Lost Your Password?
You have reached of 200 points, ( %)
Anterolateral abdominal wall is the muscular aponeurotic formation limited by the abdominal wall from the anterior and lateral sides. There are two horizontal orientation lines and two vertical orientation lines that divides it into 9 regions, namely:
· Right hypochondriac region
· Proper epigastric region
· Left hypochondriac region
· Right lateral abdominal region
· Umbilical region
· Left lateral abdominal region
· Right inguinal (ilioinguinal) region
· Hypogastric (suprapubic) region
· Left inguinal (ilioinguinal) region.
Yersinia pseudotuberculosis is primarily an animal pathogen, infecting both wild and domestic animals. Humans acquire the infection by way of an oral route after contact with infected animals. The most common manifestation of human infection is the painful swelling of the mesenteric lymph nodes, resulting in an appendicitis-like syndrome, although diarrhea and fever also are usual.
Using the Bacteriological method - Yersinia Pseudotuberculosis may be found in feces, urine, blood and mucus within a couple of days after infection. To confirm this diagnosis within the first week from the onset of disease, bacteriological method is the best option.
Sustained or repeated pressure on skin over bony prominences can cause ischemia and pressure sores. These are common in patients over 70 years old who are confined to hospital, especially those with a fracture of the neck of femur. The morbidity and mortality of those with deep ulcers is high.
*prolonged immobility and recumbency
*vascular disease (atherosclerosis)
*neurological disease causing diminished sensation.
*malnutrition,severe systemic disease and general debility.
Clinical Features: The sore begins as an area of erythema which progresses to a superficial blister or erosion. If pressure continues, deeper damage occurs with the development of a black eschar which when removed or shed reveals a deep ulcer, often colonized by Pseudomonas aeruginosa. The skin overlying the sacrum, greater trochanter, ischial tuberousity, the heel and the lateral malleolus is especially at risk.
Therefore, these drugs can provoke a response at all cholinoreceptors in the body, including both muscarinic and nicotinic receptors of the autonomic nervous system as well as at neuromuscular junctions and in the brain.
Neostigmine (proserine) is a synthetic compound that is also a carbamic acid ester and it reversibly inhibits acetylcholine esterase (AChE).
Dysentry refers to bloody diarrhea with mucus. It can be caused by a variety of micro-organism. It is a sign of large bowel disease. It can also be of infectious origin. Diarrhea could be a sign of infection, laxative abuse, inflammatory bowel disease. Diarrhea- more than 250g of stool per day. Acute diarrhea is defined as less than 3 weeks, chronic diarrhea over 4 weeks.
Important screening tests:
*Fecal smear for leucocytes.
*Stool osmotic gap.
The nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of chemically dissimilar agents that differ in their antipyretic, analgesic and anti-inflammatory activities. They act primarily by inhibiting the cyclooxygenase (COX 1 and 2) enzymes that catalyze the first step in prostanoid biosynthesis. This leads to decrease prostaglandin synthesis with both beneficial and unwanted effects. Aspirin is one of the most important NSAID. Its most common side effect is its gastrointestinal (GI) effect. Normally, prostacyclin (PGI2) inhibits gastric acid secretion, whereas PGE2 and PGF2α stimulate synthesis of protective mucus in both the stomach and small intestine.
Celecoxib is a selective cyclooxygenase 2 (COX-2) inhibitor. Approved for treatment of rheumatoid arthritis, osteoarthritis, acute to moderate pain, also approved for patients with peptic ulcers or gastroduodenitis. This is due to the fact that only COX 1 is responsible for the gastrointestinal protective functions.
Parkinson disease is associated with a loss of dopaminergic neurons in the substantia nigra. Parkinsonism is a progressive neurological disorder of muscle movement, characterized by tremors, muscular rigidity, bradykinesia (slowness in initiating and carrying out voluntary movements) and postural and gait abnormalities. Most cases involve people over the age of 65.
The disease is correlated with destruction of dopaminergic neurons in the substantial nigra with a consequent reduction of dopamine actions in the corpus striatum, parts of the brain’s basal ganglia system that are involved in motor control.
The substantial nigra, part of the extrapyramidal system is the source of dopaminergic neurons that terminate in the neostriatum.
Treatment: drugs – levodopa, carbidopa, selegiline, rasagiline
So far, levodopa has been the only drug tested on Parkinson.
Antimicrobial agents are drugs for the treatment and prevention of infectious diseases. They are divided into disinfectants, antiseptics and chemotherapeutics. Disinfectants realize their antimicrobial properties in the environment outside the body. Antiseptics act on the surface of the body. Chemotherapeutics produce an antimicrobial effect inside the body.
Antiseptics could be inorganic or organic.
· Inorganic substances: halogens, oxidizing agents, metallic salts, acids and alkalis
· Organic substances: aldehydes, alcohols, phenol derivatives, dyes, detergents, nitrofuran derivatives
Halogens: iodine alcohol solution – effects of iodine are based on the interaction between atoms of halogen and proteins resulting in halogenization and oxidation of proteins. It has bactericidal, fungicidal and irritative actions. Indications – processing of small cuts of the skin, dermatomycoses, processing of the surgery skin area and surgeon’s hands.
Other halogens include solution of lugol, iodinol, ioddiccerinum, chlorinated lime, chloramine B, chlorhexidine etc.
Pain is an unpleasant sensation that can be either acute or chronic and is a consequence of complex neurochemical processes in the peripheral and central nervous system.
Analgesics are drugs reversibly and selectively inhibiting pain in the body without significant changing of consciousness. Opoid (narcotic) analgesics are the drugs that relieve intense pain which mimic the action of endogenous opiopeptides and may cause drug dependence.
Strong agonists of opoid receptors:
· Natural compounds: morphine hydrochloride, codeine phosphate
· Synthetic compounds: fentanyl, promedol
Acute poisoning with morphine: signs – state of sleep, unconsciousness, miosis, bradycardia, cheyne-stokes breathe, retention of urination, spasm of the intestine and bowel. Emergency help:
· Lavage of stomach by 0.5% sol. of potassium permanganate
· Naloxone, IV (an antagonist of narcotic analgesics)
· Atropine (for a decrease in the vagal action of morphine)
Amyloidosis is the term used for a group of diseases characterized by extracellular deposition of fibrillar proteinaceous substance called amyloid.
Amyloidosis of the kidneys is the most common and most serious because of ill-effects on renal function. Cut surface of kidney is pale, waxy and translucent. In the glomeruli, the deposits initially appear on the basement membrane of the glomerular capillaries but later extend to produce luminal narrowing and distortion of the glomerular capillary tuft. There is also narrowing of the small arterioles and venules and consequent ischemic effects.
The deposits in the kidneys are found in most cases of secondary amyloidosis. The histologic diagnosis of amyloid is based almost entirely on its staining characteristics: Congo red – all types of amyloid have affinity for Congo red stain.
Chromosomal disorders: trisomy 21 (down’s syndrome); trisomy 18 (edward’s syndrome); trisomy 13 (patau’s syndrome); monosomy X (turner’s syndrome-XO); trisomy X (XXX);
normal female (XX); normal male (XY)
Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4
Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)
Type II (cytotoxic): antibody dependent reactions e.g. Goodpasture syndrome, Myasthenia gravis, Graves disease, ABO hemolytic disease of newborn etc.
Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.
Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.
Pirogov’s stages of shock
* Erectile phase: is characterized by strong motor agitation, sweating, tremor of skeletal muscles, staggering gait, frequent urination, transient increase in blood pressure, heart rate and breath rate increases, body temperature also. Painful impulses reach CNS.
* Torpid phase: decompensation in CNS leads to deep oppression. Patient is motionless, does not answer questions or answers very silently and with long time of delay, reflexes are lowered or absent.
In the female lesser pelvis, there are two excavations: the rectouterine pouch and vesicouterine pouch. The rectouterine pouch (pouch of douglas) is an intraperitoneal space between the uterus and the rectum. It is a common place for pelvic fluid or blood from hemorrhage to collect after surgery, or rupture of any etiology.
The vesicouterine pouch is between the urinary bladder anteriorly and the uterus posteriorly. It is a shallower recess (pouch).
Aschner’s reflex (press on eyeball) → ↓heart rate. This is mediated by nerve connections between the ophthalmic branch of trigeminal cranial nerve via the ciliary ganglion and the vagus nerve of parasympathetic nervous system.
Goltz reflex (press or blow to the epigastric region) → ↓heart rate.
Sinus tachycardia is the increase in discharge of impulses from the sinoatrial (SA) node, resulting in increase in heart rate (heart rate increase up to 100beats/min).ECG is normal, except for short R-R interval.
Sinus bradycardia is the reduction in discharge of impulses from SA node resulting in decrease in heart rate. Heart rate is less than 60beats/min. Extrasystole is the premature contraction of the heart before its normal contraction. ECG is altered. Sinus arrhythmia is characterized by irregular generation of impulses and may be due to variations in the tone of the vagus nerve. ECG is altered.
For the parents to survive and have a sick anemic child, they must be heterozygous i.e. they only carry a recessive anemic allele.
A – normal gene (dominant); a – anemic gene (recessive)
Aa X Aa
AA Aa Aa aa
aa – only this child will be anemic
Glycogen phosphorylase is the rate-determining enzyme in Glycogenolysis (break down of glycogen). Glycogen phosphorylase cleaves glycogen to glucose 1-phosphate (first step in glycogenolysis). This pathway mobilizes stored glycogen in liver to replenish used glucose. It also breaks down glycogen in muscle to glucose, to produce energy during physical work. If this enzyme is deficient, then used glucose cannot be replaced leading to hypoglycemia.
In lysosomal glycosidase, there is still normal blood sugar levels (no hypoglycemia). α-amylase and ɣ-amylase is involved in digestion of polysaccharides. Glucose 6-phosphate dehydrogenase (G6PD) is the rate-limiting enzyme in pentose phosphate pathway which catalyzes an irreversible oxidation of glucose 6-phosphate to 6-phosphogluconolactone.
Juxtaglomerular apparatus is formed by 3 different structures:
· Macula densa: is the end portion of thick ascending segment as it opens into the distal convoluted tubule. It is situated between the afferent and efferent arterioles of the same nephron. It is very close to afferent arteriole. Macula densa is formed by tightly packed cuboidal epithelial cells.
· Mesangial cells: are situated in the triangular region bound by afferent arteriole, efferent arteriole and macula densa.
· Juxtaglomerular cells: are specialized smooth muscle cells situated in the wall of afferent arteriole just before it enters the Bowman’s capsule.
Superoxide dismutases (SOD) are a group of enzymes that catalyze the dismutation of superoxide radicals (O2−) to molecular oxygen (O2) and hydrogen peroxide (H2O2), providing cellular defense against reactive oxygen species.
Muscle contraction is classified into 2 types: Isotonic and Isometric.
· Isotonic contraction: the tension in the muscle remains the same but the length of the muscle fiber is changing (Iso = same; tonic = tension) e.g. simple flexion of arm, where shortening of muscle fibers occurs but the tension does not change.
· Isometric contraction: the length of muscle fibers remains the same but the tension is increased e.g. pulling any heavy object when the muscles become stiff and strained with increased tension but the length does not change. Holding (but not moving) – length does not change.
Low protein levels (low oncotic pressure) in the blood caused by malnutrition, kidney and liver disease can cause edema. The proteins help to hold salt and water inside the blood vessels so fluid does not leak out into the tissues. If a blood protein, especially albumin, gets too low, fluid is retained and edema occurs, especially in the feet, ankles and lower legs.
Tuberculin (Mantoux) skin test: this test is done by intradermal injection of tuberculoprotein (tuberculin), purified protein derivative (PPD). Type IV hypersensitivity reaction.
Immunization against tuberculosis is induced by injection of attenuated strains of bovine type of tubercle bacilli, Bacilli Calmette Guerin (BCG).
In viral hepatitis, there is generalized liver dysfunction involving uptake and conjugation of unconjugated bilirubin, secretion of conjugated bilirubin into bile ducts, and recycling of urobilinogen. Alanine transaminase (ALT) and Aspartate transaminase (AST) are increased (↑), but ALT is higher than AST and there is a slight ↑ in alkaline phosphatase (ALP) and ɣ-glutamyltransferase (GGT).
ALT is a specific enzyme for liver necrosis; present in the cytosol. ALT>AST: viral hepatitis.
AST is present in the mitochondria. Alcohol damages mitochondria AST>ALT indicates alcoholic hepatitis
Collagen, most abundant protein in human body; organizes and strengthens extracellular matrix. Collagen contains Gly-X-Y (X and Y are proline or lysine). Glycine(Gly) makes 1/3 of collagen. Oxyproline (hydroxyproline) is a major collagen amino acid which enables it to be regarded as a marker that reflects the catabolism of collagen.
Paget disease of bone (osteitis deformans): localized disorder of bone remodeling caused by increase in both osteoclastic and osteoblastic activity.
Reflex activity is the response to a peripheral nervous stimulation that occurs without our consciousness. It can be:
* Inborn or unconditioned: present from birth, does not require previous learning or training.
* Acquired or conditioned: developed after conditioning or training. Acquired after birth.
It is conditioned because the students have had a previous experience with examinations before. The manifestation of dry mouth is a sympathetic effect.
The causative agent of botulism is Clostridium botulinum.
Morphology. Cl. botulinum is a large pleomorphous rod with rounded ends, 4.4-8.6 mcm in length and 0.3-1.3 mcm in breadth. The organism sometimes occurs in short forms or long threads. Cl. botulinum is slightly motile and produces from 4 to 30 flagella per cell. In the external environment Cl. botulinum produces oval terminal or subterminal spores which give them the appearance of tennis rackets . The organisms are Gram-positive.
Pathogenesis and disease in man. Botulism is contracted by ingesting meat products, canned vegetables, sausages, ham, salted and smoked fish (red fish more frequently), canned fish, chicken and duck flesh, and other products contaminated with Cl. botulinum. The organisms enter the soil in the faeces of animals (horses, cattle, minks, and domes-tic and wild birds) and fish and survive there as spores.
The test specimens are inoculated into Kitt-Tarozzi medium which has previously been held at 100 C for 10-20 minutes.
They are actively motile, monotrichous, nonsporeforming, noncapsulated, and Gram-negative.
Vibrio cholera are facultative (anaerobes). The organisms grow readily on alkaline media at pH 6.0-9.0, and on solid media the colonies are transparent with a light-blue hue, forming domes with smooth edges. On gelatin the organisms produce transparent granular colonies which, when examined under a microscope, resemble broken glass. In 48 hours the medium surrounding the colonies becomes liquefied and the colonies sink into this area. Six-hour-old cultures on alkaline meat broth and peptone water produce a thin pellicle, which consists of cholera vibrios.
Deficiency of UGT inhibits conjugation and therefore increase unconjugated bilirubin in serum (Jaundice).
Pyruvate dehydrogenase complex: Mitochondrial enzyme complex linking glycolysis and citric acid cycle. The complex contains 3 enzymes that require 5 cofactors: Vit B1, B2, B3, B5, lipoic acid. Pyruvate → Acetyl-CoA.
The complex is similar to the α-ketoglutarate dehydrogenase complex (same cofactors, similar substrate and action), which converts α-ketoglutarate → Succinyl-CoA (CAC or TCA cycle). Arsenic inhibits lipoic acid. Findings: vomiting, rice-water stools, garlic breath.
Certain amino acids undergo decarboxylation that means the removal of their α-carboxyl group resulting in liberation of CO2 and formation of biogenic amines. Biogenic amines are physiologically active substances such as hormones, neurotransmitters etc. decarboxylation of amino acids:
· Tryptophan → Niacin → NAD+/NADP+
Tryptophan → Serotonin →Melatonin
· Histidine → Histamine
· Glutamine → GABA
Glutamine → Glutathione
Drumstick – barr body. Barr body is an inactive X-chromosome. So a boy (XY) with an inactive X-chromosome must have an additional X-chromosome – XXY (Klinefelter’s syndrome). Causes :
* nondisjunction (maternal and paternal nondisjunction in meiosis I)
* Mosaicism: with the karyotype being 46, XY/47, XXY
Manifestations: gynecomastia, female pattern of pubic hair distribution, no facial hair, high voice.
• It is marked by the outpouring of a thin fluid that is derived from either the bloodstream or the secretions of mesothelial cells.
• The skin blister resulting from a burn or viral infections represents a large accumulation of serous fluid, either within or immediately beneath the epidermis of the skin.
• Serous exudates contain up to 2% protein and less quantity cells (neutrophils, macrophages, desquamative epithelium).
• Serous inflammation can also occur on serous membranes (poly-serositis at rheumatic diseases, autointoxications - uremia), in mucus (serous rhinitis), in skin (streptococcus infections, herpes, burn), seldom in internal organs (serous pneumonia).
Secondary tuberculosis usually results from reactivation of dormant, endogenous tubercle bacilli in a sensitized patient who has had previous contact with the tubercle bacillus. Reactivation typically begins in the apical or posterior segments (often 1st and 2nd segments) of one or both upper lobes (“simon’s foci”), where the organisms were seeded during the primary infection. There are 8 forms or stages of the secondary tuberculosis: Acute local tuberculosis; Fibrous local tuberculosis; Infiltrative tuberculosis; Tuberculoma; Caseous pneumonia; Acute cavernous tuberculosis; Fibrous cavernous tuberculosis; Cirrhotic tuberculosis.
Fibrous cavernous tuberculosis is the most frequent form. Macroscopically, the lesions are spherical and cavitary (cavity can contain blood and blood clots); the so-called coin lesions. Microscopically, the outer wall of cavity shows fibrosis or sclerosis. Internal surface may be connected with bronchus. The wall of cavern has 3 membranes:
· Internal membrane occurs by necrotic tissue
· Middle membrane occurs by special granular tissue
· External membrane occurs by connective fibrous tissue
Colienteritis - Antigen structure 0-111
The causative agents of colienteritis in children are O-groups -25; -26; -44; -55; -86; -91; -111; -114; -119; -125; -126; -127; -128; -141; -146 and others (they cause diseases in infants of the first month of life and in older infants). Most widely spread serotype is O-111:K58:H2
Duplications occur when a portion of the chromosome is present on the chromosome in two copies.
Inversion involve an end-to-end reversal of a segment within the same chromosome (turn of 180o).
Deletion is a mutation in which a part of a chromosome or a sequence of DNA is missing. Deletion is the loss of genetic material.
Paraprotein, myeloma protein, M protein or spike protein is an abnormal immunoglobulin (Ig) fragment or immunoglobulin (Ig) light chain that is produced in excess by an abnormal clonal proliferation of plasma cells, typically in multiple myeloma. Monoclonal free light chains in the serum or urine are called bence jones (BJ) proteins.
Bence jones (BJ) protein: free kappa (κ) or lambda (λ) light chains that are excreted in urine associated with plasma cell malignancies (myeloma) and Waldenstrὄm macroglobulinemia. In myeloma, urinalysis for BJ protein is positive in 60-80% of cases.
Hepatic steatosis can occur when humans are deprived of choline.
Choline + Phosphatidic acid → Phosphatidylcholine (lecithin, PC). In the liver PC can also be synthesized from phosphatidylserine (PS) and phosphatidylethanolamine (PE), when free choline levels are low, because it exports significant amounts of PC in bile and as a component of serum lipoproteins (needed for fat metabolism)
PS → PE →→→ PC. 3 methylation reactions between PE and PC. S-adenosylmethionine is the methyl group donor. If choline, phosphatidylcholine or methionine is deficient, there will be abnormal phospholipid synthesis, oxidative damage caused by mitochondrial dysfunction, lipoprotein secretion (remember, if VLDL cannot be secreted it will be accumulated & cause fatty liver degeneration as seen in hepatic steatosis). PC is also a major lipid component of lung surfactant.
In the hepatocyte, the solubility of unconjugated bilirubin is increased (i.e. it is made soluble) by the addition of two molecules of glucuronic acid to produce conjugated bilirubin. This process is referred to as conjugation. This reaction is catalyzed by Uridine diphosphate (UDP) glucuronyltransferase – UGT. Varying degrees of deficiency of this enzyme result in Crigler-Najjar I & II and Gilbert syndrome; with Crigler-Najjar I being the most severe deficiency.
Neutrophilic leukocytosis: increase in neutrophil count. Depending on the proportion between the mature and premature forms of neutrophils, two types of the nuclear shift may be distinguished: to the left, when there is an elevated content of immature forms of neutrophilic granulocytes (myelocytes, metamyelocytes, bands) in the blood; And to the right, when the mature neutrophils with a large number of segments (5 – 6) prevail against a background of younger cells disappearing. The nuclear shift may be subdivided into: regenerative, hyperregenerative, degenerative and regenerative-degenerative shifts.
Regenerative shift develops against a background of mild general leukocytosis, accompanied with elevated content of bands and metamyelocytes (immature forms). This shift results from the reactive leukopoiesis (granulocytopoiesis) activation and is common in suppurative septic processes.
Neutrophils: Stab (band): 1-6% (8%)↑
Segmented: 47-72% (59%) normal
Myelocyte and Metamyelocyte: 0-1% Juvenile forms (2%)↑
Since there is an elevated content of immature forms of neutrophils, then it is a regenerative left shift.
Alveolar macrophages remove inhaled particulate matter from the air spaces and red blood cells (RBCs) from the septum of alveoli. They are unusual in that they function both in the connective tissue of the septum (alveolar wall) and in the air space of the alveolus (surface of alveolar cells). In air spaces they scavenge the surface to remove inhaled particulate matter (e.g. dust, pollen, pathogens), thus giving them one of their alternate names – Dust cells. They also phagocytose infectious organisms such as Mycobacterium tuberculosis. Other macrophages remain in the septal connective tissue, where, filled with accumulated phagocytized material, they may remain for much of an individual’s life. Thus, at autopsy, the lungs of urban dwellers as well as smokers will usually show many alveolar and septal macrophages filled with carbon particles, anthracotic pigment and birefringent needle-like particles of silica.
Type I alveolar cells (type I pneumocytes): the junctions formed between this cells form an effective barrier between the air space and the components of the septal wall. They are not capable of cell division. They make up 95% of the surface of the alveoli.
Type II alveolar cells: secretory cells; have lamellar bodies; progenitor cells for type I alveolar cells.
Clara cells: non-ciliated; low columnar/cuboidal cell with secretory granules. They secrete components of surfactant, degrade toxins and act as reserve cells.
Endothelial cells line blood vessels.
The network of membrane enclosed spaces that extends throughout the cytoplasm constitutes endoplasmic reticulum (ER). Some of these thread-like structures extend from the nuclear pores to the plasma membrane.
A large portion of the ER is studded with ribosomes to give a granular appearance which is referred to as rough endoplasmic reticulum (rER). Ribosomes are the factories of protein biosynthesis. The smooth ER (agranular ER) does not contain ribosomes. It is involved in the synthesis of lipids (triacylglycerols, phospholipids, sterols) and metabolism of drugs, besides supplying Ca2+ for the cellular functions.
Lactate, formed by the action of lactate dehydrogenase (converting pyruvate to lactate) is the final product of anaerobic glycolysis in eukaryotic cells. In organs or cells that are poorly vascularized and/or lack mitochondria, formation of lactate is the major fate of pyruvate as seen in lens, cornea of the eye, kidney medulla, testes, leukocytes and red blood cells.
Aerobic glycolysis progresses to citric acid cycle from pyruvate. The cycle occurs totally in the mitochondria.
Antidiuretic hormone (vasopressin) is secreted in response to decrease blood volume and increase plasma osmolarity. It binds to receptors on principal cells of collecting ductules causing increase number of aquaporins and increase water reabsorption which leads to decreased diuresis.
Atrial natriuretic peptide is secreted in response to increase atrial pressure. It causes increase glomerular filtration rate (GFR) and increase sodium ion filtration with no compensatory sodium ion reabsorption and water in distal nephron which leads to increase diuresis.
Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.
· Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.
· Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.
Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.
Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).
Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).
Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.
Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words: in water).
* Ramus circumflexus (circumflex coronary artery) branch of left anterior descending artery runs within – left coronary sulcus.
* Arteria coronaria dextra (right coronary artery) – right coronary sulcus.
* Ramus interventricularis posterior (posterior interventricular branch): runs along the sulcus of the same name; greatest branch of right coronary artery
* Ramus interventricularis anterior (anterior interventricular branch): runs along the sulcus of the same name.
* Vena cordis parva (small cardiac veins): right portion of coronary sinus.
The described symptoms are for type I diabetes mellitus (especially acetone odor of breath as a result of excess ketone bodies). Type I diabetes mellitus is due to decrease or absent insulin. Insulin facilitates the transport of glucose and amino acids into target organs: In liver – insulin increases the storage of glucose as glycogen. It decreases protein catabolism; In muscles – it stimulates glycogen synthesis and protein synthesis; In Adipose tissue – it facilitates triglyceride storage by activating plasma lipoprotein lipase which increase glucose transport into the cell and by reducing intracellular lipolysis.
Glibenclamide is typically used for type 2 diabetes mellitus.
Adrenaline will further exacerbate the hyperglycemic condition because it stimulates glycogen phosphorylase. Isadrinum is a non-selective β1-β2 adrenergic agonists (β-adrenomimetics); it’ll have the same effect as adrenaline. Furosemide is a loop diuretic and will not correct the comatose state of the patient; It has no effect on glucose metabolism or ketone bodies.
Anterolateral abdominal wall has 9 regions and 4 quadrants (RUQ, LUQ, RLQ, LLQ)
· Right lateral abdominal region: Ascending colon (colon ascendens), right kidney, right ureter and loops of small intestine.
· Umbilical region: Transverse colon (colon transversum), head of pancreas, duodenum (except superior part)
· Left lateral abdominal region: Descending colon (colon descendens), left kidney, left ureter and loops of small intestine.
· Left inguinal region: Sigmoid colon (colon sidmoideum), left ureter, left external iliac artery of artery and vein.
· Right Inguinal region: Caecum, vermiform appendix, right ureter
Barr body is an inactive X-chromosome. A normal female has one barr body XX, a normal male has no barr body XY.
Trisomy X – XXX (only one X is active in a female; therefore, 2 barr bodies)
Klinefelter – XXY (one barr body)
Turner’s – XO (no barr body)
46 XX is a normal female sex chromosome. All other options are karyotypes for male patients.
Hyperplasia of endometrium is classified into 3 types:
· Simple hyperplasia (cystic glandular hyperplasia)
· Adenomatous hyperplasia (complex hyperplasia without atypia)
· Atypical hyperplasia (complex hyperplasia with atypia)
Simple hyperplasia (cystic glandular hyperplasia) is characterized by the presence of large and cystically dilated varying-sized glands, which are lined by atrophic epithelium.
All muscles that elevate the rib cage are muscles of inspiration and those that depress the rib cage are muscles of expiration.
Muscles of inspiration:
· Sternocleidomastoid: lift upward on the sternum.
· Anterior serrati: lift many of the ribs.
· Scalene: lift the first two ribs.
Muscles of expiration: Abdominal recti – pull down the lower ribs and other abdominal muscles also compress the abdominal contents upwards against the diaphragm and internal intercostals.
Normal respiration is accomplished by the movement of the diaphragm only.
Cushing Syndrome: Etiology
*INCREASE Cortisol due to a variety of causes (Glucocorticoids).
*Exogenous corticosteroids: result in DECREASE ACTH (MCC).
*Primary adrenal adenoma, hyperplasia or carcinoma (Cushing’s Syndrome).
*ACTH-secreting pituitary adenoma (Cushing Disease).
Findings: Hypertension, Weight Gain, Moon Facies, Truncal Obesity, Buffalo Hump, Skin Changes (thinning striae), Osteoporosis, Hyperglycemia (Insulin resistance), Amenorrhea, Immunosuppression.
Lymph nodes are small encapsulated organs located along the pathway of lymphatic vessels. The supporting elements of the lymph node are:
*Capsule: composed of dense connective tissue that surrounds the node.
*Trabeculae: composed of dense connective tissue, which extend from the capsule into the substance of the node, forming a gross framework.
*Reticular tissue: composed of reticular cells and reticular fibers that forms a fine supporting meshwork throughout the remainder of the organ.
The parenchyma of the lymph node is divided into a cortex and medulla. The cortex consists of lymphocytes which are organized into nodules. The medulla of the lymph node consists of the medullary cords and medullary sinuses.
Tonsils: form a ring of lymphatic tissue at the entrance of the oropharynx; consisting of aggregations of lymphatic nodules.
Thymus is a lymphoepithelial organ located in the superior mediastinum. It possess a thin connective tissue capsule from which trabeculae extend into the parenchyma of the organ. The trabeculae establish domains in the thymus called thymic lobules. Thymic or hassall’s corpuscles are a distinguishing feature of the thymic medulla.
Spleen is the largest lymphatic organ. Most of the spleen consists of splenic pulp. Splenic pulp is divided into white pulp and red pulp. The spleen is enclosed by a dense connective tissue capsule from which trabeculae extend into the parenchyma of the organ.
Monoamine oxidase (MAO) is a mitochondrial enzyme found in nerve and other tissues, such as the gut and liver. In the neuron, MAO functions as a “safety valve” to oxidatively deaminate and inactivate any excess neurotransmitter molecules (norepinephrine, dopamine and serotonin) that may leak out of synaptic vesicles when the neuron is at rest.
The MAO inhibitors (MAOIs) may irreversibly or reversibly inactivate the enzyme, permitting neurotransmitter molecules to escape degradation and therefore, to both accumulate within the presynaptic neuron and leak into the synaptic space. This is believed to cause activation of norepinephrine and serotonin receptors, and it may be responsible for the indirect antidepressant action of these drugs. Four MAOIs are currently available for treatment of depression: phenelzine, tranylcypromine, isocarboxazid, selegiline.
Heparin is a natural anticoagulant produced in mast cells and basophils. It is an injectable, rapidly acting anticoagulant that is often used acutely to interfere with the formation of thrombi. Heparin is used in the prevention of venous thrombosis and the treatment of a variety of thrombotic diseases such as pulmonary embolism and acute myocardial infarction. Heparin binds to antithrombin III, with the subsequent rapid inactivation of coagulation factors. Antithrombin III inhibits serine proteases, including several of the clotting factors, most importantly, thrombin (factor IIa) and Factor Xa (a-active).
Protamine sulphate antagonizes the anticoagulant effects of heparin. The positively charged protamine interacts with the negatively charged heparin forming a stable complex without anticoagulant activity.
Blood group O(I): no antigens, therefore no agglutination.
Blood group A(II): A antigen, agglutinate with blood group B(III) and O(I).
Blood group B(III): B antigen, agglutinate with blood group A(II) and O(I).
Blood group AB(IV): A and B antigen, agglutinate with all blood groups. No antibody.
Blood group name is determined by the antigen present on RBC, but the patient has an opposite antibody. So whenever, the antibody corresponds to the antigen, there is agglutination. Since O does not have any antigen, no agglutination can occur.
Neutrophils are the first leukocytes that cross the blood vessel wall to enter inflammatory sites. Under normal conditions, leukocytes are restricted to the center of small blood vessels, where the flow is fastest. In inflammatory sites, where the vessels are dilated, the slower blood flow allows the leukocytes to move out of the center of the blood vessel and interact with the vascular endothelium. Even in the absence of infection, monocytes migrate continuously into the tissues, where they differentiate into macrophages; meanwhile, during an inflammatory response, the induction of adhesion molecules on the endothelial cells, as well as induced changes in the adhesion molecules expressed on leukocytes recruit large numbers of circulating leukocytes, initially Neutrophils and later monocytes, into the site of an infection (inflammatory focus).
First –Neutrophils; second –monocytes and macrophages; third –lymphocytes.
Linea terminalis = pectineal line (pubis) + Arcuate line + sacral promontory + superior margin of pubic symphysis. Boundary between the abdominal and pelvic cavity.
Linea semilunaris found on the lateral margin of rectus abdominis.
Linea arcuata: the region on the posterior layer, where aponeuroses end and continue into the anterior layer. Part of linea terminalis anteriorly.
↓blood supply → activates renin. Renin catalyzes the conversion of angiotensinogen to angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I → angiotensin II. Angiotensin II causes:
- vasoconstriction → ↑BP
- vasopressin (ADH) → ↑H2O reabsorption → ↑plasma volume
- aldosterone → ↑Na+ and H2O reabsorption → ↑plasma volume → ↑BP
Aerobic glycolysis progresses to citric acid cycle from pyruvate, especially when there is blood supply to make the necessary oxygen available for the process. The cycle occurs totally in the mitochondria.
Extrasystole is the premature contraction (an extra contraction) of the heart before its normal contraction. In other words, it is an extra contraction of the heart before its normal contraction. It is caused by an ectopic focus (discharge of an impulse from any part of the heart other than the Sinoatrial node).
Bradycardia: ↓heart rate; Tachycardia: ↑heart rate; Flutter: rapid heart contractions; Fibrillation: very rapid heart contractions. (In all this, there is no extra heart contraction, we just have faster contractions).
Substances necessary for coagulation or clotting of blood are called clotting factors. Fibrinogen is the factor I of the thirteen clotting factors. Most of the clotting factors are proteins in the form of enzymes synthesized in the liver.
In chronic hepatitis (i.e. relatively prolonged course of inflammation of the liver), the protein-synthetic function of the liver is impaired. Meaning, there is a marked decrease of clotting factors which results in uncontrolled and protracted hemorrhage.
Urolithiasis or formation of urinary calculi at any level of the urinary tract is a common condition. There are 4 main types of urinary calculi, namely:
· Calcium stones: are the most common comprising 75% of all urinary calculi. They may be pure stones of calcium oxalate (50%) or calcium phosphate (5%) or mixture of calcium oxalate.
· Mixed (struvite) stones: about 15% of urinary calculi are made of magnesium-ammonium-calcium phosphate often called struvite. “Staghorn stone”
· Uric acid stones: can be seen in gout, Lesch-Nyhan syndrome (hyperuricemia).
· Cystine stones: seen in cases like cystinuria.
NB: hyperparathyroidism → ↑Ca2+ concentration in blood.
Lisinopril is an angiotensin converting enzyme inhibitor (ACE Inhibitor). This drug block the ACE that cleaves angiotensin I to form the potent vasoconstrictor angiotensin II. Rennin converts angiotensinogen to angiotensin I.
Propranolol is a β-blocker; Prazosin – α1-adrenoblocker; Nifedipine – Ca2+-channel blocker; Dichlothiazide – thiazide diuretic.
For a high rate of renin, the antihypertensive drugs that are effective are: renin inhibitor (Aliskiren); angiotensin II receptor blocker and angiotensin converting enzyme (ACE) inhibitors because they block the renin –angiotensin system.
· Aminazine – neuroleptic (it is better than reserpine for emergency care. It has also proved to be useful in control of intracted hiccup).
· Diazepam – tranquilizer
· Sodium bromide – sedative
· Reserpine – neuroleptic
· Halothane – general anesthesia
The tetracyclines (minocycline, doxycycline) are broad spectrum bacteriostatic antibiotics.
Mechanism of action: entry of these drugs into susceptible organisms is mediated both by passive diffusion and by an energy-dependent transport protein mechanism. The drug binds reversibly to the 30S subunit of the bacterial ribosome, thereby blocking access of the amino acyl-tRNA to the mRNA-ribosome complex at the acceptor site.
Taking these drugs concomitantly with diary foods in the diet decreases absorption due to the formation of non-absorbable chelates of the tetracyclines with calcium ions. Non-absorbable chelates are also formed with other divalent and trivalent cations (e.g. those found in magnesium and aluminum antacids and in Iron preparations).
· Discolouration and hypoplasia of the teeth in growing children
· Phototoxicity: such as sunburn
· Gastric discomfort
So far, Doxycycline has been the only tetracycline tested in Krok.
Embolism is occlusion of a vessel by material travelling in the circulation.
* Fat/Adipose embolism: obstruction of arterioles and capillaries by fat globules constitutes fat embolism. It may occur following severe fracture trauma to bones, inflammation of bones and soft tissues, fatty liver
* Thromboembolism: a detached thrombus or part of thrombus which may arise in the arterial or venous circulation.
* Gas embolism: two main forms of gas embolism are air embolism and decompression sickness. Air embolism is usually due to accidental pumping of air into the venous circulation during intravenous (IV) injection or transfusion ( bubble – air escaped).
Tissue embolism: fragments of tissue.
Histamine is localized in ready form in granules of the mast cells and basophils. In the blood of healthy people, histamine almost totally stays in basophils. Histamine acts on the tissues cells through its receptors – H1 and H2 (commonly found in GIT). Their correlation and spreading on the cells of different cells is different.
Stimulation of H1 promotes the contraction of bronchial smooth muscles (resulting in expiratory dyspnea), endothelial cells and postcapillary part of microcirculation. This leads to increase in permeability of vessels, development of edema and inflammation (vesicle, erythema). In many cases, increase in quantity of histamine in blood is observed in the intensive stage of bronchial asthma, nettle-rash, officinal allergy, urticaria.
The cardiac manifestations of Rheumatism are in the form of focal inflammatory involvement of the interstitial tissue of all the three layers of the heart, the so-called pancarditis. The pathognomonic feature of pancarditis in Rheumatism is the presence of distinctive Aschoff nodules or Aschoff bodies. These cells tend to be arranged in a palisade manner.
Fully developed Aschoff bodies are granulomatous structures consisting of fibrinoid change, lymphocytic infiltration, occasional plasma cells and characteristically abnormal macrophages surrounding necrotic centers.
The Aschoff bodies are commonly found in the interstitium of the heart and may be visible to the naked eye. They are often found in the vicinity of small blood vessel in the myocardium and endocardium (perivascular cellular focal infiltrates) and occasionally in the pericardium and the adventitia of the proximal part of the aorta.
3 stages of development: Fibrinoid degeneration (fibrinoid necrosis); Granulomatous (proliferative or Intermediate ) Stage; Late (healing) stage.
Ascaris lumbricoides (giant roundworm) is the causative agent of Ascariasis. Transmission: fecal-oral; eggs are visible in faeces under microscope. Some patients may have pulmonary symptoms or neurological disorders during migration of the larvae. A bolus of worms may obstruct the intestine; migrating larvae may cause pneumonitis and eosinophilia.
Ascaridiasis (Ascariasis) caused by Ascaris lumbricoides (giant roundworm). The major damage occurs during larval immigration rather than from the presence of the adult worm in the intestines. The principal sites of tissue reaction are the lungs, where inflammation with an eosinophilic exudates occurs in response to larval antigens. Ascaris pneumonia with fever, cough and eosinophilia can occur with a heavy larval burden.
Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:
↑bone resorption of Ca2+ and PO43- → ↑their plasma levels
↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level
↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels
↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.
In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels. Abnormal synthesis (↑synthesis) of parathyroid hormone can lead to hypercalcemia and hypophosphatemia.
Calcitonin is secreted by parafollicular cells (C cells of the thyroid gland). It ↓bone resorption of Ca2+. It opposes actions of parathyroid hormone. But its not important in normal Ca2+ homeostasis. Calcitriol ↑ circulating Ca2+ ions as a means of enhancing intestinal absorption of calcium (NB: Calcitriol production is dependent on parathyroid hormone). Aldosterone: reabsorption of Na+, excretion of K+. Cortisol – glucocorticoid: ↑ blood pressure and gluconeogenesis; ↓ inflammatory and immune responses; ↓ bone formation (↓osteoblast activity).
Tryptophan → Serotonin →Melatonin
Glutamine → Glutathione
Boundaries of femoral triangle:
*Superiorly: inguinal ligament
*Medially: medial border of adductor longus muscle
*Laterally: medial border of the Sartorius muscle
*Roof: fascia lata
*Floor: adductor longus muscle, pectineus muscle and the iliopsoas muscle
Calcium-channel blockers: verapamil, diltiazem, nifedipine, amlodipine, felodipine, nicardipine.
The dihydropyridines are calcium channel blockers with 2 generations (e.g. nifedipine, amlodipine, felodipine etc). all dihydropyridines have a much greater affinity for vascular calcium channels than for calcium channels in the heart. They are therefore, particularly attractive in treating hypertension.
The intracellular concentration of calcium plays an important role in maintaining the tone of smooth muscle and in the contraction of the myocardium. Calcium channel blockers block the inward movement of calcium by binding to L-type calcium channels in the heart and in smooth muscle of the coronary and peripheral arteriolar vasculature. This causes vascular smooth muscle to relax, dilating mainly arterioles. Calcium-channel blockers do not dilate veins.
Vitamin D is a fat soluble vitamin. Cholecalciferol (Vit. D3) is found in animals. It is regarded as a sunshine vitamin. Calcitriol is the biologically active form of Vit. D. Calcitriol acts at 3 different levels (intestine, kidney and bone) to maintain plasma calcium.
It increases the intestinal absorption of calcium and phosphate.
In the osteoblasts of bone, it stimulates calcium uptake for deposition as calcium phosphate. Thus, calcitriol is essential for bone formation.
Calcitriol is also involved in minimizing the excretion of calcium and phosphate through the kidney, by decreasing their excretion and enhancing reabsorption.
Deficiency of Vit D causes rickets in children and osteomalacia in adults. Rickets in children is characterized by bone deformities due to incomplete bone mineralization, resulting in soft and pliable bones and delay in teeth formation. The weight bearing bones are bent to form bow legs.
Normal 36.5 – 36.8oC
Subfebrile 36.9 – 37.9oC
Febrile 38.0 – 38.9oC
Pyretic 39.0 – 40.9oC
Type IIa (familial hyperlipoproteinemia: ↑LDL and cholesterol. Autosomal dominant; due to absent or defective LDL receptors.
Type I: ↑chylomicrons, triacylglycerol (TAG), cholesterol. Autosomal recessive; due to lipoprotein lipase deficiency or altered apolipoprotein C-II.
Type IV: ↑very low density lipoprotein (VLDL) and TAG. Autosomal dominant; due to hepatic overproduction of VLDL.
Type IIb: similar to Type IIa, except that VLDL is also increased and VLDL is normal for IIa.