a respiratory
distress syndrome
• Diffuse Alveolar Damage is the most characteristic feature of Adult Respiratory Distress Syndrome
(ARDS)
• Diagnostic criteria for acute respiratory distress syndrome is Pao2/Fio2 ratio is
• Mortality rates ranges between 40 to 65% in ARDS
• Pneumonia is commonly associated with ARDS
• ARDS is seen after 6 hours of birth
18. BRONCHIOLITIS
• Fever and mild respiratory distress, wheeze and exaggerated breathlessness with hyperluscency in
Chest x-ray & obstructive pattern of PFT suggest Bronchiolitis Obliterans
• RSVH(respiratory syncitial virus or adenovirus) is the commonest etiological agent of Bronchiolitis
• Antiviral agent of choice in a child with bronchiolitis is Ribavirin
• Hyperinflation of the chest is seen in Bronchiolitis
• Intercostal and subcostal retractions and extensive rhonchi on auscultation & chest X-rayshowing
hyperinflated chest suggest Bronchiolitis
• Bronchiolitis in a self-limiting viral illness secondary to respiratory syncitial virus
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• Bronchiolitis predisposes children for later development of asthma
• Egg shell calcification is seen in bronchiolitis
• Kangaroo Mother Care (KMC) is best for transport of the newborn with maintainance of warm
temperature
• Kangaroo Mother Care (KMC) Can also be given by father
• Kangaroo Mother Care (KMC) is for Effective thermal control
• Kangaroo Mother Care (KMC) is especially for low birth weight body
• Skin to skin contact, Exclusive breast feeding & Early discharge and follow-up are the components
of Kangaroo Mother Care (KMC)
• X-ray chest showing globular cardiomegaly with oligemic lung fields in a child is suggestive
of Ebstein's anomaly
• Wolff-Parkinson-White disease may be associated with Ebstein's anomaly
• Ebstein's anomaly is characterized by Downward displacement of an abnormal tricuspid valve into
right ventricle
• Congenital heart disease associated with decreased pulmonary blood flow is Ebstein's anomaly
• Intracavitary electrocardiography is a diagnostic aid in Ebstein's anomaly
• Ebsteins anomaly is associated with Tricuspid atresia
• Ebstein's anomaly is seen with intake of Lithium
1. Placenta accreta
• Abnormal attachment of the placenta through the uterine myometrium as a result of defective
decidual formation (absent Nitabuch's layer).
• Placental villi are attached to the myometrium in placenta accreta
• Invade the myometrium in placenta increta
• Penetrate through the myometrium & extend to the uterine serosa in placenta percreta
• The abnormal adherence may involve all of the cotyledons (total placenta accreta), a few to several
cotyledons (partial placenta accreta), or a single cotyledon (focal placenta accreta).
• Two-thirds of patients with this complication require hysterectomy.
• In fact, those with a prior cesarean section carry a 25% risk
• Doppler USG- helpful in diagnosis.
3. Vesicovaginal Fistula
• The most appropriate method for collecting urine for culture in case of vesicovaginal fistula
is Foley's catheter
• Vesicovaginal fistula repair surgery, the drainage should be done for 14 days
• Vesicovaginal fistula by obstructed labour manifests After 1st week of delivery
• A 52 year old lady presents with constant leakage of urine and dysuria two weeks after a
complicated total abdominal hysterectomy diagnosed of Vesicovaginal fistula is suspected. The
most important test for the diagnosis is Triple Swab Test
4. Threatened Abortion
5. Intrauterine Death
6. Fetal circulation
• The primitive uteroplacental circulation is functionally established during end of first month.
• Fetal blood is returned to the umbilical arteries and the placenta through the Hypogastric arteries
• The immunoglobulin which passes the placental barrier in humans is IgG
• Trophoblast, Fetal capillary endothelium & Mesoderm are components of placental barrier
• The liver and heart of the fetus receive blood with very high oxygen saturation
• Maximum level of alpha feto protein is seen in Fetal serum
• Heart receives blood with high oxygen saturation
• Fetal Hb shows high pO2 saturation compared to adult Hb because Affinity to binding to DPG is
different in fetal Hb
• Human chorionic gonadotropin is produced by the human placenta having LH-like activity
• The placental hormone that participates in stimulation of ductal growth in the mammary gland
during pregnancy is Human chorionic somatotropin (HCS)
• HBV viruses is least likely to cross placenta
• Placenta develops from Placenta frondosum & Decidua basalis
• Trophoblast, Fetal capillary endothelium & Mesoderm are constituent of placental barrier
• At term, ratio of weight of fetus to weight of placenta is 6 : 1
• Syncytiotrophoblast is the inner most part of placenta
• In the placenta, maternal blood comes in direct contact with syncytiotrophoblast
• Chorionic gonadotropin, Chorionic thyrotropin & chorionic corticotropin are placental hormones
• Progesterone production require fetal steroidogenic tissue
• Weight of placenta at term is 500 grams
8. Amniotic Fluid
• Best method for the diagnosis of lung maturity is Phosphtidyl glycerol estimation in amniotic fluid
• The presence of increased levels of Acetyl cholinesterase in amniotic fluid is an indicator of open
neural tube defect in the fetus
• Nile blue sulphatase test in amniotic fluid is for Skin maturity
• Amniotic fluid contains acetyl cholinesterase enzyme can be a diagnosis of Open spina bifida
• Amniotic fluid is maximum at 38 weeks of pregnancy
• Amniotic fluid index (AFI) is calculated by adding the vertical depths of the largest pocket in each of
four equal uterine quadrants
• Fluid restriction may lower the AFI
• Significant hydramnios is defined by an index greater than 24 cm
• Prenatal diagnosis at 16 weeks of pregnancy can be performed using Amniotic fluid
• The amount of amniotic fluid at 12 weeks of pregnancy is 50 ml
• Amniotic fluid at 38 weeks in normal pregnancy is 800 cc
• pH range of amniotic fluid is 7.0 - 7.5
• pH of amniotic fluid at later weeks of gestation is 7.2
• Golden colour amniotic fluid is seen in Rh incompatibility
• The amniotic fluid is completely replaced in every 3 hours
• The major contribution of the amniotic fluid after 20 weeks of gestation is Fetal urine
• At 15 weeks of gestation, increased alpha fetoprotein in amniotic fluid is seen in Intrauterine death
• Risk of amniotic fluid embolism is greatest During labour
• Amniotic fluid is mainly produced by Fetus
• Surfactant appears in amniotic fluid at the gestational age of 32 weeks
• The amniotic fluid is in balance by Excretion by fetal kidneys, Maternal hemostasis & Fetal intestinal
absorption
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• Antenatal screening is done using Cord blood, Amniotic fluid & Chorionic villi
• Lendrum's stain is done for Amniotic fluid embolism
9. Umbilical Cord
• Prostaglandins are the first to cause uterine contraction and lowering of blood pressure
• Braxton — Hicks contractions Occur during most of the months of pregnancy
• True labour pain is Painful uterine contraction
• Formation of the bag of waters is seen in true labour
• Progressive descent of presenting part is seen in true labour pain
• Average pressure of uterine contractions during the first stage of labour is 30 mm Hg
• Engagement in primigravida occurs at Beginning of labour
• During uterine contraction of labour, the uterine blood flow Decreases
• True labour differs from false labour by Painful uterine contractions,Progressive effacement and
dilatation of the cervix & Pain often felt in front of the abdomen or radiating towards the thighs
• Pressure of normal uterine contractions is between 190-300 Montevideo units
• Bag of waters is a sure sign of labour
• Cervical ripening is mainly due to the action of PGE2
• Maximum cervical dilatation during labor is 10 cm
• True labour pains is represented by show
• Flexion, Extension & Internal rotation and Descent are the cardinal movements of the head in
normal labour.
• Suboccipitofrontal is the commonest diameter of engagement
• Engagement in primigravida occurs at Beginning of labour
• Engagement of fetal head is When the widest diameter of the presenting part has passed through
the pelvic inlet
• Engagement of foetal head is with reference to Biparietal diameter
• The cardinal movements during normal labour occur inorder as Engagement, internal rotation,
delivery of head, restitution, external rotation
• One fifth of the head may be palpable per abdomen during engagement of the head
• The vertex will be at the level of ischial spine during engagement of the head
• The biparietal diameter has passed through the pelvic inlet in engagement
• The internal rotation in mentoposterior position is 3/8th of circle
• Maximum cervical dilatation during labor is 10 cm
• During active labor, cervical dilatation per hour in primigravida is 1 cm/hour
• After a full term normal delivery patient went into shock. Most probable cause is Inversion of
uterus
• Common cause of death in inversion of uterus Hemorrhage
• Complication of manual removal of placenta is Inversion of uterus
• Inversion of the uterus, a complication is noticed in Third satge of labour
20. VERSION
• Indications for caesarean section in pregnancy are Aortic stenosis, M.R. & Aortic regurgitaion
• Lower Segment Caesarean section (LSCS) can be carried out under
• General anaesthesia
• Spinal anaesthesia
• Combined Spinal Epidural anaesthesia
• Absolute indication for caesarean section in pregnancy are
• Advanced Carcinoma Cervix
• Central Placenta Praevia
• Contracted Pelvis
• History of previous classical CS is the contraindication for trial of normal labour after caesarean
section
• Cephalopelvic disproportion is an absolute indication for Caesarean section.
• In classical caesarean section more chances of rupture of uterus is in Upper uterine segment
• Best management in Mento-posterior presentation Caesarean section
• Absolute indication for caesarean section is Type IV placenta previa
• Ideal management of a 37 weeks pregnant elderly primigravida with placenta praevia and active
bleeding is Caesarean section
• Placenat accrete complicates third stage of labour and is associated with a past history of caesarean
section
• Incidence of scar rupture in previous lower segment caesarean section 1%
• Risk of rupture of uterus with previous classical caesarean section is 4-8%
• Indicators of impending uterine rupture during labour include Fetal distress, Hematuria & Fresh
bleeding per vaginum
• Uterine rupture is least common with LSCS
• In classical Cesarean section more chances of rupture of uterus is in Upper uterine segment
• The usual site of spontaneous rupture of the intact uterus during pregnancy is the Body of the
uterus
• Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled
most simply by Ligation of hypogastric artery
• In Uterine rupture following illegal abortion air under both sides of diaphragm is visualized
• Risk of rupture of uterus with previous classical cesarean section is 4-8%
• To determine the correct amount of RhoGAM (anti-D immune globulin) that should be
given Kleihauer-Betke laboratory test should be done.
• The test used to differentiate between maternal and fetal blood in a given sample is Apt test
• Most severely affected child in Rh-isoimmunisation patient is Rh negative mother with Rh positive
in 2nd child
• In an Rh negative mother who has delivered an Rh positive baby, prophylactic anti D is indicated If
the Indirect Coomb's test (ICT) negative
• The dose of anti D gamma globulin given after term delivery for a Rh negative mother and Rh
positive baby is 300 micro gram
• The antigen lacking in Rh negative person is D
• Anti-D Rh is given for Rh positive father,Rh negative mother
• Mitral valve stenosis patient benefit by having a forceps-assisted vaginal delivery at the time of
delivery
• Infant showing asymmetric Moro reflex involving the right arm, cynosis & labored respiration
with decreased breath sounds in the right chest post low forceps delivery may be due
to Ipsilateral paralysis of the diaphragm
• Retinal hemorrhage, intracranial hemorrhage and subgaleal hemorrhage are more common in
ventouse delivery than forceps
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• Less maternal trauma by vacuum as compared with forceps
• Cephalohematoma is more common with vacuum extraction
• Forceps delivery is indicated in
• Face presentation
• Occipitoposterior
• After warming head in breech
• Prolonged second stage of labor
• In a case of prolonged labour, fetal occiput fails to spontaneously rotate anteriorly and caused
persistent occiput posterior presentation. The recommended management is Manual or forceps
rotation followed by forceps delivery
• The after coming head of breech chin to pubes is delivered by Manual rotation and extraction by
Piper's forceps
• For delivery of the after- coming head in breech presentation Kielland's foceps, Das's variety
forceps & Mauriceau smellie, veit technique are used
• In face presentation, outlet forceps delivery can be accomplished successfully in Right mento-
anterior & Direct anterior positions
• Keilland's forceps facilitates correction of asynclitism of head
• The most important point of reference in the use of forceps is Station of biparietal diameter
• Head engaged and reached the pelvic floor can be treated using Outlet forceps
• Outlet forceps delivery is safest in maternal heart disease
• Prerequisite for applying forceps are
• Aftercoming head of breech
• there should be no CPD
• Foetal head should be engaged
30. PARTOGRAM
31. Preeclampsia
• Anti-phospholipid antibody, Gestational diabetes & Molar pregnancy are predisposing factor for
Preeclampsia
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• Specific treatment of severe pre eclampsia is Magnesium sulfate
• Duration of latent phase of labour is affected by Pre-eclampsia
• Complete hydatidiform mole is associated with preeclampsia
• Pre-eclampsia is associated with placental abruption
• Low maternal serum 25-hydroxyvitamin D is associated with Pre-eclampsia
• There is decrease in in GFR is expected in a 30-year-old lady with pre-eclampsia
• Polyarteritis nodosa poses the greatest risk for development of pre-eclampsia
• Pregnant multigravida having pre-eclampsia & seizures should be treated with Pritchard's (MgSO4)
regimen
• Serum uric acid is known as ‘biochemical marker of pre-eclampsia’
• Doppler ultrasonography in IUGR & Preeclampsia shows notch in Uterine artery
32. Eclampsia
• Eclampsia, with given IV magnesium sulphate. The baby was resuscitated and transferred to the
NICU. 12 hours later, the baby showed hypotonia, lethargy, constricted pupils and two episodes of
seizures. The staging of HIE is 2
• The single most effective drug in eclampsia is Magnesium sulphate
• Hepatic infarcts are seen in Eclampsia
• Magpie’ regime for a patient with eclampsia is initiated following which respiratory rate is 6/minute
and the tendon reflexes are not elicitable should be managed with Inject calcium gluconate 10 ml
over 10 minutes
• Loss of deep tendon reflexesis the earliest sign of magnesium toxicity in a patient with eclampsia on
treatment with magnesium sulphate
• History of eclampsia classes as a high risk pregnancy
• Complications include placental abruption, uterine dysfunction, and postpartum hemorrhage are
seen in polyhydramnios
• Polyhydramnios is associated with Diabetes,Anencephaly, Open spina bifida & Tracheo esophageal
fistula
• Amniocentesis is the treatment of choice in pregnant women with polyhydramnios and marked
respiratory distress at 35 weeks of gestation
• Cleft palate is associated with polyhydramnios
• Clinical signs of Hydramnios can be demonstrated when fluid collection is more than 2 ltr.
• Causes of Hydramnios are Twins,Oesophageal atresia or Anencephaly
• ARM is contraindicated in Hydramnios
• Feature of diabetes mellitus in pregnancy is Hydramnios
• Hydramnios is complicated by Placenta abruptio, Pre-eclampsia & Atonic Hemorrhage
38. EPISIOTOMY
• Scar endometriosis can occur following Episiotomy, Hysterotomy or Classical Cesarean Section
• A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy,
an advantage of mediolateral episiotomy is Less extension of the incision
• Most suitable method of treating 4 inch size episiotomy hematoma is by Evacuation
• The most important step in the treatment of a badly infected episiotomy is Drainage
• Episiotomy is best done Mediolaterally
• Advantages of median episiotomy over mediolateral episiotomy are Less blood loss, Easy repair
& Muscles are not cut
39. OLIGOHYDRAMNIOS
• Anti-D administration, Corticosteroids & Blood transfusion are included in the expectant
management of placenta praevia
• In Browne's classification of placenta previa, the placenta covers the internal os when closed but
not when fully dilated is Type 3
• The initial hemorrhage is usually painless and fatal in placenta praevia
• Per vaginal examination is contraindicated in a patient with placenta previa prior to term.
• There may be torrential bleeding if PV is done in a patient with placenta previa.
• Expectant management of placenta praevia by Macafee and Johnson method
• Placenta previa is characterized by Painless , Causeless & Recurrent bleeding
• Expectant line of management in placenta previa is contraindicated in Active labour
• Premature labour is common in placenta previa
• The best way to diagnose the degree of placenta previa is Trans vaginal sonography
• Placenta previa mouth is associated with Large placenta, Previous C. S. scar & Previous placenta
previa
• Incidence increases by two fold after LSCS
• Conservative management is contraindicated in a case of Placenta previa in Evidence of fetal
distress, Fetal malformations & Women in labour
• Termination of pregnancy in placenta previa is indicated in Active bleeding, active labour & Fetal
malformation
• Cesarean section is absolutely indicated in Type IV placenta previa
• A case of central placenta previa with anencephaly fetus should be delivered by Cesarean section
• Vaginal delivery is contraindicated in Central placenta previa
• A preterm baby developed bullous lesion on the skin soon after birth. The X- ray shows periostitis
should be next investigated for VDRL for mother & baby
• Incidence of undescended testis in preterm infants is 30%
• Color, Heart rate & Muscle tone is used in a preterm infant to assess need for resuscitation
• Apnoea in a Preterm baby are Associated with bradycardia.
• Apnoea in a Preterm baby are Leads to hypoxia
• Apnoea in a Preterm baby are May cause cyanosis
• Breast feeding is best for both preterm & term
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• Impedence technique is the best way to monitor the baby's breathing and detect apnaea
• Decreased subcutaneous fat and brown fat, Large surface area in relation to body weight & Less
oxygen consumption are the factors that contribute to hypothermia in preterm babies
• Blood volume in preterm neonate is 90 ml/kg
• Late metabolic acidosis is seen in Preterm baby getting cow milk
• Preterm infant is defined as Born < 37 weeks
• Physiological jaundice in preterm infant lasts upto 14 days
44. LACTATION
• Alert the physician to the diagnosis of hyperemesis gravidarum early in its course include Ketonuria
• Wernicke’s encephalopathy is seen in Hyperemesis gravidarum
• Hyperemesis gravidarum is associated with molar pregnancy
• Differential diagnosis of Hyperemesis gravidarum are Gastritis, UTI, Reflux oesophagitis
• Pregnancy is terminated in hyperemesis Gravidarum when Decrease in renal output
• Hyperemesis is more common in primigravida than multigravida
46. Miscarriage(abortion)
• In cases of recurrent abortions, most common uterine malformation seen is Mullerian fusion
defects
• Lupus anticoagulant is associated with recurrent abortion and isolated prolonged APTT
• Recurrent abortion in 1st trimester is most often due to Chromosomal abnormalities
• Recurrent spontaneous abortions are seen in Uterine pathology,SLE ,Rh incompatibility & Syphilis
• Recurrent abortion in 1st trimester, investigation of choice is Karyotyping
• Hysteroscopy,Parental cytogenetics, Testing Antiphospholipid antibodies & Thyroid function tests
are investigation carried out in Recurrent abortion
• Low-dose aspirin is used to treat Antiphospholipid antibody syndrome up to 34 weeks
• The most life threatening complications of septic abortion includes Endotoxic shock
• Tricuspid valve is most likely to be involved by infective endocarditis following a septic abortion
• CT scan findings showing pockets of air within muscles of uterus indicate that she is suffering from
necrotizing endometritis caused by Clostridium species. It is caused because of incomplete
abortion.
• The findings of a single umbilical artery on examination of the umbilical cord after delivery is An
indicator of considerably increased incidence of major malformation of the fetus
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• Velamentous insertion of the cord is associated with an increased risk for Fetal exsanguinations
before labor
• Placenta in which vessels seperate before reaching margin is Velamentous placenta
• Fetal blood loss in abnormal cord insertion is seen in Vasa previa
• Single umbilical artery is associated with diabetes in mother.
• Failure of development of one artery in later months is implicated single umbilical artery case
• Vasa previa is Associated with low lying placenta
• In vasa previa Incidence is 1:1500
• In vasa previa Caesarian section is indicated
• Single umbilical artery is associated with Polyhydramnios, Fetal growth retardation & Increased
incidence of fetal malformation
• Unilateral renal agenesis is associated with Single umbilical artery
• According to WHO, anemia in pregnancy is diagnosed, when hemoglobin is less than 11.0 gm%
• In pregnancy, Iron + folic acid anemia is common in India
• With oral iron therapy, rise in Hb% can be seen after 3 weeks
• Pre-eclampsia, Intercurrent infection & Heart failure complications are likely to increase in a case of
severe anemia during the pregnancy
• As per WHO, anemia is considered to exist in pregnancy, if the hemoglobin level is below
• Type of anemia in pregnancy is Microcytic hypochromic
• Cord cutting should be delayed in Sever anemia
• For Patient with occipito posterior position Wait and watch for progress of labour
• Deep transverse arrest is most commonly seen in Android pelvis,Epidural analgesia & Uterine
inertia
• In deep transverse arrest the delivery of baby is conducted by Cesarean section, Vacuum
extraction, Keilland forcep and Manual rotation and forcep delivery
• In Sudden hyperflexion of thigh over abdomen (Mcrobert's procedure) Lateral cutaneous nerve of
thigh is most commonly involved
• Zavanelli maneuver,Woods Corkscrew Maneuver, Mcroberts manoeuver & Suprapubic pressure
are management of shoulder dystocia
• Shoulder dystocia result in Sternomastoid swelling, Erb's palsy & Klumpke's paralysis
• Shoulder dystocia is the most common complication during vaginal delivery in a diabetic women
• Shoulder dystocia is seen in predominantly Anencephaly
58. Amniocentesis
Gynecology
1. Asherman Syndrome
• The risk of Asherman syndrome is the highest if Dilatation and Curettage (D & C) is done for the
Post partum haemorrhage condition.
• Asherman syndrome is due to Postabortion curettage
• The presentation of Asherman syndrome typically involves Hypomenorrhea
• A 28 year old patient complains of amenorrhea after having dilatation & curettage.The most likely
diagnosis is Asherman's Syndrome
3. Primary amenorrhoea
• 10 year old girl with primary amenorrhoea, absent breasts, malformed uterus is diagnosed
with Turner's syndrome
• The commonest cause of primary Amenorrhoea is Ovarian dysgenesis
• Primary amenorrhoea with anosmia is seen in Kallman syndrome
• Child with primary amenorrhoea with negative progesterone challenge test but positive combined
progesterone and estrogen test. Diagnosis may be Prolactinoma
• Primary amenorrhoea, grade V thelarche, grade II pubarche and no axillary hair is seen in testicular
feminization
• Androgen insensitivity syndrome: Primary amenorrhoea normal sexual development and normal
breast but with absent public and axillary hair . B/L inguinal hernias , absent uterus & blind vagina
• PCOS, Müllerian agenesis & Congenital adrenal hyperplasia are cause of primary amenorrhoea with
eugonadism
• Primary amenorrhoea with normal breast, hirsutism and acne are features of PCOS
• Primary amenorrhoea with well developed breasts and axillary and pubic hair & missing Uterus and
vagina is diagnosed to have Mullerian agenesis
• Well-developed breasts, no hiruitism, no pubic or axillary hair with primary amenorrhea is
suggestive of Complete androgen insensitivity syndrome
5. EXTERNAL GENITALIA
• Bartholins duct open into Groove between labia minora and hymen
• Commonest reason of adherent labia minora in a newborn is Agglutination of labia
• The inner surface of the labia minora medial to the Hart line is lined by Squamous epithelium
• The embryonic development of the vestibule of the vagina is from Urogenital sinus
• Lymphatic drainage of clitoris is to Glands of cloquet & Deep inguinal lymph nodes
• Scrotum is analogus to Labia majora
• Clitoris develops from Genital tubercle
• Bartholin gland opening is at Inner side of labia minor external to hymen
• Triangular space between clitoris and hymen is called Vestibule
• Lymphatic drainage of Vulva is into Superficial inguinal nodes
6. Vagina
• The embryonic development of the vestibule of the vagina is from Urogenital sinus
• Levator prostatae muscle in male is equivalent for vaginal sphincter in female
• Ureter is related to lateral wall of vagina
• Mullerian duct give rise to the upper three fourth of vagina
• Lower part of vagina develops from Urogenital sinus
• Mucous membrane of vagina is lined by Nonkeratinized Stratified Squamous epithelium
• Vagina Lacks mucus secreting glands
• Least sensitive structure to radiation is Vagina
• Ligament extending from cervix and vagina to lateral pelvic wall is Transverse cervical ligament
• Epithelium of vagina arises from Mesoderm
• Angle of anteversion of uterus is between Long axis of uterus and vagina
• The urogenital triangle is the anterior part of the perineum that contains the vagina and associated
parts of the external genitalia.
• External iliac lymph nodes drain upper vagina & cervix
• Vaginal wall is derived from Endoderm and mesoderm
• Lower 2/ 3 of vagina, Fallopian tube, Uterus are derivatives of mullarian duct
• Length of Posterior vaginal wall is More than anterior vaginal wall
8. ESTROGEN
9. CORNIFICATION INDEX
• Bacterial vaginosis shows pH > 4.5, Fishy odour, Grey & Clue cells discharge
• Amine test is positive in Bacterial vaginosis
• Whiff test is positive in Bacterial vaginosis
• Drug of choice in bacterial vaginosis is Metronidazole
• Gardnerella is the causative agent of Bacterial vaginosis
11. TRICHOMONIASIS
• Frothy discharge with red ulceration in the vagina is seen with infection of Trichomoniasis
• Greenish vaginal discharge with severe Itching points to a diagnosis of Trichomoniasis
• Commonest genital infection in females is Trichomoniasis
• Vaginal trichomoniasis is the important cause of vaginitis in the childbearing period when the local
immunological defence is impaired.
• A woman diagnosed with Trichomoniasis should also be evaluated for Other venereal disease
• Trichomoniasis Is a sexually transmitted disease
• Trichomoniasis Produces copious thin frothy discharge
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• Trichomoniasis Is most often asymptomatic
• True hermaphroditism is when Tissues of both the ovaries and testes are present
• Commonest cause of female pseudo hermaphroditism is Congenital adrenal hyperplasia
• Empty scrotum syndrome is seen in female pseudohermaphroditism
• Ovaries present in female pseudohermaphroditism
• Excessive androgen exposure is seen in female pseudohermaphroditism
• Male pseudohermaphroditism is seen in 5-a reductase & 17 hydroxylase deficiency
• 21-Hydroxylase deficiency is Autosomal recessive
15. ENDOMETRIOSIS
16. ADENOMYOSIS
17. FIBROID
• Muscles that can cause external rotation of the hip include Obturator internus
• Pubovaginalis, External urethral sphincter & Bulbospongiosus are sphincters of lower genito urinary
tract of female
• Pelvic diaphragm is formed by Pubococcygeus,Iliococcygeus & Pubovaginalis
• Urogenital Diaphragm is made up of Sphincter urethrae , Perineal membrane & Deep transverse
Perineal muscle
• Superficial perineal muscles include Bulbospongiosus
• Lateral border of ischeorectal fossa is formed by Obturator internus
• Puborectalis is essential to maintain continence
• Sphincter urethrae is Voluntary, Arises from ischiopubic ramus and are Supplied by pudendal nerve
• Pubococcygeus supports prostate
• Precocious puberty may be seen in Granulosa cell tumour, Head injury & Corticosteroid intake
• The sexual development is considered is precocious if there is breast and public hair growth before
the age of 8 years
• GnRH analogue may be given in Prostate Ca, Fibromyoma – uterus & Precocious puberty
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• Precocious puberty is seen with Granulosa cell tumour
• Sexual maturity is attained early in precocious puberty
• Menstruation is defined as precocious if it starts before the child reaches the age of 10 years
• Precocious puberty can be heterosexual
• 21 alpha hydroxylase deficiency males present with precocious puberty
• A male child presenting with early onset puberty and hypertension is suggestive of congenital
adrenal hyperplasia due to the deficiency of 11-β hydroxylase deficiency.
• Sexual maturity attained early in precocious puberty
• Familial male limited precocious puberty is also called Testotoxicosis
• Familial male limited precocious puberty is Autosomal dominant condition
• Flutamide can be used for treatment of Familial male limited precocious puberty
• 21 alpha hydroxylase deficiency & 11β hydroxylase deficiency can cause precocious puberty in
males
• Precocious puberty is seen in Hypothyroidism, CNS irridation & Mc cune-Albright syndrome
• Congenital 21 hydroxylase deficiency causes precocious puberty in male due to excess of
androgens.
• The diagnosis of a patient presenting with familial Polyostosis, Precocious puberty and
Pigmentation is McCune Albright syndrome
24. Menopause
25. Menorrhagia
• Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and
wishing to retain her uterus in severe menorrhagia
• Fundal myomas commonly present as Menorrhagia
• Intersitial myomas predispose to menorrhagia by Inhibiting uterine contractility
• Puberty menorrhagia is treated by Progesterone, estrogen & GnRH analogues
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• Female presenting with dysmenorrhoea & menorrhagia most probably has Endometriosis & Fibroid
• A woman is said to be have menorrhagia if the menstrual blood loss is more than 80 ml
• Hysterectomy is the definitive treatment of adenomyosis
• NSAID's, Norethesterone & Tranexamic acid are indicated in menorrhagia
• Dilatation and curettage with blood transfusion is the primary treatment of puberty menorrhagia
with low Hb%
• Commonest condition associated with menorrhagia is Fibroid
• Retroverted uterus causes menorrhagia
• Puberty menorrhagia associated with anovulatory bleeding
• Puberty menorrhagia Routine screening for bleeding disorder is done
• Hematinics & Hormone therapy is the treatment of choice for Puberty menorrhagia
• A patient comes to you with history of frequent cycles with heavy bleeding. This condition is
called Polymenorrhagia
• Multipara, hypertensive woman with menorrhagia should be treated with MIRENA
• Adenomyosis presents with menorrhagia, dysmenorrhia, and an enlarged uterus
• lUCD of choice in women with menorrhagia Progesterone containing IUCD
• Mechanisms for reduce risk of upper genital tract infection in users of progestin - releasing IUDs,
include Reduced retrograde menstruation, Thickened cervical mucus & Decidual changes in the
endometrium
• Progestasert (Levonorgestrel) is used for patients with menorrhagia
• IUD Cu 7380A life span is 10 year
• Cumulative 5-year pregnancy rate for LNG-IUD (levonorgestrel intra-uterine device) is 0.5 %.
• Memory of an IUD device is important while insertion into the intrauterine cavity. Memory of
CuT380A is 5 minute
• Progesterone of choice in emergency contraception is Levonorgestrel
• Hypofibrinogenemia is most likely complication of IUD
• In calendar method of contraception, first day of fertile period is 10th day of shortest menstural
cycle
• The pregnancy rate of lippes loop and Cu-T 200 are similar
• IUD can be used for Emergency Contraception within 5 days
• Levonorgestrel releasing IUD has an effective life of 5 years
• Levonorgestrel increases the risk of ectopic pregnancy
• Levonorgestrel releases 20 µg/day of levonorgestrel
• Absolute contra indication for IUD are Pregnancy, Undiagnosed vaginal bleeding & Pelvic
infalmmatory disease
• The most common side effect of IUD insertion, which requires its removal is Pain
• Expulsion is most commonly associated side effect with Lippes loop
• The first step in the management of hirsutism due to stein leventhal syndrome is OCP
• In a 45 years old lady with polymenorrhoea for 6 months duration best line of management is OCP
for 6 months
• OCP and progesterone use over long periods may contribute in Risk factors for development of Ca
cervix
• Reversible methods of contraception are OCP
• OCP is a reversible method of contraception
• Non contraceptive use of OCPs are Ca endometrium, Rheumatoid arthritis & Endometriosis
• OCP gives protection against Endometrial & Ovary cancers
• OCPs cause Hepatic adenoma, Cancer Cervix & Hepatic vein thrombosis
• OCP's are contraindicated in Smoking 35 years,Intermittent vaginal bleeding,H/0
thromboembolism, Coronary occlusion & Cerebro vascular ds
• Complication of OCP are Hyperlipidemia, Hypertension & Depression
• OCP has LEAST pregnancy failure rate
• Estrogen in the OCP causes Breast & Endometrial carcinoma and Thromoembolism
• OCP fail when used
with Ethoxsuccimide,Phenobarbital,Griseofulvin, Carbamazepine,Primidone, Phenytoin & Rifampin
• Use of OCP is associated with increased risk of asymptomatic chlamydial infection
• combined OCP decreases the risk of ectopic pregnancy,PID, Ovarian cysts & acute salpingitis &
also improves dysmenorrhea from endometriosis
• Combined OCP is the ideal contraceptive for a newly married couple who wants to plan their family
after 6 months
• Thromboembolism is due to Estrogen in OCP
• Most common cause of stroke in young women in India among OCP users is Cortical vein
thrombosis
• OCP provides protection against Fibroadenoma breast, Carcinoma ovary & Uterine malignancy
28. Progesterone
29. Testosterone
30. Anti-Oestrogens
31. Antiprogesterone
• Decreased vascularity of fibroid is seen with Mifepristone, GnRH agonist & Danazol
• Mifepristone is also called RU — 486
• Mifepristone is a 19 — norsteroid
• Mifepristone Acts on receptors
• Anti progesterone drug is Mifepristone
• Drugs used in emergency contraception is Danazol and Mifepristone
• Mifepristone is used in Abortion, Cushing syndrome,Fibroid,Ectopic pregnancy,Molar pregnancy
& Cervical ripening
• Mifepristone is used in Medical terminations of pregnancy
• Dose of mifepristone (in mg) for post-coital contraception is 10 mg
• First trimester abortion uses Mifepristone, D & C and also Suction evacuation
• The most common pure germ cell tumour of the ovary is Dysgerminoma
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• Most common ovarian tumor in less than 20 years is Germ cell tumour
• Bilateral germ cell tumour is Embryonal cell carcinoma
• Choriocarcinoma is Malignant germ cell tumours of ovary
• Alpha feto protein, LDH & p HCG are the markers for malignant germ cell tumors of ovary
• Dysgerminoma, Polyembryoma & Endodermal sinus tumor are germ cell tumours of ovary
• Most common germ cell tumor of ovary is Dermoid
• The most common pure germ cell tumor of the ovary is Dysgerminoma
• Serum alpha feto protein level is raised in Teratoma, Endodermal sinus tumor
• Cryptochidism, Testicular feminising syndrome & Klinefelter's syndrome are Predisposing features
for germ cell tumour
• Extragonadal germ cell tumors occur in Sacrococcygeal region, Mediastinum & Brain
• The commonest site for extragonadal germ cell tumour is Mediastinum
• Germ cell tumours of testis are Seminoma, Teratoma
• Intratubular germ cell tumor found adjacent to Dysgerminoma
• Treatment of extragonadal germ cell tumour is Chemotherapy
• Seminomas are radiosensitive
34. Teratoma
36. Prolactin
• In a case of secondary amenorrhea who fails to get withdrawl bleeding after taking E and P, the
fault lies at the level of Endometrium
• In secondary amenorrhea the cause could be Stein leventhal syndrome & Premature ovarian
failure
• Commonest cause of secondary amenorrhea is Pregnancy
• Female with secondary amenorrhea with serum prolactin level 75 ng/ml is to be treated
with Cabergoline
• Secondary amenorrhea and galactorrhea with tumour of < 10mm diameter in the pituitary fossa
can be treated by Bromocriptine
• Shirodkar's abdominal sling is the treament of choice for nulliparous woman who has 3rd degree
uterovaginal prolapse without any cystocele or rectocele.
• Urinary incontinence in uterovaginal prolapse is mostly is due to Stress incontience
• Treatment of choice in a multiparous female with 2nd degree uterovaginal prolapse is Fothergill's
operation with tubal ligation
• Cystocele is formed by base of the bladder
• The most common type of genital prolapse is Cystocele
• The severity of pelvic pain in endometriosis correlates best with Depth of invasion
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• Acute pelvic /abdominal pain is seen in PID
• Pelvic pain is mediated by Autonomic nerves
• Lady with infertility with bilateral tubal block at cornua : best method of management is IVF
• Treatment for Cervical infertility can be Condom for 3 month, Gamete Intrafallopian transfer IUI
• Salpingitis, PID & Submucosal myomata are cause of infertility
• LH, GnRh and Clomiphene are used in treatment of infertility
• Endometrial biopsy for infertility is taken on 23 to 26 day
• In endometriosis, cause of infertility is Immobility of tubes, Anovulation & Tubal block
• A woman treated for infertility, presents with 6 week amenorrhea with urinary retention. The most
likely etiology is impacted Cervical Fibroid
• For infertility without significant clinical problem, most likely diagnosis is T.B. endometrium
• Laparoscopic and dye test are done doing secretory phase of the cycle for finding out the tubal
factors of infertility.
• To test ovarian reserve, FSH is measured
• MOST common cause of ovarian hyperstimulation FSH/LH therapy
• PCOS shows oligomenorrhoea, infertility and hirsuitism
• Both Bromocriptine and cabergoline can be used as both decrease prolactin levels, however,
cabergoline is better tolerated.
• Gold standard investigations for female infertility is Laparoscopy and hysteroscopy
• Methods of managing fibroid uterus include Myomectomy, Embolisation of uterine artery & Laser
myomectomy
• Drugs that reduce the size of fibroid are Danazol and GnRH analogues
• Treatment of choice in a perimenopausal woman with bleeding PV due to multiple fibroids Is Total
abdominal hysterectomy (TAH)
• Conservative surgical therapy is Indicated in a pregnant female with red degeneration of fibroid
• Pap smear is useful in the diagnosis of Trichomonas vaginalis, HPV & Inflammatory changes
• Women > 20 years,Pregnant female, Sexually active female are all indicaed for pap smear
• Pap smear in pregnancy is Routine, as a part of screening
• Pap smear can detect CIN
• Pap smear reduces incidences of Ca cervix
• Koilocytes with perinuclear halo on pap smear is pathognomic of HPV infection
• Pap smear most commonly demonstrates protozoal parasites Trichomonas vaginalis in women
• A female presented with post coital bleeding can be managed by Pap smear and colposcopy
• Pap smear is an example of Secondary level of prevention
• Screening of cervical cancer at PHC level is done by PAP smear
• Sensitivity of conventional PAP smear in picking up cervical cancer is 80%
• Intravenous pyelography, Cystoscopy & Proctoscopy investigations are used in FIGO staging of
carcinoma cervix
• A case of carcinoma cervix is found in altered sensorium and is having hiccups, likely cause is
uremia
• CA cervix is Common at squamocolumnar junction
• Post coital bleeding is a common symptom of CA cervix
• HPV 16 and 18 are associated with high risk of carcinogenesis
• In Carcinoma of cervix lymphatics drain to Hypogastric , External iliac & Obturator lymph nodes
• Adenocarcinoma cervix is associated with HPV 16, 18 & 51
• Post coital bleeding would be the earliest symptom of Ca cervix
• Carcinoma cervix involving upper 2/3 of vagina without parametrial involvement are classed as IIA
• Carcinoma cervix is the Commonest cause of pyometra
• Ca cervix can be prevented by screening
• Complication, which results in mortality, in carcinoma cervix is Renal failure
• Carcinoma cervix involving upper 2/3rd of vagina. The stage would be Stage II a
• Risk factor of CA cervix Smoking
• A case of carcinoma cervix who earlier received radiotherapy, relapses with new lesion should be
treated with Pelvic exenteration
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• Management of stage IIB cancer cervix is Radiotherapy with combination with chemotherapy
• Ca cervix of stage between II - III should be treated with Radiotherapy and chemotherapy
• Ca cervix stage III B is treated with Intracavitary brachytherapy with external beam radiation
• Point B in treatment of Ca cervix corresponds to Obturator Lymph node
• Treatment of carcinoma Cervix stage IIIB include Concurrent chemoradiation
• 80-85 and 85-90 gy. is the maximum radiation dose to point A for early and advanced Ca cervix
60. Hirsutism
• Polycystic ovaries shows obese woman presenting with Oligomenorrhea, infertility and hirsutism
• Most common cause of Hirsutism is PCOD
• Commonest cause of hirsutism in a teenage girl is Ovarian disease
• The first step in the management of hirsutism due to stein leventhal syndrome is OCP
• Spironolactone, Finasteride & Flutamide are used for hirsutism in female
• Hirsutism and amenorrhea with change in voice can be estimated by Testosterone tests
• Hirsutism is seen in Stein leventhal syndrome , Cushing syndrome & Congenital adrenal hyperplasia
• Hirsutism can be caused by Steroidogenic enzyme defects, Minoxidil & Acromegaly
• Primary overproduction of ACTH shows hirsutism, hyperglycemia, obesity, muscle wasting, and
increased circulating levels of ACTH.
• Spironolactone, Flutamide & Cyproterone are used in treatment of hirsutism
• Oligomenorrhea ,hirsutism and virilisation with enlarged left ovary & testosterone levels 4 ng/ml is
suggestive of Ovarian tumor
• Hirsutism is a Complications of cyclosporine
• Phenytoin causes hirsutism
• MC cause of hirsutism in females is Stein Leventhal syndrome
• Cystic swelling at the junction of lower 1/3rd and upper 2/3rd of anterior wall of vagina at 10 0'
Clock position is diagnosed as Gartner's cyst
• Gartner's cyst can be a congenital cyst
• Gartner's cyst arises from Remnant of mesonephric duct
• Swelling enlarges and becomes more painful with approaching menses in case of Gartner's cyst
• Gartner’s cyst is a cystic remnant of Wolffian duct
• Gartner's cyst is seen in Vagina
• 46XY, Primary amenorrhea & Vagina may be present in testicular feminization syndrome
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• High testosterone levels is seen in testicular feminization syndrome
• In Testicular Feminization syndrome Gonadectomy is indicated At puberty
• Androgen insensitivity syndrome the Phenotype may be completely female
• Androgen Insensitivity Syndrome is present with absence of both Mullerian and Wolffian duct
structures
• Short vagina and absent ovaries may be seen in Testicular Feminization syndrome
• Primary Amenorrhea with absent uterus, normal breasts and scanty pubic hair is seen in Androgen
Insensitivity Syndrome
• Calculation of pearl index is No. of pregnancies X 1200/( Number of women X number of months)
• Pearl Index is a measure of Potency of contraceptives
• Pearl index is Failure rate/100 women years
• Total accidental pregnancy is important in calculaton of pearl index
• Empty sella in skull x-ray,amenorrhea & failure of lactation following delivery are seen
in Sheehan's syndrome
• Amenorrhoea, Failure to lactate & Absence of secondary sexual characteristics are seen with
Sheehan's syndrome
• Cortisone is essential in Sheehan's syndrome
66. Dysmenorrhea
68. Laparoscopy
69. Laparotomy
70. Hysteroscopy
73. MYOMECTOMY
Orthopedics
• Ulnar nerve commonly seen involved In injuries at the elbow are usually associated with fractures
of the medial epicondyle.
• Ring & little fingers are not capable of being markedly flexed
• The patient is unable to adduct and abduct the fingers and consequently is unable to grip a piece of
paper placed between the fingers.
• It is impossible to adduct the thumb in ulnar nerve palsy
• The metacarpophalangeal joints become hyperextended in ulnar nerve palsy
• In case of lesion of ulnar nerve, paralysis of interosseous muscles occurs which leads to clumsiness
• claw deformity is seen in long standing case of ulnar nerve palsy
• Loss of skin sensation will be observed over the anterior and posterior surfaces of the medial third
of the hand
• TARDY ULNAR NERVE PALSY is seen in lateral condyle # of humerus resulting in ulnar nerve injury
• Cubitus valgus deformity and tardy ulnar nerve palsy is seen as the late complication of ulnar
nerve injury
• Hypothenar atrophy is seen in ulnar nerve injury.
• Ape thumb deformity is associated with ulnar nerve palsy.
• It is the most common nerve involved in Hansen's disease(leprosy)
• Froment sign is test use to detect ulnar nerve palsy
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• Knuckle bender splint is used in palsy of ulner nerve
3. Erb's paralysis
• Erb's point (upper trunk of brachial Plexus) Six nerves meet here(C5 ,C6)
• Nerve roots involved in erb's palsy are Mostly C5 & partly C6
• Arms: Medially Rotated (Hangs by side) owing to paralysis of teres minor & infraspinatus.
• Policeman's tip hand (or) Porter's tip hand seen in erb's palsy
• Abduction & lateral rotation of the arm
• Flexion & Supination of the fore-arm at elbow
4. KLUMPKE'S PARALYSIS
• Lower trunk of brachial plexus is the site of injury leading to brachial plexus
• Mainly T1, Partly C8 nerve roots are affected in klumpke's palsy
5. Foot Drop
6. Rickets
7. Shoulder Dislocation
8. HUMERUS FRACTURE
9. Fat Embolism
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• Multiple injuries develops fever, restlessness, tachycardia, tachypnea and periumbilical rash is
diagnosed with Fat embolism
• Fracture femur followed by breathlessness is seen in fat embolism
• Fracture mobility is a risk factor, Thrombocytopenia & On ABG PaO2 is seen in fat embolism
• Tachypnea,Systemic hypoxia, Fat globules in urine,Petechiae in anterior chest wal &
Manifestation after several days of traumais the features of fat embolism
• The management of fat embolism includes Oxygen, Heparinization, Low Molecular weight dextran
• Tachypnoeic, and conjunctival petechiae seen after femur fracture may be due to fat embolism
• After an operation on femur bone, chest X-ray shows widespread mottling throughout the lung
field like a snowstorm. It is diagnostic of Fat embolism
• Fat embolism is characterized by Petecheal haemorrhages, Closed fractures of femur & Aggregation
of chylomicrons
• Laboratory findings in fat embolism consist of Thrombocytoenia, Fat globules in urine &Anemia
10. Osteochondritis
• Pain around elbow which is held in pronation with extension and normal X ray is diagnosed with
pulled elbow
• Most common type of Elbow dislocation is Posterior
• Most common associated injury of fracture medial epicondyle is Elbow dislocation
• Three point relationship is reversed in Elbow dislocation, Medial & lateral epicondyle fracture
• A child is spinned around by holding his hand by his father. While doing this the child started crying
and does not allow his father to touch his elbow. The diagnosis is Pulled elbow
• Myositis ossificans follows either a posterior dislocation or a spuracondylar fracture of elbow joint
• Pulled Elbow is Subluxation of proximal radio ulnar joint or Dislocation of head of radius
• Vascular injury,Median nerve injury, Myositis ossificans are the Complications of elbow dislocation
• Genu valgus deformity seen when Long axis of tibia & fibula moves lateral to the long axis of femur
• Pappu, 7 yrs old young boy, had fracture of lateral condyle of femur. He developed malunion as the
fracture was not reduced anatomically. Malunion will produce Genu valgum
• Most common cause of genu valgum in children is Rickets
• Genu valgum deformity is seen in Rickets, Bone Dysplasia & RA
• A 4 year boy complaining of pain around elbow which is held in pronation with extension and
normal X ray is diagnosed to have Pulled elbow
• A child is spinned around by holding his hand by his father. While doing this the child started crying
and does not allow his father to touch his elbow. The diagnosis is Pulled elbow
• Pulled Elbow is Subluxation of proximal radio ulnar joint
• Pulled elbow is Dislocation of head of radius
• Pulled elbow Occurs due to sudden axial pull on extended elbow
• Pulled elbow Most commonly occurs between 2-5 years of age
• Forearm is held in pronation and extention in Pulled elbow
18. OSTEOMYELITIS
19. Scoliosis
• Colles fracture is fracture at cortico-cancellous junction of the distal end of the radius with dorsal
tilt
• Colles fracture is common in women because of postmenopausal osteoporosis.
• Carpal tunnel syndrome, Reflex sympathetic dystrophy (RSD), Frozen hand shoulder syndrome are
the complications of Malunited Colles fracture
• Colles fracture best describes the patient's wrist fracture
• Stiffness of wrist, Stiffness of shoulder & Carpal tunnel syndrome are complication of colles fracture
• Dinner fork deformity is the characteristic of colles fracture
• Deformities present in colles fracture is Dorsalt tilt
• Proximal impaction , Lateral rotation & Dorsal angulation is seen in colles fracture
• Colles fracture is common in old age
• Galeazzi fracture is fracture of the distal third of the radius with dislocation of the distal radio-ulnar
joint
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• Galeazzi fracture is fracture of Lower end of radius
• Galeazzi fracture is Fracture of the distal radius with inferior radio ulnar joint dislocation
• Fracture distal 1/3 radius with DRUJ subluxation
• Monteggia fracture is fracture of the proximal third of the ulna with radial head dislocation
• In Monteggia fracture Both ulnar fracture and head of radius is displaced anteriorly
• Posterior interosseous nerve is injured in Monteggia fracture dislocation
• The muscle which is affected by Volkmann's ischaemia most commonly is Flexor digitorum
profundus
• The first sign of Volkman's ischemia is Pain on passive extension of fingers
• In Volkman's ischemia, surgery should be done Immediately
• Split open the plaster of Paris cst and bandage, Decompression by fasciotomy, Exploration are done
to manage Volkmann's Ischaemia
• In Volkmann's ischaemia, surgery should be done within 1hour
• The most important sign in Volkman's ischemia is Stretch pain
• The most common nerve involved in volkmann’s ischemic contracture or forearm includes Median
• The most common cause of Volkmann's ischaemic contracture (V.I.C) in a child is Supracondylar
fracture of humerus
• The most important sign in Volkmann's ischaemic contracture is Pain
• Volkmann's ischaemic contracture mostly involves Flexor digitorum profundus
• Volkmann's contractrue Follows Ischaemia of the forearm
• Volkmann's Ischaemic Contracture is due to Ischaemic vascular injury to the muscle
• Volkmann's ischaemic contracture is commonly due to Tight palster or Tight splint
• Fracture lower half of tibia, neck of femur & scaphoid are known for nonunion
• Pappu, 7 yrs old young boy, had fracture of lateral condyle of femur. He developed malunion as the
fracture was not reduced anatomically. Malunion will produce Genu valgum
• Periosteal injuries, Absence of nerve supply & Chronic infection fascilitate non union
• The most common cause of non union is Inadequate immobilization
• Non - union is a complication of Scaphoid #
• The most common complication of clavicle fracture is Malunuion
• The most important cause of Nonunion of fracture of - humeral shaft is Distraction at fracture site
• Fracture shaft of humerus is known for Non union in children, if left untreated
• Growth disturbance, nonunion, elbow instability & late ulnar nerve palsy is commonly seen
in Fracture lateral condyle
• A 10-year-old boy presenting with a cubitus varus deformity and a history of trauma 3 months back
on clinical examination, has the preserved 3 bony point relationship of the elbow. The most
probable diagnosis is Malunited supracondylar fracture of humerus
• The malunion of supracondylar fracture of the humerus most commonly leads to Cubitus varus
• The most common complication of supracondylar fracture is Malunion with gun stock deformity
• Commonest complication of Colles' fracture is Malunion
• In nonunion of scaphoid vescularized muscle pedicle graft is taken from Pronator quadratus
• Nonunion is a very common complication of intracapsular fractures of the neck of femur most
commonly caused by Inadequate immobilization, blood supply or Inhibitory effect of synovial fluid
• Commonest complication of extra capsular intertrochanteric fracture of neck of femur is Malunion
• The most common complication of intracapsular fracture neck of femur is nonunion
• Treatment of Non-union of # shaft femur Bone grafting with internal fixation with K-Nail
• Best treatment of 3 weeks old, fracture shaft femur with nonunion is Bone graft with internal
fixation
• Non union is a common feature of fracture of Lower tibia
• Common sites of fracture non union are Waist of scaphoid, Neck of femur & Distal 1/3 tibia fibula
• Mc Murray's osteotomy is done for Nonunion transcervical neck fracture of femur
• Fracture neck femur cause of non-union is Injury to blood supply with shearing stress
27. osteoporosis
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Teriparatide
Plain X-rays:
• Plain X-rays showed a characteristic picture consisting of a transverse or short oblique fracture
line, lateral cortical thickening, and medial spiking.
• he gold standard for diagnosis of osteoporosis is dual energy X-ray absorption scan (DEXA scan).
The test is performed by passing low energy X-rays through a bone (e.g. spine, hip or wrist). The
test takes about ten minutes, is painless, and is associated with very limited radiation exposure.
The values generated by the test can then be compared to both:
• Young adult population : called a "T score", this test measures the variance between the patient
and the young adult baseline. A score above -1 is considered normal; a score between -1 and -2.5 is
considered osteopenia; and a score below -2.5 is considered osteoporosis. For each -1 standard
deviation in T score there is a 3 times increased risk of hip fracture and a 2.5 times risk of spine
fracture.
• Age-and gender-matched control groups : a "Z score" measures the variance between the patient's
and control groups' amount of bone. The control group consists of other people in the patient's
age group of the same size and gender. An unusually high or low score may indicate the need for
additional tests.
Fibrous dysplasia:
Radiological findings:
• In the long bones, the fibrous dysplasia lesions are typically well-defined, radiolucent areas with
thin cortices and a ground glass appearance. The articular ends are usually spared.
• Involvement of the facial bones usually presents as radiodense lesions, which may create a leonine
appearance ( leontiasis sea).
Regarding the location of the aneurysmal bone cyst, any bone may be affected. Approximate
frequencies by site are:
31. Chondrosarcoma
• The orthopaedic disorder shown in the picture above represents paget’s disease.
• The tibia is the bone affected most commonly.
• It is also seen in other bones like ilium, femur, skull, vertebrae, humerus, pelvis, spine and skull.
• It is rarely diagnosed in people < 40 years of age.
• Men are more commonly affected than females.
An elevated level of alkaline phosphatase in elderly patients are suggestive of paget’s disease.
• Serum calcium and phosphate levels are normal in paget’s disease.
A variety of tumor and tumor like conditions develops in paget’s disease.
• The benign lesions include: giant cell tumor, giant cell reparative granuloma and extraosseous mass
of hematopoiesis.
• The most dreaded is the conversion to sarcoma, which occurs in 0.7% to 0.9% of cases.
• The sarcomas are usually osteosarcoma, malignant fibrous histiocytoma, orchondrosarcoma, and
they arise in long bones, pelvis, skull and spine.
Chondrosarcomasdeveloping in patients with The tibia is the bone affected most commonly.
ollier's and maffucci syndrome is called
secondary chondrosarcoma. It is also seen in other bones like ilium, femur,
skull, vertebrae, humerus, pelvis, spine and skull.
Secondary chondrosarcoma
It is rarely diagnosed in people < 40 years of age.
It is the chondrosarcoma arising in benign
precursor either osteochondroma and Men are more commonly affected than females.
enchondroma. An elevated level of alkaline phosphatase in
elderly patients are suggestive of paget’s disease.
There are no reliable figures about the risk of
developing secondary chondrosarcoma in Serum calcium and phosphate levels are normal in
benign precursors. paget’s disease.
A variety of tumor and tumor like conditions
The risk of chondrosarcoma in solitary develops in paget’s disease.
osteochondroma is 2% and that for
osteochondromatosis is 5 - 25%. The benign lesions include: giant cell tumor, giant
cell reparative granuloma and extraosseous mass
Patients with ollier's disease and maffucci
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syndrome have a 25 - 30% risk of developing of hematopoiesis.
chondrosarcoma.
The most dreaded is the conversion to sarcoma,
which occurs in 0.7% to 0.9% of cases.
Commonest site
34. ACHONDROPLASIA
• Volkmann’s ischemic contracture most commonly involve flexor digitorum profundus muscle and
median nerve.
• Volkmann's ischaemia is an ischemic injury to the muscles and nerves of the flexor compartment of
the forearm.
• This occurs due to the occlusion of the brachial artery following a supracondylar fracture.
• The muscles supplied by the anterior interosseous artery are most susceptible to ischemic damage
because this artery is an end artery. Most commonly affected muscles are the flexor pollicis longus
and flexor digitorum profundus (medial-half). Severe pain will be present over forearm usually over
the flexor aspect of the forearm when the fingers are extended passively. Ischemic pain is much
severe than the pain due to the fracture.
• Anterior dislocation of the shoulder is the most common type of shoulder dislocation. Head of the
humerus comes out of the glenoid cavity and lies anteriorly. Anterior dislocation of shoulder could
be :?
• Preglenoid - It is the most common type of anterior dislocation and head lies in front of glenoid.
• Subcoracoid - The head lies below the coracoid process.
• Subclavicular (infraclavicular) - The head lies below the clavicle.
• Intrathoracic - It is very rare.
• Monteggia fracture-dislocations are classified by the Bado system Bado type I injuries are
characterized by a proximal ulnar fracture with anterior dislocation of the radial head. This is due to
a forceful pronation injury of the forearm and is the most common type. Bado type II injuries are
"reversed" Monteggia fracture-dislocation injuries. Here, there is posterior angulation of the ulnar
fracture site and posterior dislocation of the radial head. Bado type III and IV are rare injuries.
• Post-traumatic stiffness
• Mal-union
• Subluxation of the inferior radio-ulnar joint
• Acute carpal tunnel syndrome
• Sudeck's osteodystrophy.
• Rupture of the extensor pollicis longus tendon
C. Barton fractures are classified as dorsal or palmar (always intra-articular), and they always
involve carpal subluxation. The volar Barton fracture is thought to occur with the same mechanism
as the Smith fracture, with more force and loading on the wrist.
• The dorsal Barton fracture is caused by a fall on an extended and pronated wrist, increasing
carpal compression force on the dorsal rim. The salient feature is a subluxation of the wrist.
• By definition, this fracture has some degree of carpal displacement, which distinguishes it
from a Colles or Smith fracture. The palmar variety is more common than the dorsal type.
D. The chauffeur's fracture derives its name from injuries that were acquired, in the days when
motor vehicles were cranked, when a vehicle backfired.
• The force is described as a direct axial compression of the scaphoid into the radial facet.
• The radial styloid is fractured, with associated avulsion of the radial collateral ligament.
• A chauffeur's fracture represents an avulsion related to the attachment sites of the
radiocarpal ligaments or of the radial collateral ligament.
E. Galeazzi fracture results from a FOOSH mechanism with the forearm hyperpronated or from a
direct impact to the dorsal radial wrist.
• The radial diaphysis at the distal and middle third junction is fractured, with associated
subluxation of the distal radioulnar joint.
• On PA views, the radius is shortened and the radioulnar joint is disrupted.
F. The Essex-Lopresti fracture consists of a comminuted and displaced radial head fracture along
with disruption of the distal radioulnar joint and interosseous membrane.
• The muscles supplied by the anterior interosseous nerve are flexor pollicis longus, lateral half of
flexor digitorum profundus and pronator quadratus.
• Anterior interosseous nerve arise as median nerve leaves the cubital fossa and soon join company
with anterior interosseous artery and the two descend on the anterior surface of interosseous
membrane. It passes posterior to the pronator quadratus muscle and end in front of the wrist. Its
articular branches supplies the distal radioulnar, radiocarpal and intercarpal joints.
• Radial nerve is the largest branch of the posterior cord of the brachial plexus with a root value of C5
- C8 and T1. The radial nerve is commonly injured in the region of the spiral groove. this result in
the wrist drop and sensory loss over a narrow strip on the back of forearm, and on the lateral side
of the dorsum of the hand.
• Posterior interosseous nerve is the branch of radial nerve given off in the cubital fossa while
anterior interosseous nerve is a branch of the median nerve given off in the upper part of the
forearm.
• Skin of the back of the forearm (i.e. extensor compartment) is supplied by the posterior cutaneous
nerve of the forearm which is a branch of radial nerve.
40. bursitis
• Prepatellar bursitis, also known as Housemaid's knee, is a common cause of swelling and pain
above the patella, and is due to inflammation of the prepatellar bursa.
• This structure is a superficial bursa with a thin synovial lining located between the skin and the
patella.
• The bursa develops within the first years of life as a result of mechanical pressure and friction, and
it serves the purpose of reducing friction on underlying structures and allowing maximal range of
motion in the knee.
• Aseptic prepatellar bursitis is commonly caused by repetitive work in a kneeling position, hence the
name "housemaid's knee
Rigid flatfoot:
Flexible flatfoot:
• Loss of arch only on standing on the affected foot, with reconstitution of the arch when the foot is
dependent or when the patient toe-stands.
• Normal motion of the hindfoot.
42. LUMBAR DISC HERNIATION (Herniated nucleus pulposus,slipped dics Ruptured disc, Sciatica)
44. SPONDYLOLISTHESIS
• Spondylolisthesis is a forward slip of one vertebrae upon another; so it is best viewed (or seen
earliest) in sagittal images of spine i.e. lateral and oblique X rays of spine and saggital & axial views
of CT & MRIQ. AP views of X ray can only be used to demonstrate indirect evidences (eg. inverted
Napoleon's hat sign) of late/ severe spondylolisthesis.
• Oblique view of spine display the lamina and articular processes more clearly than the classical
anteroposterior & lateral views. The shadow of neural arch resembles that of Scottish terrier dogQ.
• Spondylothesis is forward slip of one vertebrae upon another. Majority of cases are due to stress
fracture of pars interarticularis leading to broken neck or presence of collar on the Scottie
doe. More displacement will lead to Beheaded (without head) Scottie terrier sign(2.
• Spondylolisthesis : ventral slipping or gliding of all or part of one vertebrae on a stationary vertebra
beneath it. Most common is between L5 - S1 and between L4 — L5.
• "Inverted Napoleon's HatQ" sign: A severe degree of spondylolisthesis at L5 - Si can be identified on
A-P view by ventrocaudal displacement of L5 over sacrum and creates curvilinear densities.
• Blount’s disease is characterized by varus and internal tibial torsion and genu recurvatum, with varus of
the proximal tibia being the primary deformity. It is not associated with external tibial torsion.