Imp Points - Khalid Iqbal Waqar Younis.docx

❖ Neurotransmitters of Sleep ► Main Neurotransmitter of REM → Ach (increases during REM) ► Main Neurotransmitter of NREM → Serotonin > GABA ➢ Haemoglobin synthesis starts in proerythroblast and early normoblast ➢ Haemoglobin is not visible in proerythroblast and early normoblast ➢ Haemoglobin first appears in Intermediate normoblast ➢ Nucleus is extruded from late normoblast with in the bone marrow. i.e first disappear in late normoblast ➢ In reticulocyte Nucleus is absent and Hb is in amount of mature RBC ➢ Total sperms produced by two testes per-day #120 million ✔ ➢ Total sperms per ejaculate 400 million /ejaculate or 120 million /ml ✔ ➢ Total number of #mature sperms #100 million /ejaculate or 20 million /ml ✔ ➢ For person to be fertile sperm count should be at least 20 million /ml✔ ◼ Perforation of anterior wall of duodenum à Leakage of contents to greater sac ➡right paracolic Gutter and right iliac fossa ◼ Perforation of posterior wall ➡Massive bleeding due to perforation of gastroduodenal artery ◼ Perforation of Posterior wall of stomach leakage of contents to lesser sac ❖ Abduction of hip joint limited by Pubofemoral ligament ❖ Extension of hip joint limited by Ileofemoral ligament ❖ Flexion of hip joint with knee extended is limited by hamstring muscles ❖ Flexion of hip joint with knee flexed is limited by anterior abdominal wall Fast adaptations ➡Pacinian > Meissner > Meckel’s disc > Hair-end > Krause > Baro-receptors ❖ Pacinian à High frequency vibration 80 to 400Hz ❖ Meissner’s à Low frequency vibration 02 to 40 Hz

◼Fascial palsy 1) A Paralysis oF Lower face sparing of upper face, location of Lesion #Cortex ✔ Explanation -> In supranuclear corticobulbar palsy lesion ➢ Sparing of upper face is Because of bilateral supply ➢ Involvement of lower face is because of contralateral supply 2) fascial weakness on right side (deviation of jaw to left side), Unable to abduct right eye, Hemiplegia on left side, location of Lesion #Pons ✔ Explanation ➢ Millard Gibbler syndrome (ventral pons CN 6 ,7 ans CST are affected) ➢ Ipsilateral fascial palsy ➢ Ipsilateral abducent nerve palsy

➢ Contra lateral Hemiplegia 3) Right sided fascial palsy, loss of taste on Right sided anterior two third of tongue, Deafness and vertigo. Location of lesion Ans. CP angle✔ Explanation At Cp angle 7th cranial nerve is in close proximity to 8th cranial nerve 4)Right sided fascial weakness, Loss of taste over right sided anterior 2/3rd of tongue, right sided hyperacusis, Pain in eardrum and decreased lacrimation. Lesion is at Ans. GENICULATE ganglion proximal to superficial greater petrosal nerve ✔ Explanation Features a) Loss of taste on anterior 2/3rd b) Hyperacusis lesion proximal to stapedius c) Pain in ear drum à geniculate ganglion involved Loss of lacrimation à lesion proximal to superficial greater petrosal nerve 5) Right sided fascial weakness, Loss of taste on right anterior 2/3rd of tongue, Hyperacusis, Lacrimation normal. Lesion is in Ans. Fascial canal distal to geniculate ganglion ane proximal to nerve to stapedius ✔ Explanation Ipsilateral LMN fascial palsy, Hyperacusis➡Leison proximal to nerve to stapedius Normal à Lesion distal to superficial greater petrosal nerve 6) Right sided fascial palsy, loss of taste on anterior 2/3rd of tongue, Hearing and lacrimation normal Ans. Lesion in facial Canal distal to nerve to stapedius and proximal to chorda tympani

ECG ➢ P Wave → Atrial Depolarization ➢ Q → Septal Depolarization ➢ R → Early Vent. depolarization (potential travelling to apex of vents) ➢ S → Late Vent. depolarization (Potential travelling to base of vents) ➢ T → Vent. repolarization ➢ U → Delayed repolarization of Purkinje system or papillary muscles Conduction pathways ➢ SA / AV Node → 0.05 m/S ➢ Atrial Pathways / Vent Myocardium / Bundle of His → 1 m/S ➢ Purkinje System → 4 m/S JVP Pathology -- JVP WAVE à A, C,X,v,Y ➢ A===> Atrial==>a....so atrial contraction ➢ C===> Closure of tricuspid valve......c in closure and in triCuspid ➢ x===> relaXation of right atrium.......X in relaxation ➢ v===> villing(filling) of right atrium ➢ y===> emptying of right atrium......Y in emptying ➢ Absent "A" wave. atrial fibrillation ➢ Large "A " wave. tricuspid stenosis ➢ Cannon "A” wave. complete heart block

➢ Large "v" wave. tricuspid regurgitation ➢ Steep "y" wave. constrictive pericarditis

Hematocrit = Red Cell Number x Mean Red Cell Volume Concept of Buffy Coat ** Light Coloured Layer B/W Plasma and Red Cells ** Contains WBCs and Platelets ** This layer of Buffy Coat containing WBCs and Platelets is EXCLUDED from Hct Estimation ------> No WBCs & Platelets are included in HEMATOCRIT. Cachexia Which of the following is not characteristic of hypopituitarism? a. Cachexia b. Infertility c. Pallor d. Low BMR ▪️ Cachexia means “weakness and wasting of the body (weight loss) due to severe chronic illness”. Hypopituitarism (diminished hormone secretion by the pituitary gland) → ↓TSH → ↓T3, T4 (hypothyroidism) → ↓BMR → ↑Body weight So, hypopituitarism (and hypothyroidism) results in weight gain, while hyperpituitarism (and hyperthyroidism) results in weight loss (cachexia). Remember that cachexia is a very common finding in end-stage “cancer”. Most common organism causing sepsis after Splenectomy is Streptococcus Pneumoniae / Pneumococus (50% of all cases). Order of infections Post-Splenectomy → S. Pneumoniae > H. Influenza > Meningococcus > βHemolytic Strept > Staph. Aureus > E. coli > Pseudomonas Q- 22-year-Old man Sickle cell anaemia, active complaints pallor lethargy headache. Lab are HB is 4.6 retic is 3%. Parvovirus infection is suspected, what is ur diagnosis◼ A) thrombotic crisis B) sequestration crisis C) hemolytic crisis D) aplastic crisis✔✔ Explanation ➢ Sequestration crisis à Sickling of RBCs with in organs like spleen or lungs. Acute chest syndrome very painful ➢ Aplastic crisis à Infection with parvovirus. Sudden fall in HB ➢ Haemolytic crisis ➡Rare ➡Fall in Hb due to increase haemolysis ➢ Thrombotic or painful crisis ➡Painful or vaso-occlusive ➡Precipitated by infection, dehydration and deoxygenation ➡avascular necrosis of head of femur, hand foot syndrome in children ➢ Bladder carcinoma Risk factors in order of frequency ◼Squamous Cell Carcinoma Schistosomiasis > calmatte Guerin treatment> smoking◼ ◼Transitional Carcinoma Smoking > Exposure to aniline Dye in printing industry > Rubber manufacture > cyclophosphamide ACL Prevents 1. Ant dislocation of tibia on femur 2. Post dislocation of femur on tibia PCL Prevents 1. Ant dislocation of femur on tibia. 2. Post dislocation of tibia on femur

Q- Coagulopathy related to liver disease which clotting factor is characteristically increased? A) factor V111 ✔ B) factor 2 C) factor IX D) factor 7 E) factor 12 F) none Explanation In liver failure all clotting factors are low except for factor 8 which is paradoxically supranormal cx it is synthesized by endothelial cells throughout the body. And for clearance of activated factor 8 good hepatic function is required, leading to increased circulating level of factor 8. Read it then it will be easy to solve such Qs. ● External intercostal muscle is replaced by anterior intercostal membrane "ANTERIORLY" only (just near the sternum) ● Internal intercostal muscle replaced by posterior/internal intercostal membrane "POSTERIORLY" only Anteriorly 1. anterior/external intercostal MEMBRANE 2. internal intercostal MUSCLE Posteriorly 1. external intercostal muscle 2. internal/posterior intercostal membrane Q- A needle inserted lateral to sternum, structure damaged A. intercostal membrane B. intercostal muscles (Select membrane as its the outer most structure at this place)

INTERNAL CAPSULE A bunch of white fibres Relations ➔ Medial Side. The tailed nucleus called Caudate Nucleus and Thalamus ➔ Lateral Side. A Lens Shaped Nucleus called Lentiform nucleus (Globus Pallidus +Putamen) Composition Its composed of ascending and descending nerve fibres that connect the cerebral cortex to the brainstem and spinal cord. It has 3 parts • Anterior Limb -> supplied by Anterior Cerebral Artery • Genu -> supplied by MCA • Posterior Limb -> supplied by MCA. Main supply of IC is MCA Posterior Limb 1 Corticospinal Tracts (Ant 2/3rd of Post. Limb). 2 Optic radiation (Most Posterior in the Post. Limb) These corticospinal tracts and optic radiation are Projection fibre (it’s a BCQ) 3 Thalamocortical projections ➢ Primary motor and sensory systems course through the posterior limb and genu. ➢ Posterior Limb is divided into Ant 2/3rd and Post 1/3rd. ➢ Ant 2/3rd of the post limb has the motor fibres that control all the skeletal muscle in the body. That’s why, IC Involved in Pure Motor Stroke. ➢ Anterior Part is Motor and Posterior Part is Sensory Genu à The corticobulbar fibres Anterior Limb à Papez circuit of Limbic System/ Mamillothalamic tract • MCA Occlusion. Contralateral Homonymous Hemianopia (Optic radiation pass through) • Pure Motor Stroke. IC • Ant part of Post. Limb + Genu. Motor • Post. Part of Post. Limb + Ant. Limb. Sensory

Incidence of Most Common Childhood Cancers ➢ Leukaemia (30%) ➢ Brain Tumour (22%) ➢ Lymphoma (11%) ➢ Neuroblastoma (8%) ➢ Soft Tissue Sarcomas (7%) ➢ Wilm’s Tumour (6%) ➢ Bone Tumours (5%) ➢ Miscellaneous (11%) ► Commonest Malignancy of Childhood → Leukemias ► Commonest Extra cranial solid tumour of childhood → Neuroblastoma ► Chid tumour with gene amplification à Neurofibromatosis ➢ RESPIRATION_PHYSIOLOGY Between trachea and alveolar sac, the respiratory tract divides for 23 times. First 16 divisions are conducting zone up to terminal bronchioles. The rest are gas exchange zones Movement of diaphragm accounts for 75% change in intrathoracic volume during quite inspiration Most of the work of breathing (65%) is to overcome ELASTIC RECOIL (past MCQ). Other are airway resistance (28%) and viscous resistance (7%) In the upright position, the ventilation per unit volume is greater at the base of the lung than that of apex… the reason is intrapleural pressure is less negative at the base so alveoli are less expanded. At the apex, the intrapleural pressure is more negative and alveoli are more expanded i.e. the %age of max lung volume is greater. Because of the stiffness of the lung, the increase in lung volume per unit increase in the pressure is smaller when lung is initially more expanded so ventilation is consequently more at base. Exercise is reported to increase the 2,3 DPG in 60 minutes… but in trained athletes this rise may not occur Four important functions of Hb. 1. Transport of O2. 2. Transport of CO2. 3. Buffer. 4. Transport of NO Chloride shift is mediated by a protein called BAND 3 one of the major membrane proteins. Of approximately 49ml of CO2 in dl of the ARTERIAL blood 2.6 ml is dissolved, 2,6 ml is carbamino compound and 43.8 ml is in bicarb form. In tissue 3.7 ml is added. O.4 ml stays in solution, o.8 ml forms carbamino compound and 2.5 ml forms bicarb Carotid and aortic bodies(GLOMUS) is made of TYPE I and TYPE II cells surrounded by fenestrated sinusoidal capillaries. Type I cells are called glomus cells which resemble chromaffin cells of adrenals and release catecholamines upon exposure to hypoxia and cyanide. ► The Commonest Neuropathy related to Child Birth à Meralgia paresthetica (Neuropathy of the Lateral Femoral Cutaneous Nerve ) Causes of gingival hyperplasia ... ⬛ Phenytoin ⬛ Cyclosporine ⬛ Calcium channel Blockers (Nefidipine) ☡mCQ ⬛ Carbamazipine ⬛ Acute myeloid leukaemia (monocytic type) Asim MCQ ➢ Grey baby syndrome à Chloramphenicol ➢ Red man syndrome à Vancomycin ➢ Grey man syndrome à Amoidarone ATT Drugs

➢ Streptomycin à Ototoxity. ➢ Isoniazid à Hepatotoxicity. ➢ Pyrazinamide à Gout ➢ Rifampacin àOrange red colour urine Protamine ➢ Protamine sulphate in normal standard does leads to Hypotension as side effect ➢ Protamine sulphate if given in excess of its recommended does can cause Paradoxical anticoagulation leading to bleeding ... ➢ Remember difference between Normal dose & excess dose Anti-Thyroid in Pregnancy ➢ 1st Trimester: PTU ➢ 2nd & 3rd : Methimazole ➢ Drug which crosses placenta and is teratogenic: Methimazole ➢ Drug which can cross Placenta: PTU, Methimazole, Thyroxine To get relieve from sickness ➢ Acetazolamide for mountain sickness ➢ Scopolamine for motion sickness ➢ Pyrodixine for morning sickness ➢ Mecolzine for Air sickness Oestrogen OCPs Oestrogen containing OCPs à Inc. risk of Thromboembolism > Breast CA High Oestrogen containing OCPs à Inc. risk of endometrial CA Low Oestrogen containing OCPs à Inc. risk of Hepatic Adenoma Thyroid Fever Investigations: Pneumonic BASU ➢ B=Blood, A=Antibody, S=Stool, U=Urine 1stweek = blood culture 2ndweek = antibody/ Widal 3rdweek = stool 4thweek = urine culture Nephritic > Na retention à In nephritic > haematuria Nephrotic > hypoalbuminemia à In nephrotic >Urine protein ++++ ➢ Best way to measure GFR à inulin Clearance ➢ Best way to estimate GFR à creatinine clearance ➢ Best way to measure renal plasma / blood flow à PAH ➢ Best way to measure GFR clinically à Creatinine ➢ Highest renal clearance à PAH ESR increasing factors increase O2, increase cholesterol, increase Alfa globulin, increase fibrinogen, acute infections. ESR decreasing factors increase co2, increase lecithin, increase albumin... Physiologic variations à lowest in new-born, increase in pregnancy & old age Pathological Conditions ➢ Premalignant change in mouth à Chronic ulcer ➢ Premalignant Condition à Lichen planus ➢ Premalignant Lesion (Most common) à Leucoplakia ➢ Premalignant Lesion (Most lethal) à Erythroplakia ➢ Bettlenut chewing à Submucosal fibrosis

Defecation ➢ 1. Colon to Rectum à mass movement + myenteric reflex ➢ 2. Rectum to anal canal thru internal sphinter à rectoanal reflex ➢ 3. Exit thru ext sphincter à parasympathetic relex ➢ 2 + 3 together are called as defecation reflex ➢ 3 is better as its final pathway. Mass movement just adds defecation reflex Some flavour of Ganong ●Pan-hypopituitarism is not associated with Cachexia (Ganong bcq). ●Room temp 21 °Humidity 80% heat is lost from uncovered body by -> Radiation and conduction. ●Diabetic Autonomic neuropathy manifests in GIT as Gastroparesis (Rx is Metoclopramide and constipation ( Katzung pharma). ●Which of the following has the greatest effect on Na excretion ==ALDOSTERONE (Ganong mcq). ●Which of the following has the greatest effect on plasma osmolality ==VASOPRESSIN (ADH) ●Aldosterone main site of action==Cortical collecting ducts (Ganong MCQs). ●The pressure diff between the heart and aorta is least in the. Left ventricle during systole. ●Injection tPA is more beneficial in mi during 2nd hour of occlusion of Coronary artery. Ganong 1.Damage to Pneumotaxic Centre à Deep Breathing (normally prevent excessive deep breathing) 2.Damage to Apneustic Centre à Shallow Irregular breathing (Normally promotes deep breathing) 3.Transection above the level of pons à No effect on respiration 4.Transection at Mid-Pontine Level with Vagi Cut à Apneusis 5.Transection at Ponto-Medullary Junction à Irregular breathing 6.Transection Below Medulla à Stoppage of Respiration. Saliva Secretions >> Hypotonic >> high potassium bicarb (⬆ K ⬆ HCO3) >>low sodium Chloride (⬇ NA⬇ CL so hypotonic) Pancreas secretions >> isotonic both at high and low flow >> At low flow Mainly Sodium chloride(⬆ NA⬆ CL) >> At high flow sodium bicarbonate (⬆ Na ⬆ HCO3) mainly Gut specific sites for absorption of Minerals • Duodenum à iron and calcium • Terminal ileum à B12 and Bile salts • Jejunum à Folic acid • Colon à short chain fatty acids ► The Commonest Neuropathy related to Child Birth → Meralgia paresthetica (Neuropathy of the Lateral Femoral Cutaneous Nerve) ► The commonest Lobe affected by Congenital Lobar Emphysema → Left Upper Lobe ►The Most Specific Diagnostic Test for H. Pylori Infection → Microbial Culture ► Commonest cause of Chronic Hypercalcemia → Primary Hyper-PTH ► Commonest opportunistic infection in HIV-infected individuals → Mycobacterium tuberculosis ► Commonest opportunistic infection in AIDS pneumonia → Pneumocystis Jiroveci ► Commonest organism to cause pneumonia in HIV → Streptococcus Pneumonia ► Commonest FUNGAL infection in HIV/AIDS → Candidiasis ►Commonest neurological manifestation in HIV infection → AIDS Dementia Complex ► Commonest skeletal muscle disorder → Inflammatory Myopathy ► Commonest Lymphoma in HIV → Immunoblastic NHLs ► Commonest HIV associated HODGKINS LYMPHOMA → Mixed cellularity HL ► Window Period of HIV → 2-4 weeks (By PCR) ► Highest Risk of opportunistic infection, CD4+ count will be → < 200/mm3 ► Most Specific Test for AIDS → Western Blot ► Most Sensitive Test for AIDS → ELISA

► Confirmatory test for AIDS in Child born to HIV infected mother → PCR (up to age of 18 months) ► Commonest Haematological manifestation in AIDS → Autoimmune Haemolytic Anaemia ► Commonest organism to cause Meningitis in AIDS → Cryptococcus ►Commonest Space occupying tumour of Brain → Primary CNS Lymphoma ► Commonest Space occupying CNS lesion in ADS → Toxoplasmosis ► Commonest cause of seizures in AIDS → HIV Encephalopathy ► Commonest dermatological Manifestation in AIDS → Seborrheic Dermatitis Malaria • Type of Anaemia in Malaria →Normochromic Normocytic anaemia • Species causing most deaths → P. Falciparum • Species with Longest intrahepatic / Pre-Erythrocyte phase → P. Malaria (15 d) • Species that cause relapse → P. vivax > P. ovale • Species with longest duration of Erythrocytic phase → P. Malaria 72hrs (Quartan) • Drug of choice for prevention of Relapse → Primaquine • Drug of choice for severe falciparum malaria → Articulate (2nd Artemether, 3rd Quinine dihydrochloride 4th Quinidine) • Most common severe complication of falciparum malaria in children → `Cerebral Malaria • Decrease delivery of oxygen to tissue à CO poisoning ✔ • Decrease Utilization of oxygen at tissue level àCyanide poisoning✔ (histotoxic hypoxia) Ptosis can be classified on the basis of size of pupil • Ptosis with dilated pupil. à Oculomotor nerve palsy • Ptosis with constricted pupil à Horner syndrome • Ptosis with normal pupil à Myasthenia Gravis Anatomy ➢ C1-C2 VERTEBRA: vocal cords ➢ C2-oropharynx and soft palate with mouth open ➢ C3-hyoid bone ➢ Level of larynx in infants-C2-C3 ➢ Level of larynx in adults-C3-C6 ➢ C3-C4: bifurcation of common carotid artery ➢ C4 &C5-thyroid cartilage ➢ C6-cricoid cartilage ➢ C6-begining of trachea ➢ C6-begining of oesophagus ➢ C7-vertebra prominence ➢ Thyroid lobe superior extent-oblique line of thyroid cartilage ➢ Isthmus of thyroid gland-2nd through 4th tracheal rings ➢ Thyroid lobe inferior extent-sixth tracheal ring ➢ Spine at root of scapula-opposite third thoracic spine ➢ Thoracic inlet-T1 ➢ Superior angle of scapula-overlies part of 2nd rib-1st intercostal space superior to angle/T2 ➢ Jugular notch-T2&T3 vertebral junction ➢ Carnia-T3-4 or T4 ➢ Manubrium Sterni-T3&T4 ➢ Sternal angle-T4&T5 ➢ Body of sternum-T5to T9 vertebra ➢ Greater splanchnic nerve-T5-T9 sympathetic ganglia

➢ Apex of heart/mitral value-5th intercostal space ➢ Base of heart/supine position-T5 to T8 vertebra ➢ Base of heart/erect position-T6 to T9 ➢ Oblique fissure of lung-T6 ➢ Inferior angle of scapula-T7 ➢ Vena caval foramen-T8 ➢ Xiphoid process-T9 ➢ Xiphisternal joint-T9 vertebra typically ➢ Oesophageal hiatus-T10 ➢ Termination of oesophagus-T11 ➢ Lesser splanchnic nerve-T10-T11 sympathetic ganglia ➢ Least splanchnic nerve- T12 sympathetic ganglion ➢ Aortic hiatus-T12 ➢ Coeliac trunk branch of abdominal aorta-T12 ➢ Median arcuate ligament of respiratory diaphragm- T12 &L1 junction ➢ Pulmonary valve-left 2nd intercostal space medial ➢ Aortic valve-right 2nd intercostal space ➢ Tricuspid valve-right lower sternum ➢ Nipple in male-4th intercostal space in midclavicular line ➢ Trans pyloric plane-L1 ➢ Celiac trunk-L1 superior border ➢ Superior mesenteric artery-L1 inferior border ➢ Pylorus of stomach-L1 ➢ 1st part of duodenum-L1 ➢ Left renal vein-L2 ➢ 2nd part of duodenum-L1, L2, L3right side ➢ 3rd part of duodenum-L3 ➢ Left crus of diagphram-L2 ➢ Right crus of diagphram-L3 vertebra ➢ Inferior mesenteric artery-L3 ➢ Subcoastal plane-L3 ➢ Spinal cord termination à ► L1 in adults ► L3 in New borns ➢ Spleen-obliquely along axis of 10th rib ➢ Right kidney à ► Superior pole-T12 ► Inferior pole-L3 ► Hilum-L1 ➢ Left kidney à ► Superior pole-T12 ► inferior pole-L3 ► Hilum-L1 ➢ Pancreases head-L2&L3 ➢ Umbilicus (in supine/recumbent position)-disc between L3-L4 ➢ Bifurcation of abdominal aorta-L4 ➢ Supracristal plane/highest point on iliac crest-L4 ➢ Trans tubercular plane-L5 ➢ Origin of inferior vena cava-L5 ➢ Anterior superior iliac spine-S1/sacral promontory ➢ Posterior superior illiac spine-S2 ➢ Pubic symphysis-tip of coccyx ►► Haemodynamic in the feto-placental circulation ➢ Fetal blood flow through placenta → 400 mL/min ➢ Pressure in the umbilical artery → 60-70 mmHg

➢ Pressure in the umbilical vein → 10 mmHg ➢ Oxygen Saturation in in the umbilical artery → 60% ➢ Oxygen Saturation in in the umbilical Vein 70-80% ➢ Partial pressure of oxygen in the umbilical artery → 20-25mmHg ➢ Partial pressure of oxygen in the umbilical Vein → 30-40 mmHg ➢ In Potter's syndrome ocular anomalies include cornea, glaucoma, cataract and prolapse of the lens and expulsive haemorrhage in one eye. ➢ Marfan à superiotemporal lens dislocation, no corneal defect, high IQ compared to homocysteinuria ➢ Homocystinuria à inferionasal lens dislocation, there is low IQ. In Homocysteinuria everything is high except lens dislocation and IQ. ➢ Ulcers • Martorell à Uncontrolled HTN • Marjolin à SCC/ External Burn • Meleny à Microaerophilic strep/ staph • Cushing à raised ICP (gastric) • Curling à Inhalational burn (gastric) • Trophic/ Neurotrophic ulcer à Untreated Lower Limb venous ulcers • Malum Perforans Pedis à Trophic Ulcer on Sole of foot

LFT (Liver Function Test) Interpretation; 1) ALP raised, ALT slightly raised – likely to be a problem in bile duct. 2) ALT raised, ALP slightly raised – likely to be a problem in liver. 3) Very high ALT, slightly raised AST – suggests viral / drug induced / sever necrosis of liver 4) ASP raised, ALT slightly raised – suggests alcoholic or drug induced cirrhosis. Q- Select the most sensitive marker for alcoholic liver disease. A. GLD B. ALT C. AST D. GGT ✔ ► GGT is most sensitive indicator here in Alcoholic Liver Disease ► ALT & AST both rise in Alcoholic LD but have less sensitivity compared to GGT ► Levels of GGT may rise >25X URL in Alcoholic Hepatitis ► Order of SPECIFICITY of Enzymes in Alcoholic LD is AST > ALT > GGT ► Ratio of AST & ALT can be useful in Differential; ► ALT is more specific for liver damage than AST 1) AST: ALT = 1 Associated with ischaemia (CCF and ischaemic necrosis and hepatitis) 2) AST: ALT >2 a. Associated with Alcoholic hepatitis b. Alcohol induced deficiency of pyridoxal phosphate 3) AST: ALT <1 a. High rise in ALT specific for Hepatocellular damage b. Paracetamol toxicity with hepatocellular necrosis c. Viral hepatitis, ischaemic necrosis, toxic hepatitis Some Important relations (Anatomy) ►Superficial epigastric #femoral ►Superior epigastric #internal thoracic. ►Inferior epigastric #external iliac. ►External laryngeal nerve #superior thyroid artery

►Internal laryngeal nerve #superior laryngeal artery ►Recurrent laryngeal nerve #inferior thyroid artery ►Desmin #muscle ►Keratin #epithelial ►Vimentin #mesenchymal ►Neurobibrillin #neuron ►GFAP #Oligodendro ►S100 #Melanoma ►Chromogranin or 5HIAA #Carcinoid ►Neuron specific enolase #small cell cancer ►Blue cells à Ewing medulloblastoma and kulchitsky cells of small cell lung cancer

Thyroid ►Primary hypothyroidism (Thyroid dysfunction) ⬇ T3 T4 & ⬆ TSH ►Secondary hypothyroidism ⬇ T3 T4 & ⬇ TSH à If TSH is low Now give TRH ➢ If TSH increases means hypothalamic disorder cx pituitary is functional (tertiary hypo) ➢ IF TSH does not increase It means Pituitary disorder (secondary hypo) ►Halothane à Increases cerebral blood Flow ►Ketamine à Decreases cerebral Blood flow • Bronchial dilation (can be used in asthmatics) • Increases BP (can be used in hemodynamically unstable) • Decreases cerebral flow leads to dissociative anesthesia (Hallucinations) Cell cycle • Chromosome 1st appear in Prophase • Thickest and best studied at Metaphase • Parallel chromatids > Prophase • Prominent chromatids > Metaphase • Dividing chromatids > Interphase • Double chromatids > Telophase • Radiosensitive à G2/M • Radio resistant à S • Chemo sensitive à S phase • Longest phase à G1 • Shortest à M • Prophase of à M phase longest • Anaphase of à M phase shortest ◼Cerebral Blood Flow /Oxygen/glucose • Cerebral Blood Flow #50ml /min/100gm of tissue • Glucose extraction is 5mg /min/100gm of tissue • Brain consumes 20%of total systemic oxygen delivered • Brain oxygen consumption is 3.5 ml/min/100gm of tissue ❖ Therapeutic dose -> Potency ❖ Therapeutic index -> Safety ❖ Therapeutic Effectiveness -> Efficacy ❖ Therapeutic window therapeutic -> Dose Range

Melanoma ▶ Dysplastic nevus most likely Develop malignant melanoma ▶ Superficial spreading melanoma is most common à 70% ▶ Lentigo melanoma occurs on à Face and most common in elderly ▶ Nodular melanoma occurs on trunk à poor prognosis ▶ Acral lentiginous melanoma occurs on à palm and sole Anatomy ◼Sensory neurons are myelinated first ◼Primary somatosensory cortex area à3,2,1 ◼Premotor Cortez area à 6 ◼Frontal eye field area à 8 ◼Primary motor area à 4 ◼Primary auditory cortex superficial temporal area à 41, 42 ◼Wernicke’s area à 22 ◼Brocas area à 44 ◼Association cortex à 5, 7 ◼Difference between somatosensory and motor cortex à granular layer ◼Supply of basal ganglia à straiate artery ◼Labyrinthine artery branch of à AICA ◼Anterior choroidal artery branch of à ICA ◼Corpus collosum contain à Commissural fibres ◼Internal capsule contain à projection fibres ◼Tarsal Bones 7 in number ◼ Calcaneum Largest tarsal bone ◼ Cuneiform forms Transverse arch of foot ◼ Talus has no muscular attachment ◼ Nerve affected in tarsal tunnel syndrome à tibial ◼ Locking of knee -> Quadriceps femoris ◼ Unlocking of knee-> Popliteus muscle ◼Stomach ulcer à commonest site in Stomach à Near Angularis Incisura on lesser curvature ◼Gastric Cancer à commonest site in Stomach à Pyloric Antrum along the lesser curvature Q- Vitamin deficiency harmful for heart A. Vit C b. Niacin C. Vit B12 D. Vit K E. thiamine ✔ Q- Vitamin used in the treatment of hyperlipidaemia is A. Niacin ✔ B. Riboflavin C. Biotin D. Thiamine Q- Excess of amount of iron stored in the form A. Ferritin B. Hemosiderin ✔ C. Transferrin D. None Q- Vitamin deficiency lead to all the feature like cobalamin deficiency except macrocytic anaemia is A. Vitamin A B. Vitamin B1 C. Niacin D. Vitamin E ✔ Q- Vitamin def leads to all the feature like cobalamin def except increase in methyl malonic acid is A. Vitamin A B. Vitamin B1 C. Niacin D. Vitamin E ✔ E. Vitamin B9 Q- Which of the following vitamin. Deficiency lead to adrenal insufficiency A. Thiamine B. Biotin C. Pantothenic acid ✔ D. Niacin Q- Which of the following lead to dilated cardiomyopathy? A. Wet Beri beri ✔ B. Dry beri beri C. Pellagra D. None Q- In acute pancreatitis serum amylase should be at least? a. double the normal b. twice c. thrice ✔ d.4 times Q. Which nerve is most likely to be injured in General anaesthesia a. Radial b. Sciatic c. Common peroneal ✔ d. Ulnar

Q. What percentage of blood volume must be lost in health patient before hypotension occurs? a. 10-20% b. 20-30% ✔ c. 30-40% d. 40-50% Q. In store blood which factors are deficient A. 1 and 5 B. 5 and 7 C. 3 and 9 D. 5 and 8 ✔ Q. Which anaesthesia should be avoided in diabetics A. Amide B. Isopropyl C. Ether ✔ D. None Q- Fast pain pathway NOT involve? A) Medial lemniscus ✔ B) Spinal lemniscus C) Glutamate D) Neospinothalamc E) A delta fibre Q- Slow pain is not transmitted by A. Lateral lemniscus B. dorsal column✔ C. Spinal cord fibres D. Substance P Q- Pain is of two types, fast and slow. Fast pain is transmitted through a specific pathway in CNS. The parts of CNS not included in fast pain pathway is: A) A delta fibre B) Collaterals in brain stem C) Primary sensory cortex D) Specific nuclei of thalamus E) Substantia geletinosa✔ Q- Slow pain is perceived by cortex in A. 1 sec✔ B. 1 mint C. 30 mint D. 1 hour Q- Maximum cortical representation a. hands b. lips ✔ Q- After removing fundus of stomach what will happen? A. Dec receptive relaxation B. decrease production of gastrin c. Dec compliance ◼ Q- If antrum of stomach is removed A. Decrease stomach compliance B. Increase acid output C. Decrease gastrin✔ D. Increase gastric emptying for solid Q- After pylorus removal: a. Solids pass easily✔ b. Basal secretion of acid increases ... c.Maximal secretion of acid increases d. gastrin increases Q- If vagotomy done A. gastric acid secretion increases B. gastric pepsin increases C. gastric emptying decreases✔ d. gastric emptying increases. Q- Vagal stimulation A. increase gastric emptying✔ B. decrease gastric emptying. C. block secretion D. constipation Q- Removal of gastroesophageal junction à Decreases receptive relaxation✔ Q- 4th heart sound is produced due to a) vibration of ventricle walls in systole b) ventricular filling ✔ C) closure of aortic and pulmonary valve D) closure of tricuspid and mitral valve E) retrograde flow in vena cava GANONG CHAPTER 30 bcq #2... KEY is B. 100% right. (In Ganong bcq, 1st option is "vibration of ventricle wall in systole" (atrial is not mentioned) which is 100% wrong as it occurs in ventricular diastole during phase of atrial systole so ganong bcq key 100% right. But here they had added one word in option i.e made it "atrial" systole which is perfectly best as vibrations of ventricle wall during ventricle filling b/c of atrial contraction/systole cause 4th sound ▪️ The Lesions ➢ Facial lesion on same side of body à UMN Lesion >> Uncrossed hemiplegia ➢ Facial lesion on opposite side of body à PONS / brainstem >>> crossed hemiplegia ➢ Lesion on ant 2/3 of tongue >>> lesion in facial canal (cords tympani in facial canal) ➢ Bell’s palsy >>> lesion in stylomastoid foramen (muscular branches here >> muscular loss)

Q- Right hemiplegia with right facial nerve palsy A) Lesion in internal capsule ✔ B) pons ➢ Facial lesion n truncal LOSS on same side (uncrossed lesion) = UMN lesion ✔ Q- Right hemiplegia with left facial nerve palsy lesion in A) Internal capsule B) pons ✔ ➢ Facia lesion opposite to TRUNKAL LOSS (crossed Hemiplegia) = LMNL Pons ✔ Q- Right sided hemiplegia plus right sided facial palsy lesion most likely in a) Internal capsule ◼ b) Cortex c) Pons d) Cerebellum e) Midbrain Q- Sensory loss on left side face n left side body. Level of lesion A. Thalamus ✔ B. Pons C. Internal capsule D. Medulla ➢ Sensory loss >>> Thalamus Q- A patient has stroke and presents with weak right limbs, mandible deviated to left upon protrusion, anesthesia f face n scalp. Lesion is in a. Pons ✔ b. Medulla c.trigeminal nerve d. posterior limb of internal capsule ➢ Here mandible Is deviated on protrusion ✔ ➢ Not the angle of mouth deviated due unopposed muscles like in UMNL ➢ Don’t confuse with post limb of internal capsule. it contains just corticospinal fibres pathway ➢ Nothing to do with cranial nerves nuclei Q- Pt has sensory and hemiparesis on R side of body with involvement of left side cranial nerves and constricted pupil, lesion is at the site of A) pons B) internal capsule C) medulla ✔ D) midbrain Typical features lateral medullary syndrome symptoms Unilateral constricted pupil Horners syndrome with sensory n hemiparesis. Q- 59 yrs old hypertensive pt presented in Emergency in coma with left side hemiplegia n pinpoint pupils lesion A) internal capsule B) medulla C) pons ✔ D) basal ganglia Bilateral Pin point pupil >>> always think Pons first ✔ followed by vomiting & COMA As efferent sympathetic (usually causing pupillary dilatation) are interrupted, but the parasympathetic fibres are unaffected. Again don’t let the Right n left confuse you Q- Patient with right side body weakness and mouth deviate to left side during talking lesion is at A) pons B) internal capsule ✔ C) cerebropontine ➢ Uncrossed lesion >> internal capsule. Here >>> Rt side body weakness is mention Again don’t confuse with left deviated mouth. Which is due to weak RT facial muscles & unopposed left facial muscles Q- Patient presents with paralysed right arm n leg right plantar up going and exaggerated reflexes lesion A. left internal capsule✔ B. right cortex C. left cortex D. basal ganglia ➢ UMN lesion >> exaggerated reflexes ➢ With left cortex >> neglect, dressing apraxia & joint loss of joint sensation Q- Least contribution to plasma osmolarity a) Urea b) Protein ◼ Q- Artery arise from ext carotid art ascend forward in the neck deep to the post belly of diagastric and stylohyoid muscle and then passes deep to the submandibular gland A. facial artery ✔ B. lingual artery C. maxillary artery Q- Deep to posterior digastric and near palatoglossus a structure runs obliquely upwards? a) lingual Artery ◼ b) Facial artery Q- Vertical artery runs obliquely upwards under submandibular gland iz a) Lingual artery b) Facial artery ◼ ➢ Vertical artery under submandibular >>>> facial ➢ Oblique >> Lingual

Q- Artery arise from ext carotid art ascend forward in the neck deep to the post belly of diagastric and stylohyoid muscle and then passes deep to the submandibular gland a) facial artery ✔ B. lingual artery C. maxillary artery ➢ Submandibular >> facial Q- Branch of external carotid artery which arises from medial side, behind the posterior belly of diagstric muscle in substance of parotid gland is a) Ligual artery b) Occipital artery c) Facial artery d) Ascending pharyngeal artery ✔ e) Superior thyroid artery ➢ Posterior auricular >> ascending pharyngeal artery Q- True about External Carotid a. Crossed by lingual artery and divides into facial and temporal terminal b. Lateral to retromandibular vein ◼◼ c. lies anterior to diagastric muscle ➢ A option wrong - Divided into superficial temporal n maxillary artery ➢ C option - lies behind the substance of posterior belly of diagastric muscle. Crossed superficially by marginal mandibular branch of facial nerve ➢ B option - Lies lateral to retro mandibular vein at the tip of mastoid angle of mandible Q- Which nerve is most likely damage during 3rd molar surgical removal a) inf alveolar nerve b) lingual nerve ✔ ➢ tip of tongue sensation loss as well >> lingual ➢ Inferior alveolar is deep sited Q- Regarding chorda tympani a. carries taste from post 1/3rd of the tongue b. joins lingual nerve after existing from skull ✔ c. passes medial to long process of incus d. carries parasympathetic fibers from lacrimal Nucleus Q- Which of the following nerve can be damaged during parotid gland surgery? a) marginal mandibular branch of facial nerve ✔ B) lingual nerve Q- While a surgery on Submandibular gland which has more chances of injury: A. Superior thyroid artery B. Lingual nerve C. Mandibular nerve D. Facial nerve ✔ ➢ Marginal branch of mandibular >> facial Q- Facial Nerve in temporal bone give A. Greater Petrosal neve ✔ B. Lingual Nerve > branch of Mandibular Q- Roof of infratemporal fossa is pierced medially by foramen ovale through which pass a. Facial Nerve b. Mandibular Nerve ◼ c. Maxillary Nerve d. Middle meningeal Vessel Q- artery which can be palpated under the mandible near angle of jaw is a. Facial ✔ b.ingual c. maxillary d. ascending pharyngeal Q- blood suply of central forehead or midline of flap of forehead a) frontal branch of frontal artery b) paired supra trochlear artery ◼ c) ophthalmic branch of trigeminal artery d) facial artery e) paired supra orbital artery Q – A pt has come with taste loss on anterior 2/3rd of tongue due to facial palsy. if is damaged in??? a) facial nucleus b) facial canal ✔ c) parotid gland d) stylomastoid Q- regarding facial nerve a. mylohyoid b. post belly of digastric ✔ c. chorda tympani arise from horizontal part ➢ Innervates>>> stylohyoid Q- Max blood flow per minute? a) Kidney b) Liver✔ c )Heart d)Brain e) Skin Q- Least blood flow per minute?

a) Kidney b) Liver c )Heart ◼ d)Brain e) Skin Q- Max blood flow per 100 gram of tissue? a) Kidney ◼ b) Liver c ) Heart d)Brain e) Skin Q- Which organ has Max O2 consumption? a) Kidney b) Liver✔ c )Heart d)Brain e) Skin Q- Max O2 consumption per 100 gram of tissue? a) Kidney b) Liver c )Heart ◼ d)Brain e) Skin Q- Least O2 consumption a) Kidney b) Liver✔ c )Heart d)Brain e) Skin ◼ Q- Max O2 extraction from the blood? a) Kidney b) Liver✔ c )Heart ◼ d)Brain e) Skin Q- 15-year-old female presents with recurrent sinopulmonary infection. What test is most likely to confirm primary immunodeficiency? a. IgG level ✔ b. IgM level Explanation. Most common primary immunodef is igA def but it is most commonly asymptomatic Most common clinically significant immune deficiency is CVID (common variable immune deficiency) It is characterised by 3 features Hypogammaglobulinemia of two or more subtypes IgG, IIgA or IgM. Most important IgG in Recurrent Sino-pulmonary infection & impaired functional antibody response