Professional Documents
Culture Documents
Physiology: <ul><li>Bile – Micelles of cholesterol, phospholipids, bile salts & bile pigmint (bilirubin, biliverdin)
</li></ul><ul><li>Fat in food Cholecystokinin Bile secretion. </li></ul><ul><li>Cholesterol (Fat crystal) - Bile salts (soap)
</li></ul><ul><li>Excess cholesterol, low bile salt Stone formation. </li></ul><ul><li>Stasis, Inflammation, infection Ca
</li></ul>
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Cholelithiasis: <ul><li>Cholelithiasis/gall stones – 95% of GB dis . </li></ul><ul><li>Incidence: West 20-40%, Asian 2-4%.
</li></ul><ul><li>70-80% asymptomatic </li></ul><ul><li>Mixed 80% - (cholesterol, ca+, bile, blood) </li></ul><ul><li>Pure 20% -
Pigment *, Cholesterol. </li></ul><ul><li>Severe colicky Upper abdomen Rt shoulder. </li></ul><ul><li>Conjugated
hyperbilirubinemia Obstruction. </li></ul><ul><li>Fat intolerance clay stools - typical in chronic. </li></ul>
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Cholelithiasis: <ul><li>Morphology & Types: </li></ul><ul><ul><li>Mixed (Chol+Ca+Bile salt)* Multiple, faceted, yellow-grey.
</li></ul></ul><ul><ul><li>Rarely pure cholesterol-Yellow spiky. </li></ul></ul><ul><ul><li>Bile pigment stones (black/brown).
</li></ul></ul><ul><ul><li>% Calcium = radio opaque </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Obstruction
cholecystitis, </li></ul></ul><ul><ul><li>Empyema, liver abscess, perforation, fistulae, mucocele, Cholangitis,
</li></ul></ul><ul><ul><li>P ancreatitis, Obstructive jaundice, Gall stone ileus (intestinal obst),
</li></ul></ul><ul><ul><li>Carcinoma (rare). </li></ul></ul>
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Cholelithiasis – Complications.
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Gallstones + Chronic Cholecystitis <ul><li>Note: </li></ul><ul><li>Multiple, Faceted, golden yellow – grey stones.
</li></ul><ul><li>thickened inflammed gall bladder. </li></ul><ul><li>Ulceration at neck suggest occlusion by small stone.
</li></ul>
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Gallstones (mixed) Note: Yellowish shiny faceted stones, and thick inflammed gallbladder.
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Cholesterol Gallstones, bleeding. Round, yellow, spiky, bleeding. Note thickened inflammed gall bladder.
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Cholesterol Gallstones.
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Pigment stones in hemolytic anemia Note: Dark Black friable soft stones – Bilirubin
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Gall stones in CBD Stones in CBD Stonees in GB 20% of mixed chol. stones and >50% of pigment stones are radio-opaque
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Primary Biliary Cirrhosis <ul><li>Autoimmune, Chronic, progressive </li></ul><ul><li>Destruction of intrahepatic bile ducts,
portal inflammation & scarring – cholestasis. </li></ul><ul><li>Leading to cirrhosis and liver failure. </li></ul><ul><li>Females
common (6:1) </li></ul><ul><li>Insidious onset of Pruritis & cholestatic jaundice. </li></ul><ul><li>Markedly high ALP, +ve
antimitochondrial Ab. </li></ul><ul><li>Histopathology: Portal inflammation, bile stasis, bile plugs & lakes, Later stages cirrhosis –
Firm fibrotic, nodular, greenish, Shrunken. </li></ul>
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Excess Bile - plugs Bile Obstruction leading to Cholestasis & Cholangitis Bile duct inflammation Bile staining
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PBC – Microscopy:
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PBC – Microscopy:
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PBC – Microscopy:
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PBC – Microscopy:
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Biliary Atresia in a 3m child. Dark bile stained liver tissue, cirrhosis & death before 2 years of age.
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Carcinoma Gallbladder: Note irregular glandular structures and clusters of similar cells.
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Great wars & Great creations start first in human mind…! -- Thoughts are seeds with potential.
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38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones <ul><li>Pure cholesterol </li></ul><ul><li>Mixed cholesterol.
</li></ul><ul><li>Pigment </li></ul><ul><li>Calcium </li></ul><ul><li>Triple phosphate. </li></ul>
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38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones <ul><li>Pure cholesterol </li></ul><ul><li>Mixed cholesterol.
</li></ul><ul><li>Pigment </li></ul><ul><li>Calcium </li></ul><ul><li>Triple phosphate. </li></ul>
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A 45y mildly obese woman, 1-week history of upper abdominal pain, fever, shaking chills, and occasional vomiting. Physical
examination shows severe right upper quadrant tenderness. Laboratory studies include serum bilirubin of 1.0 mg/dL, AST of 25
U/L, ALT of 35 U/L, alkaline phosphatase of 220 U/L (high), WBC of 14,000/µL, and amylase of 95 U/L (normal). An ultrasound
examination of the abdomen reveals a normal-appearing liver and bile duct and thickening of the wall of the gallbladder. Most
likely diagnosis? <ul><li>Acute Cholecystitis </li></ul><ul><li>Acute Pancreatitis </li></ul><ul><li>Carcinoma pancreas
</li></ul><ul><li>Carcinoma Gall bladder </li></ul><ul><li>Primary biliary cirrhosis. </li></ul>
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40y Black woman, indigestion, abdominal pain, Gallbladder: Most likely associated disease? <ul><li>Chronic Pancreatitis
</li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Familial hypercholesterolemia </li></ul><ul><li>Hyperparathyroidism
</li></ul><ul><li>Sickle cell disease </li></ul>
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38y F, Obese, abdominal colicky pain, Gallbladder: Most likely metabolic abnormality? <ul><li>Decreased bilirubin conjugation.
</li></ul><ul><li>Decreased serum albumin. </li></ul><ul><li>Increased bilirubin uptake </li></ul><ul><li>Increased hepatic
calcium secretion. </li></ul><ul><li>Increased hepatic cholesterol secretion. </li></ul>
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Complications of Cholelithiasis include all the following EXCEPT : <ul><li>Secondary Biliary Cirrhosis </li></ul><ul><li>Recurrent
Cholangitis </li></ul><ul><li>Liver Abscess </li></ul><ul><li>Chronic Pancreatitis </li></ul><ul><li>Primary Biliary cirrhosis.
</li></ul>
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62y F, Abd. Pain & jaundice. Gall bladder biopsy ? Diag <ul><li>Cholecystitis </li></ul><ul><li>Cholesterosis
</li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Aschoff-Rokitansky sinuses </li></ul><ul><li>Primary Biliary Cirrhosis.
</li></ul>
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38y F, jaundice. Gall bladder ? Pathogenesis <ul><li>Excess Bilirubin </li></ul><ul><li>Low cholesterol </li></ul><ul><li>Low Bile
Salts </li></ul><ul><li>Infection. </li></ul><ul><li>Cholestasis. </li></ul>
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34y M, alcholic, mild icterus and malaise 6 months. Liver biopsy. ? diagnosis <ul><li>Acute alcoholic Hepatitis
</li></ul><ul><li>Chronic Persistent Hepatitis. </li></ul><ul><li>Hepatitis C infection </li></ul><ul><li>Fatty Liver
</li></ul><ul><li>Alcoholic Cirrhosis </li></ul>
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42y M, alcoholic, recurrent fatigue. Liver biopsy. ? Diagnosis <ul><li>Acute Hepatitis </li></ul><ul><li>Chronic Active hepatitis.
</li></ul><ul><li>Chronic Persistant hepatitis. </li></ul><ul><li>Fulminant Hepatitis. </li></ul><ul><li>Cirrhosis. </li></ul>
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26y fem, medical student, day before pathology exam presents with mild scleral icterus. Physical Examination normal, Liver
function tests: Protein total-7.9, Albumin 4.8 g/dl, AST-36 U.L, ALT 16 U/L, ALP-36 U/L, Total Bilirubin 4.9, direct 0.7 mg/dl. Icterus
resolves week later after exams. Most likely diagnosis? <ul><li>Alcoholic hepatitis. </li></ul><ul><li>Primary biliary cirrhosis.
</li></ul><ul><li>Gilbert Syndrome. </li></ul><ul><li>Acute HAV infection. </li></ul><ul><li>Acetaminophen poisoning. </li></ul>
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Viral serology interpretation: <ul><li>Acute Viral Hepatitis </li></ul><ul><li>Immunised against Hep. B </li></ul><ul><li>Chronic
Hepatitis B </li></ul><ul><li>Hepatitis B carrier stage </li></ul><ul><li>Fulminant hepatitis B </li></ul>HBsAg Positive, Anti HBcAg
Positive Anti HBcAg IGM Negative Anti HBsAg Negative
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CPC-2.3– C ore L earning I ssues : <ul><li>Major CLI: </li></ul><ul><li>Pathology of Cholecystitis – Acute, Recurrent & Chronic.
Gross, Microscopy & complications. </li></ul><ul><li>Pathology of Cholelithiasis – Causes, Types, Morphology Gross & Micro,
Complications (choledocholithiasis) </li></ul><ul><li>Minor CLI: </li></ul><ul><li>Carcinoma of gall bladder & biliary tract.
</li></ul><ul><li>Primary Biliary cirrhosis. </li></ul><ul><li>Parasites & other forms of biliary atresia,. </li></ul>
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34y M, alcoholic, homosexual- icterus and fever 6 months. Liver biopsy. ? diagnosis <ul><li>Acute Hepatitis
</li></ul><ul><li>Chronic active Hepatitis. </li></ul><ul><li>Cirrhosis Carcinoma </li></ul><ul><li>Fulminant Hepatitis
</li></ul><ul><li>Hepatitis Cirrhosis </li></ul>
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34y M, icterus and fever. Liver biopsy. ? diagnosis <ul><li>Acute Hepatitis </li></ul><ul><li>Chronic Persistent Hepatitis.
</li></ul><ul><li>Chronic active Hepatitis </li></ul><ul><li>Fulminant Hepatitis </li></ul><ul><li>Cirrhosis </li></ul>
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56y chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils, Blood
culture E.coli. Patient dies 3 days later. Image shows his liver. Most Likely diagnosis? <ul><li>A1 antitrypsin deficiency
</li></ul><ul><li>HEV infection </li></ul><ul><li>Hereditary hemochromatosis </li></ul><ul><li>Primary sclerosing cholangitis
</li></ul><ul><li>Alcoholic cirrhosis </li></ul>
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58y M, alcoholic, distended abdomen & icterus. Liver biopsy. ? diagnosis <ul><li>Chronic active hepatitis.
</li></ul><ul><li>Chronic Persistant hepatitis. </li></ul><ul><li>Hepatocellular carcinoma. </li></ul><ul><li>Cirrhosis
</li></ul><ul><li>Chronic alcoholic hepatitis. </li></ul>
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Viral serology interpretation: <ul><li>Acute Viral Hepatitis </li></ul><ul><li>Immunised against Hep. B </li></ul><ul><li>Past
Hepatitis B </li></ul><ul><li>Hepatitis B carrier stage </li></ul><ul><li>Fulminant hepatitis B </li></ul>HBsAg Negative, Anti
HBcAg Negative Anti HBcAg IGM Negative Anti HBsAg Positive
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69y Female, Chronic bronchitis. Died following chronic Cardiac failure. Liver specimen. Likely diagnosis? <ul><li>Alcoholic
Hepatitis </li></ul><ul><li>Dubin-Johnson Syndrome </li></ul><ul><li>Alcoholic cirrhosis </li></ul><ul><li>Nutmeg liver
</li></ul><ul><li>Metastatic deposits </li></ul>
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Viral serology interpretation: <ul><li>Acute Viral Hepatitis B </li></ul><ul><li>Immunised against Hep. B </li></ul><ul><li>Past
Hepatitis B </li></ul><ul><li>Hepatitis B carrier stage </li></ul><ul><li>Carrier state of Hepatitis B </li></ul>HBsAg Negative, Anti
HBsAg Positive Anti HBcAg Positive Anti HBcAg IGM Negative
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59y Male, Alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen. Likely diagnosis? <ul><li>Dubin-
Johnson Syndrome </li></ul><ul><li>Alcoholic cirrhosis </li></ul><ul><li>Alcoholic Hepatitis </li></ul><ul><li>Fatty Liver
</li></ul><ul><li>Nutmeg liver </li></ul>
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Histopathology Image is from lung biopsy of a 61 year male chronic smoker. What is the most likely type of carcinoma?
<ul><li>Small cell carcinoma </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Metastatic deposits </li></ul><ul><li>Squamous
carcinoma </li></ul><ul><li>Lung abscesses </li></ul>
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The gross image of lung specimen from a 59year old male heavy smoker presented with high fever, shortness of breath. Likely
type of pneumonia? <ul><li>Lobar pneumonia </li></ul><ul><li>Interstitial pneumonia </li></ul><ul><li>Broncho pneumonia
</li></ul><ul><li>Fungal pneumonia </li></ul><ul><li>Carcinomatous pneumonia </li></ul>
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42y male smoker presented with recurrent cough & dyspnoea. Image shows cut section of his lung. What is the most likely
diagnosis? <ul><li>Emphysematous bullae </li></ul><ul><li>Panlobular emphysema </li></ul><ul><li>Centrilobular emphysema
</li></ul><ul><li>Chronic Bronchitis + Emphysema. </li></ul><ul><li>Smokers lung with Silicosis </li></ul>
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46 year male on treatment for lymphoma presents with pallor, shortness of breath and mild jaundice. Image shows his blood film
appearance. What is the most likely type of anemia? <ul><li>Anemia of chronic disorder </li></ul><ul><li>Megaloblastic anemia
</li></ul><ul><li>Hemolytic anemia </li></ul><ul><li>Aplastic anemia </li></ul><ul><li>Iron deficiency Anemia </li></ul>
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12 year old girl presents with two week history of fever and joint pain. The image shows her heart specimen. What feature of
the disease is shown by the arrow? <ul><li>MI with pericarditis. </li></ul><ul><li>Bacterial endocarditis
</li></ul><ul><li>Pancarditis </li></ul><ul><li>Endocarditis </li></ul><ul><li>Pericarditis </li></ul>
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78year female presents with prolonged weakness, fatigue and anemia. She has palpable spleen & few enlarged cervical
Lymphnodes. Image shows her blood film. What is the most likely diagnosis? <ul><li>Acute myeloid leukaemia
</li></ul><ul><li>Acute lymphatic leukaemia </li></ul><ul><li>Chronic myeloid leukaemia </li></ul><ul><li>Chronic lymphatic
leukaemia </li></ul><ul><li>Non-hodgkins lymphoma </li></ul>
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Self Assessment is the key…! Whether new information is "stored" or "dumped" depends, then, on our
Interest , Reciting, Writing & Reviewing the information. Source: http://www.web-us.com/memory/human_memory.htm
Retention of Learning Time Delay No review Review 7 Days 33% 83% 63 Days 14% 70%
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Reminder…. <ul><li>Online quiz, Winners club, Authors club. </li></ul><ul><ul><li>Not compulsory now… * Important..
</li></ul></ul><ul><ul><li>Formative – Does not affect your results. </li></ul></ul><ul><ul><li>Personal road sign.. Where am I
going ? </li></ul></ul><ul><ul><li>Time limited… Am I in time ? </li></ul></ul><ul><ul><li>Procrastination doesn’t help.
</li></ul></ul><ul><li>Please evaluate me..! </li></ul>
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Living becomes a glorious experience only when there is tolerance and love. Willingness to compromise with other people’s ways
of living and cooperation in common tasks, these make happy and successful societies. Divine Discourse, 17th February 1980 -
Baba. Love is Selfless Service.
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5 A’s & SNAP <ul><li>Ask: 1. patients with diabetes, hypertension, hyperlidaemia, obesity or existing vascular disease
</li></ul><ul><li>Assess: 2.Number of cigarettes or equivalent/day, Dependance 3.readiness to change/motivation
</li></ul><ul><li>Advise: 4.provide written information, 5.motivational interviewing </li></ul><ul><li>Assist: 6.NRT ?
Bupropion(Zyban) 7.Support </li></ul><ul><li>Arrange: 8.referral to QUIT 9.follow up with the GP </li></ul><ul><li>SNAP
Counseling: Smoking, Nutrition, Alcohol & Physical Activity. </li></ul>
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Silence… To the question "Who am I?" the only relevant answer is silence. You need to discard all answers in words,
including "I am Nothing" or "I am the Cosmic Self" or "I am the Self" - and just stick to the
question "Who am I?". All other answers are just thoughts. Thoughts can never be complete. Only Silence is complete.
Thoughts are not the goal in themselves. Their goal is Silence. When you ask the question "Who am I?" you get no
answer, there is silence. That is the real answer. For your soul is solidified silence. This solidified silence is wisdom, is knowledge.
The easy way to silence the thoughts is to arouse the feelings. For, through feelings only peace, joy and love dawn. And they are all
your very nature. - Sri Sri Ravishankar