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Basic Science Summary For The MRCS
Basic Science Summary For The MRCS
BASIC SCIENCE
SUMMARY
For the MRCS
A summary of more than 1800 MCQs!
By
Mahmoud Shoaib
Neuro-surgery resident – Tanta University
Dr.ma7moud@windowslive.com
Drma7moud.blogspot.com
0114 14 955 76 – 0114 610 16 16
INDEX
ABBREVIATIONS …………………………………………………………... 3
ANATOMY …………………………………………………………………..... 4
1. Thorax …………………………………………………………………………………………………….. 5
2. Upper limb & breast ………………………………………………………………………………… 9
3. Lower limb ………………………………………………………………………………………………. 14
4. Head & neck ……………………………………………………………………………………………. 18
5. Brain & cranial nerves ……………………………………………………………………………… 26
6. Back & spinal cord …………………………………………………………………………………… 28
7. Abdomen ………………………………………………………………………………………………… 29
8. Pelvis & perineum …………………………………………………………………………………… 37
9. Developmental anatomy …………………………………………………………………………. 39
ABBREVIATIONS
A
ACE Angio-tensin Converting ARF Acute Renal Failure.
Enzyme.
ASD Atrial Septal Defect.
B
BP Blood Pressure.
C
CEA Carcino-Embryonic Antigen. CO Cardiac Output.
CRF Chronic Renal Failure. CVP Central Venous Pressure.
H
HR Heart Rate.
M
MAP Mean Arterial Pressure. MRSA Methicillin-Resistant
Staphylo-coccus Aureus.
N
NK cell Natural Killer cell. NSGCTs Non-Seminomatous Germ-
Cell Tumors.
P
PAWP Pulmonary Artery Wedge Pgs Prosta-glandins.
Pressure.
R
RPF Renal Plasma Flow.
S
SLE Systemic Lupus SV Stroke Volume.
Erythematosus.
SVR Systemic Vascular Resistance.
T
TPA Tissue Plasminogen Activator. TPN Total Parenteral Nutrition.
U
US Ultra-Sono-graphy.
V
VSD Ventricular Septal Defect.
ANATOMY
THORAX
THORACIC CAGE
The tubercle of the 7th rib articulates with the transverse process of T7.
Sternal angle is palpated to identify the 2nd costal cartilage = T4-5 inter-vertebral disc =
inferior border of superior mediastinum.
The sterno-clavicular joint is in close proximity to the articulation of the 1st rib with the
sternum.
THE LUNGS
The carina is a keel-shaped cartilage at the tracheal bifurcation separating the right &
left main stem bronchi.
The oblique fissure of the right lung separates the lower lobe from the upper & middle
lobes.
The minor (horizontal) fissure separates the middle lobe from the upper lobe.
A stab in the back nicking the left lung halfway between its apex & the diaphragmatic
surface injures the inferior lobe as the posterior surface of the left lung is almost
entirely composed of the inferior lobe.
Inhaled objects are more likely to enter the right lung (the right main bronchus) instead
of the left lung.
They are most likely to end in the superior segmental bronchus of the right lower lobe.
Also, a right lung abscess is most likely to accumulate in the superior segment of the
lower lobe.
Enlarged tracheo-bronchial LNs (at the tracheal bifurcation) irritate the left RLN.
This nerve loops under the aorta to ascend to the larynx, lies immediately dorsal to the
ductus arteriosus & may be injured during its ligation.
A blood clot travelling from a leg vein to the apical segmental pulmonary artery passes
through:
1. IVC.
2. Right atrium.
3. Tricuspid valve.
4. Right ventricle.
5. Pulmonary trunk.
6. Left pulmonary artery.
7. Left superior lobar artery.
8. Left apical segmental artery.
PLEURA
The pulmonary ligament lies posteriorly inferior to the root of the lung.
Cupola is the portion of the parietal pleura extending above the 1st rib.
It lies superior to the upper edge of the left clavicle near its head.
In the erect posture, fluid tends to accumulate in the costo-diaphragmatic recess of the
pleural space (the lowest extent of the pleural cavity) which is found at:
1. The mid-clavicular line between ribs 6 & 8.
2. The mid-axillary line between ribs 8 & 10.
3. The para-vertebral line between ribs 10 & 12.
The aspiration needle is inserted in this recess at the top of the rib (or the bottom of
the inter-costal space) for avoiding damage of the neuro-vascular bundle that is found
below the rib, in the costal groove.
During aspiration of fluid from the pleural space, the structures passed through from
superficial to deep are:
1. External inter-costals.
2. Internal inter-costals.
3. Inner-most inter-costals.
4. Parietal pleura.
The costo-mediastinal recess is an area right next (just above) to the cardiac notch (an
indentation in the superior lobe of the left lung only).
During deep breath, the lingual which is formed by the cardiac notch expands into this
recess.
THE HEART
The great cardiac vein is the largest tributary of the coronary sinus.
It starts at the apex of the heart & ascends with the anterior ventricular bracnch of the
left coronary artery.
A part of the right bundle branch of AV bundle is carried by the crsita terminalis.
Coronary arteries
Artery Supply
1. Left coronary artery. Both ventricles.
A part of the left branch of AV bundle.
2. Circumflex branch of left coronary Left atrium & ventricle.
artery.
PERI-CARDIUM
A hand slipped under the heart apex, passing upward & to the right within the sac &
finally stopped by the cul-de-sac formed by the peri-cardial reflection near the heart
base is in the oblique peri-cardial sinus.
A finger passed immediately behind the 2 great arteries (pulmonary trunk & aorta) in
the peri-cardial sac is inserted into the transverse per-cardial sinus.
MEDIASTINUM
The left brachio-cephalic vein courses across the mediastinum in a horizontal fashion.
It lies immediately antero-superior to the ascending aorta & posterior to the thymus.
The azygos vein lies in the posterior mediastinum & empties into the SVC.
The esophagus lies posterior to the peri-cardial sac & may be compressed by a tumor of
the posterior mediastinum.
The thoracic duct extends from L2 to the root of the neck & lies immediately posterior
to the esophagus & may be injured while mobilizing the esophagus in the neck.
The ascending aorta lies in the middle mediastinum while the arch lies in the superior
mediastinum leaving an impression on the mediastinal surface of the left lung.
The left vagus nerve lies on & partly curves posteriorly around the arch of aorta.
MUSCLES
1
The upper sub-scapular nerve is an infra-clavicular branch of the brachial plexus.
The lower sub-scapular nerve supplies teres major.
All anterior compartment muscles of the arm are supplied by the musculo-cutaneous
nerve.
All superficial fore-arm muscles originate from the common flexor origin (the front of
the medial epi-condyle).
So, a displaced fracture of the medial epi-condyle affects all these muscles but not the
deep muscles.
All adductors of the digits (palmar inter-ossei) are supplied by the ulnar nerve (C8 & T1).
All hypo-thenar muscles are supplied by the ulnar nerve (C8).
The lumbrical muscles assist in extension of the middle & distal phalanges.
ARTERIES
Arteria princeps pollicis supplying the thumb is a branch of the radial artery.
NERVES
Nerve Injury
1. Median nerve Atrophy of the thenar eminence (flexor
& abductor pollicis brevis & opponens
pollicis).
Numbness of skin over it.
2. The roots of C5-6 Loss of abduction of the arm (Erb
Duchenne's paralysis).
3. Musculo-cutaneous nerve Weakness of shoulder & elbow flexion &
arm supination.
Loss of cutaneous sensation on the
antero-lateral surface of the fore-arm.
4. Radial nerve: Numbness on the dorsum of the thumb
It spirals around the humerus in the & parts of digits 1 & 2.
radial groove & may be injured in
fractures of the middle of the humerus.
5. Posterior inter-osseus nerve Inability to extend the wrist & meta-
carpo-phalangeal joints.
MISCELLANEOUS
The inter-tubercular (bicipital) groove of the humerus contains the tendon of the long
head of biceps brachii muscle.
A fracture passing through the superior surface of olecranon process of ulna disrupts
the attachment of triceps brachii.
Olecranon process is used for resting elbows on the desk.
Annular ligament encircles the head of radius & its injury makes supination painful.
The extensor retinaculum prevents the tendons of the posterior compartment of the
forearm from "brow-stringing" when the hand is extended.
Brachial plexus
Carpal bones
1
It is most commonly dis-located by a fall on the out-stretched hand.
2
It has a single articular facet.
LOWER LIMB
MUSCLES
6. Biceps femoris: 1. Tibial nerve (long Extension of the hip & flexion of the
Its long head crosses head). knee.
2 joints. 2. Common Lateral rotation of the leg.
peroneal nerve
(short head).
7. Semi-tendinosus Extension of the hip & flexion of the
8. Semi-membranosus o Sciatic nerve. knee.
Medial rotation of the leg.
Obturator internus muscle emerges from the pelvis through the lesser sciatic foramen.
Adductors of the thigh (longus, brevis & pubic part of magnus) are inserted into linea
aspera of the femur.
All superficial muscles of the back of the leg are inserted into the calcaneus.
Peroneus brevis muscle is inserted into the base of the 5th meta-tarsal bone.
Tibialis posterior is inserted into the tuberosity on the medial surface of navicular.
The popliteal artery is crossed in its middle part from lateral to medial by the tibial
nerve & the popliteal vein.
Great saphenous vein terminates in the femoral vein within the femoral sheath.
The small saphenous vein begins posterior to the lateral malleolus as as continuation of
the lateral marginal vein (dorsal venous arch), has 9-12 valves & is in close relation with:
1. Sural nerve in the lower 1/3 of the leg.
2. Medial sural cutaneous nerve in the upper 2/3 of the leg.
It terminates in the popliteal vein.
The pulsation of dorsalis pedis artery is felt just lateral to the tendon of extensor
hallucis longus.
NERVES
Obturator nerve (ventral divisions of L2, 3 & 4) emerges from the medial border of
psoas major muscle & passes through the obturator foramen.
It innervates the medial compartment of the thigh (adductors).
The lateral femoral cutaneous nerve arises from the dorsal divisions of L2-3.
2) Deep peroneal (anterior tibial) nerve (L4-5 & S1) which supplies "Tom Has Dog
Pobby" (Tibialis anterior, extensor Hallucis longus, extensor Digitorum longus,
Peroneus tertius) & extensor digitorum brevis
It is injured in fracture of the upper end of fibula.
1
Its function is affected in a fracture of the sustentaculum tali.
MISCELLANEOUS
The femoral nerve lies lateral to the femoral artery (outside the femoral sheath).
Tibial nerve is the most superficial structure encountered in the popliteal fossa.
The 1st ligament to rupture with a plantar-flexion-inversion ankle sprain is the anterior
talo-fibular ligament which is the shortest of the 3 lateral ankle ligaments.
Twisting of the ankle with forcible eversion during skiing will most probably strain the
deltoid ligament.
BONE
The pterion is an important clinical landmark because it overlies the anterior branches
of the middle meningeal artery.
It marks the junction between 3 bones: sphenoid, parietal & temporal.
A blow to the pterion (as in boxing) may rupture the artery causing an extra-dural (epi-
dural) hematoma between the dura & the cranial bone.
The sphenoid bone contains the optic foramen, superior orbital fissure, foramen
rotundum, ovale & spinosum.
The medial boundary of the infra-temporal fossa is formed by the lateral pterygoid
plate of the sphenoid bone.
1 th
So, an acoustic neuroma (tumor of the 8 CN) is also likely to involve the facial nerve.
Styloid process of the temporal bone cannot be easily palpated in a live subject.
The hyoid bone serves as an attachment for the middle pharyngeal constrictor muscle.
MUSCLES
The rectus capitis anterior muscle is innervated by ventral rami from C1-2.
Both tensors are supplied by the mandibular division of the tri-geminal nerve:
1. Tensor veli palate that opens the auditory tube & tenses the palate.
It hooks around the pterygoid hamulus of the medial pterygoid plate.
2. Tensor tympani that tenses the tympanic membrane (supplied by the otic ganglion).
The otic ganglion is found on the medial side of the mandibular division of the tri-
geminal nerve.
It receives its pre-ganglionic sympathetic fibers from the 9th CN (glosso-pharyngeal).
The stapedius dampens the movement of the stapes & is supplied by the facial nerve.
The muscles of facial expression are in the same sub-cutaneous plane as the platysma.
ARTERIES
The internal carotid artery passes through the carotid canal in the petrous part of the
temporal bone to reach the intra-cranial cavity.
The anterior cerebral artery supplies the medial surface of the frontal, parietal & limbic
lobes.
The middle meningeal artery is a branch of the 1st (retro-mandibular) part of the
maxillary artery & is the principal artery supplying the meninges.
The central artery of the retina is the 1st & one of the smallest branches of the
ophthalmic artery.
It is the sole supply for the retina.
The dural venous sinuses are located between the 2 layers (meningeal & periosteal) of
the dura matter.
Infections in the skin of the face, scalp or diploic bone of the neuro-cranium reach the
dural venous sinuses because valves do not exist in the veins of these areas & they
communicate directly with the dural venous sinuses through the superior ophthalmic
vein.
An infected blood clot courses through the facial vein to the cavernous sinus.
The cavernous & transverse sinuses are connected by the superior petrosal sinus.
The pterygoid venous plexus drains the infra-temporal fossa via the maxillary vein.
NERVES
Injury to the sympathetic efferent fibers of the oculo-motor nerve will affect the ciliary
muscle.
The cell bodies of the para-sympathetic pre-ganglionic nerve fibers to the ciliary muscle
of accommodation are located in the 3rd CN nucleus (Edinger-Westphal nucleus).
Motor innervation of the orbicularis oculi muscle is by a branch of a nerve that exists
through the stylo-mastoid foramen.
Damage to the facial nerve after it emerges from the stylo-mastoid foramen would
affect facial expression.
The ophthalmic division of the tri-geminal nerve as a single structure does not reach the
interior of the globe.
It carries general sensory innervation of the cornea.
The supra-trochlear nerve is the terminal branch of the frontal nerve which is the
largest branch of the ophthalmic nerve & is situated on the superior surface of the
levator palpebrae superioris.
The inferior palpebral nerve is the terminal branch of the infra-orbital branch of the
maxillary nerve.
The inferior alveolar nerve is the largest branch of the mandibular nerve.
It supplies sensory innervation to the mandibular teeth & bone.
Laryngeal nerves:
1. Superior laryngeal nerve which gives:
External laryngeal nerve:
It may be injured in thyroid surgery during ligation of the superior thyroid artery.
1
Its injury results in loss of sensation from the temporal region & loss of secretory function of the
parotid gland.
The transverse cervical nerve (C2-3) carries touch sensation from the skin of the
anterior triangle of the neck.
The ansa cervicalis is embedded in the carotid sheath & is therefore vulnerable to injury
during surgical procedures to the carotid artery.
The phrenic nerves course over anterior scalene muscles in the neck.
It is accompanied by the peri-cardio-phrenic branch of the internal mammary artery in
the thorax.
The supra-clavicular nerve may be injured with a stab in the posterior triangle of the
neck 4 cm above the clavicle causing anesthesia over the acromion & clavicle.
During thyroidectomy, the order of structures encountered, from superficial to deep is:
1. Skin.
2. Investing fascia.
3. Pre-tracheal fascia.
4. Thyroid gland.
5. Para-thyroid glands.
The parotid duct reaches the oral vestibule by piercing the buccinators muscle.
The sub-mandibular duct opens near the mid-line in the anterior aspect of the floor of
the mouth beside the lingual frenulum through the sub-lingual caruncle.
THE EYE
Aqueous humor is the only source of nutrients for the lens of the eye.
The anterior chamber of the eye is separated from the posterior chamber by the iris.
Directing the gaze downward when the eye is abducted requires the IR muscle.
To test the 4th CN (trochlear), have the patient gaze in (medially), then down.
MISCELLANEOUS
The nerves & blood vessels to the scalp are found in the CT layer.
Infection in the mastoid air cells could probably be transmitted to the middle ear
directly through the epi-tympanic (attic) recess.
It could result from entry of bacteria through the naso-pharyngeal tube.
The vocal ligaments are formed by the superior free edge of the conus elasticus.
The pyri-form recess is located on either side of the larynx within the laryngo-pharynx.
The inferior part of the carotid sheath contains: common carotid artery, internal
jugular vein & 10th CN (vagus).
The sympathetic trunk lies parallel & immediately deep to the carotid sheath in the
neck.
The carotid body is located behind the angle of bifurcation of the common carotid
artery (C4 = the upper border of thyroid cartilage).
It is supplied by the 9th CN (glosso-pharyngeal) & senses changes in blood composition
(it detects ↓ PaO2 "dissolved O2 only") by chemo-receptors.
Sinus Meatus
1. Sphenoidal sinus. Superior meatus.
2. Frontal & maxillary sinuses. Middle meatus.
3. Naso-lacrimal duct. Inferior meatus.
Occlusion of the posterior inferior cerebellar artery is most likely to affect the entire
dorso-lateral part of the rostral medulla & produce the lateral medullary syndrome.
The superior cerebral veins (8-12) drain into the superior sagittal sinus.
The great cerebral vein (of Galen) is formed by the union of the 2 internal cerebral
veins.
CRANIAL NERVES
Lesions of the 9th CN (glosso-pharyngeal) would result in general sensory deficit to the
pharynx.
MISCELLANEOUS
BONE
The vertebrae in the upper 3 regions of the column are true (movable) while those in
the lower 2 regions are false (fixed).
The spinous process serves for the attachment of muscles & ligaments.
The 7th cervical vertebra has a F. transversarium for the passage of the vertebral artery.
Iliac crests are palpated to identify the spine of L4 for performing a lumbar puncture.
Immediately superior to the iliac crest, the hernia passes through the lumbar triangle.
NERVES
A lesion in the caudal medulla affecting the spinal tri-geminal tract will result in ipsi-
lateral loss of perception of pain over much of the face.
The cutaneous branch of the posterior 1ry ramus of C2 is the greater occipital nerve.
Itching sensation from the skin immediately over the base of the spine of scapula is
mediated through the posterior 1ry ramus of C7.
Absent vibration sense in toes indicates a lesion in the posterior white columns of SC.
MISCELLANEOUS
The spinal arachnoid matter is thinner than the cranial part & invests the cauda equina.
The sub-arachnoid cavity communicates with the general ventricular cavity of the brain
by 3 openings.
It is very wide in the spinal part.
The ligamentum denticulatum separates the anterior from the posterior nerve roots.
The medial group of nuclei in the anterior horn of the spinal cord controls the function
of the axial muscles.
Affection of substantia gelatinosa (a nucleus of the posterior grey column) results in loss
of pain & temperature sensations.
ABDOMEN
Splenic ligaments:
1. Gastro-splenic ligament (between stomach & splenic hilum) contains left gastro-epiploic
& short gastric vessels.
2. Lieno (spleno)-renal ligament (between left kidney & splenic hilum) contains splenic
vessels & tail of pancreas.
Pubic tubercle is felt down the edge of the medial crus of the superficial inguinal ring
deep to the lateral edge of the spermatic cord.
The round ligament of the uterus passes through the deep inguinal ring & then along-
side the indirect inguinal herniated mass in the inguinal canal.
A lump protruding from the superficial inguinal ring is either a direct or an indirect
inguinal hernia.
A left-sided indirect inguinal hernia most likely involves the sigmoid colon as it is mobile
due to the presence of sigmoid meso-colon.
GASTRO-INTESTINAL TRACT
Distal jejunum, caecum & vermi-form appendix lie within the right lower quadrant of
the abdomen.
On a barium contrast X-ray, the small intestine is characterized by circular folds of the
mucosa.
The rectum is an important anastomosis site for the portal & caval (systemic) venous
systems.
The division between the true (functional or internal) right & left lobes of the liver may
be visualized on the outside as a plane passing through the gall-bladder fossa & IVC.
The superior liver surface is related to the 7th & 8th costal cartilages on the left side.
The fundus of the gall-bladder usually lies at the tip of the 9th costal cartilage in the
mid-clavicular line.
The common bile duct lies behind the head of pancreas, close to the right border.
BLOOD VESSELS
The splenic artery gives off short gastric arteries which supply blood to the fundus of
the stomach.
The hepatic artery passes near the upper margin of the superior part of the duodenum
& also forms the lower boundary of the epi-ploic foramen (foramen of Winslow).
The hepatic veins are arranged in 2 groups.
The superior mesenteric artery courses between the body & uncinate process of the
pancreas before it supplies the jejunum & ileum.
It lies immediately posterior to the neck of pancreas.
It gives the inferior pancreatico-duodenal artery supplying the pancreas.
The IVC if formed by the junction of the 2 common iliac veins on the right side of L5.
The inferior epi-gastric artery is a branch of the external iliac artery near the deep
inguinal ring.
It runs in the extra-peritoneal CT (pre-peritoneal fat, between transversus abdominis
muscle & peritoneum) vertically just medial to the bowel as the bowel passes through
the abdominal wall.
It will have increased flow through it after dividing the internal thoracic artery at its
distal end so that adequate blood flow is maintained to the rectus abdominis on the left
site.
Inferior mesenteric artery occlusion is seldom (rarely) symptomatic because its territory
may be supplied by branches of left & middle colic arteries.
Inferior mesenteric vein does not run a course parallel to superior mesenteric artery
however they supply/drain the same region.
The marginal artery is the anastomotic artery running along the border of the large
intestine.
The artery of Adamkiewicz is a radicular artery on the left side in the lower thoracic or
upper lumbar region.
The superior gluteal artery exists the pelvis between the lumbo-sacral trunk & S1
nerve.
The celiac ganglia are traversed by vagal (para-sympathetic) fibers that do not synapse
in the ganglia.
Liver, duodenum & gall-bladder pain radiates to the right shoulder & scapula.
Myo-cardial infarction pain is referred to the left upper extremity by the left inter-
costo-brachial nerve.
A spinal cord injury at T10 results in loss of cutaneous sensation from umbilicus to toes.
Its injury during appendicectomy results in weakness of the falx inguinalis resulting in a
right direct inguinal hernia.
It is compressed by a long-standing large indirect inguinal hernia producing pain in the
scrotum.
Its terminal branch is the anterior labial (scrotal) nerve which supplies the skin of the
mons pubis.
INCISIONS
An incision in the epi-gastric region is used to treat an ulcer in the 1st part of the
duodenum.
A mid-line incision between the 2 rectus sheaths passes through the linea alba.
MISCELLANEOUS
The trans-pyloric plane lies roughly a hand's breadth below the xephi-sternal junction.
The venous & lymphatic drainage of the superficial tissue of the anterior abdominal wall
is arranged around a horizontal plane corresponding to the level of the umbilicus:
1. Above that plane, drainage is in a cranial direction (axillary LNs & superior epi-gastric
vein → internal thoracic vein).
2. Below the plane, drainage is in a caudal direction (superficial inguinal LNs & inferior
epi-gastric vein → external iliac vein).
A bypass between the vessels between the portal & caval systems for treating portal
hypertension can be done between splenic vein (portal) & left renal vein (caval).
The site of the cloacal membrane (the point of demarcation between the endo-dermal
& ecto-dermal epithelium "upper 2/3 & lower 1/3") is represented in the adult anal
canal by the anal valves (pectinate/dentate line).
The lower anterior abdominal wall as seen from inside the peritoneal cavity (top) & in the transverse plane (bottom)
GENITAL TRACT
The seminal vesicles are found between the base of the bladder & rectum.
The arteries supplying them are derived from:
1. Middle & inferior vesical arteries.
2. Middle rectal arteries.
The ductus deferens unites with the duct of the seminal vesicle to form the ejaculatory
duct which perforates the prostate gland to open into the prostatic urethra.
An extensive malignant growth in the anterior wall of the vagina is most likely to involve
the fundus of the bladder.
BLOOD VESSELS
The hemorrhoidal plexus is most likely to dilate in a patient with portal hypertension.
Pressure in the portal vein is 8-10 mmHg.
Pain arising from the urinary bladder, uterus/cervix, vagina & rectum is felt in the pelvis
along the mid-line from the pubic bone in front to the sacrum at the back.
Pain arising from acute anal fissure is transmitted by the inferior rectal nerve.
The principal motor & sensory nerve of the perineum is the pudendal nerve (S2, 3 & 4).
It may be injured by a stab into the ischio-rectal fossa 2 cm lateral to the anal canal.
Pudendal nerve block is achieved by palpating the ischial spine vaginally to inject the
anesthetic.
The prostatic plexus of nerves originate from the pelvic splanchnics & its injury during
prostatectomy causes loss of penile erection.
MISCELLANEOUS
The ureter is crossed by the left colic vessels on the left side.
It may be injured:
1. While clamping the uterine arteries during hysterectomy.
2. During excision of the right ovary as the ureter lies posterior to it.
The perineum is divided into 2 triangles by a line connecting the ischial tuberosities.
The inferior part of the uro-genital diaphragm is called the perineal membrane.
The external anal sphincter lies immediately posterior to the perineal body.
DEVELOPMENTAL ANATOMY
Ecto-derm Meso-derm Endo-derm
1. Epidermis of skin, nails & hair. 1. Epithelium of the:
2. Sweat, sebaceous & mammary o GIT & its associated glands as well
glands. as glandular cells of the liver &
3. Nervous system. pancreas.
4. Pupillary muscle of the iris, lens o Urachus & urinary bladder.
& retina. o Respiratory passages (pharynx,
5. Pineal body, posterior pituitary & trachea, bronchi & alveoli).
adrenal medulla. 2. Epithelial parts of the:
6. Melano-cytes, Schwann cells & o Tonsils, thyroid, para-thyroids,
odonto-blasts. tympanic cavity & thymus.
o Anterior pituitary.
1st, 2nd & 3rd arches contribute to structures above the larynx.
4th & 6th arches contribute to the larynx.
5th arch exists transiently during embryological growth & development.
In early fetal life, the heart lies immediately below the mandibular arch & is relatively
large.
In the fetus, the valve of the IVC serves to direct the blood from that vessel through the
foramen ovale into the left atrium.
At birth, left atrial pressure increases pushing the atrial septum premium against the
septum secundum, functionally closing the foramen ovale.
Its incomplete closure results in ASD.
The sinus venosus which is the large quadrangular cavity between the 2 vena cava in
the embryonic human heart gives rise to the coronary sinus.
The right 4th aortic arch forms the right sub-clavian as far as the origin of its internal
mammary branch.
Complete failure of development of the spiral septum in the heart results in persistent
truncus arteriosus in which the vessel never properly divides into the pulmonary artery
& aorta.
THE GIT
The mesenchyme of the pharyngeal arches forms the CT, lymphatic & blood vessels of
the tongue.
The mid-gut gives rise to the GIT from the duodenum (distal 1/2) to the transverse
colon (proximal 2/3).
The yolk sac is the 1st element seen in the gestational sac during pregnancy as 5 weeks'
gestation.
It opens into the digestive tube by a long narrow tube, the vitelline duct.
One of the vitelline duct anomalies is the umbilical fistula.
The allantois is carried backward with the development of the hind-gut & then opens
into the cloaca of terminal part of the hind-gut.
The neuro-enteric canal is a transitory communication between the neural tube & the
primitive digestive tube.
The ventral pancreatic bud forms part of the head & uncinate process of the pancreas.
THE KIDNEY
Meta-nephric glomeruli are derived from a distal (caudal) dorsal region of the meso-
derm.
Meso-nephric tubules are genital ridges next to the developing meso-nephros in a fetus
& give rise to efferent ductules.
MISCELLANEOUS
The ova (1ry oocytes) are developed from the primitive germ cells which are embedded
in the substance of the ovaries.
The thyroid gland is developed from a median diverticulum that appears on the summit
of the tuberculum impar.
The fetal portion of the placenta consists of the villi of the chorion laeve.
Week Events
1. The amnion contains liquor amnii.
4th 2. The cerebral hemi-spheres appear as hollow buds.
3. The heart tube is formed & the heart begins to beat.
5th The cloacal tubercle is evident.
Month
2nd The eyelids are present in the shape of folds above & below the eye.
The loop of gut that projected into the umbilical cord is withdrawn within
4th
the fetus.
7th The testis descends with the vaginal sac of the peritoneum.
9th The baby weighs 3-3.5 Kg (6.5-8 lb).
PHYSIOLOGY
&
PATHOLOGY
ORGANELLES
Structure Function
1. Gap junctions Transport between cells.
2. Lyso-somes Regression of uterine size after delivery.
3. Rough ER Protein synthesis.
4. Mito-chondria replicate spontaneously.
It is the site of electron transport chain which is inhibited by atractyloside, so this drug
has no effect on the function of RBCs as they do not contain mito-chondria.
CELLS
Cells Functions
1. RBCs o It is an example of permanent cells.
o RBCs count of men is > than that of women.
2. Neutro-phils. o The predominant WBC type (70%).
o ↓ number or functional defects in neutro-phils
explains the cause of repeated pyogenic infections
(e.g. strepto-coccal pneumonia).
3. Eosino-phils. o ↑ in patients with hydatid cysts.
Lympho-cytes & mono-cytes are most commonly seen in tissue undergoing chronic
inflammation.
Langhans giant cells are the hallmarks of granulomatous inflammation & are formed by
the fusion of epithelioid cells (macro-phages) (e.g. tuberculosis).
Giant cell is the most characteristic of the inflammatory response around a glass foreign
body.
G A M E D
Highest In mucus- Largest Ab. It binds to
percentage in containing allergens &
a newborn. areas. triggers
Most histamine
abundant Ab. release.
Pgs
D2 E2 F2α I2
It is a 2 mediator
ry
It sensitizes It inhibits platelet
of inflammation. nociceptive nerve aggregation.
endings causing
pain.
It relaxes bronchial It contracts It dilates blood
smooth muscles. bronchial smooth vessels.
muscles.
Arachidonic acid is one of the essential fatty acids required for the synthesis of Pgs.
COMPLEMENT
3b 5a 5b
Opsonin (enhances phago- Chemo-tactic7. It initiates membrane
cytosis). Anaphylatoxin. attack complex (MAC).
Anaphylatoxin.
The critical step in the elaboration of the biological functions of complement is the
activation of C3.
7
Chemo-taxis is the uni-directional migration of WBCs towards a specific target.
Anti-thrombin III inactivates 2, 7, 9, 10, 11 & 12 & its deficiency predisposes to DVT &
pulmonary embolism.
Heparin which is normally produced by mast cells & baso-phils enhances the activity of
anti-thrombin III.
Hageman factor (factor 12) activates both the coagulation & kinin systems on contact
with injured vascular basement membrane.
BLOOD TESTS
HEMO-PHILIA
A2 B C Owren para-hemo-philia
Factor 8. Factor 9. Factor 11. Factor 5.
Haem-arthrosis. Clinical bleeding. Autosomal
Normal PT & BT. recessive.
↑ PTT.
Normal or ↑ VWF.
1
Thrombin clotting time or thrombin time.
2
Treated by infusion of factor 8 concentrate.
Cholesterol crystals are seen within the joint space following episodes of pain.
CBC
PLASMA PROTEINS
Albumin Fibrinogen
It is the most abundant & lightest 1.5-4 g/L in plasma.
plasma protein in terms of weight. It is an acute-phase protein.
DRUGS
ANEMIAS
Vitamin B12 or folic acid deficiency causes pernicious anemia with ovoid RBCs rather
than bi-concave-disc-shape.
Megalo-blastic anemia is characterized by:
1. Pan-cyto-penia.
2. ↑ MCV.
3. ↓ reticulo-cyte index.
4. Hyper-segmented PMN neutro-phils.
DISEASES
Liver disease causes depression of normal coagulation system & excessive bleeding
after surgery.
3. Renal insufficiency.
4. CNS disorder (e.g. mental confusion).
5. Thrombo-cyto-penia.
6. Platelet transfusion is contra-indicated.
7. Pink hyaline thrombi in small arteries.
OTHERS
Iron is more effectively absorbed in the ferrous state (Fe2+) than in the ferric state (Fe3+).
Dietary iron is more readily absorbed when ferritin stores of intestinal epithelium are
low.
Iron deficiency causes micro-cytic hypo-chromic anemia with moderate poikilo-cytosis.
↑ by strepto-kinase, uro-kinase
& recombinant human TPA
Plasminogen Plasmin.
↓ by ε-amino caproic acid
After a trip to the Himalayas, a person complains of headache & peripheral cyanosis
due to physiological poly-cythemia.
The myeloid -erythroid ratio of bone marrow of a voluntary bone marrow donor should
be 3:1.
Substances with high oil:water partition co-efficient readily permeates cell membranes
e.g. O2, Co2 & steroid hormones.
NERVE
During activation of a nerve cell membrane (action potential), Na+ ions flow inward.
Voltage-gated Na+ channels have specialized trans-membrane domains (S4) that sense
trans-membrane voltage.
K+ channels are responsible for the resting membrane potential of vascular smooth
muscle cells.
Na+/K+ pump generates the ion gradient across the cell membrane.
Nerve gas (organo-phosphate) causes respiratory & CV failure by decreasing the rate of
rhythmicity of SAN by inducing hyper-polarization.
MUSCLE
Miniature end-plate potential represents opening of multiple ion channels in the muscle
membrane caused by spontaneous release of a small amount of neuro-transmitter.
Troponin is a protein involved in skeletal but not smooth muscle contraction (instead,
there is calmodulin in smooth muscles).
Ca2+ initiates contraction by binding to it.
EQUATIONS
Clearance =
It is ↓ after kidney donation.
o Inulin clearance = GFR (120 ml/min) as it is freely filtered, not secreted nor absorbed.
o Glucose clearance = 0 as it is completely absorbed & not secreted).
GFR is ↑ by:
1. Efferent arteriolar constriction.
2. ↑ RBF.
3. ↑ glomerular capillary hydro-static pressure.
RPF =
o PAH (Para-Amino Hippuric acid) is completely removed from the plasma in a single pass
through the kidney (about 80% of it is secreted at the tubules), so it is used for
measuring RPF (650 ml/min = GFR X 5).
=
Total body water (TBW) = 60% of body weight (45 L for a 75 Kg man)
Extra-cellular fluid Intra-cellular fluid
Percentage 40% (15 L). 60% (30 L).
1. Glucose. 1. Amino acids.
+
Rich in 2. Na . 2. K+, Ca+2 & Mg+2.
3. Cl- & HCo-3. 3. Po4-3 & So4-2.
Infusion of a hyper-tonic saline solution Infusion of water for fluid & salt loss (e.g.
causes: after excessive sweating) causes:
1. ↑ extra-cellular & intra-cellular 1. ↓ extra-cellular fluid volume.
osmolarity. 2. ↑ intra-cellular fluid volume.
2. ↑ extra-cellular fluid volume. 3. The most appropriate initial therapy is IV
3. ↓ intra-cellular fluid volume. administration of iso-tonic normal
saline.
Na+ K+
Normal 135 – 145 mEq/L. 3.5 – 4.5 mEq/L1.
↓ 1. Diuretics. 1. Diuretics.
2. ↓ ADH. 2. Renal tubular disorders.
3. Diarrhea, sweating, burns … 3. Diarrhea, vomiting …
4. Addison's disease. 4. Hyper-aldosteronism.
5. Cushing's syndrome.
Eu-volemic hypo-natremia: 6. Liddle syndrome.
psychosis.
It is associated with ↑ synthesis of
Hyper-volemic hypo-natremia: ammonia in the kidneys.
o Edematous disorders (e.g.
cirrhosis).
↑ 1.Patients on osmotic cathartics. Acidosis.
2.Hyper-alimentation (hyper-
volemic hyper-natremia).
Only 1% of Ca+2 is available for buffering changes in Ca+2 balance in the body.
PCo2 HCo3-
pH
(mmHg) (mmol/L)
Normal 7.35 – 7.45 35 - 45 22-26
Mixed acidosis ↓ ↑ ↓
Mixed alkalosis ↑ ↓ ↑
1
Intra-cellular concentration is 150 mmol/L.
Metabolic acidosis with ↓ anion gap Metabolic acidosis with ↑ anion gap
5. Hypo-albuminemia (↓ anions). 5. Hyper-albuminemia.
6. ↑ Ca+2, Mg+2 & gamma globulins (↑ 6. ↓ Ca+2 & Mg+2.
cations).
7. Hyper-viscosity. 7. Uremia.
8. Lithium or halide (bromide or iodide) 8. Lactic acidosis.
intoxication.
Loss of fluid from the colon causes acidosis & hypo-kalemia as it secretes K+.
BBB
DISEASES
Pelvic floor muscle weakness (e.g. after prostatectomy) causes stress incontinence.
Aldosteronism:
1. 1ry: ↓ renin.
2. 2ry: ↑ renin (caused by heart failure & renal artery stenosis).
1
They appear with pronounced proteinuria & lipiduria.
2
In such cases, therapy depends on the severity & nature of the renal disease so a per-cutaneous
needle biopsy of the kidney is appropriate & helpful.
Destruction of the supra-optic nuclei of the brain causes ↓ ADH secretion which causes
↓ water reabsorption in DCTs & collecting ducts with resultant ↑ urinary volume & a
very dilute urine.
Bladder exstrophy carries the greatest significance in terms of morbidity among other
congenital anomalies of the urinary tract.
Sexually transmitted urethritis, cervicitis, proctitis & pharyngitis infections that are not
due to gonorrhea are caused predominantly by chlamydia & infrequently by
mycoplasma or urea-plasma (non-gonococcal infections).
1
Oral enalapril (ACE inhibitor) is contra-indicated in its treatment.
DRUGS
MISCELLANEOUS
Squamous epithelium is normally not seen above the outer urethra (it is lacking in the
renal cortex & medulla).
The most important physiological function of the lymphatic system is to transport fluid
& proteins from inter-stitium to blood.
Transport maximum (Tm) is the point at which ↑ concentration does not ↑ the
movement of a substance across a membrane.
For glucose, it is 300 mg/dL.
Plasma & inter-stitial fluid are very similar except for RBCs, platelets & plasma proteins
which cannot pass through capillaries.
1
Its destruction causes hyper-kalemia.
Osmolality is measured by
mosmol/L.
Diuretics
Diuretic type (example) Site of action Mechanism (see figure)
1. Carbonic anhydrase o PCT. CA is an enzyme involved in the breakdown of H2Co3 in the following reaction:
inhibitor H2O + CO2 ←CA→ H2CO3 ↔ HCO3- + H+.
(acetazolamide)
Under physiologic conditions, filtered HCO3 combines with H+ ions to generate H2CO3, which is acted
on by CA to make CO2 & H2O.
As CO2 diffuses into the tubular cells, more HCO3 is absorbed from the serum.
In the presence of acetazolamide, CA is inhibited, allowing for H2CO3 to build up in the tubules &
hence urinary HCO3 wasting (H+ alternatively is reabsorbed via a different pathway). This leads to a
↓ ability to reabsorb Na+ in exchange for H+ leading to mild diuresis.
2. Osmotic (mannitol) o PCT. Mannitol is filtered through the glomerulus but cannot be reabsorbed.
This ↑ the osmolality of the filtrate & water is retained in the tubules to ensure urine osmolality.
3. Loop (furosemide) o LoH. Blocks the Na+-K+-Cl- pump (NKCC) in the thick ascending limb of LoH allowing for more Na+ &
subsequently fluid loss from the nephrons.
4. Thiazide (hydro-chloro- o DCT. They block the activity of Na+-Cl- channels in the DCT allowing more Na+ & water loss.
thiazide)
5. K+ Sparing: o CD. Aldosterone acts on the cells of CDs & induces expression of Na/K exchangers & ENaC.
1) Aldosterone This allows for the exchange of Na+ for K+ (Na+ enters the tubular cells & K+ is lost in the urine).
Antagonists Aldosterone antagonists competitively inhibit the action of aldosterone on the principal cells &
(spironolactone). therefore ↓ the expression of the exchanger. With the lack of Na+ uptake from the nephrons & loss
2) Epithelial Na+ in the urine, diuresis also occurs.
channel (ENaC)
blocker (amiloride & Aldosterone also controls expression of ENaC channels in the DCTs to absorb Na+.
triamterene). Inhibition of the ENaC ↓ Na+ uptake & K+ loss from the tubular cells.
Loss of Na+ in the urine leads to mild diuresis.
CVS
CO =
CO =
–
Flow =
The Frank-Starling law of the heart states that: within physiological limits, the heart
pumps all the blood that comes to it.
So, if the EDV ↑ (e.g. by a vaso-constrictor agent) within physiological limits, the stroke
volume ↑.
↑ systemic blood pressure leads to an ↑ in the residual volume of the left ventricle.
CARDIAC CYCLE
Opening of the AV valves occurs at about the same time in the cardiac cycle as the
beginning of diastole.
Their closure occurs at about the same time in the cardiac cycle as the 1st hear sound.
Closure of the aortic valves producing the 2nd heart sound occurs at the onset of the iso-
volumetric relaxation phase of the cardiac cycle.
Para-sympathetic nervous stimulation of the heart ↓ heart rate (slowing of the heart).
Its inhibition ↑ heart rate.
The rate of conduction of action potentials in Purkinje fibers is about 1.5-4 m/s.
A direct stroke to the left carotid sinus causes fainting due to ↓ firing rate of cardiac
sympathetic fibers.
↑ sympathetic activity via renal nerves is a major stimulus for the release of renin from
the juxta-glomerular apparatus.
L-type Ca2+ channels are responsible for the plateau phase of the cardiac action
potential that is reflected by the Q-T interval.
Loss of sympathetic tone in vessels of the arms or legs causes acute vaso-dilatation (e.g.
cutting sympathetic nerve fibers).
ECG
Normal criteria:
1. P-wave: < 0.12 s.
2. P-R interval: 0.12-2 s.
It is ↑ with ↓ conduction through the A-V node.
Abnormality Findings
1. Hypo-thermia. Sinus brady-cardia.
2. Atrial fibrillation. Irregularly irregular pulse.
Absent P-waves.
Irregular P-R intervals.
3. Peri-cardial effusion & peri-carditis. Small or low voltage QRS complexes.
4. Myo-cardial infarction (MI) Elevated ST-segment.
5. Failure of the AVN to conduct. Independence of P-waves & QRS complexes.
A myo-cardial infarction involving the inferior wall of the heart is picked up by leads II,
III & aVF.
DISEASES
Kidneys are especially vulnerable during shock (prolonged hypo-tension) while skeletal
muscles are most likely to sustain the least damage.
Giant-cell (temporal) arteritis is the most common form of systemic vasculitis in adults.
1
During the acute phase of rheumatic fever, the characteristic inflammatory lesions found in the
heart are known as aschoff's bodies.
The leading cause of death after the 1st post-transplantation year is allo-graft coronary
artery disease (coronary athero-sclerosis causing ischemia).
Eisenmenger syndrome is the process in which a left-to-right shunt in the heart (e.g.
VSD) causes ↑ flow through the pulmonary vasculature, causing pulmonary hyper-
tension, which in turn causes ↑ pressure in the right side of the heart & reversal of the
shunt.
A tumor of the right atrium & cardiac tamponade cause systemic edema, congestion of
the systemic veins & ascites.
MISCELLANEOUS
Obstruction of venous return to the right side of the heart causes the CO to fall &
systemic arterial BP to ↑ as compensation.
↑ systemic arterial pressure from 100 to 300 mmHg ↑ the resistance to blood flow in
the cerebral circulation.
Vaso-dilation 2ry to the effects of local metabolites is the most important for
maintaining ↑ blood flow to the athlete's skeletal muscles.
If a blood sample is withdrawn from the pulmonary artery, it will show the following
criteria:
1. 70% O2 saturation.
2. 12-24 mmHg pressure.
Under normal (basal) conditions, most of the energy used by the cardiac muscle comes
from the metabolism of fatty acids.
Sympathetic stimulation of the arterioles (e.g. after a major trauma) causes the greatest
↑ in total peripheral resistance as they represent 1/2 of the resistance of the systemic
circulation.
A regular tachy-cardia due to a small ventricular postero-septal infarct indicates that the
infarct has involved only a localized region of ventricular myo-cardium.
Duplex scan has > 90% sensitivity & >95% specificity for thrombus in DVT.
Turbulence in a blood vessel is more likely to occur if the velocity of blood within the
vessel ↑.
RESPIRATORY SYSTEM
Compliance =
o Palv = ambient atmospheric pressure = zero reference pressure.
o Ppl = -ve intra-pleural pressure.
↑ ↓
Lung surfactant (it also enhances ARDS.
alveolar stability).
LUNG VOLUMES
To calculate Inspiratory reserve volume: tidal volume, vital capacity & expiratory
reserve volume must be known.
DISEASES
A lung abscess is seen on the X-ray as a mass lesion with air-fluid level.
In pneumo-thorax, the most likely response upon entry of air into the chest would be
for the lung to collapse inward & the chest wall to spring outward.
It is the most common problem associated with fine-needle aspiration from the lung.
Transection of the afferent fibers of the 9th & 10th CNs (vagus & glosso-pharyngeal)
results in prolonged inspiration & shortened expiration.
Disease Finding
Asthma
o ↓ ratio.
Anemia with normal o ↓ PO2 of mixed venous blood.
lungs
Mild Co poisoning o ↓ arterial O2 concentration.
MISCELLANEOUS
Normal values:
1. Pleural fluid volume: 10 ml.
Its glucose content is the same as the plasma glucose content.
2. Mean arterial pulmonary pressure: 15 mmHg (systemic is 90 mmHg).
3. O2 carriage: 20 ml/100 ml blood.
1
It is the volume of gas in the lungs at the end of a normal expiration.
2
It is affected by the volume of blood in the pulmonary capillaries.
↑ blood Co2 tension produces the most potent effect in stimulating the respiratory
center & so increasing respiration.
Hypoxia causes pulmonary VC (which improves matching of ventilation & blood flow in
some lung diseases) while nitric oxide causes pulmonary VD.
In the stomach, chief cells release pepsinogen which is activated by acid pH & pepsin.
After Gastrectomy, pepsin will be produced in inadequate amounts.
The stomach does not digest itself because the gastric mucosal cells transport H+ out of
the gastric mucosa causing ↓ local H+ concentration.
Acetyl-choline ↑ gastric acid secretion.
When acid secretion is stimulated in the stomach, the potential difference between
mucosa & serosa falls to -20 mV.
Ca2+ is concentrated in hepatic bile in the gall-bladder where bile becomes more acidic.
Intra-mural fats or amino acids in the intestine stimulate chole-cysto-kinin (CCK)
release from the duodenum which causes sustained gall-bladder contractions &
relaxation of the sphincter of Oddi1.
In the presence of gall-stones, CCK action aggravates inflammation.
Bile acids are derivatives of cholesterol synthesized in the hepato-cytes.
Stored fat is usually transported from one part of the body to another in the form of
free fatty acids.
Chylo-microns have the highest content of tri-glycerides (80%).
Amino acids are transported across the luminal surface of the intestinal epithelium by a
co-transport with Na+.
The essential amino acids must be present in the diet.
Absorption:
1. Vitamin B12, electrolytes & bile salts in ileum.
2. Fat-soluble vitamins in jejunum.
3. Water in colon & ileum.
1
CCK deficiency causes contraction of the sphincter of Oddi.
DISEASES
6. Weight loss.
7. +ve anti-nuclear Ab.
Following total colectomy & ileostomy, the volume & water content of ileal discharge
↓ over time.
Glycogen storage disease type I (Von Gierke's disease) is the most common of the
glycogen storage diseases.
It results from deficiency of the enzyme glucose-6-phosphatase.
It is characterized by:
1. ↑ concentration of hepatic glycogen with normal structure.
2. No detectable ↑ in serum glucose from gluco-neo-genesis after oral intake of protein-
rich diet.
After an episode of hepatitis A, a liver biopsy shows normal architecture but with
scattered loss of individual cells with the micro-scopic appearance of karyorrhexis & cell
fragmentation.
Jaundice:
Pre-hepatic Post-hepatic (obstructive)
(e.g. hemo-lysis or Hepatic (e.g. blockage of the CBD or
Gilbert syndrome) pancreatic head cancer) 1
1. Anemia. 1. ↓ plasma albumin. 1. Conjugated hyper-bilirubinemia.
2. Un-conjugated 2. Serum amino- 2. ↑ urine bilirubin levels.
hyper-bilirubinemia transferase > 500 3. ↓ urine uro-bilinogen levels.
(↑ indirect units. 4. ↑ alkaline phosphatase.
bilirubin). 5. Pale stools.
6. Deficiency of vitamin K-
dependent clotting factors.
1
The most common cause of neonatal chole-stasis is extra-hepatic biliary atresia.
MISCELLANEOUS
The gastro-colic reflex involves an ↑ in the motility of the colon in response to stretch in
the stomach & by-products of digestion in the small intestine leading to defecation.
Segmentation is the motility pattern primarily responsible for the propulsion of chyme
along the small intestine.
NEUROLOGY
DISEASES
A patient with mitral valve disease & atrial fibrillation is most likely to have a mural
thrombus in the left atrium predisposing to a massive stroke in the left middle cerebral
artery & death (thrombo-embolism).
A diffuse cerebral edema is most severe in the white matter of the brain.
Cerebellar tremor is a slow, broad tremor of the extremities that occurs at the end of a
purposeful (directed or voluntary) movement (intention tremor) & may be
accompanied by dys-arthria, nystagmus, gait problems & postural tremor of the trunk &
neck.
UMNL LMNL
o Spasticity.
o Hypo-tonia.
o Clasp-knife response.
o No muscle wasting. o Muscle wasting.
o Brisk (exaggerated) tendon jerk (stretch)
reflex (e.g. knee jerk).
o Babinski sign +ve (the big toe is raised
rather than curled downwards).
Large injury to the non-dominant parietal cortex (e.g. right posterior parietal cortex)
may cause the patient to ignore the serous nature of his illness & to neglect or even
deny the presence of the paralysis affecting the side of the body opposite to the lesion.
Fixation of the ossicles due to fibrosis causes depressed hearing when tested by air
conduction but normal bone conduction.
Lesion Effect
1. Inter-collicular brain stem o De-cerebrate rigidity.
transection.
2. Complete transection of o Areflexia in the immediate post-injury period.
the spinal cord at T6.
3. Brown-sequard 1. Ipsi-lateral spastic paralysis (cortico-spinal tract).
syndrome (hemi-section 2. Ipsi-lateral loss of vibration & proprioception (position
of the spinal cord). sense) (fasiculus gracilis or cuneatus).
3. Contra-lateral loss of pain & temperature sensation
beginning 1-2 segments below the lesion (spino-
thalamic tract).
A neural tube defect (e.g. open spina bifida & anencephaly) is characterized by ↑ AFP.
HEMORRHAGES
Sub-dural hemorrhage (SDH) occurs due to damage of the dural bridging vein.
It is characterized by:
1. Headache, irritability & strange behavior.
2. On CT brain: a concave area of hemorrhage.
TUMORS
Schwannoma has the best prognosis following surgery among the intra-cranial
neoplasms.
2. WBCs < 5/ml (2/3 lympho-cytes & 1/3 mono-cytes). o > 10 with neutron-
phil predominance.
3. Glucose 50-100 mg/dl (2/3 of plasma value). o < 40 mg/dl.
4. Protein 20-40 mg/dl (0.2-0.4 gm/L) (0.3% of plasma o > 4.5 mg/dl.
value).
MISCELLANEOUS
3. Neuro-genesis.
4. It is as a potent vaso-dilator.
The introduction of cold water in one ear may cause giddiness & nausea due to
convection currents in endo-lymph.
A sudden ↑ in the pitch of a voice causes the location of maximal basilar membrane
displacement to move toward the base of the cochlea.
A sudden loud sound is more likely to damage the cochlea than a loud sound that
develops slowly because there is a latent period before the attenuation reflex can occur
(40-80 ms).
During periods of silent counting, regional cerebral blood flow (rCBF) ↑ within the
supplementary motor area.
In the vestibular labyrinth, the utricle senses motion in the horizontal plane.
ENDOCRINOLOGY
PITUITARY GLAND
In diabetes insipidus, blood volume is maintained at near normal levels because water
intake is appropriately adjusted.
A patient with syndrome of in-appropriate ADH secretion (SIADH) has a low serum Na+
due to the dilutional effect of ADH-induced water retention in the collecting tubules.
Hypo-thyroidism (↑ TSH1, ↓ T3 resin uptake, T3 & T4 e.g. Grave's disease or after total
thyroidectomy) is characterized by:
1. Lethargy.
2. Peri-orbital swelling.
After thyroidectomy, serum Ca2+ is requested in the early post-operative period to help
management of problems associated with hypo-calcemia due to hypo-para-thyroidism.
1
Also in endemic goiter.
CRF (e.g. in a diabetic patient) causes 2ry hyper-para-thyroidism with osteo-malacia &
spontaneous bone fractures.
ADRENAL GLAND
1
Its formation is ↑ with ↑ PTH levels.
It is ↓ in patients with rickets due to vitamin D deficiency.
MISCELLANEOUS
A patient with blood glucose level of 200 mg/dl & -ve dipstick test for urinary glucose
has significantly ↓ GFR.
The Cori cycle deals with conversion of glucose to lactate & vice versa.
1
Its secretion is inhibited by α2-adrenergic agonists (e.g. somato-statin, sympathetic nervous
stimulation & adrenaline).
2
In its presence, the glomerular filtrate will be iso-tonic to plasma in the cortical collecting tubule.
1 ry
e.g. severe de-hydration causes 2 hyper-aldosteronism.
Sertoli cells produce the hormone inhibin & androgen binding protein which is
regulated by FSH.
Semen:
Part Secretion
1. The seminal vesicles Large amounts of ascorbic acid.
2. The ampulla of the vas Fructose.
3. The prostate Citric acid & acid phosphatase.
TESTIS
PENIS
DISEASES
Varico-cele presents by a painless, twisted mass along the spermatic cord which is
more prominent when the patient stands & feels like a bag of worms.
Dark field micro-scopic examination of exudate or secretions is the best test for
diagnosing 1ry syphilis.
In pregnancy, RBC volume ↑ but this frequently lags behind the plasma volume,
resulting in ↓ hematocrit & Hb concentration (physiological anemia of pregnancy).
Progesterone:
1. It is an absolute requirement for maintenance of pregnancy.
2. Menstrual bleeding is a consequent of its withdrawal.
3. It is produced by the corpus luteum during the 1st 2 weeks of pregnancy then from the
syncytio-tropho-blast tissue of the fetal placenta.
4. It stimulates respiration & ↓ pCo2.
5. Its ↑ concentrations blocks the action of prolactin so lactation does not occur during
pregnancy.
Estrogens:
1. They are produced from androgens.
2. ↑ circulating level of coagulation factors 2, 7, 9 & 10.
Human placental lactogen (hPL) is a placental hormone that is similar in structure &
function to growth hormone.
Oxytocin produces contraction of the smooth muscle cells underlying the milk-
producing alveolar cells.
Prolactin prevents the menstrual cycle during the early post-partum period (↓
gonado-trophins).
Labor:
1. Maternal Pgs is the most important factor for initiation of labor.
2. Estrogen stimulates the number of oxytocin receptors in the decidua & myo-metrium.
DISEASES
BREAST
Acute mastitis usually occurs 2-3 weeks after delivery but it can occur at any time.
The nipple becomes cracked or fissured with nursing.
Typical causative organisms include staphylo-coccus aureus, strepto-coccus species &
Escherichia coli.
Oral contra-ceptive use is most likely associated with breast cyst formation.
A woman with a leaking silicone breast implant is at an ↑ risk of pain & contracture.
PATHOLOGY,
MICRO-BIOLOGY &
PHARMACOLOGY
Lipo-chrome (lipo-fuscin = age) pigment from wear & tear accumulates in the myo-
cardial fibers with age causing a small heart with a dark brown color on section.
The tanning of skin (dark skin complexion) is achieved by melano-cytes having the
enzyme tyrosinase to oxidize tyrosine to di-hydroxy-phenyl-alanine in the pathway for
melanin production.
Wet gangrene occurs in case of small intestinal infarction following sudden & total
occlusion of mesenteric arterial blood flow.
The splenic flexure is at greatest risk because it is the watershed between the
distribution of the superior & inferior mesenteric arteries.
The liver is most likely to suffer severe damage after exposure to carbon tetra-chloride
used in dry cleaning facilities, either on the skin or by inhalation.
ATP depletion associated with hypoxic & chemical (toxic) injury causes ↑ un-folded
protein response.
Wound healing:
1. Almost all of the tensile strength that can be obtained is achieved within 3 months.
2. Malignancy is not a complication of wound healing.
3. Vitamin A deficiency is not likely to influence wound healing.
4. Presence of sutures aids wound healing.
5. Tyrosine kinase functions intra-cellularly in cells involved in wound healing.
The time required for a scar of a small myo-cardial infarct to reach full strength is
several months.
1
Fibro-blast growth factor stimulates angio-genesis, wound repair, development & hemato-poiesis.
After a bee sting, a patient develops a raised, red, swollen lesion at the site of injury due
to vaso-dilation.
The functions of ICAM 1 (inter-cellular adhesion molecule 1) & VCAM 1 (V for vascular)
in inflammation is leuco-cyte adhesion.
The skin test response in allergy is most likely to be the result of releasing histamine
from mast cells.
Inter-stitial lung disease caused by inhaling silica dust for many years is attributed to
release of growth factors by macro-phages.
Acute inflammation of the throat (e.g. sore throat) is characterized by the presence of a
pharyngeal purulent exudate.
Recurrent bacterial infections suggest a lack of B-cell immune function (e.g. X-linked
agamma-globulinemia).
REJECTION
HYPER-SENSITIVITY
GRAFTS
CYTO-KINES
1
IM administration of anti-Rh Ab (Rh immune-globulin) to the mother protects the baby.
NEO-PLASIA
Un-controlled (autonomous) growth would best distinguish a lesion as a neo-plasm
rather than a granuloma.
Cyto-keratin stain of inter-mediate filaments within cells is useful for confirmation that
a neo-plasm is a carcinoma (i.e. of epithelial origin), however, cells found to be
vimentin +ve are of mesenchymal origin (e.g. osteo-sarcoma).
Invasion is the micro-scopic finding which indicates that the neo-plasm is malignant.
It is also the feature that is taken into account when staging a cancer.
Tumors of the skin, lung, breast, prostate & colon are more likely to occur in adults
than in children.
Skin cancer, ano-genital cancer, non-Hodgkin's lymphoma & Kaposi sarcoma are the
most common cancers in organ trans-plant recipients.
The malignant potential of renal adeno-carcinoma & carcinoid tumors is most often
associated with tumor size.
In new-borns, the sacro-coccygeal area most commonly gives rise to tumors derived
from all 3 germ-cell layers.
PRE-MALIGNANT LESIONS
Lesion Cancer
Solar (senile or actinic) keratosis o SCC.
Erythro-plasia. o Carcinoma of the oral cavity.
Barrett's esophagus due to GERD. o Esoghageal adeno-carcinoma.
Cervical dys-plasia. o
CARCINO-GENS
Substance Tumor
Arsenic. o Hepatic angio-sarcoma.
Asbestos (in ship-building & insulation o Meso-thelioma (most common
industries). malignant pleural tumor).
Smoking (nitrosamine, 2-naphthyl o Bladder cancer.
amine, …).
P53 is a tumor-suppressor gene.
TUMOR MARKERS
CANCER ONCO-GENES
Onco-gene Tumor
Erb B3. o Breast.
C-abl. o CML.
N-myc. o Neuro-blastoma.
C-myc. o Burkitt's lymphoma.
Ras. o Colon.
PARA-NEO-PLASTIC SYNDROMES
TUMOR-CHROMO-SOME ASSOCIATION
Chromo-some Tumor
1. o Neuro-blastoma.
11. o Wilm's tumor.
13. o Retino-blastoma.
17. o Neuro-fibroma & osteo-genic sarcoma.
SITE-SPECIFIC TUMORS
SKIN
BONE
LUNGS
Familial poly-posis coli has 100% risk of carcinoma within 30 years of diagnosis.
The 5-year survival rate of infiltrating ductal adeno-carcinoma of the pancreas is < 5%.
URINARY TRACT
The lack of findings in the bladder (-ve cysto-scopy) but the presence of atypical cells in
urinalysis specimen suggests that the lesion is located higher up, possibly in the renal
pelvis or ureter e.g. transitional cell carcinoma of renal pelvis which is characterized
also by:
1. Long history of smoking.
2. A multi-centric origin.
o Stage 3: tumors extending into the renal vein or vena cava, involving the ipsi-lateral
adrenal gland &/or peri-nephric fat, or which have spread to local LNs.
o Stage 4: tumors extending beyond Gerota's fascia, to > 1 local LN, or with distant
metastasis.
NERVOUS SYSTEM
Schwannoma has the best prognosis following surgery among the intra-cranial
neoplasms.
PITUITARY GLAND
PAROTID GLAND
Pleo-morphic adenoma (mixed tumor) of the parotid gland is the most common benign
parotid tumor followed by Warthin's tumor.
It is characterized by:
1. Epithelial & myo-epithelial cells forming acini, tubules & ducts.
2. Myxoid & chondroid stroma.
3. Local recurrence after enucleation.
ADRENAL GLAND
TESTIS
Cervical intra-epithelial neo-plasia (CIN) is most strongly associated with HPV infection.
The most reliable & easy method to confirm the diagnosis of cervical carcinoma is PAP
(cervical) smear.
Fibro-thecoma is a benign ovarian tumor that is most likely to be associated with endo-
metrial hyper-plasia.
BREAST
A lobular carcinoma in situ of the breast indicates that the opposite breast might also
be involved.
MICRO-BIOLOGY
The virulence of bacteria is related to toxin & enzyme production.
Endo-toxins cause fever, hypo-tension, erythema & neck stiffness (e.g. meningitis
caused by Neisseria meningitides).
It produces coagulase which is used for its identification in the laboratory as this enzyme
causes clotting of plasma (formation of fibrin).
Strepto-coccus viridans is the most likely causative agent for infective endo-carditis.
Endo-carditis with staphylo-coccus aureus is most likely to be associated with a mycotic
aneurysm.
Escherichia coli with pilli cause the vast majority of cases of bacterial pyelo-nephritis &
cystitis (after catheter introduction into the urethra).
Lacto-bacillus is a gram +ve facultative bacteria present in the vagina & GIT.
It produces lactic acid making its environment acidic.
The outer membrane is found in gram –ve but not in gram +ve bacteria.
The respiratory tract is the most common portal of entry in Blastomyces dermatidis.
When a child is bitten by a stray dog, the physician should immediately start rabies
vaccine & give anti-rabies serum.
The most likely reason for varicella-zoster infection in a patient receiving cancer chemo-
therapy is T-cell deficiency.
PHARMACOLOGY
ANTI-BIOTICS
ANALGESICS
ANTI-FUNGAL DRUGS
ANTI-ULCER DRUGS
CHEMO-THERAPEUTIC AGENTS
Cancer Regimen
Colo-rectal FOLFOX (FOL= 5-fluro-uracil – F= Folinic acid1 – OX= oxaliplatin).
Hodgkin's ABVD (Adria-mycin – Bleo-mycin – Vinblastine - Dacarbazine).
lymphoma
Non-Hodgkin's CHOP (Cyclo-phosphamide – Hydroxy-rubicin – Oncovin
lymphoma (vincristine) - Prednisone).
MISCELLANEOUS
1
It is used as an Adjuvant chemo-therapy for colo-rectal carcinoma as it enhances the effect of 5-
fluro-uracil.
Buspirone Anxio-lytic.
Spironolactone Potassium-sparing diuretic (↑ Na+
excretion & ↓ K+ excretion).
Mithra-mycin o Hyper-calcemia of
malignancy.
Methimazole Inhibition of the addition of
Propyl-thio-uracil iodide to thyro-globulin.
Cyclo-phosphamide S/E: urinary bladder cancer.
Methotrexate o Crohn's disease. Inhibition of T-cell activation.
GENERAL
COLLECTIONS
TUBERCULOSIS
1ry tuberculosis is characterized by:
1. Sub-pleural nodule, predominantly in the lower lung, usually in one site1.
The granuloma (tubercle) is characterized by the presence of central caseous
(caseation) necrosis (cheesy white material) enclosed within a distinctive inflammatory
border of mono-nuclear giant cells, lympho-cytes & plasma cells.
2. Enlarged regional (e.g. hilar or mediastinal) LNs.
3. Sputum sample contains acid-fast bacilli with +ve Mantoux test.
Initial therapy is Rifampicin + isoniazid (or streptomycin) + pyrazinamide + ethambutol.
Tuberculosis of the lumbar spine with a cold abscess tracks along the psoas major
muscle to the groin.
Tuberculous trophic ulcer is usually found over the ball of the big toe.
ANTI-TUBERCULOSIS DRUGS
In tuberculosis, those patient contacts who have a +ve skin test but no other signs of
disease should receive prophylactic isoniazid.
LYMPHATICS
1. Tip of the tongue Sub-mental LNs.
2. Ovary Lateral & pre-aortic LNs (located at the origin of the
ovarian arteries).
3. Scrotum/labia majora & Superficial inguinal LNs (vertical group in case of acute
anus. paronychia involving the big toe).
4. Lower part of the vagina
& anal canal, dorsum of
the foot, big toe & penile
urethra.
5. Anal canal Internal iliac LNs.
1 ry
The 1 lesion (Gohn focus) is located in the lower part of the upper lobe or the upper part of the
lower lobe.