Basic Science & Surgery Summary For The MRCS

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BASIC SCIENCE & SURGERY
SUMMARY
For the MRCS
A summary of more than 6000 MCQs!
1st edition - 1441
By
Mahmoud Shoaib
Assistant Lecturer & Specialist of Neuro-surgery, Tanta, Egypt
[email protected] – Drma7moud.blogspot.com – 02001014139579
Basic Science & Surgery Summary for the MRCS Mahmoud Shoaib
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NOTES BEFORE YOU START
 Some applied parts may be written with basic parts (e.g. nerve injury may be
written with anatomy of nerves).
 All diagrams are very important (some very important information is found only
in diagrams & not in text).
 Highlighted points in (Basic Science Part) are more important. Others may be
less important or belong to old questions.
 All (Surgery Part) is important.
 It is important to have look at the abbreviations which are heavily used in these
notes to make sentences simple.
 Joint types are collected under (Anatomy > Upper limb > Miscellaneous).
 Most of general collections are very important.
 Words consisting of 2 or more segments are written with a dash between the
segments like this (tri-cuspid, micro-biology, hydro-cele, …). Take care of this
while searching in the document.
 How to use this summary:

Start studying directly by answering questions (e.g. through Passtest). After each
question & whether your answer is right or wrong, search for the topic in this
summary & read the related part.
For example, you will start with anatomy (upper limb questions) & you saw a
question about the median nerve. After answering the question, read the answer
& the details on the site. Then, search for brachial artery in this summary & read
the related part & so on. Artery in this summarized as “n.”, so you will search for
“median” or “median n.”.
I hope you best of luck. If you found anything wrong or anything that can be
improved in this summary, test me on WhatsApp or send an e-mail.
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INDEX
 ABBREVIATIONS …………………………………………………………..................... 4
 ANATOMY …………………………………………………………………........................ 5
1. Thorax (chest) …………………………. 6 6. Back & spinal cord ……………………….. 33
2. Upper limb & breast ………………… 11 7. Abdomen …………………………………….. 34
3. Lower limb ………………………………. 18 8. Pelvis & perineum ………………………… 44
4. Head & neck ……………………………. 23 9. Developmental anatomy ……………… 47
5. Brain & cranial nerves ……………… 32
 PHYSIOLOGY ……………………………………………………………………………….. 50
1. General physiology & blood ………………………………………………………………………………. 51
2. Fluids, electrolytes & acid-base balance – renal system …………………………………….. 60
3. CVS ……………………………………………………………………………………………………………………. 69
4. Respiratory system …………………………………………………………………………………………….. 74
5. GIT & hepato-biliary system ………………………………………………….…………………………… 78
6. Neurology ………………………………………………………………………………………………………….. 81
7. Endocrinology ……………………………………………………………………………………..…………….. 86
8. Male re-productive system ………………………………………………………………………………... 88
9. Female re-productive system & breast ………………………………………………………………. 89
 PATHOLOGY, MICRO-BIOLOGY & PHARMACOLOGY ……...................... 90

1. Cell injury & wound healing ……………………………………………………………………………….. 91
1. Inflammation & immunology …………………………………….………………………………………. 93
2. Neo-plasia ………………………………………………………………………………………………………….. 95
3. Site-specific tumors ……………………………………………………………………………………………. 96
4. Micro-biology …………………………………………………………………………………………………….. 98
5. Pharmacology ……………………………………………………………………………………………………. 101
 GENERAL SURGERY ……………………………………………………………………... 104

1. Skin (grafts, wounds, scars, burns, lesions) ………………………………………………………... 105
2. Head & neck (sinuses, ear, salivary glands, tongue, oral cavity) ………………............ 107
3. Endocraine glands (thyroid, para-thyroid, Ca metabolism, pancreatic endocrine,
adrenal) ……………………………………………………………………………………………………………… 110
4. Syndrome ………………………………………………………………………………………………………….. 115
5. Renal (trans-plant, stones, trauma, bladder, prostate, testis, hydro-cele, varico-
vele, penis, uro-dynamics) …………………………………………………………………………………. 116
6. Female genital system & breast ………………………………………………………………………… 123
7. Vascualr (abdominal vessels, aorta, ulcers, arteries, grafts, amputation, venous,
lymphatics) ………………………………………………………………………………………………………… 126
8. GIT (oro-pharyngeal, esophagus, stomach, small & large intestine, anal,
appendix, spleen, pancreas, gall bladder, liver) ………………………………………………….. 131
9. Pediatric surgery, incisions, hernia ……………………………………………………………………. 140
10. Orthopedics ………………………………………………………………………………………………………. 143
11. Cardio-thoracic surgery …………………………………………………………………………………….. 148
 GENERAL COLLECTIONS ……………………………………………….. 150

 Anesthesia, shock, pre-, peri- & post-operative, volumes, radiation, nerves,
lymphatic drainage, vitamins, tumor markers, pre-malignant, tuberculosis,
grading of organ injury, audit, statistics, consent …................................................ 151
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ABBREVIATIONS
A
A. Artery a.a. Arteries
AAA Abdominal Aortic Aneurysm ACE Angio-tensin Converting Enzyme.
ARF Acute Renal Failure. ASD Atrial Septal Defect.
B
BP Blood Pressure.
C
CEA Carcino-Embryonic Antigen. CO Cardiac Output.
CRF Chronic Renal Failure. CVP Central Venous Pressure.
F
F Factor.
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 Erythematosus. SV Stroke Volume.
SVR Systemic Vascular Resistance.
T
TPA Tissue Plasminogen Activator. TPN Total Parenteral Nutrition.
U
US Ultra-Sono-graphy.
V
V. Vein v.v. Veins
VSD Ventricular Septal Defect. VWF Von Willebrand Factor
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ANATOMY
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THORAX (CHEST)
Heart valves
Coronary
a.a.
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Cardiac v.v.
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THORACIC CAGE
 th
The tubercle of the 7 rib articulates with the transverse process of T7.
 C6 = start of trachea = junction between pharynx & esophagus.
 Sternal angle is palpated to identify the 2nd costal cartilage = inferior border of superior
mediastinum= T4-5 disc = start of aortic arch = bi-furcation of trachea.
 The sterno-clavicular joint is in close proximity to the articulation of the 1st rib with the sternum.
 The posterior inter-costal a.a:

1. The upper 2 arise from the supreme inter-costal a., a branch of the costo-cervical trunk of the
sub-clavian a.
2. The lower 9 arise from the back of the thoracic aorta.
 1st aortic inter-costals supply the right bronchus.
 The thoracic wall is innervated by the inter-costal n.n.:

1) Ventral 1ry rami of spinal n.n. T1-11 provide:
1. Motor innervation to inter-costal muscles & muscles of abdominal wall, fore-arm & hand.
2. Sensory innervation to the skin of the chest & abdomen on the anterior & lateral sides.
2) Dorsal 1ry rami provide:

1. Motor innervation to true back muscles.
2. Sensory innervation to the skin on the back.
 Endo-thoracic fascia is a natural cleavage plane of CT for surgical separation of the costal parietal
pleura from the thoracic wall.
THE LUNGS
 The carina is a keel-shaped cartilage at the tracheal bifurcation separating the right & left main
stem bronchi.
 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 v. to the apical segmental pulmonary a. passes through:
1. IVC. 5. Pulmonary trunk.
2. Right atrium. 6. Left pulmonary a.
3. Tri-cuspid valve. 7. Left superior lobar a.
4. Right ventricle. 8. Left apical segmental a.
 The oblique fissure of the lung corresponds to the media border of the scapula when the arm is
fully abducted.
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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. 3. Inner-most inter-costals.
2. Internal 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 lingula which is formed by the cardiac notch expands into this recess.
DIAPHRAGM OPENINGS (VEA)

Vena caval Esophageal Aortic
o T8 o T10 o T12
o In the central tendon & is o In the right crus taking origin o Behind the median
quadri-lateral in shape. from L1-3. arcuate ligament.
o 1" to the right of the mid-line. o 1" to the left of the mid-line. o In the mid-line.
o IVC. o Esophagus & its vessels. o Aorta.
o Right phrenic n. o 2 vagi. o Thoracic duct.
o LNs. o Azygos v.
 Nerve supply (mnemonic): C3, 4 & five keeps diaphragm alive!
THE HEART
Artery Location Branches Supply
o Rt coronary  SA node & AV node (90%).
1. Rt coronary a. (RCA)
sulcus.  Inferior wall of the LV (1/3
(origin: anterior aortic sinus)
of LV).
2. Posterior inter-ventricular a.  AV node.
(branch of RCA)
 Both ventricles.
3. Left coronary a. (LCA) o Circumflex &  Anterior 2/3 of inter-
(origin: Lt posterior aortic anterior inter- ventricular septum.
sinus) ventricular a.  A part of the left branch of
AV bundle.
4. Circumflex (branch of LCA)  Left atrium & ventricle.
 The great cardiac v. is the largest tributary of the coronary sinus.

It starts at the apex of the heart & ascends with the anterior ventricular branch of the left
coronary a.
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 The following cardiac v.v. do not end in the coronary sinus:

1. Anterior cardiac v.v. which collect blood from the right ventricle & open into the right atrium.
2. Smallest cardiac v.v. which arise in the muscular wall of the heart.
 An anomalous SVC drains via the coronary sinus.
 A part of the right branch of AV bundle is carried by the crsita terminalis.
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 a.a. (pulmonary trunk & aorta) in the peri-
cardial sac is inserted into the transverse per-cardial sinus.
MEDIASTINUM
 Mediastinal pleura form the lateral boundary of the superior mediastinum.
 The left brachio-cephalic v. courses across the mediastinum in a horizontal fashion.

It lies immediately antero-superior to the ascending aorta & posterior to the thymus.
 The azygos v. 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 n. lies on & partly curves posteriorly around the arch of aorta.
 Contents of the posterior mediastinum:

1. Thoracic aorta.
2. Esophagus.
3. Azygos v.
4. Thoracic duct.
5. Sympathetic trunks.
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UPPER LIMB & BREAST
Brachial
plexus
Relations of the
median n. & bechial a.
(Rt arm)
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Anastomosis around elbow joint

Radial recurrent a. lies on supinator muscle, immediately below the elbow.
Carpal bones
 From lateral to medial – from proximal to distal:

1. Scaphoid1 – Lunate2 – Triquetrum – Pisi-form3.
2. Trapezium – Trapezoid – Capitate – Hamate.
!‫ تـكسب تـخسر كـله هـبل‬.. ‫سـملمى لـازم تـرمي بـمب‬
1 Blood supply: dorsal carpal branch of radial a.

2 It is most commonly dis-located by a fall on the out-stretched hand.
3 It has a single articular facet.
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Dermatomes of the upper limb
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Ulnar a. & n. in the wrist & hand
Verden Zones of the hand
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MUSCLES
Muscle Nerve supply Action Paralysis
1. Pectoralis minor  Depression of the
glenoid fossa directly.
2. Serratus anterior o Long thoracic n. (C5, 6, 7)  Main protractor of  Winged
(accompanied by long scapula. scapula.
thoracic a.).
3. Sub-scapularis: o Upper & lower sub-  Adduction & medial
Insertion: lesser scapular n1. rotation of humerus.
tuberosity of
humerus.
4. Trapezius o Spinal accessory n. + C3-  Upper fibers: elevation  In-ability to
4. of the scapula. elevate the
 Middle fibers: retraction shoulder
 Transverse cervical a. of the scapula. tip.
 Lower fibers: rotation of  Difficult
the glenoid cavity full arm
upwards. abduction.
5. Latissimus dorsi: o Thoraco-dorsal (long sub-  Adduction, medial
It forms the scapular) n. (C6, 7 & 8). rotation & extension of
posterior wall of  Accompanied by thoraco- humerus.
axilla. dorsal a. from sub-clavian
→ axillary → sub-scapular.
6. Supra-spinatus: o Supra-scapular n. (C5-6,  Initiation of abduction
Insertion: uppermost trunks of brachial plexus) of humerus (0-15O).
facet of greater “passes through supra-
tuberosity of scapular foramen”.
humerus (SIT).
7. Rhomboid major o Dorsal scapular n.  Retraction of scapula
(antagonist to serratus
anterior).
8. Brachialis:
Insertion: ulna &
anterior aspect of
fibrous capsule of
elbow joint.
9. Pronator teres  Production of the main movement of the

proximal radio-ulnar joint.
10. Flexor carpi radialis
11. Extensor carpi  Abduction of the wrist.
radialis brevis
12. Flexor digitorum o Median & ulnar n.n. 
profundus
 Shoulder stabilizers (rotator cuff): "SITS" “all are inserted into greater tuberosity”
1. Supra-spinatus. 3. Teres minor.
2. Infra-spinatus. 4. Sub-scapularis.
 All anterior compartment muscles of the arm are supplied by the musculo-cutaneous n.
 All superficial fore-arm muscles originate from the common flexor origin (the front of the medial
epi-condyle).
1The upper sub-scapular n. is an infra-clavicular branch of the brachial plexus.

The lower sub-scapular n. supplies teres major.
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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 n. (C8 & T1).
 All hypo-thenar muscles are supplied by the ulnar n. (C8).
 The lumbrical muscles assist in extension of the middle & distal phalanges.
ARTERIES
 60% of arterial supply to the breast is derived from internal mammary a.
 Branches of the axillary a. (devided by the pectoralis minor):

1. 1st part: superior thoracic a.
2. 2nd part: acromio- thoracic & lateral thoracic a.a.
3. 3rd part: sub-scapular a. (the largest branch) - Posterior & anterior circumflex humeral a.a.
 Arteria princeps pollicis supplying the thumb is a branch of the radial a.
NERVES
Nerve Injury
1. Musculo-cutaneous n.  Weakness of shoulder & elbow flexion & arm
supination.
 Loss of cutaneous sensation on the antero-
lateral surface of the fore-arm.
2. Median n.  Atrophy of the thenar eminence (flexor &
abductor pollicis brevis & opponens pollicis).
 Numbness of skin over it.
 Weak pronation.
3. Anterior inter-osseus n.  Inability to flex the thumb & index fingers to
create the “OK” sign.
4. Radial n.:  Numbness on the dorsum of the thumb &
It spirals around the humerus in the radial parts of digits 1 & 2.
groove & may be injured in fractures of the  It is thte most commonly affected nerve as a
middle of the humerus. result of crutch palsy.
5. Posterior inter-osseus n.  Inability to extend the wrist & meta-carpo-
phalangeal joints.
MISCELLANEOUS
 Site of axillary LNs:
1. Apical are medial to the medial edge of the pectoralis minor muscle.
2. Central are behind the muscle (draining 75% of the breast lymph).
3. Lateral, pectoral & sub-scapular are lateral to the medial edge of the muscle.
 The quadrangular space of the shoulder contains:

1. Axillary n. (sensory to the point of insertion of deltoid into humerus).
2. Posterior circumflex humeral a. (injured in fracture of the surgical neck of humerus).
 The inter-tubercular (bicipital) groove of the humerus contains the tendon of the long head of
biceps brachii.
 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.
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 The extensor retinaculum prevents the tendons of the posterior compartment of the forearm
from "brow-stringing" when the hand is extended.
 It contains 6 tunnels that transmit the tendons of the extensor muscles.
 The anatomical snuff-box contains

the radial a.
o Boundaries
- Medial: tendon of extensor pollicis
longus.
- Lateral: tendons of extensor pollicis
brevis & abductor pollicis longus.
- Proximal: styloid process of radius.
- Floor: trapezium & scaphoid.
o Contents:
1. Radial a.
2. Superficial branch of radial n.
3. Origin of cephalic v.
 Examples of joints:
1. Mid-line joints (e.g. manubrio-sternal, pubic symphysis, xiphi-sternal, inter-vertebral): 2ry
cartilagenous.
2. Temporo-mandibular joint: synovial, condylar & hinge.
3. Elbow joint: hinge.
4. knee joint: modified synovial hinge (consists of 3 articulations in one joint).
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LOWER LIMB
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MUSCLES
Muscle Nerve supply Action
1. Psoas major o Anterior rami of
Origin: lateral borders of D12-L5 L1-3.
bodies.
Insertion: lesser trochanter.
o Inferior gluteal 1. Main extensor of the hip.
2. Gluteus maximus
n. (L5 & S1-2). 2. Lateral rotation of the thigh. ‫العكس‬
3. Gluteus medius o Superior gluteal 1. Abduction of the hip. ‫بالعكس‬
Insertion: greater trochanter. n. (L4-5 & S1). 2. Medial rotation of the thigh.
 It acts on 2 joints putting the lower
limb in cross-leg position:
4. Sartorius 1. Flexion, abduction & lateral rotation
o Femoral n.
of the thigh.
(dorsal divisions
2. Flexion & medial rotation of the leg.
of L2-4).
5. Quadriceps femoris:  Extension of the leg (knee).
Insertion: tibial tuberosity.
6. Pectineus
1. Tibial n. (long head).  Extension of the hip & flexion

7. Biceps femoris:
2. Common peroneal n. of the knee.
Its long head crosses 2 joints.
(short head).  Lateral rotation of the leg.
8. Semi-tendinosus  Extension of the hip & flexion
o Sciatic n. of the knee.
9. Semi-membranosus
 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.
 Muscle attachment on greater trochanter: POGO:

1. Piriformis. 3. Gemelli.
2. Obturator internus. 4. Obturator externus.
 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.
ARTERIES & VEINS

 Obturator a. is found in the medial compartment of the thigh.
It gives the A. of the round ligament of the head of femur.
 Ligamnetum teres contains arterial supply to the head of femur in children.
 Femoral a. → popliteal a. →
1. Posterior tibial a. → peroneal a. (between Tibialis posterior & flexor Hallucis longus).
2. Anterior tibial a. → dorsalis pedis a. → deep plantar a. – medial & lateral tarsal a.a.
 Femoral a. = 1-2 cm inferior to the mid-inguinal point.
 The popliteal a. is crossed in its middle part from lateral to medial by the tibial n. & the popliteal
v.
 Arteries supplying the hip joint:
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1. Obturator & femoral a.a.

2. Medial & lateral femoral circumflex a.a. (injury of the medial a. after fracture of the femoral
neck causes avascular necrosis of the head).
3. Superior & inferior gluteal a.a.
 Superficial external pudendal a. passes through the saphenous opening.
 Profunda femoris (deep femoral) a. gives:

1. Medial & lateral circumflex femoral a.a. (main supply of the femoral head).
2. 4 perforating branches which supply the posterior compartment of the thigh.
 Great saphenous v. terminates in the femoral v. within the femoral sheath (by piercing the
medial wall of the sheath).
 Small saphenous v. begins posterior to the lateral malleolus as as continuation of the lateral
marginal v. (dorsal venous arch), has 9-12 valves & is in close relation with:
1. Sural n. in the lower 1/3 of the leg.
2. Medial sural cutaneous n. in the upper 2/3 of the leg.
It terminates in the popliteal v.
 The pulsation of dorsalis pedis a. is felt just lateral to the tendon of extensor hallucis longus.
NERVES
 Obturator n. (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).
 Lateral femoral cutaneous n. (lateral cutaneous n. of the thigh) arises from the dorsal divisions
of L2-3.
 Sciatic n. gives:
1. Medial popliteal (tibial) n.:
It supplies superficial muscles of back of leg (gastrocnemius, plantaris & soleus) & popliteus.
It gives medial (flexor digitorum & hallucis brevis, abductor hallucis & 1 st lumbrical) & lateral
plantar n.n. (other muscles in the sole of the foot).
It ends by becoming posterior tibial n. which supplies deep muscles of back of leg except
popliteus "Tom Does Homework" (Tibialis posterior, flexor Digitorum longus & flexor Hallucis
longus1).
2. Lateral popliteal (common peroneal) n. gives:

1) Superficial peroneal (musculo-cutaneous) n. which supplies muscles of the lateral aspect of
the leg (peroneus longus & brevis) & skin on the dorsum of the foot.
2) Deep peroneal (anterior tibial) n. (L4-5 & S1) which supplies "Tom Has Dog Pobby" (Tibialis
anterior, extensor Hallucis longus, extensor Digitorum longus, Peroneus tertius) & extensor
digitorum brevis & skin of the 1st web space.
It is injured in fracture of the upper end of fibula.
MISCELLANEOUS
 Structures passing through the greater sciatic foramen:
1. Superior & infeior gluteal vs & n.n. 4. Internal pudendal a. & dudendal n*.
2. Sciatic n. 5. Posterior cutaneous n. of the thigh.
3. N. to obturator internus*.
1 Its function is affected in a fracture of the sustentaculum tali.
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 Those with * pass also through the lessser sciatic foramen.
 Ischial tuberosities are used for sitting on.
 Boundaries of the femoral triangle:

1. Laterally: the medial border of Sartorius.
2. Medially: the lateral border of adductor longus.
3. Base (above): the inguinal ligament.
4. Apex (below): meeting of Sartorius & adductor longus.
 It is continuous below with the adductor canal.
 The femoral sheath is divided into 3 compartments:

1. The medial is called the femoral canal.
2. The middle contains the femoral v.
3. The lateral contains the femoral a.
 The femoral n. lies lateral to the femoral a. (outside the femoral sheath) on iliacus muscle.
 Sub-sartorial (Hunter's or adductor) canal contains:

1. Femoral a. & v.
2. Saphenous n.
3. N. to vastus medialis.
 Popliteal fossa is bounded by:

1. Supero-laterally: Biceps femoris.
2. Supero-medially: Semi-tendinosus & semi-membranosus.
3. Infero-laterally: Medial head of gastrocnemius.
4. Supero-laterally: Lateral head of gastrocnemius & plantaris.
 Tibial n. is the most superficial structure encountered in the popliteal fossa.
 Structures on the lateral aspect of the knee from superficial-to-deep:

1. Skin. 3. Popliteus muscle tendon.
2. Fibular collateral ligament. 4. Lateral meniscus.
 The posterior cruciate ligament (PCL) prevents posterior sliding of the tibia on the femur.
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HEAD & NECK
24
25
26
Cranial fossa Foramina Contents

1. Cribri-form plate  1st CN.
Anterior
 Emissary v.v.
2. Optic canal  2nd CN.

 Ophthalmic a.
3. Superior orbital  3rd, 4th & 6th CNs.

Sphenoid bone
fissure (SOF) Ophthalmic division of tri-geminal n.
 Ophthalmic v.v.
 Sympathetic n.n.
Middle
4. F. rotundum  Maxillary division of tri-geminal n.
5. F. ovale  Mandibular division of tri-geminal n.
 Accessory meningeal a.
6. F. spinosum  Middle meningeal a.
 Meningeal branch of mandibular n.
7. F. lacerum  ICA.
8. F. magnum  Medulla oblongata, spinal cord & dura matter.

 Vertebral a.a.
 Accessory n.n.
9. Jugular F.  9th, 10th & 11th CNs.
 IJV (continuation of sigmoid sinus).
Posterior
 Inferior petrosal sinus.
10. Hypo-glossal  12th CN.
canal  Meningeal branch of ascending pharyngeal a.
11. Internal auditory  7th & 8th CNs1.
(acoustic) meatus  Labyrinthine a.
BONE
 The pterion is an important clinical landmark because it overlies the anterior branches of the
middle meningeal a.
It marks the junction between 3 bones: sphenoid, parietal & temporal.
A blow to the pterion (as in boxing) may rupture the a. causing an extra-dural (epi-dural)
hematoma between the dura & the cranial bone.
 The medial boundary of the infra-temporal fossa is formed by the lateral pterygoid plate of the
sphenoid bone.
 The mental foramen is found in the mandible.
 Styloid process of the temporal bone cannot be easily palpated in a live subject.
 It separates between parotid gland & carotid sheath.
 Pterygo-mandibular raphe serves as an attachment for superior pharyngeal constrictor muscle.
 The hyoid bone serves as an attachment for the middle pharyngeal constrictor muscle.
 The TMJ lies anterior to the squamo-tymanic suture.
MUSCLES
 The rectus capitis anterior muscle is innervated by ventral rami from C1-2.
1 So, an acoustic neuroma (tumor of the 8th CN) is also likely to involve the facial n.
27
 Both tensors are supplied by the mandibular division of the tri-geminal n.:
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 n.
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 n.
 The muscles of facial expression are in the same sub-cutaneous plane as the platysma.
 The lateral pterygoid muscles:

1. Acting alone, they shift the mandible to the opposite side.
2. Acting together, they protrude the mandible.
 The palato-glossus muscle is contained in the anterior palatal arch.

It acts on the tongue & is supplied (with the levator veli palatini) by the 10th CN (vagus) via the
pharyngeal plexus.
 Muscles of the vocal folds (innervated by the recurrent laryngeal n.):

1. Crico-thyroid o Tensor (the only muscle innervated by the
external branch of the superior laryngeal).
2. Thyro-arytenoid. o Relaxer.
3. Posterior crico-arytenoid o Abductor.
4. Arytenoid, lateral crico-arytenoid & o Adductors.
thyro-arytenoid
ARTERIES
 The common carotid a. (CCA) is enclosed within the carotid sheath throughout its course.
It bi-furcates opposite C4.
 The internal carotid a. (ICA) passes through the carotid canal in the petrous part of the
temporal bone to reach the intra-cranial cavity.
 The anterior cerebral a. supplies the medial surface of the frontal, parietal & limbic lobes.
 The middle meningeal a. is a branch of the 1st (retro-mandibular) part of the maxillary a. & is
the principal a. supplying the meninges.
 Branches of the external carotid a.:

o Anterior branches:
1. Superior thyroid a.
2. Lingual a.:
To reach it from inside the mouth, you should go through the hyo-glossus muscle.
3. Facial a.:
It is crossed by the branches of the facial n. from behind forward.
It can be felt pulsating at the lower border of the mandible just anterior to the masseter
muscle which consists of superficial & deep portions.
Its ligation here will ↓ blood flow to some parts of the nasal septum (through superior
labial a. which gives a septal branch).
o Posterior branches:
4. Occipital a. (it is associated laterally with the 12th CN (hypo-glossal)).
5. Posterior auricular a.
28
o Ascending branch:
6. Ascending pharyngeal a.
o Terminal branches:
7. Superficial temporal a. (its pulsation is felt in front of the upper part of the ear).
8. Internal maxillary a.
 ECA may be damaged during surgery of the parotid.
 The central a. of the retina is the 1st & one of the smallest branches of the ophthalmic a.
It is the sole supply for the retina.
 Branches of the lingual a.:

1. Hyoid branch supplying the muscles attaches to the hyoid bone.
2. Dorsal lingual a. on the superficial posterior surface of the tongue.
3. Deep lingual a. (profunda linguae) on the deep surface of the tongue.
4. Sub-lingual a. in the floor of the mouth supplying the sub-lingual gland.
 It is crossed by the 12th CN (hypo-glossal).
 Branches of the 3rd part of the internal maxillary a.:

1. Spheno-palatine a. (a. of epistaxis) which supplies the lateral nasal wall & nasal septum.
2. Descending palatine a. which arises within the pterygo-palatine fossa.
 Branches of the thyro-cervical trunk (enters thyroid at C6):

1. Inferior thyroid a. which passes medially over the 1st portion of the vertebral a.
Supply: cervical esophagus.
2. Transverse cervical a.
3. Supra-scapular a. which passes over the phrenic n. (C3, 4 & 5) to enter the posterior triangle of
the neck.
VEINS & SINUSES

 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 v.
 An infected blood clot courses through the facial v. 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 v.
NERVES
 Nerve supply of the lacrimal gland:
1. General sensation is supplied by the ophthalmic n.
2. Para-sympathetic supply originates from the lacrimal nucleus of the facial n. in the pons &
travels via the pterygo-palatine ganglion & maxillary n.
It can be injured by compression at the internal acoustic meatus resulting in dry eye.
3. Post-ganglionic sympathetic fibers originate from the superior cervical ganglion & travel through
the same route as the para-sympathetic fibers.
 Autonomic nerve supply of the muscles of the iris:

1. Post-ganglionic sympathetic fibers originate from the superior cervical ganglion & innervate the
dilator pupillae muscle.
29
2. Post-ganglionic para-sympathetic fibers originate from the ciliary ganglion & innervate the
sphincter pupillae muscle (3rd CN (oculo-motor)).
 The ciliary ganglion would be affected by severance of the 3rd CN.
 The 3rd CN (oculo-motor) supplies:

1. The levator palpebrae superioris which elevates the upper eyelid.
2. The sphincter pupillae muscles.
 Its damages causes eyelid drooping & dilated pupil.
 Injury to the sympathetic efferent fibers of the oculo-motor n. 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 n. after it emerges from the stylo-mastoid foramen would affect facial
expression.
 The ophthalmic division of the tri-geminal n. as a single structure does not reach the interior of
the globe.
It carries general sensory innervation of the cornea.
 The supra-trochlear n. is the terminal branch of the frontal n. which is the largest branch of the
ophthalmic n. & is situated on the superior surface of the levator palpebrae superioris.
 The inferior palpebral n. is the terminal branch of the infra-orbital branch of the maxillary n.
 Pre-ganglionic para-sympathetic fibers to the nose synapse in the pterygo-palatine ganglion.
 The vidian n. running in the pterygoid canal contains:

1. Post-ganglionic sympathetic fibers (deep petrosal n.).
2. Pre-ganglionic para-sympathetic fibers (great petrosal n.).
 Nerve supply of the tympanic membrane:

o Outer surface:
 Upper & anterior part: auriculo-temporal branch of the mandibular n.1.
 Lower & posterior part: auricular branch of 10th CN (vagus).
o Inner surface:
 Tympanic branch of 12th CN (glosso-pharyngeal).
 Nerve supply of the tongue:

o Sensory:
 Anterior 2/3: lingual n. (general sensation) & chorda tympani (taste, also though the lingual
nerve).
 Posterior 1/3: glosso-pharyngeal n. (all sensations).
o Motor:
 Hypo-glossal n. (all muscles except palate-glossus which is supplied by the 10th CN (vagus)).
 Chorda tympani can be injured by erroneous placement of a tympanic membrane shunt as it

runs across the ear-drum.
1 Its injury results in loss of sensation from the temporal region & loss of secretory function of the parotid
gland.
30
 The inferior alveolar n. is the largest branch of the mandibular n. → mental n. (lower lip).
It supplies sensory innervation to the mandibular teeth & bone.
 Laryngeal n.n.:
1. Superior laryngeal n. which gives:
 External laryngeal n.:  Internal laryngeal n.:
It may be injured in thyroid surgery Supply: mucosa of the larynx superior
during ligation of the superior thyroid a. to the true vocal folds + intrinsic
Supply: crico-thyroid ms. laryngeal ms except crico-thyroid.
2. Recurrent laryngeal n.:

 It runs along the posterior surface of the thyroid gland.
 It supplies the mucosa of the larynx inferior to the true vocal folds.
 Its injury causes hoarseness of voice.
 Its inferior laryngeal branch supplies the posterior crico-arytenoid muscle.
 The transverse cervical n. (C2-3) carries touch sensation from the skin of the anterior triangle of
the neck.
It is superficial to SCM & is affected by cervical plexus block.
 The ansa cervicalis (C1, 2 & 3) is embedded in the pre-tracheal fascia & carotid sheath & is
therefore vulnerable to injury during surgical procedures to the carotid a.
 The phrenic n.n. course over anterior scalene muscles in the neck.
It is accompanied by the peri-cardio-phrenic branch of the internal mammary a. in the thorax.
The Rt phrenic n. lies in contact with the peri-cardium of the Rt atrium.
 The supra-clavicular n. may be injured with a stab in the posterior triangle of the neck 4 cm
above the clavicle causing anesthesia over the acromion & clavicle.
THYROID, SUB-MANDIBULAR & PAROTID GLANDS

 Berry’s ligament connects the thyroid to the cricoid cartilage & upper trachea.
 During thyroidectomy, the order of structures encountered, from superficial to deep is:
1. Skin. 4. Thyroid gland.
2. Investing fascia. 5. Para-thyroid glands.
3. Pre-tracheal fascia.
 Arterial supply of the thyroid gland:

1. Superior thyroid a. from external carotid a.
2. Inferior thyroid a. from thyro-cervical trunk of sub-clavian a.
It should be ligated in continuity before the vein to avoid injury of the recurrent laryngeal n. by
mass ligation.
3. The thyroidea ima a. which would take origin from the:
1) Brachio-cephalic trunk (innominate a.).
2) Aorta.
3) Right carotid a., sub-clavian or internal mammary.
 Venous drainage of the thyroid gland:

1. Superior thyroid v. to IJV.
2. Middle thyroid v. to IJV.
3. Inferior thyroid v. from the isthmus to brachio-cephalic v. (left innominate v.).
 Parotid (Stensen’s) duct reaches the oral vestibule by piercing the buccinators muscle (opens
opposite 2nd molar tooth).
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 Sub-mandibular (Wharton’s) 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.
 It provides 70% of salivary secretions.
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.
 The deep cervical fascia (fascia colli = investing fascia) invests:

1. The carotid vessels.
2. The muscles forming the borders of the posterior triangle of the neck.
 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: CCA, IJV & 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 CCA (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 & posterior ethmoid  Superior meatus.
2. Frontal & maxillary  Middle meatus (via hiatus semi-lunaris).
3. Naso-lacrimal duct.  Inferior meatus.
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BRAIN & CRANIAL NERVES
Cerebral arterial circle (of Willis)

It is contained in the cisterna basalis
ARTERIES & VEINS

 Cerebral a. thrombosis causes contra-lateral hemi-plegia.
 Occlusion of the posterior inferior cerebellar a. is most likely to affect the entire dorso-lateral
part of the rostral medulla & produce the lateral medullary syndrome.
 The superior cerebral v.v. (8-12) drain into the superior sagittal sinus.
 The great cerebral v. (of Galen) is formed by the union of the 2 internal cerebral v.v.
CRANIAL NERVES
 th
Lesions of the 9 CN (glosso-pharyngeal) would result in general sensory deficit to the pharynx.
 11th CN (abducens) is purely motor.
 12th CN (hypo-glossal) supplies the hyo-glossus muscle (tongue depressor).
MISCELLANEOUS
 All pre-ganglionic & post-ganglionic to sweak glands → acetyl choline.
 Post-ganglionic sympathetic → nor-adrenaline.
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BACK & SPINAL CORD

BONE & VERTEBRAE
 The vertebrae in the upper 3 regions of the column are true (movable) while those in the lower 2
regions are false (fixed).
 A typical vertebra consists of:

1. An anterior segment (body) which has a few small apertures for the passage of nutrient vessels
on its anterior surface in thoracic vertebrae.
2. A posterior segment (vertebral or neural arch) which consists of a pair of pedicles & a pair of
laminae.
 The spinous process serves for the attachment of muscles & ligaments.
 C2 has a large & bifid spinous process.

 C7 has a F. transversarium for the passage of the vertebral a.
 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 n.
 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 (foramina of Magendie & Luschka).
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.
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ABDOMEN
Mnemonic:
VC on same side of VC
(ligamentum venosum &
caudate lobe – vena cava)
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Arterial supply of the stomach
Superior & inferior mesenteric a.a.
36
Renal, supra-renal & gonadal v.v.
37
38
39
Epi-ploic foramen (foramen of Winslow)
The lower anterior abdominal wall as seen from inside the peritoneal cavity (top) & in the
transverse plane (bottom)
40
PERITONEUM & LIGAMENTS

 The inguinal ligament is formed by the external abdominal oblique aponeurosis.
 Suspensory muscle of duodenum (ligament of Treitz) suspends the duodeno-jejunal flexure to

the right crus of diaphragm.
 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.
 The spleen is completely covered by peritoneum.
 Pancreas is normally the least mobile structure in the peritoneal cavity.
 The following structures are retro-peritoneal:

1. Part of esophagus & rectum1. 4. Kidneys, supra-renal glands, bladder & ureters.
2. 2nd, 3rd & 4th parts of duodenum. 5. IVC.
3. Pancreas.
INGUINAL CANAL & HERNIA

 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.
1. The superficial inguinal ring is an opening in the external abdominal oblique aponeurosis.
2. The deep inguinal ring is above the mid-point of the inguinal ligament (lateral to the mid-
inguinal point).
3. The roof of the inguinal canal is formed by the arched fibers of internal oblique & transversus
abdominis.
 The round ligament of the uterus passes through the deep inguinal ring & then along-side the
in-direct inguinal herniated mass in the inguinal canal.
It is derived from the gubernaculum (meso-derm).
 A lump protruding from the superficial inguinal ring is either a direct or an in-direct inguinal
hernia.
 A left-sided in-direct inguinal hernia most likely involves the sigmoid colon as it is mobile due to
the presence of sigmoid meso-colon.
 Spermatic cord contains:

1. Genital branch of GFN. 3. Vas & pampini-form plexus.
2. Cremasteric a., testicular a. & a. of vas. 4. Sympathetic nerves & lymphatics.
GASTRO-INTESTINAL TRACT
 The 2nd (descending) part of the duodenum:
1. The major duodenal papilla is located at the middle of the postero-medial aspect of it.
2. The right colic flexure lies anterior to it.
3. The hilum of the right kidney may be injured while mobilizing this part.
1 Peritoneum covers antero-lateral surface in upper 1/3 & anterior surface in middle 1/3.
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 Nutcracker-like compression of the 3rd (transverse) part of the duodenum occurs between the
superior mesenteric a. & the aorta.
 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.
 During appendicectomy, the appendix is located by looking at the confluence of taenia coli.
 During exploratory laparotomy:

1. The jejunum is characterized by sparse aggregated LNs & larger villi.
2. The ileum is characterized by larger & more numerous aggregated LNs.
3. The large intestine is characterized by epi-ploic appendages.
 The rectum is an important anastomosis site for the portal & caval (systemic) venous systems.
SPLEEN, LIVER, PANCREAS & ADRENAL GLANDS

 The spleen is injured in case of:
1. Fractures near the angles of the left 9th & 10th ribs.
2. Traction on the attachment between the spleen & the left colic flexure.
 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.
 During laparo-scopic chole-cystectomy, cystic a. is exposed in the triangle of Calot (cysto-hepatic

triangle) between common hepatic dust, liver & cystic duct.
 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.
 The main pancreatic duct is also called the duct of Wirsung.
 Adrenal cortex zones:

Glomerulosa Mineralo-corticoids Aldosterone
Fasciculata Gluco-corticoids Cortisol
Reticularis Androgens Di-hydro-epi-androsterone (DHEA)
BLOOD VESSELS
 Arterial supply of the esophagus:
1. The thyro-cervical trunk.
2. The left inferior phrenic a.
3. The left gastric a.
 Arterial supply of supra-renal glands:

1. Superior supra-renal from inferior phrenic a.
2. Middle supra-renal from abdominal aorta.
3. Inferior supra-renal from renal a.
 Venous drainage of supra-renal glands: via short v.v. into IVC.
42
 The splenic a. gives off short gastric a.a. which supply blood to the fundus of the stomach.
 The hepatic a. 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 v.v. are arranged in 2 groups.
 The superior mesenteric a. 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 inferior epi-gastric a. is a branch of the external iliac a. near the deep inguinal ring.
It runs1 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 ↑ 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 a. occlusion is seldom (rarely) symptomatic because its territory may be
supplied by branches of left & middle colic a.a.
 Inferior mesenteric v. does not run a course parallel to superior mesenteric a. however they
supply/drain the same region.
 The marginal a. is the anastomotic a. running along the border of the large intestine.
 A. of Adamkiewicz is a radicular a. on the left side in the lower thoracic or upper lumbar region.
 The middle sacral a. is a branch of the abdominal aorta.
 The superior gluteal a. exists the pelvis between the lumbo-sacral trunk & S1 nerve.
NERVES & PAIN

 Blood & para-sympathetic supply of the abdominal organs:
1. All GIT up to the last part  Celiac trunk & superior o Vagus n.
of the transverse colon mesenteric a. (a. of the Its compression may result
mid-gut around which the in a loss of elevation of the
mid-gut bends). soft palate.
2. All GIT distal to that point  Inferior mesenteric a. o Pelvic splanchnic n.n.
 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 n.
 A spinal cord injury at T10 results in loss of cutaneous sensation from umbilicus to toes.
 Nerve supply of testis: T10.
 Injury of the ilio-hypo-gastric n. (L1) during appendicectomy results in paraesthesia (numbness)

of the skin at the pubic region (lower abdominal wall), upper hip & thigh.
1 Beneath Camper’s fascia.
43
 The ilio-inguinal n. passes through the superficial inguinal ring.

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 in-direct inguinal hernia producing pain in the scrotum.
Its terminal branch is the anterior labial (scrotal) n. which supplies the skin of the mons pubis.
MISCELLANEOUS
 Trans-pyloric plane of Addison = L1 =
A hand's breadth below the xephi-sternal junction =
Mid-way between supra-sternal (jugular) notch & symphysis pubis:
1. SMA, renal & splenic hilum. 4. Transverse meso-colon.
2. Origin of PV. 5. Pylorus, 1st part of duodenum & duodeno-jejunal flexure.
3. Pancreatic neck. 6. GB fundus.
 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 v. →
internal thoracic v.).
2. Below the plane, drainage is in a caudal direction (superficial inguinal LNs & inferior epi-gastric
v. → external iliac v.).
 A bypass between the vessels between the portal & caval systems for treating portal HTN can be
done between splenic v. (portal) & left renal v. (caval).
 The anterior relations of the supra-renal gland include:

1. On the right side: IVC.
2. On the left side: pancreas.
 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)
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PELVIS & PERINEUM
45
Male pelvis Female pelvis

Inlet Oval & round
Greater sciatic notch Narrow (almost 70O)
GENITAL TRACT
 The fallopian tubes lie between the 2 layers of the meso-salpinx.
 The base of the prostate is directly related to the urinary bladder.

o Arterial supply: auperior & inferior vesical a.a.
o Venous drainage: vesical venous plexus.
 The seminal vesicles are found between the base of the bladder & rectum.
The arteries supplying them are derived from:
1. Middle & inferior vesical a.a.
2. Middle rectal a.a.
 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
 Branches of the internal iliac a.:
o From the posterior division: o From the anterior division:
1. Ilio-lumbar a. 4. Umbilical a. which gives 6. Inferior
2. Lateral sacral as. superior vesical a. then vesical/Vaginal a.
3. Superior gluteal a. becomes obliterated 7. Middle rectal a.
forming the lateral 8. Inferior gluteal a.
umbilical ligament. 9. Internal pudendal a.
5. Obturator a.
 Uterine a.a. lie anterior & superior to ureter near the lateral portion of the fornix.
 The inferior rectal v. is a tributary of the internal pudendal v.
 The hemorrhoidal plexus is most likely to dilate in a patient with portal HTN.
Normal portal venous pressure is 5-7 mmHg. If it is > the pressure in the IVC by > 5 mmHg →
portal HTN.
NERVES & PAIN

 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 n.
 The principal motor & sensory nerve of the perineum is the pudendal nerve (S2, 3 & 41).
It passes through greater & lesser sciatic notches.
It supplies external anal & urethral sphincters.
It may be injured by:
1) A stab into the ischio-rectal fossa 2 cm lateral to the anal canal.
2) During normal vaginal labor.
1 Mnemonic: S2, 3 & 4 keeps poo of the floor!
46
Pudendal n. block for episiotomy is achieved by palpating the ischial spine vaginally to inject the
anesthetic.
It is located in the deep perineal space.
 The prostatic plexus of nerves originate from the pelvic splanchnics & its injury during
prostatectomy causes loss of penile erection.
 Nerve supply of the scrotum:

1. Anterior ½: ilio-inguinal n.
2. Posterior ½: pudendal n.
MISCELLANEOUS
 The ureter is crossed by the left colic vessels on the left side.
 It may be injured:
1. While clamping the uterine a.a. during hysterectomy.
2. During excision of the right ovary as the ureter lies posterior to it.
 Narrow points of the ureter:

1. Pelvi-ureteric junction.
2. Vesico-ureteric junction (commonest site of stone impaction).
3. Where iliac vessels cross the ureter.
 Renal hilum: From anterior to posterior: VAU (renal v., a., ureter).
 Ureters enter the bladder at the upper lateral aspect of the base.
 Narrowest part of urethra: external urethral orifice → membranous urethra.
 The pelvic diaphragm is formed by the:

1. Levator ani muscle (ilio-coccygeus, pubo-coccygeus & pubo-rectalis muscles):
It arises from the tendinous arch of the fascia of obturator internus (arcus tendineus levator ani).
2. Coccygeus muscle.
 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.
 Central perineal tendon/cardinal (uretero-sacral) ligaments provide the main structural support
to the uterus.
 The external anal sphincter lies immediately posterior to the perineal body.
47
DEVELOPMENTAL ANATOMY
Ecto-derm Meso-derm Endo-derm
1. Epidermis of skin, nails & hair. 1. Epithelium of the:
2. Sweat, sebaceous & mammary glands. o GIT & its associated glands as well as
3. Nervous system. glandular cells of the liver & pancreas.
4. Pupillary muscle of the iris, lens & o Urachus & urinary bladder.
retina. o Respiratory passages (pharynx,
5. Pineal body, posterior pituitary & trachea1, 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.
Arch Nerve Derivatives Summary

1st 5th  Malleus (& its anterior ligament) & incus  3 M.
(mandibular) (Meckel's cartilage).  2 tensors.
 2 anterior.
 Mastication & mylo-hyoid.
 Spheno-mandibular ligament.
 Tensor tympani & palati.
 Anterior belly of di-gastric - Anterior part of
tongue.
2nd (hyoid) 8th  Stapes & styloid process.  4 S.
 Hyoid: upper part of body & lesser cornu.  Facial.
 Hyoid.
 Facial expression.  Posterior
 Stylo-hyoid & stapedius. belly.
 Posterior belly of di-gastric.
3rd 9th  Hyoid: lower part of body & greater cornu.  S-ph.
 Stylo-pharyngeus.  Hyoid.
4th-6th 10th (recurrent  Thyroid, arytenoid, corniculate & cuneiform  Cartilages.
& superior cartilages.  Muscles.
laryngeal)  Muscles of pharynx, larynx & palate.
 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.
THE CIRCULATORY SYSTEM

 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.
 Incomplete fusion of the endo-cardial cushions results in AV septal defect.
 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.
1 Origin: fore-gut endo-derm.
48
 The ductus arteriosus receives blood from the pulmonary a.
 Rt 4th aortic arch → Rt sub-clavian as far as the origin of its internal mammary branch.
 Lt 4th aortic arch → aortic arch.
 Rt 6th arches → Rt pulmonary a.

 Lt 6th arches → ductus arteriosus.
 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 a. & aorta.
THE GIT
Derivatives of the meso-gastrium
Dorsal Ventral
1. Spleen. 1. Liver & all ligaments associated with it
2. Pancreas. (falciform, coronary & right & left triangular
3. Greater omentum (gastro-phrenic, -splenic & ligaments).
-colic ligaments). 2. Lesser omentum (hepato-gastric & -
4. Lieno (spleno)-renal ligament. duodenal ligaments).
 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.
 Normal herniation of the gut in fetus is accompanied by anti-clock-wise rotation of the

herniated gut loop.
 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 & RE-PRODUCTIVE SYSTEM

 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.
 Cloaca → male urethra.

 Meso-nephric ducts → genito-urinary system in males – urinary system in females.
 Para-meso-nephric (Mullerian) ducts → uterus.
 Adrenal rests are a very common finding in term neonates (50%).
 The bladder is endo-dermal in origin except for the tri-gone which is meso-dermal in origin.
49
MISCELLANEOUS
 In meiosis, chiasmata separate during ana-phase I.
 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.
 4th pharyngeal pouch → superior para-thyroid. ‫العكس‬

 3rd pharyngeal pouch → inferior para-thyroid. ‫بالعكس‬
 Foramen cecum (endo-derm) → thyroid gland.
 The umbilical cord is filled with jelly of Wharton.
 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 the
4th
fetus.
7th  The testis descends with the vaginal sac of the peritoneum.
9th  The baby weighs 3-3.5 Kg (6.5-8 lb).
 Bartholin’s glands are embryologically equivalent to bulbo-urethral glands (origin: uro-genital

sinus).
50
PHYSIOLOGY
51
GENERAL PHYSIOLOGY & BLOOD

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. strept.
pneumonia).
3. Eosino-phils. o ↑ in patients with hydatid cysts.
4. Helper T-cells (CD 4) o Activate other immune cells.

5. Cyto-toxic T-cells (CD 8) o Specific cellular defense mechanism with cyto-toxic
activity.
o It has perforin in its granules.
6. Natural killer cells o Host rejection of tumor cells.
o It has perforin in its granules.
7. Mono-cytes o Become activated macro-phages.
o Have a large bi-lobed nucleus.
o ↑ in chronic inflammation (+ lympho-cytes).
8. Plasma cells o Production of ABs.

9. Mast cells o Its granules contain heparin (like baso-phils), histamine &
chondroitin sulphate.
10. Dendritic (Langerhan's) cells o APCs present in skin.
11. Kupffer cells in the liver o Re-cycling of old RBCs.
 Lympho-cytes & mono-cytes are most commonly seen in tissue undergoing chronic
inflammation.
 Langhans giant cells are the hallmarks of granulomatous inflammation (e.g. tuberculosis) & are
formed by the fusion of epithelioid cells (macro-phages).
 Giant cell is the most characteristic of the inflammatory response around a glass foreign body.
ANTI-BODIES (ABs) (IMMUNO-GLOBULINS)

G A M E D
 Highest percentage in a  In mucus-  Largest Ab.  It binds to allergens
newborn. containing & triggers histamine
 Most abundant AB. areas. release.
 Its deposition in the
vessels results in Henoch-
Schonlein purpura.
52
Pgs
D2 E2 F2α I2
 It is a 2ry mediator of  It sensitizes  It inhibits platelet
inflammation. nociceptive nerve aggregation.
endings causing pain.
 It relaxes bronchial  It contracts bronchial  It dilates blood
smooth muscles. smooth muscles. vessels.
 Arachidonic acid is one of the essential fatty acids required for the synthesis of Pgs.
COMPLEMENT
3b 5a 5b
 Opsonin (enhances phago-  Chemo-tactic1.  It initiates membrane attack
cytosis).  Anaphylatoxin. complex (MAC).
 Anaphylatoxin.
 The critical step in the elaboration of the biological functions of complement is the activation of
C3.
1 Chemo-taxis is the uni-directional migration of WBCs towards a specific target.
53
54
 Tenase complex = activated F8 + F9.
 Coagulation factors are serine proteases except 5 + 8 (glycol-proteins) = 13 (trans-glutaminase).
 F5 can bind to activated platelets.

 F8 is synthesized by vascular endothelium & not by the liver.
 F13 (fibrin stabilizing factor) cross links fibrin.
 VWF stabilizes F8.
 Anti-thrombin III inactivates 2, 7, 9, 10, 11 & 12.

Its deficiency predisposes to DVT & pulmonary embolism.
 Heparin-induced thrombo-cyto-penia is a thrombotic dis-order whose risk is lower with LMWH

which acts by inhibition of F10a.
 Warfarin:
o It is only effective after 72 hours, metabolized in liver (half life 40 hours).
o Side effects: protein C deficiency → Warafarin skin necrosis.
 Tranexamic acid inhibits plasmin & inhibits fibrin de-gradation.
 Hageman factor (F12) activates both the coagulation & kinin systems on contact with injured
vascular basement membrane.
 The whole clotting cascade is dependent on Ca to function.
Drug Factors Mechanism Reversal Assessment

Activates anti-thrombin III
Protamine
Heparin 1921 (2, 9, 10, 11) which in-activates PTT/aPTT
sulphate
protease
Pro-thrombin
1972 (2, 7, 9, 10) Impairs re-cycling of complex concentrate
Warfarin
Vitamin-K dependent vitamin K (PCC) (e.g. actaplex),
vitamin K
DIC 1, 2, 5, 8, 11
Liver Heparin + Wafarin + 1, 5
Binds to anti-thrombin,
LMWH 10
can be used in pregnancy
 Chatacteristics of F5 & F8:

1. Sensitive to temperature. 3. De-activated by protiens C & S.
2. Not serine proteases (+ 13). 4. Most rapidly consumed in DIC.
55
BLOOD TESTS
PTT & aPTT PT & INR BT (bleeding time) Clotting time1
Control  25 seconds.  12 seconds.  1-9 minutes.
Measures  Intrinsic & common  Extrinsic &  Platelets, vessels &  Fibrin
the pathways (8, 9, 10 & common pathways VWF (required for formation.
efficacy of 12). (1, 2, 5, 7 & 10). platelet adhesion).
1. Heparin use. 1. Liver disease. 1. Thrombo-cyto- 1. Heparin
2. Anti-phospho-lipid 2. ↓ coagulation penia. use.
Prolonged Ab. factors. 2. Aspirin use. 2. ↓
in 3. ↓ coagulation fibrinogen.
factors (8, 9, 10 & 3. Lupus anti-
12) e.g. hemo-philia. coagulant.
CBC
MCV MCH MCHC
HCT Hb Hb
X 1000 X 10
RBCs count RBCs count HCT
80-100 Fl. 25-35 pg/cell. 30-35 g/dL.
PLASMA PROTEINS
Albumin Fibrinogen
 It is the most abundant & lightest plasma  1.5-4 g/L in plasma.
protein in terms of weight.  It is an acute-phase protein.
ANEMIAS
 Anemia → ↓ PO2 of mixed venous blood.
 Iron deficiency anemia may be caused by:

1. Peptic ulcer (the commonest cause in males).
2. Parasitic infestations.
 Anemia of chronic disease: caribbean.

1. ↓ serum iron & total iron-binding capacity (TIBC).
2. ↑ serum ferritin.
 Crisis results from vaso-occlusive episode.
 Ferritin is also ↑ during acute illness (e.g. sepsis, bowel perforation).
 Sickle-cell anemia (hemoglobin S) is characterized by:

1. Destruction of circulating RBCs.
2. Auto-splenectomy (not palpable spleen).
 Vitamin B12 or folic acid deficiency causes megalo-blastic (pernicious) anemia with ovoid RBCs
rather than bi-concave-disc-shape.
1. Pan-cyto-penia. 3. ↓ reticulo-cyte index.
2. ↑ MCV. 4. Hyper-segmented PMN neutro-phils.
 Causes include atrophic gastritis.
 β-thalassemia:
1. Micro-cystic hypo-chromic anemia. 3. Hemo-chromatosis.
2. Splenomegaly.
1 Thrombin clotting time or thrombin time.
56
DISEASES
 Liver disease causes depression of normal coagulation system & excessive bleeding after
surgery.
 Poly-cythemia vera is characterized by:

1. ↑ RBCs. 3. ↑ platelets.
2. ↑ WBCs. 4. Splenomegaly.
 Myelo-fibrosis causes massive splenomegaly.
 Platelets deficiency (thrombo-cyto-penia) causes a defect of 1ry hemostasis (characterized by

petechiae, purpura & epistaxis).
 Coagulation factors deficiency causes a defect of 2ry hemostasis (formation of fibrin).
 DIC is characterized by: ↑ fibrino-lysis →

1. ↑ D-dimer assay (fibrin de-gradation products (FDPs) > 500 ng/ml). 3. ↑ PT & PTT.
2. Schisto-cytes (fragmented RBCs). 4. ↓ platelets.
 TTT: FFP & platelets.
Hemo-philia A1 B C Owren para-hemo-philia

 F8.  F9.  F11.  F5.
 Haem-arthrosis.  Clinical bleeding.  Autosomal
Normal PT & BT. recessive.
↑ PTT.
 Normal or ↑ VWF.
X-linked recessive.
Anti-phospho-
Scurvery VW disease (AD)
lipid syndrome
1. Normal blood 1. Normal blood 1. Bruising. 6. ↑ aPTT & BT.
tests. tests. 2. Bleeding from wounds. 7. Ab-normal F8 &
2. Skin & mucosal 2. Lupus anti- 3. Epistaxis. platelet dys-
petechiae. coagulants. 4. Menorrhagia. function (VWF dys-
5. Normal PT & platelet function).
count.  TTT: desmopressin.
 Grey platelet syndrome is characterized by thrombo-cyto-penia & large agranular platelets

(deficient alpha granules).
 A LN excised from a boy with a sore throat & runny nose shows prominent, well-defined para-
cortical follicles with germinal centers.
 IMN (EBV infection) is characterized by:

1. Pharyngitis. 4. +ve mono-spot test.
2. Fever, fatigue & malaise. 5. Atypical (re-active) lympho-cytes.
3. Enlarged & tender LNs (e.g. cervical, axillary, 6. Splenomegaly & mild hepatomegaly
inguinal, …). (jaundice).
 Mycosis fungoides is skin infiltration by neoplastic T-lympho-cytes.
 Sphero-cytosis: AD.
1Treated by infusion of F8 concentrate.

Cholesterol crystals are seen within the joint space following episodes of pain.
57
Idiopathic thrombo-
Thrombotic thrombo-cyto-penic purpura
cyto-penic purpura
1. Fever. 5. Thrombo-cyto-penia.  Normal-sized
2. Skin & mucosal petechiae. 6. Platelet transfusion is contra- spleen.
3. Renal insufficiency. indicated.
4. CNS dis-order (e.g. mental 7. Pink hyaline thrombi in small a.a.
confusion).
BLOOD TRANSFUSION & BLOOD PRODUCTS

 Infection & malignancy are contra-indications to use of cell saver devices.
 Platelet transfusion: after ligation of splenic a. – shelf life: 5 days.

 FFP can be stored at ≤ - 25OC for up to 36 months.
 Cryo-precipitate: fibrinogen, F8, VWF.
 Commonest adverse events:

- Packed RBCs: pyrexia, iatrogenic septicemia (G –ve).
- FFP: urticaria, transfusion-associated lung injury.
- Platelets: iatrogenic septicemia (G +ve).
 Graft vs host disease: lympho-cytic proliferation, immuni-compromized, 4-30 days, diarrhea, ab-
normal LFTs, fever, erythema, descuamation.
 Acute hemo-lytic transfusion reaction: within hours, abdominal pain, nausea, fever, dark urine,
shock.
 Transfusion-associated lung injury: rare, acute, neutro-philic-mediated allergic pulmonary
edema.
 Major hemorrhage due to trauma: packed RCBs, FFP & platelets in a 1:1:1 ratio.
 Autologus blood transfusion: ↓ risk of infection transmission – maximum 4-5 units.
 Screening of blood donors:

- HbsAg – HCV DNA. - HIV 1 & 2 ABs.
- Trponema Pallodum AB (syphilis). - HTLV I/II.
 In IHD, blood transfusion is considered if Hb is < 8 g/L.
OTHERS
 Erythro-poietin stimulates differentiation of erythroid-forming units (EFU-E) into colony-forming
units (CFU-E).
It is used in treating anemia of CRF & cancer chemo-therapy.
It is synthesized by peri-tubular fibro-blasts of the kidney.
 Dietary iron is more readily absorbed when ferritin stores of intestinal epithelium are low.
Iron deficiency causes micro-cytic hypo-chromic anemia with aniso-cytosis, poikilo-cytosis, ↓
ferritin, ↑ trans-ferrin & ↓ MCV.
70% of body iron is in is Hb.
↑ by strepto-kinase, uro-kinase
& recombinant human TPA
 Plasminogen Plasmin.
↓ by ε-amino caproic acid
 Platelet activating factor functions as a soluble signal messenger.
 Spectrin is a cyto-skeletal protein enabling RBCs to withstand stress on its plasma membrane.
58
 After hemolysis, bilirubin level & reticulo-cytic count are ↑.
 Immune-globulin D is given to Rh -ve women after delivery of Rh +ve baby.
 After a trip to the Himalayas, a person complains of headache & peripheral cyanosis due to
physiological poly-cythemia.
 Citrate is the preferred anti-coagulant for blood storage.

It combines with Ca2+ forming un-ionized Ca complex.
 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. O 2,
Co2 & steroid hormones.
NERVE
 During activation of a nerve cell membrane (action potential), Na+ ions flow inward.
 The re-polarization phase is a result of ↓ Na+ permeability & rapidly ↑ K+ permeability.
 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.
 Opening Cl- channels in a neuronal membrane causes hyper-polarization to -70 mv.

Resting membrane potential of a neuronal cell body is -60 mv.
 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.
 Myo-globin acts like hemo-globin & binds with O2.

It does not exhibit co-operative binding of O2 (not affected by O2 pressure) giving a hyper-bolic
O2 dissociation curve.
 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.
 ↓ extra-cellular Ca2+ inhibits release of vesicles at all types of synapses.
 Stretch reflex is mono-synaptic.
 Golgi tendon organ reflex causes inhibition of motor neurons.
 A burst of vigorous physical activity (seconds-minutes) requires energy which is derived from
the breakdown of glycogen to lactic acid (faster sources than ATP & creatine phosphate).
59
 Malignant hyper-thermia with halothane is caused by increased heat production by skeletal

muscles.
It is treated by a ryanodine receptor (e.g. dantrolene which is a muscle relaxant).
 Acetyl-choline release at the NMJ causes post-synaptic depolarization due to increased post-
synaptic membrane permeability to small cations (Na+ & K+).
Type II (fast-twitch) Type I (slow-twitch)

 Use anaerobic metabolism. 
 Rich in glycogen. 
 Stored blood has ↑ affinity for O2.
60
RENAL SYSTEM – FLUIDS, ELECTROLYTES & ACID-BASE BALANCE

EQUATIONS
 Fluid movement "Starling forces" = K (capillary hydro-static pressure – inter-stitial h.p.) –
(capillary colloid osmotic pressure - inter-stitial c.o.p.).
K = capillary filtration coefficient = 1.
𝐔rine conc. X urine 𝐕olume

 Clearance =
𝐏lasma conc.
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.
𝐔rine conc.of the substance X urine 𝐕olume

 RPF =
Arterial − Venous 𝐏lasma conc.
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).
 Excretion = (filtration + secretion) – re-absorption.
 Anion gap = (Na+ + K+) – (Cl- + HCo3-) = 8-16 mmol/L.
𝐇𝐂𝐨𝟑− 𝟐𝟎
 =
𝐒 (𝟎.𝟎𝟑) 𝐗 𝐏𝐚𝐂𝐨𝟐 𝟏
 Mesurement of GFR: inulin (in lab) & cratinine clearance (in practice, not identical because it is
slightly secreted by renal tubules).
 Measurement of RPF: PAH.
61
FLUIDS & ELECTROLYTES

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
3. Cl & HCo . 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 osmolarity. 1. ↓ extra-cellular fluid volume.
2. ↑ extra-cellular fluid volume. 2. ↑ intra-cellular fluid volume.
3. ↓ intra-cellular fluid volume. 3. The most appropriate initial therapy is IV
administration of iso-tonic normal saline.
Na+ K+
Normal  135 – 145 mEq/L.  3.5 – 4.5 mEq/L . 1
↓  Hypo-volemic hypo-Na:
1. Diuretics. 1. Diuretics.
2. ↓ ADH. 2. Renal tubular dis-orders.
3. Diarrhea, sweating, burns … 3. Diarrhea.
4. Addison's disease. 4. Metabolic alkalosis (vomiting, gastric out-let
o TTT: normal saline. obstruction).
5. Hyper-aldosteronism.
 Eu-volemic hypo-Na: psychosis. 6. Cushing's syndrome.
7. Liddle syndrome.
 Hyper-volemic hypo-Na: 8. Salbutamol.
edematous dis-orders (e.g.
cirrhosis). It is associated with ↑ synthesis of ammonia in the
o TTT: fluid restriction. kidneys.
↑  Patients on osmotic cathartics. 1. Metabolic acidosis (diabetic keto-acidosis, renal
failure, organ ischemia “↑ anion gap, -ve base
 Hyper-volemic hyper-Na: excess”).
hyper-alimentation. 2. Heparin.
3. Hemo-lysis.
4. Burns.
5. Familial periodic paralysis.
6. Type 4 renal tubular acidosis.
 TTT: insulin & dextrose.
 Normal plasma mg2+ concentration is 0.7-1.05 mmol/L (1.4-2.1 mEq/L).

o Hyper-Mg with CRF is characterized by respiratory depression.
o Hypo-Mg is characterized by hypo-Ca (seizures).
 Normal plasma Po43- level is 0.8-1.45 mmol/L.

 Hyper-phosphatemia is characterized by metastatic calcification.
 Only 1% of Ca+2 is available for buffering changes in Ca+2 balance in the body.
 Most of filtered Ca is re-absorbed (95%).
1 Intra-cellular concentration is 150 mmol/L.
62
ARTERIAL BLOOD ACID-BASE DATA

pH PCo2 (mmHg) HCo3- (mmol/L)
 Normal 7.35 – 7.45 35 - 45 22-26
 Metabolic alkalosis (e.g. persistent vomiting) ↑ Normal ↑

 Partially compensated metabolic acidosis ↓ ↓ ↓
 Partially compensated metabolic alkalosis (e.g.
persistent vomiting or naso-gastric suctioning → ↑ ↑ ↑
hypo-chloremic)
 Respiratory acidosis (e.g. acute exacerbation of

↓ ↑ Normal
COPD or hypo-ventilation, type II respiratory failure)
↑ (hypo-
 Fully compensated respiratory acidosis Normal ↑
ventilation)
↓ (hyper-
 Uncompensated respiratory alkalosis ↑ Normal
ventilation)
↓ (hyper-
 Fully compensated respiratory alkalosis Normal ↓
ventilation)
 Mixed acidosis ↓ ↑ ↓
 Mixed alkalosis ↑ ↓ ↑
 Metabolic acidosis is caused by severe diarrhea (↓ HCo3-) or renal disease (↑ H+).

It is treated by NaHCo3-.
 Persistent diarrhea causes ↑ H+ secretion by the distal tubule.
 Systemic venous blood PaO2: 5.33 kPa (40 mmHg) at rest.
Respiratory failure Type I Type II

PaO2 ↓ ↓
PaO2 - ↑
Metabolic acidosis with Metabolic acidosis with

Metabolic acidosis with ↓ anion gap
normal anion gap ↑ anion gap
1. Hypo-albuminemia (↓ anions).  Uretero- 1. Hyper-albuminemia.
2. ↑ Ca+2, Mg+2 & gamma globulins (↑ sigmoidostomy. 2. ↓ Ca+2 & Mg+2.
cations).
3. Hyper-viscosity. 3. Uremia.
4. Lithium or halide (bromide or iodide) 4. Lactic acidosis.
intoxication.
 Lactic acidosis is classified into:

1. Type A occurs with poor tissue perfusion or oxygenation.
2. Type B is further divided into:
1) Type B1 occurs with systemic diseases (e.g. renal & hepatic failure, diabetes & malignancy).
2) Type B2 is caused by several drugs & toxins.
3) Type B3 is caused by inborn errors of metabolism.
 Metabolic alkalosis due to intra-cellular shift of H+ ions occurs with hypo-K.
 Severe metabolic alkalosis associated with profuse vomiting causes ↓ cerebral perfusion.
 Loss of fluid from the colon causes acidosis & hypo-K as it secretes K+.
63
BBB
 It is more permeable in infants & breaks down in infected areas.
 It allows the passage of:
1. Lipid-soluble substances (O2, Co2, ethanol & steroid hormones).
2. Substances having transport systems (sugars & some amino acids).
3. Serotonin (5HT).
DISEASES
 Nephrotic syndrome is characterized by:
1. Proteinuria (> 3.5 gm/day) causing hypo-albuminemia & ↓ oncotic pressure.
2. Edema occurs due to ↓ oncotic pressure, salt & water retention by the diseased kidney &
congestive heart failure.
3. Hyper-cholesterolemia.
4. Coagulation ab-normalities.
5. Oval fat bodies1 in urinalysis specimen (characteristic).
 Minimal-change disease (MCD) is the commonest cause of nephrotic syndrome in children (4-8
years).
 Group A strept. sore throat causes acute nephritic syndrome (glomerulo-nephritis): generalized
body edema, HTN, hematuria.
Disease Biopsy (pathology)

1. Rapidly progressive o Extensive glomerular crescent formation.
glomerulo-nephritis
2. Goodpasture's syndrome o A linear pattern of immune-globulin deposition along the
glomerular basement membrane.
3. SLE2 o Sub-endothelial granular electron-dense deposits.
 Pre-eclampsia is characterized by:

1. HTN (2 readings at least 6 hours apart > 140/90).
2. Proteinuria (> 300 mg/day).
3. Edema of hands & feet.
Hyper-aldosteronism Hypo-aldosteronism
1. HTN & hypo-K. 1. ↓ serum & ↑ urinary Na+.
2. Aldosterone > 15 ng/dL. 2. ↑ serum & ↓ urinary K+.
3. Aldosterone/renin ratio > 20. 3. ↓ serum HCo3-.
 Pelvic floor muscle weakness (e.g. after prostatectomy) causes stress incontinence.
 Aldosteronism:
1. 1ry: ↓ renin.
2. 2ry: ↑ renin (caused by heart failure & renal a. stenosis).
 Destruction of the supra-optic nuclei of the brain causes ↓ ADH secretion which causes ↓ water
re-absorption in DCTs & collecting ducts with resultant ↑ urinary volume & a very dilute urine.
 ↑ K+, BUN & creatinine (CRF) indicate hemo-dialysis.

Patients in RF who cannot be dialysed should be given a TPN solution without amino acids.
 Metabolic acidosis (↓ HCo3-) & hyper-K1 are the most life-threatening in ARF.
1They appear with pronounced proteinuria & lipiduria.

2In such cases, therapy depends on the severity & nature of the renal disease so a per-cutaneous needle biopsy
of the kidney is appropriate & helpful.
64
 The diffuse form of scleroderma is characterized by:

1. Hyper-plastic arteriolo-sclerosis.
2. Malignant HTN.
3. Fibrinoid necrosis, petechial hemorrhages & micro-infarcts in the kidneys.
 The commonest causes of acute tubular necrosis (ATN) are:

1. Hypo-tension (e.g. during a prolonged operation).
2. Nephron-toxins (e.g. amino-glycoside anti-biotics & ethylene glycol).
3. Septic shock.
It is characterized by:
1. ↑ serum urea & creatinine.
2. Granular & hyaline casts in urinalysis specimen.
 Acute tubule-inter-stitial nephritis (acute pyelo-nephritis) is characterized by:

1. Dull pain in the lower back.
2. Burning dys-uria.
3. Leuco-cytosis with left shift.
4. WBC casts (characteristic).
 A ureteric calculus is characterized by:

1. Sudden-onset, severe, flank pain that comes in waves.
2. The urine contains blood but few WBCs with ↑ acidity & normal specific gravity.
 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).
 Myo-globinuria is usually associated with rhabdo-myo-lysis (muscle destruction – ischemia-re-

perfusion injury):
1. +ve urine dipstick test for blood.
2. -ve RBCs.
 Causes of rhabdo-myo-lysis include extreme physical activity, trauma, drugs (e.g. ethanol) &
infections (e.g. strept., clostridiium difficile & legionella).
DRUGS
 A drug bound to plasma proteins has ↓ renal excretion.
 Solution of choice for parenteral nutrition is crystalline amino acids.
 Thiazide & loop diuretics cause hypo-K metabolic alkalosis (↓ H+).
 K-sparing diuretics oppose the action of aldosterone.
MISCELLANEOUS
 Squamous epithelium is normally not seen above the outer urethra (it is lacking in the renal
cortex & medulla).
 Renal concentrating ability is reflected by the specific gravity (1.002-1.028 g/ml).
1 Oral enalapril (ACE inhibitor) is contra-indicated in its treatment. S/E: angio-edema.
65
 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.
 Angio-tensin II is a powerful dipsogen hormone which stimulates thirst.
 Juxta-glomerular apparatus consists of:

1. Extra-glomerular mesangial (lacis) cells.
2. Macula densa of DCT.
3. Juxta-glomerular cells of afferent arteriole.
It controls BP through production of renin (renin-angio-tensin-aldosterone system)1.
1 Its destruction causes hyper-K.
66
 PCT is particularly vulnerable to

ischemic damage.
 H+ secretion is coupled to Na+

& HCo3- re-absorption (85% in
PCT).
 ↓ Na+ re-absorption causes ↑

urinary volume.
 From DCT & on, K+ is secreted

& influenced by aldosterone.
 K+ secretion is the main cause

of ↑ renal excretion of K+.
 In case of dehydration (e.g.

hemorrhage), CDs re-absorb
24% of filtered water instead of
5% in normal circumstances.
 Transport of glucose, amino

acids & phosphate occurs
through 2ry active transport
with Na+.
 Osmolality is measured by
mosmol/L.
67
Physiologic hormones affecting the kidney

Hormone Trigger & pathway Site of action in the nephron Net effect
 Hypo-tension → synthesis. o Afferent & efferent arterioles. 1. Afferent & efferent (higher degree) arteriolar constriction leading to ↑
GFR.
1. Angio-tensin II 2. Compensatory Na+ absorption occurs in the proximal as well as the distal
nephron to maintain fluid balance (via water osmosis following Na +).
3. ↑ ADH release.
 ↑ atrial pressure → release. o Afferent & efferent arteriole. 1. Afferent arteriolar dilation & efferent arteriolar constriction leading to
2. Atrial natriuretic o DCT. ↑ GFR & Na+ filtration.
peptide (ANP) 2. At the DCT, it inhibits Na+ uptake to ensure volume loss.
3. ↓ aldosterone secretion.
3. Vitamin D3  ↓ Ca2+. o DCT.  ↑ Ca2+ uptake.
(calcitriol)
 ↓ Ca2+. o Ascending limb of LoH.  ↑ Ca2+ uptake.
4. Parathyroid
 ↑ Po43-. o DCT.
hormone (PTH)
 ↓ vitamin D.
 Hypo-volemia. o CD.  ↑ Na+ uptake & K+ excretion causing net fluid retention.
5. Aldosterone  Hypo-tension (via Ang II).  ↑ Na & water re-absorption from sweat glands.
 ↓ Na & ↑ K+.
 Hypo-volemia. o CD.  ↑ free water uptake from the CD.
6. Antidiuretic
 Hypo-tension (via Ang II).
hormone (ADH)
 ↑ plasma osmolality.
68
Diuretics
Diuretic type (example) Site of action Mechanism (see figure)
1. Carbonic anhydrase inhibitor o PCT.  CA is an enzyme involved in the breakdown of H2Co3 in the following reaction:
(acetazolamide) H2O + CO2 ←CA→ H2CO3 ↔ HCO3- + H+.
 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 HCO 3 is absorbed from the serum.
 In the presence of acetazolamide, CA is inhibited, allowing for H 2CO3 to build up in the tubules & hence
urinary HCO3 wasting (H+ alternatively is re-absorbed via a different pathway). This leads to a ↓ ability to
re-absorb Na+ in exchange for H+ leading to mild diuresis.
2. Osmotic (mannitol) o PCT.  Mannitol is filtered through the glomerulus but cannot be re-absorbed.
 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-thiazide) o DCT.  They block the activity of Na+-Cl- channels in the DCT allowing more Na+ & water loss.
5. K+ Sparing: o CD.  Aldosterone acts on the cells of CDs & induces expression of Na/K exchangers & ENaC.
1) Aldosterone Antagonists  This allows for the exchange of Na+ for K+ (Na+ enters the tubular cells & K+ is lost in the urine).
(spironolactone).  Aldosterone antagonists competitively inhibit the action of aldosterone on the principal cells & therefore
2) Epithelial Na+ channel (ENaC) ↓ the expression of the exchanger. With the lack of Na+ uptake from the nephrons & loss in the urine,
blocker (amiloride & diuresis also occurs.
triamterene).
 Aldosterone also controls expression of ENaC channels in the DCTs to absorb Na +.
 Inhibition of the ENaC ↓ Na+ uptake & K+ loss from the tubular cells.
 Loss of Na+ in the urine leads to mild diuresis.
69
CVS
EQUATIONS & LAWS
 Mean arterial BP = diastolic + 1/3 (systolic – diastolic).
Mean arterial pressure

 CO =
Total peripheral resistance
O2 consumption (ml/min)
 CO =
Arterial O2 content – mixed venous O2 content "pulmonary artery"
 CO (ml/min) = HR X SV (heart rate X stroke volume).

15% 2% 2%
Brain Skin Bronchial circulation
 CO of the right ventricle ↑ during deep inspiration.

 CO can ↑ 6-fold during exercise.
 Cardiac index = CO/m2 body surface area.
 HR ↓:
1. During an exercise which involves iso-metric muscle contractions.
2. By para-sympathetic nervous stimulation of the heart (slowing of the heart).
Its inhibition ↑ HR.
 Resting HR in the trans-planted heart is 90-110 bpm.
 Brainbridge reflex: atrial stretch → ↑ HR.
Pressure difference
 Flow =
Resistance
CVP
 SVR = (MAP - ) X 80.
CO
 MAP = { (2 x DBP) + SBP } / 3
 Cardiac index is related to body surface area.
 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
↑.
 According to Poiseuille-Hagen formula, increasing the diameter of a vessel to twice the initial
diameter would ↓ the vessel resistance to 1/16 of the initial resistance.
So, if the resistance of a blood vessels is 16 PRU then doubling the vessel diameter would change
the resistance to 1 PRU.
 Pulse pressure is determined by the stroke volume (normally about 40 mmHg).
 ↑ systemic BP → ↑ residual volume of the left ventricle.
 ↑ pre-load (venous return) → ↑ ventricular wall tension & SV.
 Left atrial pressure equals PAWP.
70
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.
JUGULAR VENOUS PULSE (IVP)

 NORMAL:
 A: right atrial contraction.
 C: bulging (closure) of the tri-cuspid valve into the right atrium (during right ventricular iso-
volumic systole).
 X: atrial relaxation & downward displacement of the tri-cuspid valve (during right ventricular
systole).
 V: ↑blood volume in the vena cava & right atrium during ventricular systole the tri-cuspid valve
is closed.
 Y: opening of the tri-cuspid valve & flow of blood into the right ventricle.
 The v wave is equal to the a wave in patients with ASD.
 AB-NORMALITIES:
1. Absent a waves = Atrial fibrillation.
2. Large a waves = Any cause of right ventricular hyper-trophy, tri-cuspid stenosis.
3. Cannon waves (extra large a waves) = Complete heart block.
4. Prominent v waves = Tri-cuspid regurgitation.
5. Slow y descent = Tri-cuspid stenosis, right atrial myxoma.
6. Steep y descent = Right ventricular failure, constrictive peri-carditis, tri-cuspid regurgitation.
↑ JVP = SVC obstruction.
NERVES & CONDUCTION SYSTEM

 SAN is located near the superior end of the sulcus terminalis.
It has the highest rate of automatic discharge.
Phase 0 of an SA nodal action potential results from influx of Ca2+ ions.
 Ventricular filling occurs due to conduction delay in the AV node.
 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.
71
 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.
3. Q-T interval: 0.4 s. (varies with HR).

4. S-T segment: 0.08 s.
5. T-wave: ventricular re-polarization.
Ab-normality Findings
1. Hypo-thermia  Sinus brady-cardia.
 J-waves.
2. Atrial fibrillation  Irregularly irregular pulse.
 Absent P-waves.
 Irregular PR 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  In-dependence of P-waves & QRS complexes.
6. ↓ K+  Depressed S-T segment (↓).

 Flattened (notched) T-waves.
 Prominent (elevated) U-waves.
7. ↑ K+  Tented T-waves (↑).
8. ↑ Ca2+  Short Q-T interval.
9. Very fast HR
10. ↓ conduction velocity through AVN  ↑ PR internval.

11. Conduction defect  Wider QRS complexes
 Anterior wall o Leads V1-5.

 Lateral wall o Leads I, II & aVL.
 Inferior wall o Leads II, III & aVF.
DISEASES
 Hypo-Mg → ventricular tachy-cardia → verapamil is contra-indicated.
 Following severe hemorrhage, transfusion of blood ↓ the total peripheral resistance.
 Kidneys are especially vulnerable during shock (prolonged hypo-tension) while skeletal muscles
are most likely to sustain the least damage.
 Cardiogenic shock is characterized by:

1. ↑ pre-load, PAWP, CVP & vascular resistance.
2. ↓ CO & mixed venous O2.
 Tetralogy of Fallot: VSD, RVOTO (pulmonary stenosis), over-riding aorta, RV hyper-trophy.
72
 X-ray: small boot-shaped heart & ↓ pulmonary vascular markings.
 A pulsus paradoxus is an exaggeration of the normal variation in the pulse during respiration in
which systolic pressure ↓ by > 10 mmHg during inspiration.
 Non-bacterial thrombotic endocarditis (NBTE) is the deposition of small sterile vegetations on

valve leaflets.
The previous term was marantic endocarditis, from the Greek marantikos, meaning “wasting
away”.
o Risk factors:
1. Wasting diseases. 4. Mucin-producing metastatic carcinomas (of
2. DIC. lung, stomach or pancreas).
3. Previous rheumatic fever1. 5. Chronic infections (e.g. tuberculosis).
 Giant-cell (temporal) arteritis is the commonest form of systemic vasculitis in adults.
 Acute peri-carditis:
1. Peri-cordial friction rub.
2. ST-segment elevation.
3. No pathological Q waves.
 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 HTN, 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 v.v. & ascites.
EMBOLISM
 Pulmonary embolism:
o C/P: sudden onset chest pain, dysnea, tachypnea & anxiety.
o Signs: Accentuated pulmonary S2, leuco-cytosis, ↑ ventilation/perfusion ratio, ↑ pulmonary
vascular resistance.
o ABG: respiratory alkalosis + hypoxia.
o ECG: sinus tachy-cardia, P-pulmonale, RV strain, inverted T-wave in inferior leads.
o Invest.: CT pulmonary angio-graphy (1st line).
 TTT: fibrino-lytic (thrombo-lytic) agent as alteplase.
 Fat embolism: triad:

o Respiratory, neurological & petechial rach (trunk, axilla & conjunctiva) – retinal hemorrhage.
 Venosu air embolism:

o Cause: open heart surgery.
o Cause of death: air trapped in RV out-flow tract.
o C/P: hypo-tension, hypoxia, Mill-wheel murmur, normal intial chest X-ray.
MISCELLANEOUS
 Ejection fraction is normally > 60%.
 Carotid body stimulation causes stimulation of the respiratory center.

If the 9th CNs are blocked bilaterally in the neck, the subject will no longer respond to hypoxia (↓
O2) by causing an ↑ respiratory minute volume.
1During the acute phase of rheumatic fever, the characteristic inflammatory lesions found in the heart are
known as aschoff's bodies.
73
 ↓ CO ↑ pulmonary vascular resistance & ↓ pulmonary a. pressure.
 Obstruction of venous return to the right side of the heart causes the CO to fall & systemic
arterial BP to ↑ as compensation.
 ↓ blood (ECF) volume (e.g. hemorrhage) causes:

1. ↑ sympathetic nerve activity. 3. Stimulation of baro-receptor reflex to ↑ the BP.
2. ↑ plasma ADH (vaso-pressin). 4. Constriction of skin vessels.
 Angio-tensin II ↑ BP acutely & causes hypo-K chronically.
 ↑ systemic arterial pressure from 100 to 300 mmHg ↑ the resistance to blood flow in the
cerebral circulation.
 Under resting conditions, a marathon runner has a higher SV compared to un-trained people.
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 a., 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.
 Digoxin is a +ve inotropic agent that ↑ contractility of the heart.
 Tissue cooling ↓ O2 extraction by tissues.
 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.
 The left coronary flow peaks in early diastole.
 A valvular lesion is best assessed by echo-cardio-graphy.
 Turbulence in a blood vessel is more likely to occur if the velocity of blood within the vessel ↑.
 Creatine kinase (CK) has 3 different iso-enzymes:

1. MM which is expressed by skeletal muscles (98%) & cardiac muscles (70%).
2. BB occurs mainly in tissues & its levels rarely have any significance.
3. MB which is expressed by skeletal muscles (1%) & cardiac muscles (30%).
 Endo-thelin is a naturally-occurring peptide that produces intense vaso-constriction.
74
RESPIRATORY SYSTEM
EQUATIONS & LAWS
Change in lung volume
 Compliance =
Change in distending pressue (Palv − Ppl)
o Palv = ambient atmospheric pressure = zero reference pressure.
o Ppl = -ve intra-pleural pressure.
o During inspiration, normal –ve intra-thoracic pressure is 1-3 mmHg.
↑ ↓
 Lung surfactant (it also enhances alveolar stability).  ARDS.
 Older age.  Atelectasis, fibrosis.
 COPD, emphysema.  Pneumonia.
 Head-up position.
 Boher's equation: 𝐕D
=
Arterial Co2 pressure – Mixed expired Co2
𝐕T Arterial Co2 pressure
 By Fowler's method, 𝐕D
= 0.25
𝐕T
 Driving pressure is the difference between inflow & outflow pressure.

o Pulmonary driving pressure = pulmonary arterial pressure (Pa) – left atrial pressure (PLA) = 15 – 5
= 10 mmHg.
o Systemic driving pressure = aortic pressure (Pa) – right atrial pressure (PRA) = 100 mmHg.
LUNG VOLUMES
 Total ventilation = RR X tidal volume.

 Alveolar ventilation = RR (tidal volume - anatomical dead space).
o To cause the greatest ↑ in alveolar ventilation in a man who is swimming & breathing though a
snorkel, ↑ the tidal volume by 2 folds & use a shorter snorkel.
o If alveolar ventilation is halved (& if Co2 production remains unchanged), then arterial & alveolar
Co2 pressures will double.
 To correct respiratory alkalosis, you should ↓ the tidal volume.
 Vital capacity = maximum inspiration & expiration = 5.9 L.
 Forced vital capacity (FVC): volume of expired air at forced expiration following maximal
inspiration.
75
Dead space Fowler’s method.

Functional residual capacity Helium wash-out technique.
FEV1 & FVC – residual volume Spiro-meter.
Peak expiratory flow rate (PEFR) Wright’s peak flow-meter.
DISEASES
 Lobar pneumonia is usually community-acquired.
The most commonly identified pathogens are srepto-coccus pneumonia, hemo-philus influenza
& atypical organisms.
 α1-anti-trypsin deficiency is characterized by:

1. Pan-lobular pulmonary emphysema.
2. Liver cirrhosis.
 A lung abscess is seen on the X-ray as a mass lesion with air-fluid level.
 Asbestosis is a form of inter-stitial pulmonary fibrosis seen in ship-builders & textile workers.
o X-ray may show:
1. Linear reticular opacities, usually in the 2. Pleural plaques.
peripheral lower lobes. 3. Honey-combing.
 In pneumo-thorax, with inspiration the lung collapses inward & the chest wall springs outward.
It is the commonest problem associated with FNAC from the lung.
 Pulmonary edema favors diffusion limitation of O2 transfer from alveolar to pulmonary capillary
blood.
 Transection of the afferent fibers of the 9th & 10th CNs (vagus & glosso-pharyngeal) results in
prolonged inspiration & shortened expiration.
 ARDS is a diffuse pulmonary parenchymal injury associated with non-cardiogenic pulmonary

edema.
 Causes include excessive crystalloid administration.
 CXR: diffuse alveolar shadows.
 Nurse in a prone position to improve refractory hypoxemia.
 De-compression sickness results from nitrogen bubbles in the body fluids.
 Hypoxic hypoxia is the only form of hypoxia with ↓ PaO2.
 Aspiration of the stomach contents results in chemical pneumonia.
 Nocardia asteroids: pulmonary nocardiosis, opportunistic infection, immmuno-suppression (e.g.

malignancy, organ trans-plantation, steroids).
It causes a chronic abscessing pneumonia.
Obstructive Restrictive diseases

Asthma
diseases (COPD) (fibrosis, kypho-scoliosis)
 Total lung capacity ↑ ↓
 Functional residual capacity1 ↑ ↑ ↓
 Residual volume ↑ ↓
 FEV1/FVC ↓ ↓ Normal or ↑
 Diffusion capacity of CO2 (DLCo)1 Normal or ↑ ↓ ?
1 It is the volume of gas in the lungs at the end of a normal expiration.
76
Disease Finding
 Asthma o ↓
1st second 𝐅orced 𝐄xpiratory 𝐕olume (FEV1)
ratio.
𝐅orced 𝐕ital 𝐂apacity (FVC)
 Anemia with normal o ↓ PO2 of mixed venous blood.
lungs
 Mild Co poisoning o ↓ arterial O2 concentration.
 The commonest cause of:

1. Serous pleural effusion: congestive heart failure & hypo-albuminemia.
2. Chylo-thorax: mediastinal malignant lymphoma.
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.
4. Arterial O2 pressure is slightly < alveolar O2 pressure due to shunted blood.

5. About 70% of Co2 is transported to the lungs in the form of HCo3-.
6. Maximum amount of work of breathing is required to overcome elastance (compliance) "60-
66%".
7. Pulmonary vessels can accommodate about 500 ml blood in an adult man.
 Physiological changes due to a 2-year stay in the Himalayas (high altitude):

1. ↑ ventilation (the ↑ in ventilation that 2. ↑ pulmonary vascular resistance.
occurs immediately after ascent ↑ still 3. ↑ number of mito-chondria in a muscle
further over the course in the next 1-3 days. biopsy.
4. ↑ renal excretion of HCo3-.
 Diaphragm & external inter-costals are muscles of inspiration.

 Abdominal muscles & internal inter-costals are muscles of expiration.
O2-Hb dissociation curve
1 It is affected by the volume of blood in the pulmonary capillaries.
77
 One of the non-respiratory functions of the lungs is ectopic ACTH secretion.
 Breathing 100% O2 ↑ PaO2 to almost 670 mmHg.

If the ↑ is as low as 125 mmHg, this indicates an anatomical right-to-left shunting.
 Acetazolamide ↑ urinary HCo3- & is used for prevention of mountain sickness.
 ↑ PaCo2 (hyper-capnea) produces the most potent effect in stimulating the respiratory center
(central (medullary) chemo-receptors) & so increasing respiration.
Central chemo-receptors are sensitive to CO2 content of CSF.
 A man competing in a 1500 m. running event show s↑ alveolar-capillary PO2 gradient.
 Hypoxia causes pulmonary VC (which improves matching of ventilation & blood flow in some
lung diseases) while nitric oxide causes pulmonary VD.
 The airway resistance is ↓ by ↑ airway Co2.
 Cheyne-Stokes breathing is characterized by periods of waxing & waning tidal volumes

separated by periods of apnea.
78
GIT & HEPATO-BILIARY SYSTEM

DIGESTION & TRANSPORT
 The breakdown of complex food-stuffs is accomplished by hydrolysis.
 Secretion of saliva is most dependent on vagal stimulation.

 70% of salivary secretions is provided by sub-mandibular gland.
 Complex starches are mainly digested by enzymes secreted from the pancreas.
 The columnar epithelial cells of the pancreatic ducts secrete most of the aqueous component of
the pancreatic juice where HCo3- content is greater in response to secretin (which stimulates
HCO3- secretion from the pancreas & pepsinogen secretion).
 Abolition of the cephalic phase of pancreatic secretion occurs after vagotomy.
 Cells of the stomach:

- Chief cells  Pepsinogen which is activated by acid pH & pepsin.
- Parietal cells  Gastric acid & intrinsic factor.
 Intra-gastric PH is usually 2.
 The stomach does not digest it-self 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.
 Gastric emptying is proportional to the volume of stomach contents.
 Cells of the duodenum:

- S-cells  Secretin → secretion of water & electrolytes from pancreas.
- I-cells  Chole-cysto-kinin → enzymatic secretion from pancreas – ↓ gastric
emptying – sustained gall-bladder contractions & relaxation of the sphincter
of Oddi1 (its release is ↑ by intra-mural fats or amino acids in the intestine).
 Ca2+ is concentrated in hepatic bile in the gall-bladder where bile becomes more acidic.
 Bile acids are derivatives of cholesterol synthesized in the hepato-cytes.
 Stored fat is usually transported in the body in the form of free fatty acids.
 Chylo-microns have the highest content of tri-glycerides (80%).
 Lactase is secreted by the mucosa of the small intestine.
 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.
 Intestinal peristalsis requires an intact myenteric nerve plexus.

 It occurs as a result of automatic de-polarization by cells in the wall of the bowel.
Saliva Pancreatic juice Bile

Alkaline (8) Alkaline
1-1.5 L/day
1 CCK deficiency causes contraction of the sphincter of Oddi.
79
Zinc & Fe2+ Duodenum & jejunum

Ca, fat & fat-soluble vitamins Small bowel (proximal jejunum)
Vitamin B12, electrolytes & bile salts Ileum
Water Small intestine (mainly) & colon
Na Colon
DISEASES
 CREST syndrome is characterized by:
1. Calcinosis. 5. Telangiectasia.
2. Raynaud's phenomenon (fingers turn blue on cold exposure). 6. Weight loss.
3. Esophageal dys-motility. 7. +ve anti-nuclear Ab.
4. Sclero-dactyly (difficult fine movement of fingers because the
skin becomes increasingly tight with mask face).
 Esophageal laceration (Mallory-Weiss syndrome) presents as a massive hematemesis after a

prolonged bout of vomiting, tear in the mucosa & sub-mucosa.
 Duodenal ulcer disease is characterized by:

1. Pain in the upper central abdomen 2-3 hours after meals.
2. Waking up during the night with a similar pain.
 Gastrectomy causes:
1. ↓ production of pepsin.
2. Vitamin B12 deficiency (macro-cytic anemia).
3. Iron-deficiency anemia (acid secretion enhances iron absorption).
 Vitamin B12 deficiency may occur due to:

1. Absence of parietal cells which secrete the intrinsic factor on which vitamin B12 absorption
depends on.
2. Complete resection of the ileum which is the site of its absorption.
 Following total colectomy & ileostomy, the volume & water content of ileal discharge ↓ over
time.
 Extension of an adeno-carcinoma of the colon to the serosa suggests a poor prognosis.
 Glycogen storage disease type I (Von Gierke's disease) is the commonest 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.
 HBeAg signifies active viral replication.
 Mallory bodies are characteristically present in alcoholic hepatitis.
 1ry biliary cirrhosis is characterized by:

1. Pruritus. 3. +ve anti-mito-chondrial Ab.
2. ↑ alkaline phosphatase level. 4. Absence of ir-regular regenerative nodules.
 Micro-nodular cirrhosis is characterized by:
80
1. Ascites.
2. Clear, yellow ascetic fluid with a protein of 2.1 g/dl & contains a few metho-thelial & mono-
nuclear cells.
 Gall-stones are composed mainly of cholesterol.

Cholesterol gall-stones account for about 80% of gall-stones.
 Jaundice:
Pre-hepatic Post-hepatic (obstructive)
(e.g. hemo-lysis or Hepatic (e.g. blockage of CBD or
Gilbert syndrome, AR) pancreatic head cancer) 1
Jaundice Mild Variable Variable
Urine Normal Dark
Faeces Normal Slightly pale Pale
Serum bilirubin Un-conjugated Un- & conjugated Conjugated
Serum trans-aminases Normal ↑ Normal or ↑
Serum ALP Normal Normal or ↑ ↑
↑ urine bilirubin levels.
Anemia. ↓ plasma albumin.
↓ urine uro-bilinogen levels.
Others ↑ urine uro- Serum amino-
↓ vitamin K-dependent
bilinogen. transferase > 500 U.
clotting factors.
 Deficiency of maltase in the brush border of small intestine results in ↑ passage of maltose in
stool.
 Hyper-tri-glyceridemia 2ry to lipo-protein lipase deficiency is characterized by:

1. Attacks of pancreatitis.
2. Eruptive xanthomas.
3. ↑ plasma tri-glyceride level (2000 mg/dL).
 Osmotic diarrhea stops when the patient stops taking food.
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.
 Defecation is facilitated by employing the Valsalva manoeuver.
 Omeprazole is a proton pump inhibitor that blocks H+/K+ ATPase.
 Vaso-active intestinal peptide dilates GI resistance vessels.
 ↓ body temperature ↓ BMR.
 Gastric emptying can occur without brain-stem co-ordination.
 Segmentation is the motility pattern primarily responsible for the propulsion of chyme along the
small intestine.
1 The commonest cause of neonatal chole-stasis is extra-hepatic biliary atresia.
81
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 MCA & death (thrombo-embolism).
 Confusion is a recognized side effect of pre-frontal leucotomy (= lobotomy).
 A cerebral abscess is characterized by:

1. Headache & fever.
2. Ring enhancing mass in CT.
3. At biopsy: gliosis, fibrosis, necrosis, neutro-phils & lympho-cytes.
 A diffuse cerebral edema is most severe in the white matter of the brain.
 Cerebral edema with uncal herniation is characterized by:

1. Headache. 3. Death.
2. Papilledema. 4. At autopsy: recent hemorrhages in the pons.
 Herpes simplex virus (HSV) meningitis is characterized by:

1. Confusion or seizure.
2. Normal CSF analysis except there is ↑ lympho-cytes +/- RBCs.
3. Hemorrhagic lesions of the temporal lobe (characteristic).
 Vestibular neuron-itis (inflammation of the vestibular division of the 8th C.N.) is characterized by:
1. Abrupt onset of dizziness with nausea & vomiting.
2. Headache.
3. Nystagmus towards the affected side.
 These symptoms would dis-appear in 7-10 days.
 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.
 In Parkinsonism, the 1ry area involved is substantia nigra.
 Guillain-Barre syndrome (GBS) is an acute, auto-immune poly-radiculo-pathy which affects the

peripheral nervous system & is characterized by:
1. An acute infection (e.g. URTI) within the past 1-4 weeks.
2. Ascending paralysis (weakness in the legs that spreads to the upper limbs & face).
3. Complete loss of deep tendon reflexes.
4. Normal CSF analysis except there is ↑ lympho-cytes & protein.
5. Gradual recovery after 4 weeks.
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).
Site of the lesion Affected function

1. Dominant Broca's area (frontal lobe)  Motor aphasia (language production).
2. Wernicke’s area (temporal lobe)  Language comprehension.
82
3. Thalamus  Contra-lateral hemi-anesthesia, hyper-

esthesia & para-esthesia (Dejerine-Roussy $).
4. Lateral geniculate nucleus of thalamus  Vision.
5. Supra-chiasmatic nucleus of hypo-thalamus  Circadian rhythm.
6. Ventro-medial nucleus of hypo-thalamus  Satiety & female sexual drive.
7. Optic radiation  Homonymous hemianopia.
8. Pons  Rapid eye movement (REM) sleep.

Events occurring during this phase include
penile erections, night mares & hypo-tonia
except in ocular muscles.
9. Reticular activating system  Level of awakeness.
10. Gracile nucleus  Fine touch, vibration & proprioception in the

lower part of the body (below T6).
11. Cuneate nucleus  Fine touch, vibration & proprioception in the
upper part of the body (above T6).
12. Fasiculus cuneatus (lateral portion of dorsal  Fine touch, vibration & proprioception in the
column) ipsi-lateral arm.
13. 1ry sensory tri-geminal nucleus  Fine touch, vibration & proprioception in the
face & ear.
14. Posterior column-medial lemniscus  Fine touch.
15. Lateral spino-thalamic tract  Contra-lateral loss of pain & temperature

below the level of the lesion.
16. Anterior spino-thalamic tract  Contra-lateral loss of crude touch & pressure
sensation below the level of the lesion.
 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.
 In myasthenia gravis, the response of skeletal muscle to nerve stimulation is weakened (ABs to
acetyl-choline receptors).
 Horner's syndrome (uni-lateral loss of sympathetic innervation of the face) is characterized by

ipsi-lateral ptosis, miosis & an-hydrosis (red & dry skin due to loss of vaso-dilatation & sweating).
 Fixation of the ossicles due to fibrosis causes depressed hearing when tested by air conduction
but normal bone conduction.
 Hyper-opia (far sightedness) can be corrected with convex glasses.
 Glaucoma is not a rare cause of blindness in the UK.

Emergency treatment of acute angle glaucoma is by anti-muscarinics (pilocarpine) or β-blockers
(timolol) to dilate the pupils.
Carbonic anhydrase inhibitors can also be used but they are not useful for long-term treatment.
Lesion Effect
1. Inter-collicular brain o De-cerebrate rigidity.
stem 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 sense)
83
of the spinal cord). (fasiculus gracilis or cuneatus).

3. Contra-lateral loss of pain & temperature sensation beginning
1-2 segments below the lesion (spino-thalamic tract).
 There is also ipsi-lateral loss of all sensory modalities & flaccid

paralysis at the level of the lesion.
 A neural tube defect (e.g. open spina bifida & an-encephaly) is characterized by ↑ AFP.
 An-encephaly: failure of the neural tube to close anteriorly which should occurs on day 24.
HEMORRHAGES
Sub-dural hemorrhage Spontaneous sub-arachnoid
Epi-dural hematoma (EDH)
(SDH) hemorrhage (SAH)
 Damage of the dural  Ruptured berry
bridging v. aneurysm.
Cause
1. A lucid interval (a period of 1. Headache, irritability 1. Headache.

Characteris
alertness of about 30 minutes & strange behavior. 2. Sudden loss of

tics
followed by un-consciousness). 2. On CT brain: a consciousness.

2. On CT brain: a convex, lens- concave area of
shaped area of hemorrhage. hemorrhage.
TUMORS
 Meningioma is among the commonest intra-cranial tumors.
It is the only brain tumor that is more common in women.
 Schwannoma has the best prognosis following surgery among the intra-cranial neoplasms.
 Glioblastoma multiforme (grade 4 astro-cytoma) presents as a large poorly demarcated mass

with central necrosis.
It is the commonest & aggressive type of 1ry brain tumor (52%).
 Well differentiated astro-cytoma is the commonest type of astro-cytomas.

It expresses giant fibrillary acidic protein (GFAP) which possibly functions as a tumor suppressor
& is a useful diagnostic marker in a tissue biopsy.
 Mets are typically located at the grey-white junction.

They mostly originate in the lung, skin, kidney, breast & colon.
 In children, medullo-blastoma (neuro-blastoma or granulo-balstoma) usually originates in the

region of the cerebellar vermis.
 Neuro-fibroma arises from the CT of the nerve sheath.
Tumor site Compressed structure

1. The choroidal plexus of the lateral ventricle.  The caudate nucleus.
2. The roof of the posterior horn of the LV.  Fibers of the corpus callosum.
3. The medial wall of the body of the LV.  Posterior part of the septum pellucidum.
4. The floor of the inferior horn of the LV.  Inferior surface of the tapetum of the corpus
callosum.
84
CSF in health & disease

 It is actively secreted by the choroid plexus.
 It is drained into the venous system by the arachnoid granulations.
 Cerebral aque-duct is located between the 3rd & 4th ventricles.
o Volume: 150 ml. o Formation: 500 ml/day. o pH: < arterial blood.
Normal Bacterial meningitis

1. Pressure  50-180 mmH2o (8-15 mmHg). o > 180 mmH2o.
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 value). o > 4.5 mg/dl.
MISCELLANEOUS
 ry
Pre-central gyrus is the 1 motor cortex.
 Post-central gyrus is the 1ry sensory cortex.
 In EEG, α waves have a frequency wave of 8-12 Hz.
 Dopamine is the neuro-transmitter of the nigro-striatal pathway.
 Substance P has been associated in the regulation of:

1. Pain. 3. Neuro-genesis.
2. Mood dis-orders, anxiety & stress. 4. It is as a potent vaso-dilator.
 Pacinian corpuscle is depolarized by mechanical distortion & is in-dependent of K+ channels.
 Phentolamine is an α-adrenergic receptor blocker causing pupil constriction.
 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.
 The dark current of retinal photo-receptors is generated by non-selective cation channels.
 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 far accommodation, the ciliary muscles are relaxed.
 During periods of silent counting, regional cerebral blood flow (rCBF) ↑ within the
supplementary motor area.
CBF is directly auto-regulated by arterial PaO2.
 γ-motor neurons are inhibited by descending motor tracts.
 In the vestibular labyrinth, the utricle senses motion in the horizontal plane.
 Presbycusis is characterized by loss of sensitivity to high-frequency sounds.
85
 Lateral sinus thrombosis: ↑ ICP, papilledema, tenderness & edema over the mastoid
(Griesinger’s sign).
86
ENDOCRINOLOGY
 Half life of some hormones:
PTH < 10 minutes
Insulin 30 minutes
T3 1 day
PITUITARY GLAND
 Hyper-prolactinemia (e.g. pituitary adenoma) is characterized by:
1. Absence of menstrual periods. 3. Headache.
2. Milk production from breasts. 4. Lost temporal vision (bi-temporal hemianopia).
 Cranio-pharyngioma: supra-sellar neoplasm with calcifications that is eroding the bone of the
surrounding sella turcica, children between 5-10 years.
 Sheehan's syndrome (pituitary necrosis or post-partum hypo-pituitarism) occurs due to post-

partum hemorrhage.
 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.
 Nelson’s $: expanding pituitary tumor, skin hyper-pigmentation.
 Acro-megaly: invest.:
1. Diagnostic test: oral glucose tolerance test with GH levels (in normal subjects, GH ↓ to < 2 mU/L
while in acro-megaly, it is not suppressed).
2. IGF-I level.
HORMONES & RECEPTORS

 The intra-cellular domain of insulin receptors has tyrosine kinase activity.
 Steroid hormones act via gene transcription.
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.
 The basic patho-physiology of diabetic keto-acidosis is insulin insufficiency.

It is characterized by ↓ plasma C-peptide levels.
 The hypo-thalamic hypo-physeal venous portal system carries prolactin-inhibitory hormone from
the hypo-thalamus to the anterior pituitary.
In the absence of this hormone, prolactin secretion ↑.
 ACTH stimulates the conversion of cholesterol to pregnenolone to promote the production of

cortisol & adrenal androgens.
 Pro-opio-melano-cortin (POMC) is the precursor hormone for ACTH which exhibits diurnal
rhythm in its secretion.
87
Catecholamines Gluco-corticoids Glucagon

Liver glycogen ↓ ↑ ↓
Hormone Induction of secretion Effects

1. Growth hormone o Exercise.  ↑ blood glucose (↑ hepatic glyco-
o ↓ blood glucose. genolysis & Gluco-neo-genesis).
2. Glucagon o ↓ blood glucose.  ↑ lipo-lysis.
o ↑ blood amino acids.  ↓ blood amino acids.
3. Insulin1 o ↑ blood glucose.  ↓ lipo-lysis.
o ↑ blood amino acids.  ↓ proteo-lysis.
4. FSH  Synthesis of androgen-binding protein
(in men).
5. ADH (vaso-pressin) o ↑ plasma osmolarity.  ↓ urine volume.

2
o ↓ plasma volume.  ↓ gastric blood flow.
6. Thyroxin  Depletes fat stores.
7. PTH o ↓ extra-cellular ionized  ↑ loss of Po43- in the urine.
Ca2+.  Activation of vitamin D → ↑ Ca
o ↑ plasma Po43-. absorption from small intestine.
8. Aldosterone o ↑ renin & angio-tensin  Re-absorption of Na+ in distal tubules,
(secreted from II3. saliva, sweat & stool.
zona glomerulosa)
9. Cortisol  ↑ normal sensitivity of vascular smooth
muscle to the vaso-constrictor effects of
cate-cholamines.
 ↓ phago-cytosis by WBCs.
10. Cate-cholamines  Glyco-geno-lysis in live & muscle cells
increasing blood glucose.
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.
3 e.g. severe de-hydration causes 2ry hyper-aldosteronism.
88
MALE RE-PRODUCTIVE SYSTEM

LH (of pituitary baso-phils) FSH
 It is a glycol-protein hormone that  It stimulates spermato-genesis (↑ sperm
stimulates the inter-stitial (leydig) cells in count).
the testes to secrete testosterone.
 Testosterone is synthesized from cholesterol & is converted to di-hydro-testosterone by 5-α-

reductase.
In plasma, 2% of testosterone circulates as free testosterone.
It is responsible for the formation of the external genitalia in male fetus.
It stimulates bone marrow, ↑ protein synthesis, spermato-genesis & erythro-poiesis.
 Sertoli cells produce the hormone inhibin & androgen binding protein which is regulated by FSH.
 Activation of spermatozoa is a Ca2+-dependent event.

Capacitation occurs in the uterus allowing enhanced motility.
Organ Component of semen secreted

1. The seminal vesicles  Large amounts of ascorbic acid.
2. The ampulla of the vas  Fructose.
3. The prostate  Citric acid & acid phosphatase.
 Normal sperm count = 200-500 million/ejaculate.
TESTIS
 Hypo-gonadism due to deficiency of GnRH is termed Kallman's syndrome.
 Removal of the testes ↑ GnRH secretion.
89
FEMALE RE-PRODUCTIVE SYSTEM & BREAST

 In the menstrual cycle:
1. 17β-estradiol measures typically < 50 ng/ml at menstruation, rises with follicular development
reaching a peak (surge) before ovulation, drop briefly at ovulation & rise again during the luteal
phase for a 2nd peak.
2. The secretory stage is characterized by highly coiled arteries with edema in endometrial biopsy.
3. Menstruation occurs after the demise of corpus luteum in the ovary.
 In the ovarian cycle:

1. Formation of Graafian follicles is a feature of the antral phase.
 In the 1st trimester, there is:

1. ↑ CO. 2. ↑ alveolar ventilation. 3. ↑ RPF.
 In the 2nd trimester, there is ↓ pCo2.
 In pregnancy, RBC volume ↑ but this frequently lags behind the plasma volume, resulting in ↓
hematocrit & Hb concentration (physiological anemia of pregnancy).
 Administration of an Ab that neutralizes hCG for 7 days starting 4 weeks after conception causes
death of the embryo & its subsequent expulsion.
 FSH secretion ↑ after menopause.
 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 during pregnancy.
5. Its ↑ concentrations blocks the action of prolactin so lactation does not occur during pregnancy.
 Deficiency of progesterone is associated with habitual abortion.
 Estrogens:
1. They are produced from androgens.
2. ↑ circulating level of coagulation F2, 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.
 Hot flush (night sweat) is a symptom of changing hormone levels considered characteristic of
menopause.
 Glucose is transported by facilitated diffusion across the placental barrier.
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PATHOLOGY,
MICRO-BIOLOGY &
PHARMACOLOGY
91
CELL INJURY & WOUND HEALING

1. Hyper-trophy o ↑ cell size & its contents.
 E.g. a heart of a patient with long-standing HTN & aortic stenosis.
2. Hyper-plasia  E.g. During pregnancy, the breast shows lobular hyper-plasia allowing the
mother to nurse her infant for a long time.
 Uterine growth during pregnancy is an example of concomitant hyper-

plasia & hyper-trophy.
3. Atrophy o ↓ cell size (early).
o ↓ cell number (late).
o ↑ number of auto-phagic vacuoles.
e.g. immobilization of a broken limb in a plaster cast.
4. Apoptosis o Single cell necrosis (micro-scopic):

1. Cell shrinkage.
2. Chromatin condensation.
3. Formation of cyto-plasmic blebs & apoptotic bodies.
4. Phago-cytosis of apoptotic cells or cell bodies.
5. Fat necrosis o It is a feature of:
1. Breast trauma.
2. Acute pancreatitis (enzymatic fat necrosis causing hypo-Ca).
6. Coagulative o It is accompanied by disruption of the cell membrane.
necrosis
7. Liquefactive o It is a feature of cerebral infarction due to high lipid content.
necrosis
8. Meta-plasia o The reversible substitution of one adult tissue type (epithelial or

mesenchymal) normally found at a site for another.
o It is an adaptive response.
o Examples:
1. In habitual smokers, the respiratory epithelium shows stratified
squamous meta-plasia.
2. In GERD, the esophageal epithelium shows columnar meta-plasia
(columnar epithelium with goblet cells).
3. Myo-sitis ossificans.
 It is most likely to occur with vitamin A deficiency.
 A severe soft-tissue injury following a RTA causes mobilization of fat stores.
 A man working in a power plant (exposed to radio-active materials) suffers radiation injury due
to free radical formation.
Free radical injury also causes sun-burn on the cheeks (redness & pain) after spending a sunny
day on the beach.
 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.
 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 a.a.
92
 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. Maturation & re-modelling can continue beyond a year.
3. Malignancy is not a complication of wound healing.
4. Vitamin A deficiency is not likely to influence wound healing.
5. Presence of sutures aids wound healing.
6. Tyrosine kinase functions intra-cellularly in cells involved in wound healing.
Neutro-phils (inflammatory phase) Hours to 2 days

Epithelial cells 3-5 days
 Hyaline degeneration is characterized by homogenous, ground-glass, pink-staining appearance

of cells.
 Hamartoma is an ab-normal amount & arrangement of normal tissue that is appropriate or

normal for the area in which the tissue arises.
 Organization of the hematoma is infiltration of its periphery by new capillaries, fibro-blasts &
collagen (the same composition of granulation tissue)1.
 Diapedesis is the passage of WBCs through the blood vessel wall.
 The time required for a scar of a small myo-cardial infarct to reach full strength is several
months.
 Chemical burns may be aggravated by the use of neutralizing agents.
1 Fibro-blast growth factor stimulates angio-genesis, wound repair, development & hemato-poiesis.
93
INFLAMMATION & IMMUNOLOGY

 The main step in the mechanism of cell injury in case of hemo-lytic anemia after taking an over-
the-counter analgesic is the formation of IgG/IgM Abs.
 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.
 The receptor-platelet-derived growth factor (PDGF) complex activates tyrosine kinase to signal
the cell to divide.
PDGF plays an important rule in angio-genesis & development of an athermoatous plaque.
 Pg & bradykinin production is associated with pain (e.g. acute appendicitis).
 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).
 Tissue typing before a renal transplant ↓ CD4 lympho-cyte activation.
 Ciclo-sporin is an immune-suppressant drug that binds to a cyto-solic protein (cyclo-philin) of

immune-competent lympho-cytes.
It inhibits release of IL-2 from T-cells.
 Bone marrow is the origin of the mono-nuclear phago-cyte system.
 Blockage of 5-lipoxygenase inhibits the synthesis of leuko-trienes.
 HLA-B27 is associated with post-gono-coccal arthritis.
HYPER-SENSITIVITY REACTIONS
‫أكيد‬
Asthma, latex (anaphylactic shock: IM adrenaline
Anaphylactic Ig E + Mast cells
1:1000).
Cyto-toxic Ig GM AHA (auto-ABs against cell surface antigen).
Immune complex Ig GAM SLE.
Contact deramtitis (latex), granulomas, chronic
Delayed T-cell
rejeciton (years).
GRAFTS
Rejection
1. Iso- (syn-) o Between genetically identical individuals (identical twins).
graft o Does not occur.
2. Auto-graft o Between 2 parts of the body of the same individual.
94
3. Allo-graft o Between 2 members of the same species (2 humans). o Likely.

4. Xeno-graft o Between 2 members of 2 species (baboon to human). o Highly likely.
CYTO-KINES
1. IL-1 o It ↑ the expression of adhesion factors on endothelial cells.
o It is an endogenous pyrogen.
o ↑ mucus secretion in intestinal tract.
2. IL-5 o It is a major regulator of esino-philic accumulation in tissues.
3. IL-6 o It is secreted by T-cells, macro-phages, muscles & osteo-blasts.
Pro-inflammatory properties, coagulation activation.
4. IL-7 o It is involved in B-cell, T-cell & NK cell survival, development & homeo-
stasis.
5. IL-10 o It has anti-inflammatory properties.
6. γ-interferon o It is produced by T-cells & induces MHC II proteins.
7. TNF o It is an appetite suppressant.
 Macro-phages are responsible for predominantly releasing ILs.
95
NEO-PLASIA
 Un-controlled (autonomous) growth would best distinguish a lesion as a neo-plasm rather than
a granuloma.
 Well-defined encapsulation of a lesion tends to point towards a benign neo-plasm rather than a
malignant one.
 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
commonest 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.
CANCER ONCO-GENES
Onco-gene Tumor
 Erb B2. o Growth factor receptor onco-gene.
 Erb B3. o Breast.
 C-abl. o CML.
 N-myc. o Neuro-blastoma.
 C-myc. o Burkitt's lymphoma.
 K-ras. o Colon (cecal adeno-carcinoma).
PARA-NEO-PLASTIC SYNDROMES
Para-neo-plastic syndrome Tumor
 Dermato-myo-sitis. o Breast carcinoma.
 Acanthosis nigricans. o Gastric carcinoma.
 Trousseau's superficial migratory thrombo- o Pancreatic carcinoma.
phlebitis.
 Pure RBC aplasia. o Thymoma (masaoka calssification).
 ↑ ADH & ACTH. o Small-cell carcinoma of the lung.
TUMOR-CHROMO-SOME ASSOCIATION
Chromo-some Tumor
 1 o Neuro-blastoma.
 9 o Bladder TCC.
 11p o Wilm's tumor.
 13 o Retino-blastoma.
 17 o Neuro-fibroma & osteo-genic sarcoma.
 17q21 o Breast cancer.
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SITE-SPECIFIC TUMORS
 Sarcomas are commonest in extremities.
 They spread initially via fascial planes.
 Sarcomas often metastasise via haematogenous route to the lung (commonest site).
 Lipo-sarcoma is the commonest soft tissue sarcoma & is radio-resistant.

 Malignant fibrous histiocytoma is the commonest variant of sarcoma & lipo-sarcoma is the 2nd
most common.
SKIN
 TNM staging of SCC:
1ry tumor (T) Regional LNs (N) Distant mets (M)
o Tis: pre-invasive cancer (carcinoma o N0. o M0: no distant mets.
in situ). o N1: movable homo-lateral o M1: distant mets.
o T1: ≤ 2 cm. regional LNs.
o T2: 2-4 cm. o N2: movable contra-lateral or
o T3: > 5 cm. bi-lateral regional LNs.
o T4: extension to bone, muscle, skin, o N3: fixed regional LNs.
antrum, neck, …
 Xero-derma pigmentosum is characterized by defective DNA repair.
LEUKEMIAS, LYMPHOMAS & MULTIPLE MYELOMA

AML CLL CML Leukemoid reaction
1. ↓ RBCs. 1. ↓ RBCs. 1. ↑ WBCs (e.g. 1. ↑ WBCs (e.g.
2. ↓ platelets. 2. ↓ platelets. 100.000/mm3). 50.000/mm3).
3. ↑ WBCs. 3. ↑ WBCs. 2. ↓ LAP (leuco-cyte 2. ↑ LAP.
4. Blasts with Auer 4. Numerous small alkaline
rods. mature lympho- phosphatase).
5. Splenomegaly. cytes.
 Hodgkin's lymphoma is characterized by:

1. Low-grade fever, night sweats & malaise.
2. Non-tender cervical & supra-cervical lymph-adenopathy with Reed-Sternberg cells.
 Burkitt's lymphoma (a type of non-Hodgkin's lymphoma associated with EBV) presents with
enlarged lower jaw, blast cells & macro-phages.
 Multiple myeloma:
1. Bone pain. 6. +ve semi-quantitative sulpho-salicylic acid
2. Renal in-sufficiency. test for urine protein (Bence Jones protein).
3. Hyper-Ca. 7. -ve urine dip-stick test for protein (most
4. Skull X-ray: mmultiple osteo-lytic lesions. sensitive for albumin, not globulins).
5. Bone marrow biopsy: numerous plasma cells.
TESTIS
 TNM staging of seminoma:
1ry tumor LNs Serum tumor marker
o Ts: intra-tubular germ cell neoplasia o N0: no regional o S0: normal.
(carcinoma in situ). LN mets. o S1: LDH < 1.5 times the reference, β-
o T1: tumor limited to testis/epididymis o N1: LNs ≤ 2 cm. hCG < 5000 mIU/ml & AFP < 1000
– invasion of tunica albunginea. o N2: LNs 2-5 ng/ml.
o T2: vascular or lymphatic invasion – cm. o S2: LDH 1.5-10 times the reference,
invasion of tunica vaginalis. o N3: LNs ≥ 5 cm. β-hCG 5000-50.000 mIU/ml & AFP
97
o T3: invasion of spermatic cord. 1000-10.000 ng/ml.

o T4: invasion of scrotum. o S3: LDH > 10 times the reference, β-
hCG > 50.000 mIU/ml & AFP > 10.000
ng/ml.
 NSGCTs have a poorer prognosis than seminomas.
 Sertoli-leyding tumor (arrheno-blastoma) is a hormone-producing tumor that secretes

testosterone.
98
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).
 Exo-toxin production is the mechanism for patho-genesis in:

1. Pseudomonas infection.
2. Diphtheria infection.
3. Tetanus.
 The outer membrane is found in gram –ve but not in gram +ve bacteria.
 Steven-Johnson syndrome (erythema multi-forme major) is a recognized serious side effect of

sulphonamides.
 Risk of wound infection can be ↓ by:

1. Administration of prophylactic anti-biotics.
2. Iodophor impregnated drapes.
Oragnisms
 Staph. aureus causes:
1. Folliculitis which is inflammation of ≥ 1 hair follicles.
2. Infective endo-carditis in IV drug abusers.
3. Meningitis where gram staining of CSF reveals gram +ve cocci in grape-like clusters.
It is assumed to be a β-lactamase-producing organism until the laboratory reports its anti-biotic
sensitivity & the drug of choice will be methicillin as it is also bactericidal & is not associated with
toxicity.
 It produces coagulase which is used for its identification in the laboratory as this enzyme causes
clotting of plasma (formation of fibrin).
 Staph. aureus is the commonest causative agent in:

1. Bacterial parotitis. 6. UTI after cysto-scopy.
2. Septic arthritis (children & adults). 7. Vertebral osteo-myelitis.
3. Prothetic joint infections (50%). 8. Psoas abscess.
4. Balanitis. 9. Mycotic AAA (+ strept. & salmonella).
5. Breast abscess.
 Staph. epidermidis (aerobic cocci, co-agulase -ve) is the commonest causative agent for plastic
devices colonization.
 Strept. viridans is the commonest causative agent for infective endo-carditis in ab-normal heart
valves.
Endo-carditis with staph. aureus is most likely to be associated with a mycotic aneurysm.
 Strept. bovis septicaemia is associated with carcinoma of the colon & can also cause endo-
carditis.
Invest.: colono-scopy.
 Clearance of strept. pneumoniae from the lung parenchyma is accomplished through generation
of hydrogen peroxide by the major inflammatory cell type responding to this infection.
 E. coli is the commonest causative agent for:

1. Bacterial pyelo-nephritis & cystitis (after catheter introduction into the urethra).
2. Cholangitis.
99
3. Epi-didymitis.
4. Fournier's Gangrene (+ mixed flora, bacteroides).
 It produces vero-toxin.
 E. coli septicemia:
1. Delirium, confusion & un-co-operation. 3. Hypo-tension, tachy-cardia & tachypnea.
2. High grade fever (> 39oC). 4. Urinary WBCs > 200/HPF.
 Entero-invasive E. coli: necrosis & ulcers of the large bowel, bloody diarrhea, tenesmus.
 hemo-philus influenza: epi-glottitis.
 Widal test is a serological test for Salmonella typhi.
 Brucellosis (un-dulant or Malta fever) is transmitted by un-pasteurized milk.
 Clostridium:
1. Difficile: diarrhea after AB therapy (co-amoxiclav, 3rd generation cephalo-sporins “ceftazidime”).
- Diagnosis: toxin in faeces.
- Colono-scopy: elevated yellow-white plaques (coalesce to form pseudo-membranes on the
mucosa) (pseudo-membranous colitis).
- Complications: electrolyte disturbance, paralytic ileus, toxic mega-colon, endo-toxic shock, bowel
perforation.
- TTT: oral metronidazole & vanco-mycin. If severe → IV metronidazole & oral vanco-mmycin.
2. Perfringens: causes:
1) Gas gangrene (ttt: clindamycin & metronidazole).
2) Food borne illness – within several hours.
- Staph. aureus: entero-toxin – rapid onset of symptoms.
3. Botulinum → fetal food poisoning (botulism).
 Cryptosporidium parvum: protozoal infection, immuno-compromised (AIDS), diarrhea.

Stool micro-scopy: acid-fast cysts.
 Lacto-bacillus is a gram +ve facultative an-aerobe bacteria (bacilli) present in the vagina & GIT.
It produces lactic acid making its environment acidic.
 Bacteroides fragilis is a gram –ve obligate an-aerobe bacillus of the gut.

It is involved in 90% of an-aerobic potential infections.
 Cholera toxin continually stimulates adenylate cyclase to over-produce cAMP by catalyzing the
binding of ADP-ribose t Gs protein.
 The respiratory tract is the commonest portal of entry in Blastomyces dermatidis.
 An abscess containing sulphur granules is a feature of action-mycosis.
 Greenish pus ear discharge is characteristic of pseudomonas aeruginosa.
 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.
100
 Interferon-α & ribavirin are the treatments of choice for hepatitis C (single stranded RNA virus).
 Hepatitis B: double stranded DNA virus.
 Birds are a recognised reservoir of camylobacter jejuni, fever, malaise, severe abdominal pain &
diarrhea.
 Giardia causes fat mal-absorption, therefore greasy stool can occur. It is resistant to
chlorination, hence risk of transfer in swimming pools.
 Infection with enterobius is extremely common. Pruritus is the main symptom.
 Vibrio cholera: very loose & watery stools.
 Yersinia entero-colitica can be mistaken for acute appendicitis due to mesenteric lymphadenitis
& ileitis. Yersinia infection of the terminal ileum typically produces more marked clinical changes
of this segment of bowel than infection with campylobacter.
 Yersinia pestis causes plague.
 Ascaris lumbricoides: sub Saharan Africa or far east (india), worms & eggs in stool, coughing due
to migration of the larva through the lungs.
 HIV: p24 antigen test.
DIS-INFECTION & OT SET-UP

Sterilization method Isntruments
Glutaraldehyde Endoscopic equipment.
Chemicals (formaldehyde & ethylene oxide) Flexible cysto-scope.
 Povidone-iodine is active against spore-forming organisms.
 Chlorhexidine → bacterial cell membrane disruption.
 UV light is used as an anti-microbial physical agent because it causes the formation of pyrimidine
dimers.
 Bowie-Dick test is used to test steam penetration at the center of a load in an autoclave.
 Browne’s tube is used to identify when instruments have completed the sterilisation process.
 In desiccation the device is placed in direct contact with the tissues (un-like fulguration).
Because it is applied over a broad area it tends not to cause protein damage (un-like coagulation).
 Fulguration typically avoids contact between the electrode & the tissue with the current
configured to favor arc formation.
 Cutting current: sinusoidal, non-modulated wave-form → vaporisation & cleavage of tissues.
 Mono-polar diathermy produces a local heating effect up to 1000OC.

Heat is generated by the passage of high frequency alternating current through body tissues.
 Bi-polar diathermy: low current, low voltage, very high frequency.
 Torniquet is not appropriate for debrideent of a traumatic dirty injury to the lower limb (it
prevents assessment of the de-vascularized zone of injury).
101
PHARMACOLOGY
ANTI-BIOTICS
Drug Uses Mechanism of action
 Meropenem o Meningitis & pneumonia.
 Inhibition of bacterial wall synthesis.
 Co-amoxclav o
 Ciprofloxacin o Pulmonary anthrax.  Inhibition of bacterial DNA replication &
(quinolone) "drug of transcription (DNA gyrase).
choice"
 Doxycycline o Prostatitis, sinusitis,  Inhibition of protein synthesis by
syphilis & chlamydia preventing the amino-acyl tRNA from
infections. binding to the A site of the ribo-some.
 Amikacin o Pneumonia caused by  Inhibition of protein synthesis by binding
pseudo-monas aeruginosa. to the 30S sub-unit of the ribo-some.
 Di-cloxacillin o Folliculitis.
(penicillin) o Group A stept.
 Tri-methoprim o UTIs.  Inhibition of di-hydro-folate reductase.
 Tazobactam  Inhibition of β-lactamase.
 Pipera-cillin "1st o Pneumonia caused by
choice" pseudo-monas aeruginosa.
 Azlo-cillin "2nd choice"
 Oral vanco-mycin o Clostridium difficile 
infection.
o MRSA (or rifampicin).
 Linezolid o MRSA.  Inhibition of initiation of bacterial
protein synthesis.
 Erythro-mycin  Inhibition of trans-location of peptides
(macrolide anti-biotic) (protein synthesis).
 Fusidic acid o Staph. aureus wound  Inhibition of the trans-location of
infection. elongation factor G from ribo-some.
 Ceftriaxone (3rd
generation cephalo-
sporin)
 Genta-mycin o Gram –ve sepsis.  S/E: disturbed hearing & loss of balance.
 Metronidazole o  Inhibition of bacterial DNA synthesis.
NAUSEA, VOMITING, DIARRHEA & CONSTIPATION

 Ondasetron o Chemo-therapy-  Serotonin antagonist.
induced vomiting.
 Di-phenoxy-late o Non-infective  Opiate agonist slowing down intestinal
 Loperamide diarrhea. contractions.
 Methyl-cellulose o Chronic constipation &  Holds water in the stool.
 Psyllium diverticulosis.
 Metoclopramide o Nausea & vomiting.  Dopamine antagonist.
 S/E: extra-pyramidal dis-orders (oculo-gyric
crisis)
 Docusate Na o Constipation &  Lowers the surface tension of the stool
hemorrhoids. facilitating penetration of water & fats.
ANALGESICS
 Sufentanil o Pain relief for a short period of time.  Opiate agonist.
102
 Tramadol o Pain relief.  Modulation of GABAergic, nor-

adrenergic & serotonergic systems.
 Morphine o Analgesic of choice in acute myo-cardial  Stimulation of µ receptors.
infarction.  S/E: constipation
 NSAIDs  Inhibition of cyclo-oxygenase.
 Naproxen  Non-selective COX inhibitor.
ASPIRIN (ACETYL SALICYLIC ACID)

 It ↓ thromboxane A2 formation in platelets producing inhibition of platelet aggregation.
Warfarin dose must be ↓ if taken simultaneously with aspirin.
 It ↓ pain by ↓ the production of Pgs & thromboxanes through non-competitive & irreversible
inhibition of COX enzyme.
 It exerts a protective effect against colon cancer.
 Its effects last for 10 days.
ANTI-FUNGAL DRUGS
Drug Mechanism of action
 Ketoconazole o Inhibition of the fungal ergosterol synthesis.
 Griseofulvin
 Fluconazole o Inhibition of cyto-chrome p450.
ANTI-ULCER DRUGS
 Cimetidine  Competitive inhibition of H2 receptors.
 Lansoprazole  Irreversible inhibition of H+/K+ ATPase.
CHEMO-THERAPEUTIC AGENTS
 Etoposide o Lung cancer.
 Vincristine o Hodgkin's lymphoma.  S/E: peripheral neuro-pathy.
 Cisplatin o Small-cell lung cancer.  Cross-linking of DNA → inhibiton of mitosis.
 Epirubicin o Breast cancer.  Intercalation of DNA.
 Rapamycin  Inhibition of IL-2.
 5-fluoro-uracil  Anti-metabolite (inhibits DNA & RNA synthesis).
CHEMO-THERAPY REGIMENS (ACRONYMS)

Cancer Regimen
 Colo-rectal  FOLFOX (FOL= 5-fluro-uracil – F= Folinic acid1 – OX= oxaliplatin).
 Hodgkin's lymphoma  ABVD (Adria-mycin – Bleo-mycin – Vinblastine - Dacarbazine).
 Non-Hodgkin's  CHOP (Cyclo-phosphamide – Hydroxy-rubicin – Oncovin (vincristine) -
lymphoma Prednisone).
1 It is used as an Adjuvant chemo-therapy for colo-rectal carcinoma as it enhances the effect of 5-fluro-uracil.
103
ADRENALINE, NOR-ADRENALINE & DOBUTAMINE

 Adrenaline stimulates β-receptors inducing lipolysis – inotrope affecting myo-cardial
contractility.
 Nor-adrenaline is α1 agonist → VC → ↑ BP & CO.

It is the 1st choice in septic shock followed by dopamine.
 Dobutamine (sympatho-mimetic): prominent β1-effect (cardiac receptors), mild β-2 & α effects.
 Salbutamol → stinulation of β-receptors → tachy-cardia.
 Stimulation of either β1 or β2 receptors activates adenylate cyclase.
 α-adrenergic β-blockers → ↓ release of insulin.
MISCELLANEOUS
 Atorvastatin o After coronary a. by-pass surgery.  Inhibits cholesterol synthesis.
 Na nitroprusside o After repair of an AAA.  Vaso-dilator (peripheral).
infusion o In cardio-genic shock.
 Desmopressin o Mild hemo-philia A & thrombo-cyto-penia  It induces the release of stored
which occurs after a prolonged surgery F8 & VWF.
on cardio-pulmonary by-pass.
 Abciximab o Prevention of re-stenosis after angio-  Inhibition of platelet
plasty. aggregation.
 Strepto-kinase o Myo-cardial infarction & pulmonary  It is usually given once because
embolism. of the risk of allergic reaction.
 Carbachol o Open-angle glaucoma & during cataract  It is a para-sympatho-mimetic
surgery. that causes miosis & ↑ flow of
aqueous humor.
 Mexiletine o Ventricular arrhythmias.
 Buspirone  Anxio-lytic.
 Spironolactone  K-sparing diuretic (↑ Na+
excretion & ↓ K+ excretion).
 Mithra-mycin o Hyper-Ca of malignancy.
 Methimazole  Inhibition of the addition of
 Propyl-thio-uracil iodide to thyro-globulin.
 Cyclo- o It is one of the alkylating agents.  S/E: urinary bladder cancer.
phosphamide
 Methotrexate o Crohn's disease.  Inhibition of T-cell activation.
 S/E: folate deficiency.
 Nitrates  Vaso-dilatation of large veins.
 Drugs causing SIADH: ABCCD (Analgesics, Barbiturates, Cyclo-phosphamide, Carpamazepine &

Diuretic).
 Chemo-therapy for acute myeloid leukemia: Groshong line.
 Nadolol is poorly lipid-soluble.
104
GENERAL
SURGERY
105
SKIN GRAFT
Full thickness Split thickness
 Epi-dermis + variable amount of dermal
appendages.
 Require well vascularized & non-contaminated
bed (higher metabolic requirements).
 Resist contraction.  Shrink considerably.
 Have a potential for growth, maintain the texture
& pigmentation similar to normal skin.
 Better cosmesis.
 Higher rate of failure.  Higher rate of survival.
WOUNDS & SCARS

Keloid scars: children & adults, sternal, mandibular & deltoid areas, extend beyond the margins of the
wound, often recur following excision, may occur even after superficial injury.
TTT: injection of triamcinolone.
Hyper-trophic scars: afro-caribbean, confined to the wound edges.

TTT: intra-lesional steroids, pressure therapy, silicone gel.
Abdominal wound dehiscence: commonest at 6 days.

Early: sero-sanginous fluid.
TTT: remove 1-2 stitches, if there is separation of rectus fascia → 1ry closure.
Wound granulation tissue:

TTT: topical silver nitrates to cauterize it.
Infected & exuding wounds (e.g. diabetic foot ulcers) → iodien-based dressings (bacteriocidal).
BURNS
Full thickness burn →
1. Surgical debridement (burn wound excision).
2. Early Split thickness skin grafting.
Parkland formula = 2-4 X % burn X weight (kg) = No. ml. over 24 hours (1/2 the volume in the 1st 8
hours).
Small blisters → non-adherent dressing.

Large blisters (> 1 cm2) → de-roofing.
Indications of intubation:
1. Change in voice.
2. Facial burns.
3. Singed nasal hair & eye-brows.
Hydro-fluoric acid burn: deep penetration into tissues.

TTT: copcious lavage with water, topical Ca glucoante, systemic Ca.
106
SKIN LESIONS History S Color Site Other features TTT

Pyogenic granuloma Red (purple) Contact bleeding, ulceration
Trauma1
Dermato-fibroma F May be pigm. Extremities Often larger than they appear
Seborrheic warts (keratosis) Pigmented Trunk Superficial, itchy, sebum (greasy), keratin plugs Shave biopsy (excision) & cautery – pathology
Dermatitis herpitiformis Extremities Itchy, blisters
Painful, ulcerated, Margherita pizza (red base,
Pyoderma gangrenosum2 IBD (Crohns) Lower limbs Steroids
yellow topping)
Kerato-acanthoma3 Red Origin: epi- Nodule, central defect with keratin, rapid growth, spontaneous resolution with scarring
SCC4 Sun (farmer) M dermis Lymphatic > blood spread – If perineal & genital: HPV 16 & 18.
BBC5 Pearly white edges Raised edges, overlying telangectasia, ulcerated < 2 cm: 0.5 cm safety margin
M & F: back
White fair-haired, Excision (NO BIOPSY), Berslow thickness (depth of
Melanoma6 Dark F: legs (better Familia: CDK4 – CDK N2A – BRCA 1.
blue eyed people tissue invasion, 4 stages): 1-2-4 mm → 1-2-3 cm
(pigmented) prognosis)
Acanthosis nigricans GI malig. Axilla Velvety
If infected → I&D, wall excision & defect

Central punctum (epithelial defect), cyst wall, if infected
Sebaceous cysts7 Scalp
→ superficial ulcer (Cock’s peculiar tumor) packing
Pilar cysts Sebum (foul smelling cheesy material), surrounded by outer root sheath of hair follicle
Punch biopsy (full thickness tissue with minimal
Lichen sclerosis Elderly Benign
disruption)
Dermoid cyst Mid-line of scalp, neck & lower jaw May contain hair, keratin & sebaceous glands Excision
Kaposi’s sarcoma HIV Purple Mucous m. May be multiple, patch → plaque & polypoid Biopsy
Oslers nodes (tender, purple/red, raised lesions with pale centre): endo-carditis & SLE – Dercum disease (adiposis dolorosa): multiple lipomas – Pyo = red * D = extremities.
Hydradenitis suppurativa (HS): chronic suppurative diseaes of apocrine sweat glands – axilla (limitation of shoulder abduction), groin & perineum.
Cutaneous anthax: IVDU, ulcer, black eschar.
Sclero-derma (CREST): Calcinosis cutis (Ca deposits in skin), Raynaud’s phenomenon, Esophageal dys-function, Sclero-dactyly & Telangiectasia syndrome.
Pigmented lesions with regular borders & normal dermal appendages are mostly benign: diagnostic excision (NO BIOPSY).
Punch biopsy is advisable for long standing or non healing lesions (e.g. suspected malignant change of a venous ulcer).
1 Koebner phenomenon: skin lesions that appear at the site of injury (e.g. insect bite, Marjolin’s ulcer).
2 Vs. Merkel cell tumor – SCC.
3 Vs. Amelanotic melanoma.
4 Pre-malignant: solar (senile or actinic) keratosis (old, white, TTT: curettage, electro-essication or cryo-therapy with liquid nitrogen), Bowen’s disease (SCC in situ, epi-dermis, legs), leuko-
plakia (oral, vulval or vaginal – cannot be scrapped off) – smoking & alcohol.
5 Commonest skin carcinoma of the head & neck.
6 Vs. Spitz nevus – types of melanoma: superficial spreading (most common), lentigo maligna (face & neck, elderly, F, > 3 cm), acral (palms, soles & nails, dark-skinned people).
Features of malignant trans-formation of nevus (aggressiveness): change in size, shape or color – bleeding, ulceration, crusting or itching – satellite spots within 2 cm of 1ry site.
7 Fordyce’s granules: creamy spots of sebaceous glands, around the vermilion border of the lips.
107
HEAD & NECK LESIONS

Sub-hyoid
Mid-line lesions Dermoid Thyro-glossal cyst
bursa
F, 15-30 years
Relation to hyoid Above Below (between hyoid & thyroid Between hyoid
isthmus) bone & thyro-
Movement with tongue hyoid
(connection with foramen No Yes membrane
cecum)
small, smooth & round,
Multi-locular & commonest mid-line neck cyst in
heterogenous children.
Pre-op. invest.: Isotope scan.
Sistrunks procedure (excision of
cyst, its track, central portion of
TTT
hyoid & wedge of tongue muscle
behind hyoid).
Acute bacterial tonsillitis

Glandular fever (EBV) Diphteria
(strept. pyogenes)
Cervical lymph-adenopathy
Enlarged tonsils meeting in the mid-line.
(bulls neck appearance).
Splenomegly. Fever but systemically well. Systemically un-well.
Pharyngitis, oro-pharyngeal petechial White film with bleeding on Thick grey membrane with
hemorrhages (if penicillin is given). removal. bleeding on removal.
Cystic hygroma Branchial cyst

Posterior ∆. Anterior ∆ – Lt – junction of upper & middle 1/3 of SCM.
Young adults (15-25 years, rare > 40 years) – soft – aspiration shows
Soft – trans-illuminates.
opalescent fluid containing cholesterol crystals – stratified sqamous.
Nerves at risk durign excision (mandibualr branch of 7th CN, great auricular
n. & accessory n.).
Quinsy: strept. pyogenes, uni-lateral tonsillar swelling & fever.

TTT: surgical draianage.
Bleeding after tonsillectomy:

Source: external palatine v. (lateral to tonsis).
Reactionary: 1st 24 hours → return to theater.
2ry: after 1st 24 hours = 5-10 days → admission & ABs (infection) (Feeding does not ↑ the risk & may
actually ↓ it).
Idiopathic epistaxis:
Commonest site: Kiesselbac’s plexus (internal & external CAs) = Little’s area (anterior nasal septum).
It has no association with HTN.
Naso-pharyngeal carcinoma: Hong Kong, EBV, Trotter’s triad: ipsi-lateral:

1. Facial & ear pain.
2. Conductive HL.
3. Soft palate paralysis.
TTT: chemo-radio-therapy.
Epi-glottic carcinoma: referred otalgia (the epi-glottis is supplied by the vagus n.).
Laryngeal tumors: papillomas are commonest benign tumors – msot malignant tumors arise on vocal
cords.
108
Chest X-ray & NT examination (naso-endoscopy) are mandatory before taking deep cervical node
biopsy.
SINUSES
Osteo-myelitis (rare) most commonly develops from the frontal sinus → sub-peri-osteal abscess
(Pott’s puffy tumor) – strept., staph. & anerobes – TTT: surgical drainage & IV ABs.
Ethmoidal sinusitis:
Fever, swelling overlying the supero-medial aspect of the eye, purulent discharge from the inner
canthus, spread to the peri-orbital tissues results in peri-orbital cellulitis (proptosis, conjunctival
edema, lost color differentiation).
Ethmoid sinus cancer:

Wood work, nasal pain, anosmia, rhinorrhea.
Pathology: adeno-carcinomas.
Maxillary sinus cancer: African, Arabic or Jabanese – harwood, nickel, radiation, mustard gas, boot
making.
Anosmia, nasal obstruction, epistaxis, proptosis, diplopia, nerve invasion.
EAR
Pre-auricular sinus:
Epithelial defect anterior to the ear, foul smelling discharge.
Malignant otitis externa:

Immuno-compromised (e.g. DM), pseudomonas (greenish pus), severe otalgia, 7th CN palsy.
Spread outside the EAC occurs through the fissures of Santorini & the osseo-cartilaginous junction.
Acute suppurative otitis media:

Young children, ear pain, rupture of the tympanic membrane (rare) → foul smelling fluid from the ear.
Commonest complication: glue ear (otitis media with effusion) which is the commonest cause of HL
in children.
Cholesteatoma:
Long history, foul smelling ear discharge, HL, 7th CN palsy.
It should be completely removed at initial surgery.
Otitis hydro-cephalus: children & adolescents, middle ear infection, un-known etiology, ↑ ICP (no
brain abscess), headache, 6th CN palsy & papilledema.
SALIVARY GLANDS
Parotid pleo-morphic adenoma: commonest benign parotid tumor.
Posterior to angle of mandible, inferior to ear lobule, benign, malignant trans-formation (sudden ↑ in
size, skin involvement, fixation, 7th CN palsy, trismus, mets “neck lump”, medialisation of palatine
tonsil).
Pathology: bi-phasic (epithelial & stromal “mesenchymal”) – mucinous CT – fibrous pseudo-capsule.
TTT: superfical parotidectomy (NO BIOPSY).
Complication: Frey’s syndrome (redness & sweating in the cheek with meal times, ab-normal re-
generation of sympathetic & para-sympathetic supply of the parotid).
Parotid adenoid cystic carcinoma:

Commonly infiltrates 7th CN → neuro-pathy & facial pain.
Warthin’s tumor: commonest bi-lateral benign tumor, elderly, smoker.
Sub-mandibular gland:
109
Commonest site for salivary calculi, pain which is worse on eating.

TTT: if the lesion is distal → the duct may be laid open & the stone excised – gland removal.
Neuro-vascular injury: mandibualr branch of 7th CN, lingual n. & 12th CN – faical a. & retro-mandibular
v.
Suspected sub-mandibular gland malignancy: gland excision.
Granulomatous sialo-adenitis: most commonly TB, 2ry to regional LN involement & in sub-
mandibular gland.
1ry Sjogren's syndrome:

F, post-menpausal, multi-system involvement (dry eye, dry mouth1 & symmetrical salivary glands
swelling), ↑ rheumatoid factor.
2ry Sjogren's syndrome: co-existing CT ab-normality (most commonly rheumatiod arthritis).
Sarcoidosis: Afro-caribbean, fever, weight loss & shortness of breath.

Bi-lateral parotid enlargement, bi-lateral 7th CN palsy, splenomegaly, pulmonary inter-stitial disease.
Non-caseating epithelioid granulomas in ≥ 1 organs & tissues, hilar lymph-adenopathy (Asteroid
bodies), hyper-Ca.
Mumps: young adult, viral parotitis (parotid swelling), pancreatitis/orchitis/HL/meningo-encephalitis.
TONGUE & ORAL CAVITY

Carcinoma of the tongue: M, > 40 years, anterior 2/3 (especially lateral margins), radio-sensitive,
common cause of death is aspiration pneumonia 2ry to dys-phagia.
Risk factors: as in SCC + HPV.
Amelo-blastomas: rare, odonto-genic epithelium, slow growing, cracking bone (crepitus) with
palpation.
Jaw cysts: enucleation – if infected → marsupialisation.
Lt cleft lip is more common than the Rt which is more common than bi-lateral cleft lip (6:3:1).
Incidence of cleft lip or palate: 0.1% - those who have one child affected: 4%.
NERVES
Uni-lateral Bi-lateral
Ab-normalities in pitch & in-
Superior laryngeal n.
ability to sing high notes.
Recurrent (inferior) laryngeal
Gargling voice. Stridor & aphonia.
n.
Superior laryngeal n.: crico-thyroid muscle – tenses the vocal cords – singing high notes.
1 Salivary flow ↑ with nausea.
110
THYROID GLAND
Thyro-toxicosis:
Commonest casues: Grave’s disease (commonest), toxic multi-nodular goitre, toxic solitary nodule.
Hyper-Ca (bone resorption).
< 1% of functioning adenomas show enough secretory activity to cause hyper-thyroidism.
Invest.: ↑ free T3 & T4 (T3 is 3-5 times more active) – ↓ TSH.
TTT:
Medical: β-blockers, thionamides, carbimazole (causes sialo-megaly & gyneco-mastia), propyl-thio-
uracil (used in 1st trimester), radio-iodine (not used if there are eye signs).
If failed → total thyroidectomy (commonest complication is hypo-Ca).
Grave’s disease: IgG ABs to TSH receptors on thyroid gland, F, 20-40 years.
Clinical: exophthalmos is more common than pre-tibial myxedema & finger clubbing.
High relapse rate with anti-thyroid drugs is noted:
1. In children.
2. When therapy is dis-continued.
3.
Hashimoto’s (chronic lympho-cytic) thyroiditis: anti-thyroid peroxidase (micro-somal) & anti-thyro-
globulin ABs, auto-immune, F, 30-50 years, lympho-cytic infiltration & fibrosis, predisposes to
lymphoma.
Commonest cause of hypo-thyroidism in iodine-defiicient areas.
Sub-acute thyroiditis: hyper-thyroid, tender, ↑ ESR, ↓ uptake on Technetium scan. TTT: not
required.
De-Quervain’s (sub-acute granulomatous) thyroiditis: viral infection, diffuse swelling, pain which is
worsened by swallowing & couhging. Invest.: ↑ T3 & T4 for 4-6 weeks then ↓.
Sick eu-thyroid syndrome: chronically-ill patient, starvation.

Invest.: mild ↓ of total & free T3 & T4 & TSH.
Large goiter with significant retro-sternal extension: dys-phagia. TTT: total thyroidectomy.
Hpo-thyroidism is the 2nd commonest cause of hyper-cholesterolemia after diet.
3ry hypo-thyroidism (hypo-thalamic failure): improves with TRH administration.
111
Thyroid nodules: U/S & FNAC.
Recurrent filling thyroid cyst → resection of the ipsi-lateral thyroid lobe.
THYROID CARCINOMA
Papillary Follicular Anaplastic
F, 35-40 years Caucasian F, elderly (60-70 years)
Commonest (80%) Less common (20%) Less common
Iodine deficiency & multi-
Childhood radiation exposure Iodine deficiency
nodular goitre
Non-capsulated, Psammoma Hard, hoarse voice, (tracheal
Encapsulated, Hurthle (oxyphil)
bodies (calcification) = Orphan compression & RLN
cells → worse prognosis
Annie nuclei involvement)
Lymphatic spread, multi-focal Blood (lung, skull) Both
FNAC→ total thyroidectomy +/-
Hemi- or total thyroidectomy &
regional LN clearance & radio- Palliative de-compression, RT
radio-active iodine1
active iodine
Excellent prognosis (5-year Serum thyro-globulin is the
survival is 90%) initial assesment for recurrence
Features of malignancy: hard fixed mass, laryngeal n. palsy, LN involvement & Berry’s sign (absent
carotid pulse due to malignant thyro-megaly).
Medullary carcinoma:
Sporadic: uni-lateral, spread early to cervical LNs.
Familial (MEN II) (20%): bilateral, multi-centric. TTT: prophylactic thyroidectomy.
1 FNAC cannot distinguish between follicular adenoma & carcinoma.
112
PARA-THYROID
Hyper-para-
1ry 2ry 3ry
thyroidism
Adenoma (85%), hyper-plasia Chronic renal failure (e.g.
Renal
(10-15%), carcinoma (1%). DM) → chronic hypo-Ca →
transplant
Commonly asymptomatic para-thyroid hyper-plasia
PTH ↑ ↑
Ca ↑ ↓ ↑
Phosphate (P) ↓ ↑
Urea & electrolytes Normal Ab-normal
ALP ↑
Elective para-
thyroidectomy
Para-thyroid adenoma (functioning):

C/P:
1. Stones (nephro-lithiasis). 3. Abdominal groans (peptic ulcer or
2. Bones (brown tumors, bone pain). pancreatitis).
4. Psychic moans (depression).
Invest.: combination of ultra-sound & sestamibi radio-nucleotide scan.

Bi-lateral neck exploration has the highest sensitivity & specificity in localizing para-thyroid adenomas.
↑ PTH (short half life = < 10 minutes) → ↑ serum Ca by:

1. Bone: ↑ osteo-clastic activity → ↑ bone resorption.
2. Kidney & GIT: ↑ conversion of 25-hydroxy-cholecalciferol → 1,25 di-hydroxy-cholecalciferol
(active form of vitamin D = calciterol) → ↑ Ca & P absorption from the gut1.
3. ↑ P excretion in PCTs & Ca re-absorption in DCTs.
TTT: adrenalectomy. If not fit → vitamin D, calci-mimetics & bisphosphonates (e.g. alendronate)2.
Indications of para-thyroidectomy:
1. Nephro-lithiasis. 3. ↓ bone mineral density > 2.5 SD below peak bone mass.
2. Age < 50 years. 4. Episode of life-threatening hyper-Ca.
Para-thyroid carcinoma: 5%.
Methylene blue stains para-thyroid glands.
1 1st step of hydroxylation occurs in the liver. 2nd step occurs in the kidney.
2 They ↓ serum Ca by inhibiting bone resorption through 2 mechanisms:
1) Binding to Ca-phosphate crystals in the bone inhibiting their break-down.
2) Inhibiting osteo-clasts function.
113
Ca Metabolism
Body Ca: 99% is bound in the skeleton, 1% is available for buffering changes in Ca balance. This 1% is
the total serum Ca which is composed of 3 fractions: protein-bound, complexed & free ionized.
Hyper-Ca: depression, fatigue, weakness, abdominal pain, constipation, confusion.

The commonest cause in hospitalized patients is metastatic cancer & in community is hyper-para-
thyroidism.
Hyper-Ca is the commonest para-neo-plastic syndrome (caused by ↑ level of PTH-related protein).
TTT:
1. IV fluids (0.9% Nacl, 4-6 L in 24 hours), bis-phosphonates (if Ca is > 3), diuretics.
2. IV Pamidronate (drug of choice, most effective & has long lasting effects), IV zoledronate (if
there is malignancy).
Hypo-Ca:
Neuro-muscular irritability & laryngo-spasm.
Trousseau’s sign: clawing of the hand on applying a blood pressure cuff.
Chvostek’s sign: spasm of the facial muscles after tapping the facial n. below & infront of the ear.
TTT: 10ml of 10% Ca gluconate over 10 minutes.
Familial hypo-calcuric hyper-Ca: ↑ serum PTH, Ca & Mg, ↓ urinary Ca, Ca:creatinine ratio < 0.01.
TTT: not required.
Osteo-malacia: F, post-menopause, ↓ Ca absorption from the gut, ↓ serum Ca, ↑ osteo-blastic

activity (osteoid formation = less dense).
PANCREAS ENDOCRINE
Gastrinoma
Glucagonoma Insulinoma
(Zollinger Ellison syndrome)
Duodenum (most common), pancreas α-cells Β-cells, benign
Secretory diarrhea, abdominal pain & Hyper-glycemia, diarrhea, weight Hypo-glycemia, improves with
C/P multiple ulcers. Invest.: somato- loss, necrolytic migratory erythema glucose administration.
statin sensitive scinti-graphy. (Zinc deficiency). Early mets. ↑ insulin, pro-insulin & C-peptide.
Invest. CT scan.
PPI, surgical excision or chemo-
TTT Resection. Enucleation (NO radical resection).
therapy.
Insulin deficiency → protein catabolism.

Diagnosis of type II DM: HbA1c > 6.5% (48 mmol/mol).
114
ADRENAL GLANDS
Conn syndrome (1ry hyper-aldosteronism): F, 30-50 years.
Clinical: HTN, ↑ Na, ↓ K & renin & metabolic alkalosis – abdominal distension, weakness, ileus.
TTT: spironolactone (aldosterone antagonist) or adrenalectomy.
Drugs with the suffix “pril” (lisinopril, ramipril) antagonize the action of aldosterone → ↑ Na
excretion.
Cushing Syndrome (↑ cortisol)

Iatrogenic (gluco-corticoids for Adrenal Pituitary Ectopic
chronic conditions e.g.COPD) cause adenoma ACTH
ACTH Commonest cause - ↑ ↑
Dexamethasone suppression S/E: avascular necrosis of bone &
- ↓ ↑
test (morning cortisol) osteo-porosis.
Earliest manifestation: loss of diurnal variation.
Congenital adrenal hyper-plasia: 21-hydroxylase deficiency, F (pseudo-hermaphroditism) & M

(precocious maturity).
If late onset → partial enzyme deficieny.
Addison’s disease: destruction of zona glomerulosa & fasiculata, ↓ cortisol.

Weakness & easy fatigability, anorexia, nausea, vomiting, weight loss, diarrhea.
↑ K, ↓ glucose, Na & BP.
1ry: adrenal cortical defect (↑ skin pigmentation) – 2ry: pituitary does not produce ACTH (no
pigmentation).
Acute adrenal in-sufficiency: TTT: IV hydro-cortisone 100 mg.
Abrupt dis-continuation of cortico-steroid therapy without tapering the dose is the commonest
cause of Addisonian crisis (acute adrenal failure).
Adrenal Small (2.5 cm): most are incidental, benign & non-functioning → hormonal assay.
lesions: Large (> 4 cm): 25% are malignant → adrenalectomy.
Adrenal cortical carcinoma: F, bi-modal age distribution, functioning tumors (secreting cortisol), early
mets.
TTT: adrenalectomy or chemo-therapy +/- RT.
Pheo-chromo-cytoma: chromaffin cells (adrenal medulla), ↑ catecholamines, bi-lateral (10%), benign

(90%).
α-receptors → vaso-constriction (HTN, 90%).
β-receptors → tachy-cardia (palpitations) & ↑ cardiac contractility.
Hyper-glycemia (↓ insluin) & glycosuria.
Invest.: 24-hour urinary catecholamines, metanephrines & vanillyl-mandelic & homo-vanillic acids
(VMA) – meta-iodo-benzyl-guanidine (MIBG) scinti-graphy.
TTT: α- & β-blockers → adrenalectomy.
Water-house-friderichsen syndrome:
Adrenal gland failure due to bleeding into it (usually bi-lateral).
Cause: severe bacterial infection (meningo-coccus, Nisseria meningitidis)
115
SYNDROMES
MEN (AD)
MEN I MEN II A MEN II B
  Pheo-chromo-cytoma
 Medullary thyroid carcinoma
 Pituitary  Para-thyroid hyper-plasia  Marfanoid habitus
 Para-thyroid adenoma  Cutaneous lichen  Mucosal neuroma (visceral
 Pancreatic (gastrinoma = amyloidosis ganglio-neuromas)
Zollinger Ellison syndrome)
NF I NF II
 Plexi-form neuro-fibroma (difference in size between 2 lower limbs)  Bilateral vestibular
 Schwannoma schwannomas (VSs)
 > Café au lait spots, axillary freckling & Lisch nodules
 Optic glioma
 Meningioma, glioma
Cystic fibrosis: autosomal recessive, ab-normal gene encodes cAMP-regulated Cl- channel → ↑
sweat Cl-.
Bronchiectasis, recurrent chest infections, absent Vas.
Kartagener’s (immotile cilia) syndrome: sinusitis, sinus inversus.
Li-Fraumeni syndrome: sarcoma, leukemia, cancer of breast, brain & adrenal gladns, P53 gene
mutation.
Acute internittent porphyria (lead poisoning): abdominal pain, neurological signs.
Peutz-Jeghers syndrome:
1. Small bowel benign hamartomatous polyps.
2. Inguinal hernia.
3. Pigmented spots on lips, face, palms & soles.
Lynch syndrome (HNPCC): AD, mutation of mis-match repair genes.

Rt colonic malignancy, cancers of the stomach, endometrium & ovary.
Pathology: mucinous, poorly-differentiated, signet-ring appearance.
Fitz-Hugh Curtis syndrome (PID): chlamydia.

Fever, peri-hepatic adhesions (Rt upper quadrant pain), vaginal discharge.
Familial adenomatous polyposis (FAP):

Gardner’s syndrome: AD, mutation in APC gene on ch. 5.
1. Colonic polyps, retro-peritoneal desmoid tumors 3. Hyper-trophy of retinal pigment.
(myo-fibro-blasts). 4. Fibroms, epi-dermoids, sebaceous cysts.
2. Super-numerary teeth – jaw & skull osteomas.
Invest.: ophthalmo-scopy & DNA screening.
Felty’s syndrome: rheumatoid disease, splenomegaly, neutro-penia.
Cowden disease: PTEN mutation, intestinal hamartomas.
Liddie syndrome: HTN, renal K wasting (↓ K).
Gitelman’s $: AR or AD, hypo-K metabolic alkalosis, hypo-calciuria, hypo-Mg. normal or low

BP.
116
RENAL
Renal adeno-carcinoma (Grawitz tumor) (75%): yellow or brown.
M, smoking, frack hematuria, para-neo-plastic syndrome (HTN, polycythemia, hyper-Ca), mets to
bone (30%, hyper-vascular lesions).
Invest.: contrast CT.
Staging: TI (confined), TII (peri-nephric fat, limited to gerota’s fascia), TIII (A: renal v. – B: nodal – C:
both), TIV (A: adjacent structures, B: distant mets).
TTT: radical nephrectomy (NO biopsy or chemo-therapy).
Benign renal adenoma: usually < 2 cm.

Renal adeno-carcinoma: usually > 3 cm.
TCC of renal pelvis: pink, seeding down the ureter, multi-centric, smoking.
Cause: exposure to textile, plastic & rubber industry.
Nephro-blastoma (Wilm’s tumor): MF, child, bi-lateral (10%), mass, HTN, fever, hematuria.
Genetics: mutation or deletion of both copies of WT-1 tumor suppressor gene (ch. 11P).
TTT: nephrectomy & chemo-therapy.
Acute renal faliure: metabolic acidosis → ↑ respiratory rate → ↓ Na & Ca (all others ↑).
Acute renal tubular necrosis: following surgery → ↓ BP → medullary ischemia.

TTT: osmotic diuretics.
Kndneys are small in size on U/S in chronic renal failure except when this is due to amyloid or PKD.
Pyelo-nephritis: fever, loin pain, hematuria, dys-uria.

TTT: if on top of ureteric stone with difficult extraction → nephrostomy, IV ABs & fluid resuscitation.
Benign renal tumors: rare, msot important are oncocytoma & angio-myo-lipoa.
Tuberous sclerosis: hemorrhagic renal lesion, angio-myo-lipomata (20%), epilepsy, learning dis-ability.
Early manifestation of drug-induced nephro-toxicity → ↑ serum urea & creatinine.
117
RENAL TRANS-PLANT
HLA-DR is most important in matching.
Renal allo-graft is the most susceptible to donor-recpient HLA mis-match.
Types of graft: auto (self), iso- (twins, genetically identical), allo- (niece, not identical).
1st time criteria: Lt or Rt iliac fossa, Rutherford Morrison incision, external iliac A&V.
Post-trans-plant complications:
1. Hyper-acute rejection 2. Acute rejection 3. Chronic rejection
Minutes 11-14 days Several months-years
Complement-mediated Cell-mediated Poorly under-stood
Weight gain, oliguria, systemic
Pre-existing ABs to HLA Neo-intimal hyper-plasia of
un-wellness, swelling over the
antigens (IgG), thrombosis donor aretrioles
graft site
Reversed by anti-lymphocyte
Not reversed Not reversed
globulin
4. CMV is the commonest viral infection in solid organ trans-plant recipients (4 weeks – 6 months).
5. EBV: post-trans-plant lympho-proliferative disease (> 6 months).
6. G-ve bacilli (pseudo-monas aeruginosa & klebsiella pneumoniae): early post-trans-plant infection.
7. Renal a. stenosis: after several months, HTN. Invest.: duplex. TTT: angio-plasty.
8. Sudden loss of urine out-put in a trans-plant patient: blocked catheter (1st, do bladder wash),
arterial thrombosis (2nd).
9. Lympho-cele: swelling over the graft site, normal RFTs, limb swelling. TTT: surgery.
The leading cause of death after the 1st post-transplantation year is allo-graft coronary a. disease
(coronary athero-sclerosis causing ischemia).
Post-trans-plant medications:
NSAIDs (diclofenac) → nephro-toxic (better avoided).
Steroids → apoptosis (not necrosis) of activated lympho-cytes.
Immuno-suppressants:
Ciclo-sporin → nephro-, hepat- & neuro-toxic, gingival hyper-trophy.
Tacrolimus → avoid intake of grape fruit.
RENAL STONES
Ca phosphate Most radio-dense
Ca oxalate (most
Radio-dense
common, 80-85 %)
Inherited recessive metabolic dis-order (family
Cystine Semi-opaque Acidic urine
history).
Uric acid Radio-lucent Chemo-therapy & cell death.
Stag-horn, may predispose to SCC, urease producing
Alkaline
Struvite bacteria e.g. proteus, klebsiella, pseudomonas,
urine
entero-bacter.
Indinavir Radio-lucent Anti-retro-viral used in HIV.
C/P: renal pain, may radiate to groin, hematuria (macro- or micro-scopic).
Predisposing factors: de-hydration (diarrhea, vomiting).
Invest.: U/S → non-contrast CT KUB.
TTT:
- < 5 mm → follow up.
- < 2 cm → ESWL (contra-ind.: pregnancy, AAA, clotting ab-normality). If pregnant → uretero-
scope.
- Complex, multiple & stag-horn → PCNL (contra-ind.: clotting ab-normality).
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TRAUMA
Pelvic fractures + urine retention (no urine out-put):
+ in-ability to palpate the prostate by PR1 → membranous urethral rupture.
Invest.: retro-grade urethro-graphy.
TTT: U/S-guided supra-pubic catheterization.
+ extravasation into scrotal CT → anterior bulbar urethral rupture.
Pelvic fracture + ability to void + peritonitis → bladder rupture.

Extra-peritoneal is more common than intra-peritoneal.
Bladder lacerations are repaired in layers with absorbable sutures.
Iatrogenic urethral injury by a catheter inserted for urine retention → U/S-guided supra-pubic
catheter.
Previous placenta previa + CS → placenta percreta → bladder invasion → frank hematuria.
Fistulae:
Vesico-vaginal fistula: prolonged labor followed by drippling in-continence.
Colo-vesical fistula: sigmoid diverticular disease. Invest.: CT of the abdomen & pelvis. SEE COLON
BLADDER
TCC (90-95%): M, pain-less hematuria, weight loss (deletion of ch. 9).
Risk factors: smoking, benzidine, cyclo-phosphamide (hemorrhagic cystitis), rubber & dye (azo-dye as
β-naphthyl-amine), nitros-amine.
Staging: T1: lamina propria, T2: muscularis propria, T3: peri-vesical fat, T4: adjacent organs.
TTT:
If young & fit → radical cystectomy.
Co-morbidities → intra-vesical BCG therapy.
SCC (5-10%): solid & invasive.

Risk factors: schistosomiasis, long term endwellign catheter.
Invest.: flexible cysto-scopy.
Schistosomiasis: commonest cause of bladder calcification world-wide (Zimbabwe, Egypt).

Schistosoma hematobium → hematuria.
Bladder stoens: proteus, Mg-ammonium phosphate.
1 Normally, the prostate is palpable anteriorly, opposite the middle phalanx.
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PROSTATE
BPH: median lobe, hematuria.
TTT:
1. Medical:
- 5 α-reductase inhibitor (anti-androgens e.g. finasteride): slower action, safer, ↓ risk of urine
retention.
- α1-blockers (prazosin, afuzosin).
2. Surgical: TURP → complications:

- Intra-op.: brady-cardia.
- Post-op.: TURP syndrome (↑ fluid1, ↑ glycine, ↓ Na), retro-grade ejaculation.
Prostate cancer: posterior lobe, 70% multi-focal, 50% have skeletal mets at presentation through
internal vertebral venous plexus (average survival is 12 months if mets are symptomatic).
It almost never occurs in men castrated before puberty.
LHRH analogues may flare metastatic disease (anti-androgens, bis-phosphonates & RT should be
used).
Gleason score: higher number indicated higher grade (up to 10).
TTT:
Small with no spread → biopsy → TURP is an option.
Confirmed adeno-carcinoma, young & fit → radical prostatectomy.
Co-morbidities → external beam RT.
Prostatitis: fever, tender prostate, pus on meatus, terminal hematuria.
PSA is ↑ by prostatic massage (e.g. cycling), after ejaculation (1 hour) & acute urinary retention.
A small proportion of poorly-differentiated prostatic cancer fail to express PSA.
1 HTN & reflex brady-cardia.
120
TESTIS
Testicular hematoma (acute hemato-cele): TTT: scrotal exploration, evacuation & repair.
Torsion of the testis: absent cremasteric reflex (genito-femoral n.).

TTT: exploration via scrotal approach.
It is associated with ↑ risk of testicular cancer in both the ipsi- & contra-lateral testis.
Torsion of testicular hydatid (hydatid of Morgagni is most common): preserved reflex.

Blue-dot dis-coloration of the testis.
Epi-didymo-orchitis: preserved reflex, fever, gonorrhea & chlamydia. Amiodarone → epidiymitis

(rare).
TTT: ABs.
Testicular tumors
 Germ cell tumors:
1. Seminoma (40%). 4. Terato-carcinoma (25%).
2. Embryonal carcinoma (25%). 5. Chorio-carcinoma (1%).
3. Teratoma (5%) (elements similar to skin & its appendages).
Seminoma Teratoma
30-40 years (commonest (40%) & commonest in mal-descended testis) 20-30 years
Normal AFP & β-HCG ↑
Radio-sensitive Radio-resistant
May occur after injury, classical: lympho-cytic stromal infiltration
Invest.: blood tests, CT.
Staging: I (no mets), II (abdominal LNs), III (supra-diaphragmatic LNs), IV (distant mets).
TTT: orchidectomy via an inguinal approach + chemo-therapy (NO biopsy, NO scrotal approach).
Leydig cell tumor: rare, sex cord stromal tumor, gyneco-mastia.
Rhabdo-myo-sarcoma: spermatic cord firm mass, bi-modal age distribution (3-4 months – 16 years).
Most of mal-descended testes (80%) are ectopic.

Un-descended testis (cryptorchidism) has 8-fold higher risk of testicular cancer. Also, ↓ fertility.
Commonest site of ectopic testis is superficial inguinal pouch. It is least likely to be found in the
perineum.
Surgery for un-descended testis: 6-12 months.
Retractile testis: conservative ttt (re-assess in 6 months).
Suturing of scrotum in children: 5/0 vicryl rapide.
HYDRO-CELE & VARICO-CELE

Hydro-cele: testis cannot be palpated.
Cause: trauma, infection, tumor.
TTT: Children → inguinal approach → ligation of patent processus vaginalis.
Adults → scrotal approach → Jaboulay.
Varico-cele: painless, a bag of worms which is more prominent when the patient stands.
LT: abdominal U/S to exclude a renal mass as Lt testicualr v. drains into Lt renal v.
Spermato-cele: painless, trans-illuminant swelling at the upper pole of the testis.
Epi-didymal cyst: pain-lesss, may be bi-lateral, testis can be palpated.
121
PENIS
Balanitis: inflammation of the glans penis.
Candida albicans (ttt: albendazole) is commonest cause followed by → strept. pyogenes.
Suspected penile fracture:

TTT: surgical exploration (NO imaging).
Priapism: prolonged un-wanted erection for > 4 hours.

Low flow (dark blood) → aspiration.
High flow (bright red) → observation.
Hypo-spadius:
Commonest site is glanuar (distal ventral surface).
Associations: cryptorchidism (most common), inguinal hernia, cleft lip/palate & congenital heart
disease.
Painless ulcer + inguinal lymph-adenopathy: treponema pallidum (1ry lesion of syphilis, best test is
dark field micro-scopic examination of exudate or secretions).
Peyronie’s disease: chronic inflammation of the tunica albuginea which wurrounds the corpora
cavernosa.
C/P: Ab-normal penile curvature, erectile dys-function & pain.
Phimosis: tight fore-skin making retraction difficult (un-circumscribed male).

Para-phimosis: retracted prepuce beyound the glans & cannot be reduced.
By 16 years of age, almost all fore-skin should be retractile. If not → circumcision.
Cirmucision for phimosis: bi-polar for hemo-stasis (diathermy carries risk of trauma to end vessels).
TNM classification of 1ry penile tumors: T1: sub-epithelial CT, T2: corpora spongiosum or
cavernosum, T3: urethra or prostate, T4: adjacent structures.
DM is the commonest organic cause of impotence.
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URO-DYNAMICS & OTHERS

Stress in-continence:
TTT: pelvic floor ecvercises for 3 months → Burch colpo-suspension.
Neuro-pathic bladder:
Sacral peripheral n. → under-activity (e.g. DM).
Above → over-activity (e.g. CVA, MS).
Over-active bladder: urgency +/- urge in-continence, detrusor over-activity.

TTT: behavioral modifications, anti-cholinergics (e.g. oxybutynin) (S/Es: dry mouth, constipation, urine
retention, blurred vision, cognitive impairment).
Urine color:
Cloudy → phosphaturia.
Red → Rifampicin, rhubarb, beetroot, black berries, phenytoin, levo-dopa, methyl-dopa & guinine.
Blood-stained (pseudo-hematuria, no RBCs) → myo-globinuria (e.g. excessive excercise).
Micro-scopic hematuria: < 5 RBCs/HPF → flexible cysto-scopy (even if patient is on Warfarin).
Renal investigations:
Scarring in pediatrics → DMSA scan.
Function:
MAG 3 reno-gram (Especially in trans-plant).
DTPA (renal tumor shows hyper-vascualr flush).
Lower UTI:
Irritative: frequency, urgency, nocturia (FUN).
Obstructive: hesitency, poor flow, in-complete emptying, dribbling.
Ascending infection of the genito-urinary tract: E-coli.
Urinary Na:
> 80 mmol/L → tubular necrosis (renal failure).
< 20 mmol/L → pre-renal (↓ BP).
Sperm granuloma: common sequelae of vasectomy, smooth, round, adherent to the vas.
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FEMALE GENITAL SYSTEM

Im-perforate hymen is most likely to be associated with hemato-colpos.
Mittelschmerz (mid cycle pain): normal inflammatory markers, pain typically subsides over the next
24-48 hours.
Endo-metriosis causes dys-pareunia.
75-80% of post-partum hemorrhages are due to uterine atony which is characterized by severe
vaginal bleeding.
Ectopic pregnancy: ampulla of the fallopian tube is the commonest site.
Acute fatty live of pregnancy is a rare life-threatening complication of pregnancy that occurs in the
3rd trimester or the immediate period after delivery.
Intra-hepatic cholestasis of pregnancy causes marked pruritus.
Following bi-lateral oophorectomy, there is ↓ fat deposition.
TUMORS
Kiss cancer of the labium majus: spread of malignant tumors by implantation.
Cervical carcinoma: HPV, PAP (cervical) smear.
Dermoid cyst (benign cystic teratoma): commonest benign germ cell tumor of the ovaries in the pre-
meno-pausal women.
Chorio-carcinoma:
1. Hydatidi-form mole (50%). 3. Normal term pregnancy (20-30%).
2. Abortion of ectopic pregnancy (20%). 4. Progressive ↑ in β-hCG levels.
The geno-type of a complete hydatidi-form mole is 46 XX (90%) or 46 XY (10%) & is completely

paternal in origin.
Poly-cystic ovary (Stein Leventhal) syndrome (PCO):

1. Lack of regular ovulation. 3. Hirsutism.
2. Excessive amount or effects of androgenic hormones. 4. Enlarged ovaries.
Fibro-thecoma is a benign ovarian tumor that is most likely to be associated with endo-metrial hyper-
plasia.
Meig’s $: fibro-thecoma + Rt hydro-thorax.
Micro-glandular hyper-plasia: OCP (progesterone), ab-normal vaginal bleeding, endo-cervical poly-

poid mass. DD: adeno-carcinoma.
Ovarian serous cyst-adeno-carcinoma: ascites, uni-locular cystic tumor, clusters of malignant

epithelial cells surrounding Psammoma bodies.
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BREAST
Imaging of a breast lump in a young patient with implants: USS. If not conclusive → then MRI.
Commonest causes of mastalgia: cyclical → trigger point.
Breast abscess: nipple retraction, painful fissures.

Age: childhodd, perperium, breast feeding.
Fibro-adenoma: 18-25 years, firm or hard, smooth, mobile. Invest.: core biopsy for lesions > 4 cm.
Lympho-cytic lobulitis: young, type 1 DM, irregular firm mass. Invest.: core biopsy.
Peri-ductal mastitis: young, smoker, recurrent infection, painful lump, pus-like discharge.
TTT: co-amoxyclav. If failed → duct excision (Hadfield’s procedure).
Duct ectasia: meno-pause, recurrent infection, short & dilated ducts, slit-like nipple retraction,
cheese-like discharge (green or brown), micro-scopic blood, no palpable lump.
TTT: conservative ttt. If faield → duct excision (Hadfield’s procedure).
Breast cyst: peri-meno-pausal, dis-comfort, fluctuant, OCP.

Mammo-gram: halo sign. U/S: black hypo-echoic centers without internal echos.
TTT: aspiration if symptomatic (green, yellow or brown fluid).
Gyneco-mastia: liver cirrhosis (bi-lateral).

Drugs causing gyneco-mastia: DISCEA (Digitalis, Isoniazid, Spironolactone, Cimetidine, Estrogen,
Amlodipine).
Tumors
Intra-ductal papilloma: single duct discharge (clear or bloody), no palpable lump, ↑ risk of invasive
ductal carcinoma. TTT: micro-ductectomy.
Eczema of the nipply: areola.

Paget’s disease of the nipple: nipple then areola. If suspected + normal mammo-gram & U/S → punch
biopsy (invasive ductal carcinoma).
Ductal carcinoma in situ (CIS): bloody discharge, calcification, Comedo necrosis.

Lobular carcinoma in situ (CIS): close follow up (MRI).
Risk factors for developing breast cancer:

1. Increasing age. 6. Early menarche & late meno-pause.
2. Inherited mutations in BRCA1/2 genes (ch. 17q21). 7. Alcohol consumption.
3. Family history of breast or early ovarian cancer. 8. Post-meno-pausal obesity.
4. Exposure to ionizing radiation before the age of 30. 9. Prolonged use of HRT.
5. 1st pregnancy after the age of 35.
TNM staging:
T1 (< 2 cm), T2 (2-5 cm), T3 (> 5 cm), T4 (spread to chest wall or overlying skin).
N1 (axillary LNs, mobile), T2 (axillary LNs, fixed), T3 (other LNs).
Women with +ve BRCA1 gene have 50% chance of developing breast cancer by age 50.
Malignant lesion + palpable axillary LN: FNAC of LNs.

If +ve → axillary clearance. If -ve → sentinel LN biopsy.
Nodal status is the most important prognostic factor in breast cancer.
Allergy to patent V dye occurs in 1% of cases of SLN mapping.
Blue dye is contra-indicated during pregnancy.
125
LNs levels: Level I: inferior & lateral to pectoralis minor. Level II: posterior. Level III: medial.
Lympahtics start from the breast lobules that drain into the sub-areolar plexus (Sappey’s plexus).
Malignant lesion + +ve axillary LN: axillary LN clearance +

Invasive ductal carcinoma (post-meno-pause, single focus) → simple mastectomy.
Invasive lobular carcinoma (multi-focal, mets to contra-lateral breast, occult mammo-gram) → wide
local excision.
Mastectomy Wide local excision

- Central. - Peripheral.
- Multi-focal. - Solitary.
- Large lesion in small breast. - Small lesion in large breast.
- DCIS > 4 cm. - DCIS < 4 cm.
Axillary LN clearance involves division of the clavi-pectoral fascia at the edge of pectoralis minor
muscle.
Closed suction drainage system (poly-propylene).

Latissimus dorsi flap re-construction → risk of damage of thoraco-dorsal n.
RT is mandatory after breast conserving surgery to:

Breast alone if -ve LNs.
Breast & axilla if +ve LNs.
Trastuzumab (herceptin): ER -ve, HER2 +ve, metastatic disease (given for 1 year).
Cyto-toxic chemo-therapy: ER -ve, HER2 -ve, metastatic disease (LNs).
Aromatase inhibitors (letrozole): ER +ve, elderly.
Tamoxifen: estrogen receptor antagonist (causes breast epithelial cells to rest in G0 phase).
Predisposes to venous thrombo-embolism & endometrial hyper-plasia/cancer (post-meno-pausal
vaginal bleeding).
Inflammatory carcinoma: young, pregnancy or lactation, erythema, swelling, mets (jaundice).
Phyllodes tumor: pre-meno-pausal, rapidly growing, large breast mass. Stromal & epithelial
components.
Beign (may turn malignant) & melignant (TTT: wide local excision).
Medullary carcinoma: soft fleshy mass, lymphoid stroma with little fibrosis surrounding sheets of
large vesicular cells.
UK breast screening program:

Mammo-graphy/3 years (2 views read by 2 consultant radiologists, cranio-caudal & lateral oblique
views).
Early detection of CIS.
50-70 years (in some areas, 47-73 years).
> 20% of detected tumors were not clinically palpable.

In UK, the risk of any woman developing breast cancer is 12.5%.
Metastatic breast cancer to bone: osteo-lytic lesions (↑ Ca & ALP).

Invest.: serum ALP → bone scan.
126
ABDOMINAL VESSELS
Mesentric vacular disease: cardiac history, central post-prandial abdominal pain, diarrhea, blood PR.
Mesentric venous thrombosis: severe intra-abdominal sepsis, OCPs, patchy areas of infarction.
Invest.: CT angio-gram, duplex (if impaired RFTs).
SMA is more common / Acute embolism is more common.

Acute embolus → acute infarction → sudden pain followed by forceful evacuation (diarrhea) &
collapse.
Acute on chronic ischemia: history of weight loss.
Median arcuate ligament syndrome: epi-gastric post-prandial pain, bruit, no masses.
AORTA
Aortic rupture: deceleration injury (FFH).
Proximal to Lt sub-clavian a.: un-likely to survive → cardiac tamponade.
Distal: chest pain, ↓ BP.
CXR:
Widened mediastinum & para-spinal inter-faces. Depression of the Lt main bronchus.
Tracheal deviation to the Rt. Obliteration of the aortic knob.
AAA: true aneurysm, M, 75% asymptomatic.

Etiology: defect in fibrillin protein.
Mural thrombus → distal ischemia.
Risk of rupture over 5 years: 5-5.9 cm : 25%
6-6.9 cm : 35%
≥ 7 cm : 75%
Invest.: U/S every 12 months if < 4.4 cm – every 6 months if < 4.5-5.4 cm.
Indications of surgery: 1. Symptomatic (tender → urgent (within 48 hours)).
2. Asymptomatic > 5.5 cm.
3. Rupture (emergency).
The patient should not receive aggressive IV fluid resuscitation for hypo-
tension.
Dissecting aneurysm of ascending aorta: HTN, cystic medial necrosis.

Sudden onset of tearing chest pain that radiates to back & arms, no pressure reading from the left
arm. TTT: aortic root replacement.
Inflammatory AAA: M, young, smoker, infra-renal.

Fever, abdominal/back pain, weight loss, ↑ ESR.
127
ULCERS
Arterial Venous/post-phlebitic Neuro-pathic
M F, > 40 years
Well defined Well defined (may be irregular)
Painful Pain-less Pain-less
Punched out edges, grey-white Sloping edges, hesmo-siderin
Punched out edges, bleed easily
base (brown)
Pressure points (planter
Dorsal Medial malleolus
surface, heads of meta-tarsals)
No or mild ankle swelling May cause charcot foot (deformity)
Venous ulcer:
If heaped or raised edges or exophytic granulation tissue → marjolin’s ulcer (punch biopsy).
TTT: NO excision. NO routine use of ABs.
1. Limb elevation to ↓ edema. 3. Compression bandage.
2. Glycemic control, pntoxifylline. 4. Skin graft (in selected cases).
Chrcot foot: trauma (even minor), erarly: bounding pulses & erythema.
128
ARTERIES
Acute ischemia/embolus: TTT: < 6 hours → embolectomy.
> 6 hours → embolectomy + below knee fasciotomy.
Acute on chronic ischemia: invest.: angio-gram.
Chronic ischemia/stenosis:
TTT: Good run-off: Short segment → angio-plasty, aspirin, statin.
Long segment → graft.
Poor run-off: Amputation (trans-femoral or above knee).
Syndromes
Takayasu’s arteritis: F, young, Asian, pulseless peripheries, systolic murmur, CNS symptoms.
Burger’s vasculitis (thromo-angitis obliterans): M, young, smoker, cork-screw collaterals, small &
medium-sized a.a.
Raynaud’s syndrome: 1ry: bi-lateral, WBC (White → Blue → Crimson (red)) (one cause is TOS).
2ry: CT dis-orders e.g. rheumatoid arthritis, SLE.
Adductor canal compression: M, young, ischaemia on exertion, present popliteal pulse with knee
extension.
Cause: compression of the femoral a. by the musculo-tendinous band from adductor magnus muscle.
Popliteal fossa entrapment: absent popliteal pulse with knee extension.
Frost bite: aspirin 300 mg.
Grafts
SFA to above knee popliteal Vein or PTFE.
SFA to distal by-pass Vein or PTFE + Miller cuff → ↓ risk of neo-intimal hyper-plasia.
External iliac a. Femoro-gemoral cross-over graft.
Bi-lateral common iliac a. Young & fit → aorto-bi-femoral by-pass graft.
Major cardiac co-morbidities → axillo-femoral by-pass graft.
Better long-term patency is associated with vein grafts then synthetic graft & above knee than infra-
popliteal anastomoses.
Vein cannot be used if there is varicose veins.
3 minutes before cross clamping, 3000 units of un-fractionated heparin are given.
129
Amputation
1. Ray: DM foot infections. Vacuum-assistede closure devices (NO 1ry closure).
2. Below knee: skew or burgess flaps.
At least 8 cm of tibia is required to fit a below knee prothesis (15 cm is desirable).
3. Trans-knee (Gritti-stoke): femoral condyles are removed, patella is conserved & swung
posteriorly to cover distal femoral surface.
4. Above knee (trans-femoral): 1. Fixed flexion deformity.
indicaitons: 2. Fixed mottling.
3. Wheel-chair bound (non-ambulant).
Ankle-brachial pressure index (ABPI)

≥ 1.2 Vesel calcification (e.g. DM)
1-1.2 Normal
0.8-1 Mild stenotic lesion Risk factor management.
Risk factor management.
0.5-0.8 Moderate Duplex
If mixed ulcers → avoid tight compression.
0.3-0.5 Significant (rest pain) Duplex Avoid tight compression.
< 0.3 Critical ischemia Urgent detailed imaging
130
VENOUS
Axillary v. thrombosis: painful swollen arm, dusky fingers, present pulses.
Invest.: duplex.
TTT: catheter-directed tPA.
Varicose veins: TTT: Trendlenberg’s operation.

If recurred or residual varicosities → sclero-therapy (complications: brown dis-coloration, DVT, skin
ulceration).
DVT:
Risk factor: factor 5 leiden, deficiency of anti-thrombin III & protein C.
Commonest acquired cause is malignancy.
Invest.: veno-graphy → duplex scan (> 90% sensitivity & > 95% specificity for thrombus in DVT).
Klippel Trenauny syndrome: varicosities of klippel Trenauny v. (large lateral superficial v.), , of a
Spared saphenous distribution, port-wine stain, bony or soft tissue hyper-trophy (limb gigantism), AV
fistulae.
LYMPHATICS
Lymphedema:
1ry: < 1 year: Milroy’s disease (congenital). 2ry (commonest cause is malignant
1-35 years: Meige’s disease. neoplastic lymphatic infiltration).
> 35 years: lymphedema tarda.
TTT:
Multi-layer compression bandage (hosiery).
If failed: Young, healthy distal lymphatics, no patent proximal lymphatics → lympho-venous
anastomosis.
Limb deformity, healthy overlying skin → Homans operation.
Un-healthy skin → Charles operation.
Lymphedema precox: F, puberty/adolescence, 1ry, one leg.
Groin lymph-adenitis: tender mass, red streaks on thigh.
Lymph-angio-sarcoma: chronic edema, aggressive malignancy.
Risk factors for Hodgkin’s lymphoma:

1. HIV. 3. Solid organ trans-plant recipient.
2. EBV. 4. ↓ exposure to childhood infections.
Reed-sternberg cells: multi-nucleated ab-normal lymphoid cells (mature B-cells).
OTHERS
TIA: invest.: CT brain, carotid duplex.
Neuro-pathic pain: TTT: amitryptyline (S/E: ortho-static hypo-tension) or pregabalin.
Internal mammary a. is an excellent conduit for coronary a. by-pass with better long term patency
rates than venous grafts.
131
ORO-PHARYNGEAL
Origin of GIT: endo-derm except spleen (mesenchymal tissue).
Parts of GIT: fore-gut (from mouth to major duodenal papilla), mid-gut & hind-gut.
Carcinoma of the oral cavity: erythro-plasia is a pre-malignant lesion.
Pharyngeal pouch: early difficulty in esophageal intubation.

Killian’s dehiscence: defect between thyro- & crico-pharyngeus elements of the inferior constrictor of
the pharynx.
Regurgitation of un-digested food, cough at night, halitosis, throat infections.
If perforated → surgical emphysema.
Invest.: upper GI fluro-scopic swallowing study (ENDO-SCOPY IS CONTRA-INDICATED).
ESOPHAGUS
GORD: symptoms are worse at night.
Complication: esophageal stricture.
Invest.: 24-hour esophageal pH monitoring, upper GI endo-scopy.
Iatrogenic perforation: TTT: conservative (NPO, TPN).
Achalasia of the cardia: dys-phagia to soldis & liquids, infection with Trypanosoma Cruzi results in a
similar C/P (destruction of ganglion cells of myenteric plexus = Chagas’ disease).
Invest.: barium swallow shows “rat-tail” appearance.
Predisposes to SCC.
TTT: nifedipine → balloom dilatation → Heller’s cardio-myotomy + partial fundoplication.
Leio-myoma is the commonest benign tumor of the esophagus.
Barret’s esophagus: intestinal meta-plasia, Goblet cells.

6-monthly upper GI endo-scopy + quadrantic biopsies or endo-scopic mucosal resection (EMR).
EMR is also reasonable for small areas of malignancy occurring on a background of Barretts change.
Adeno-carcinoma: Asia & Africa, middle age.

Short history of dys-phagia, food debris, Barret’s.
Invest. (staging before TTT): PET CT, endo-scopic U/S.
TTT: Young, fit & multi-focal disease: esophagectomy.
+ mets: palliation (metallic stent) (NO staging or surgery).
Upper 1/3 SCC: TTT: combined chemo-RT.
Dieulfoy lesion: single large tortious arteriole in sub-mucosa.
Boerhaave syndrome (mackler triad): M, middle age, alcohol, vomiting, thoracic pain, sub-cutaneous
emphysema.
Plummer Vinson syndrome (esophageal web): dys-phagia, iron deficiency anemia.
132
STOMACH
Cushing ulcers: ↑ ICP.
Curling ulcers: burn.
H. pylori: ↑ acid production Gastric ulcers.

→ Duodenal meta-plasia → duodenal ulcers.
Invest.: urea breath test.
Ulcer in 1st part of duodenum: 1. Endo-scopic clip & injection, if failed

TTT: 2. Labarotomy & under-running of the ulcer, if failed
3. Resection.
Rockall scoring system to predict risk of re-bleeding: age, shock, co-morbidities, post-endo-scopy,
diagnosis & major stigmata.
Gastric carcinoma:
Risk factors: H. pylori, blood group A, pernicious anemia, alcohol, previous gastric surgery, gastric
polyps.
Signet ring cells → poorly → ↑ risk of metastatic disease.
NO metastatic disease: Gastric cardia: Total gastrectomy + Reux en Y re-construction.
Greater curvaature: Sub-tatal gastrectomy + Reux en Y re-construction + D2
lymph-adenectomy.
Post-gactrectomy jaundice + NO focal hepatic lesion + normal caliber CBD + dilated intra-hepatic
ducts: peri-hilar lymph-adenopathy.
Procedures: Anterior gastro-jejunostomy → ↓ gastric emptying.

Reux en Y gastro-jejunostomy → ↑ gastric emptying (best function).
Linitis plastica: no mass, thickened stomach, poor prognosis.

Sigent ring cells, intra-cyto-plasmic mucin
Case selection for bariatric surgery: BMI ≥ 40 kg/m2 or 35-40 kg/m2 + other significant disease (e.g.
type 2 DM or HTN) that could be improved with weight loss.
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SMALL INTESTINE
Meckel’s diverticulum: 2%, M, derived from vitello-intestinal duct, 60 cm proximal to ileo-cecal valve,
anti-mesenteric border.
Asymptomatic: ileal mucosa – symptomatic (bleeding): gastric mucosa.
Blood supply: vitelline a.
IBS: variability in site & intensity of pain, abdominal bloating.

It is the commonest cause of abdominal pain.
IBD: urban areas, weight loss, bloody diarrhea, nocturnal diarrhea, in-continence.
Invest.: measurement of faecal cal-protectin.
Crohn’s disease Ulcerative colitis

o Smoking. o Risk of malignancy.
 Non-caseating granulomas.  Superficial (mucosal) inflammation.
 Small bowel strictures.  Colon & rectum (NO anal canal).
 Skip lesions.  Mega colon (NO obstruction).
 Fat wrapping of terminal ileum.
 Barium study: cobble-stoning & rose thorn  Colono-scopy: pseudo-polyps.
ulcers.
o Gall stones (cholesterol) & renal stones. o 1ry sclerosing cholangitis.
o Iritis, clubbing, aphthous ulcers, pyo-derma
gangrenosum.
o Terminal ileal stricture: Rt hemi-colectomy o If well: pan-procto-colectomy + ileo-anal

→ ↓ PTH. pouch.
o Rectal: proctectomy & end stoma. Also if:
o Complex peri-anal: drainage, setons & 1) Associated with 1ry sclerosing cholangitis.
infliximab. 2) Associated with DALM lesions.
3) Failed medical ttt.
o If acutely un-well: sub-total colectomy + end
ileostomy (120 mmol Na/L of ilesotomy fluid).
Complciations of ileostomy:
1. Earilest: necrosis.
2. Commonest: dermatitis.
3. High volume ilesotomy → hypo-Mg → ↓ PTH secretion → hypo-Ca.
Celiac disease: T-cell-mediated, auto-immune, anti-tissue trans-glutaminase AB (anti-tTG).

Gluten in-tolerance, splenic atrophy, abdominal pain, bloating, steatorrhea.
Invest.: jejunal biopsy (villous atrophy, crypt hyper-plasia).
Diaphragm disease: NSAIDs, small bowel obstruction.
Hand sewn anastomosis of the proximal ileum has the lowest risk of anastomotic leak.
Locally un-resectable gastro-intestinal stromal tumour (GIST): imatinib.
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COLON & RECTUM

Rt sided colon cancer: anemia, exo-phytic.
+ obstruction: Rt hemi-colectomy + ileo-colic anastomosis (NO stenting).
If elective → Oral carbohydrate loading drink 2 hours pre operatively.
oral intake within 24 hours after surgery.
Invest.: gastro-graffin enema, sigmoido-scopy or CT scan.
Carcinoma of the splenic flexure:

- obstruction: Lt hemi-colectomy.
+ obstruction: extended Rt hemi-colectomy + ileo-colic anastomosis.
Lt sided colon cancer: obstruction.

+ obstruction: Hartmann’s procedure (resection + end colostomy).
Wallace Robinson drain (non-suction).
Mid-rectal tumor with no mets:

- obstruction: Low stage Abdomino-perineal excision of the colon & rectum (ELAPE) + loop
ileostomy.
High stage (T4) Combined chemo-RT.
+ obstruction: loop colostomy (NO emergency resection).
Colo-rectal cancer:
+ liver mets: curable → chemo-therapy followed by resection.
+ nodal disease → resection + cheo-therapy.
Suspected large bowel obstruction due to tumour: gastro-graffin enema, sigmoido-scopy or CT scan.
Familial cancer syndrome + colonic cancer: pan-procto-colectomy + terminal ileostomy.

Familial polyposis coli + high grade dys-plasia in 1 polyp: pan-procto-colectomy + ileo-anal pouch.
Special feature: duodenal polyps.
Sub-type: Gardener’s syndrome (skull osteomas).
Familial poly-posis coli has 100% risk of carcinoma within 30 years of diagnosis.
5-year survival rate after surgical resection of colon cancer:

Stage (Duke's stage) 5-year survival rate
I (A) Confined to bowel mucosa. > 90%.
II (B) Invading bowel wall (muscularis propria B1 – serosa B2). 70-85%.
III (C) Regional LNs (1-4 LNs C1 – > 4 LNs C2). 30-60%.
IV (D) Distant mets. 5%.
Diverticular disease: commonest cause of colonic bleeding in adults (NEVER in rectum).

Also, one of the commonest causes of colo-vesical fistula.
Bleeding → conservative ttt (endo-scopic hemo-stais is usually un-necessary).
Sigmoid + colo-vesical fistula → CT of the abdomen & pelvis.
Stricture + large bowel obstruction → Hartmann’s procedure (NO stent or dilatation).
Perforation → Hartmann’s procedure (risk of infection: 35%).
Hartmann’s procedure → diversion proctitis → painless blood stained mucous rectal discharge.
Ogilvies syndrome:
Surgery + electrolyte disturbance → colonic pseudo-obstruction.
Invest.: contrast enema.
TTT: symptomatic. If failed → de-compression.
Damage of the nervi erigentes → impotence.
135
All colonic adenomas are dys-plastic.

Villous adenoma: highest risk of malignant trans-formation. Secretory activity → hypo-K.
Cancer identified during endo-scopy (e.g. polyp): NO intervention (risk of seeding).
Hyper-plastic rectal polyp has no tendency to turn malignant.

Meta-plastic polyp is the commonest colo-rectal lesion of epithelial derivation.
Full thickness rectal prolapse: commonest complication is in-continence. TTT: recto-pexy (if young).
Rectal varices in case of portal HTN:

TTT: IV terlipressin, band ligation, TIPSS (NO injection).
Senna (laxative) works by direct bowel stimulation.

Laxative abuse: diarrhea, weight loss, melanosis coli in colono-scopy (lipo-fuschin laden macro-
phages, brown).
Definite plans for early re-look surgery & it is desirable to visualize the viscera → application of a
Bogota bag.
The commonest cause of peritonitis is post-operative complications.
ANAL
Anal fissure: 90% posterior.
Painful, post-defecation, bright red bleeding, sentinel pile.
TTT: stool softener & topical HTN (nitrates) → if failed
F → Botulinum toxin injection (↓ pre-synaptic acetyl-choline release).
M → lateral internal sphincterotomy (NO devision of external sphincter).
Anal fistula:
+ IBD → insertion of a loose seton (NO complex procedure).
+ discovered during I&D of peri-anal abscess → no probing.
Anterior: internal opening opposite external opening.
Posterior: internal opening mid-line (6 Ooclock).
Inter-sphincteric fistula: commonest type.

External opening may be internal or external.
Hemorrhoids: painless bright red blood.

TTT: rubber band ligation. If failed or prolapsed → excisional hemorrhoidectomy.
Anal cancer: HPV 16, most commonly SCC, rectal bleeding.

TTT: combined chemo-radio-therapy.
If within 5 cm of the anal verge → abdomino-perineal excision.
If in the upper 2/3 of the rectum → low anterior resection.
Pilo-nidal sinus: M.
Ischeo-rectal abscess: inferior & lateral to levator ani.
Peri-anal abscesses: M, crohn’s disease, 2ry intention healing.
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APPENDIX
Appendix mass without peritonitis: conservative ttt (ABs).
Absent Rovsing’s sign: retro-cecal appendicitis.
Mesentric adenitis: preceding flu-like illness, no abdominal signs. TTT: active observation.
Perforated appendicitis: fluid accumulation in pelvis (by gravity).
Paralytic ileus after appendicectomy for a perforated gangrenous appendicitis: Insertion of wide
bore NGT (de-compress the stomach).
Carcinoid tumor: appendix is the commonest site.

< 2 cm & limited to appendix → no intervention.
Large (5 cm) → radio-isotope scan.
If resection margin is +ve or if radio-isotope scan suggests lymphatic mets → Rt hemi-colectomy.
Carcinoid syndrome:
It occurs only in the presence of liver mets.
Clinical: flushing, diarrhea, broncho-spasm, telangiectasia, Rt heart valve lesions, pellagra.
Blood: 5HT (serotonin), chromo-granin A, neuron-specific enolase (NSE), substance P & gastric.
Urinary: 5-HIAA (5-hydroxy-indol-acetic acid).
TTT: octreotide (synthetic alternative to somato-statin).
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SPLEEN
Post-splenectomy blood film features:
1. Howell-Jolly bodies. 4. Target cells.
2. Pappenheimer bodies. 5. Irregular contracted erythro-cytes (siderotic granules).
3. Thrombo-cytosis (after 7-10 days).
Post-op.:
1. Vaccination against Hib, meningo-coccus B & 2. Annual influenza vaccinations.
C & pneumo-coccus (4-6 weeks pre- 3. Life-long oral penicillin.
operatively & then every 5 years).
Post-splenectomy sepsis:
1. Strept. pneumoniae ( commonest).
2. Neisseria meningitidis.
Splenic injuries: Hilar (G. IV) → splenectomy. ≤ G. III → close monitoring.

Splenic bleeding → argon plasma coagulation system.
Chronic granulomatous leukemia: massive splenomegaly.
PANCREAS
Pancreatitis:
Fat saponification → hypo-Ca.
Mild-moderate + early fluid collection → no specific ttt (NO draiange for fear of infection).
Necrosis → image-guided FNAC for culture. If proven infection → necrosectomy.
Pseudo-cyst (> 4 weeks).
Chronic: Chronic excess alcohol is the commonest cause, steatorrhea (exocrine in-sufficiency).
Octreotide (somato-statin) ↓ the output from pancreatic fistulae (↓ pancreatic enzyme secretion).
Serum lipase is the most sensitive blood test in acute pancreatitis.
Glasgow score (pancreatitis - PANCREAS):

1. PaO2 < 8 KPA. 5. Renal (urea > 16 mmol/L).
2. Age > 55. 6. Enzymes (LDH > 600 IU/L or AST > 200 IU/L).
3. Neutro-phils (WBCs > 18 X 109/L). 7. Albumin < 32 g/L.
4. Ca < 2 mmol/L. 8. Sugar (glucose > 10 mmol/L).
≥ 3 = severe disease.
Pancreatic carcinoma: most commonly adeno-carcinoma (origin: ductular epithelium).

Smooth Rt upper quadrant mass (Corvoisiers law), pain-less jaundice, thrombo-phlebitis migrans
(Trosseau’s sign).
5-year survival rate: < 5%.
+ liver mets → palliative chemo-therapy (NO surgery).
+ obstructive jaundice → ERCP + stent. If failed → PTC + stent.
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GALL BLADDER
Anomalies of the gall bladder & biliary tree are found in 50% of subjects.
Acute chole-cystitis: murphy’s sign.

Boa’s sign: hyper-esthesia of the tip of the Rt scapula.
10% have stones in the CBD.
Management: LFTs – U/S to show diameter of the CBD.

Labaro-scopic chole-cystectomy:
- Intra-abd. pressure: 10 mmHg (7-15 mmHg) – carbon monoxide.
- If difficult to detect Calots triangle (adhesions) & fundus only is visible → operative chole-
cystostomy.
- Mirrizi syndrome: gall stones impacted in Hartman’s pouch → recurrent inflammation → CBD
compression → obliterated Callot ∆.
- Reatined CBD stones (pain & obstructive jaundice) → MRCP → if confirmed → ERCP.
- Post-op. cystic stump leak → ERCP, sphincterotomy (mono-polar diathermy, cutting mode) &
stent.
- Late complication: retained gall-stone.
- Risk of infection if un-complicated: 5%.
- Conversion to open procedure occurs in 5%.
- Risk of common bile duct injury: 0.5%.
Recurrent chole-cystitis: Aschoff-Rokitansky sinuses: hyper-plasia & herniation of epithelial cells

through the fibro-muscular layer of the gall bladder wall.
Gall stones are the commonest cause of obstructive jaundice.

10% of gall stones can be seen on plain abdominal X-ray.
Gall stone pancreatitis: TTT: chole-cystectomy once the attck has settled.
Gall stone ileus: emergency laparotomy, remove the stone with enterotomy proximal to the site of
obstruction, leave the gall bladder.
Acalcular chole-cystitis: type II DM, critically-ill patients in ICU.
Chloangitis: Charcot triad, surgical emergency, E-coli. TTT: ERCP + stent.

+ pancreatitis → ERCP.
Sclerosing cholangitis: HIV, jaundice, ab-normal LFTs.
Gall-bladder carcinoma: 5-year survival rate: 1% despite surgical intervention.
Klatskin tumor: hilar cholangio-carcinoma = at the confluence of the Rt & Lt hepatic bile ducts.
Latex T-tube on passive drainage is used to elicit a fibrotic response (so that a track will form).
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LIVER
↑ ALT & AST denote live damage – ↑ ALP denotes chole-stasis (both are ↑ in acute alcoholic
hepatitis).
Hemangioma: commonest benign tumor, hyper-echoic, well-defined, large, normal LFTs, OCPs.
HCC: Asia & Sub-saharan Africa, Aflatoxin, ↑ AFP.

80% occur in cirrhotic liver & other chronic diseases (e.g. Wilsons disease).
If a lesion is suspicious by U/S: MRI prior to resection decision, AFP (NO biopsy, risk of seeding).
Hepato-cellular adenoma: OCPs, ↑ risk of malignant trans-formation. TTT: resection.
Angio-sarcoma: rare, PVC (poly-vinyl chloride) & arsenic.
Amebic abscess: far east, Entamoeba histiolytica.

Fever, pain, ill-defined lesion (CT).
Abscess: G-ve rods (E. coli & klebsiella pneumoniae).
Hydatid disease (Echino-coccus granlosus): greece, biliary colic, jaundice, urticarial rash.
TTT: albendazole, mebendazole.
Wilson’s disease: AR, copper accumulation in liver (ab-normal LFTs), CNS (basal ganglia) & iris (Keiser
Flischer rings).
1ry biliray cirrhosis: F, 40-60 years, pruiritis, malaise, jaundice.

Auto-immune, anti-mito-chondrial ABs.
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PEDIATRIC SURGERY
Average sized term infant requires 150 ml/Kg of formula feed/day.
Pyloric stenosis:
M, Projectile non-bile stained vomiting, 4-6 weeks, hypo-chloraemic metabolic alkalosis, palpable
tumor on test feeding, USS.
TTT: Ramstedt pyloromyotomy (open or laparoscopic).
Bilious vomiting in neonates: surgical emergency – intestinal mal-rotation & volvulus until otherwise
proven.
Invest.: upper GI contrast study.
TTT: Ladd’s procedure = urgent laparotomy, rotate the volvulus anti-clock-wise, return small bowel to
the Rt of the abdomen, cecum & colon to the Lt & perform an appendicectomy.
It is commonly associated with exomphalos & diaphragmatic hernia.
Intussusception: M, winter.
Ileo-colic (ileo-cecal): 6-9 months age, Colicky pain, diarrhoea & vomiting, sausage shaped mass, red
jelly stool.
TTT: ressuscitation (fludis & ABs) > reduction with air insufflation.
Ileo-ileal: less common, ressuscitation (fludis & ABs) > surgery (labarotomy, not amenable to
pneumatic reduction).
Intussusception can precipitated by hyper-trophic peyer’s patch (commonest) or mesentric cysts.

It is the commonest abdominal emergency in children under 1 year of age.
Mal-rotation:
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia (Trisomy 21),
bilious vomiting.
Invest.: upper GI contrast study & USS.
TTT: laparotomy (if volvulus is present, Ladds procedure), transverse supra-umbilical incision.
Hirschsprung's disease:
Absence of ganglion cells from myenteric & sub-mucosal plexuses of rectun (failure of ganglionic cell
migration down the hind-gut).
Delayed passage of meconium & abdominal distension.
Invest.: full thickness rectal biopsy.
TTT: rectal washouts > ano-rectal pull through procedure.
Oesophageal atresia:
Associated with tracheo-oesophageal fistula & poly-hydramnios (in-ability of the fetus to swallow
amniotic fluid), choking & cyanotic spells following aspiration, VACTERL associations.
VACTERL: Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal & Radial limb anomalies.
Meconium ileus:
Usually delayed passage of meconium & abdominal distension, Majority have cystic fibrosis.
X-Rays may not show a fluid level, PR contrast studies may dis-lodge meconium plugs & be
therapeutic.
NG N-acetyl cysteine, if failed > surgery to remove the plugs.
Biliary atresia: jaundice > 14 days, hepato-spleno-megaly,↑ conjugated bilirubin, pale stools/dark
urine, absent gall bladder!
TTT: Urgent Kasai procedure (Roux-en-Y porto-jejunostomy).
Necrotising enterocolitis
Prematurity, delayed presentation for days, abdominal distension & passage of bloody stools.
141
X-Rays: pneumatosis intestinalis & evidence of free air.

Increased risk when empirical anti-biotics are given to infants beyond 5 days.
TTT: total gut rest & TPN, babies with perforations will require laparotomy.
High output ileostomy in a 2 year old child > 0.9% saline + K.
Posterior urethral valves: F, obstructive developmental uro-pathy, commonest causes of poor urinary
stream & hesitancy in children.
Para-esophageal & hiatus hernias are very rare in children.
Commonest congenital heart diseases:

Cyanotic: TGA at birth, Fallot's overall (Rt ventricular out-flow tract obstruction, over-riding aorta, pan
systolic murmur, Rt to Lt shunt, Rt ventricular hyper-trophy).
Acyanotic: VSD.
Gastroschesis: no peritoneal covering.

Omphalo-cele minor: covered by a sac – defect < 4 cm.
Omphalo-cele major: covered by a sac – defect > 4 cm – Association: tetralogy of Fallot.
INCISIONS – PEDIATRICS
Operation Incision
1. Appendicectomy o Lanz incision.
2. Abdominal exploration o Transverse supra-umbilical incision.
3. Inguinal hernia o Urgent surgery
INCISIONS – ADULTS
Operation Incision
o Transverse incision 3 cm below the mandible
1. Sub-mandibular sial-adenectomy (avodi injury of marginal mandibular branch of
facial n.).
2. Ulcer in the 1st part of the duodenum o Epi-gastric incision.
3. Whipple procedure (pancreatic o Roof top incision.
carcinoma)
4. Descending thoracic aorta o Lt thoracotomy.
5. Femoral hernia o mcEvedy incision.
o Laparo-scopic or open Lichenstein repair.
6. Inguinal hernia
 Risk of infection: <5%.
During a transverse supra-pubic (Pfannenstiel) incision, posterior rectus sheath will not be
encountered as it ends in a thin curved margin (arcuate line or linea semi-circularis) half-way
between umbilicus & symphysis pubis.
A mid-line incision between the 2 rectus sheaths passes through the linea alba.
Retro-peritoneal fibrosis Retro-peritoneal malignancy

Un-common, HTN
Ureters Medially dis-placed Laterally dis-placed
CT Para-aortic mass
142
HERNIA
1. Spigelian  Lateral to rectus abdominis, at the level of arcuate line.
2. Lumbar  Iliac crest (inferior), external oblique (lateral), latissimus dorsi (medial).
3. Obturator  F, obturator canal, obstruction.
4. Richter  Part of the wall of the small intestine.
5. Littre’s  Meckel’s diverticulum.
Umbilical Para-umbilical
1. Childhood. 1. Adulthood.
2. Surgery (after 3 year of age). 2. Mayos technique.
3. Weak umbilicus. 3. Defect in linea alba.
Bochdalek, M Morgagni
1. Congenital. 1. Rare.
2. Lt hemi-diaphragm. 2. Foramen of Morgagni.
3. Lung hypo-plasia. 3. Un-common.
4. Direct anatomical repair or mesh. 4. Direct anatomical repair.
5. May contain transverse colon.
143
ORTHOPEDICS
Upper limbs
Heberdens nodes: distal inter-phalangeal joints (osteo-arthritis).
Bouchards nodes: proxiaml inter-phalangeal joints.
Dupuytren’s contracture: ring & little fingers, nodules in medial palm (contraction of the palmar
fascia), pain is un-usual.
Scaphoid #: fall on out-stretched hand or direct blow to palm, tender base of anatomical snuff box.
Injury of extensor pollicis longus.
If suspected + normal X-ray → Futura splint + review in fracture clinic.
If open → surgical debridement.
Bennett’s: fist fight, intra-articular fracture of 1st carpo-meta-carpal joint.

If comminuted → Rolando’s.
Colle’s (dinner fork deformity): fall on out-stretched hand.

TTT: reduction → dorsal back slap with the distal fragment in palamr flexion & ulnar deviation → open
reduction & internal fixation.
Late complication: rupture of the tendon of extensor pollicis longus.
Smith’s (reversed Colle’s): volar angulation.
Barton’s: Colle’s/Smith’s + radio-carpal dis-location.
Monteggia’s: proximal radio-ulnar joint + ulna.

Galeazzi: distal radio-ulnar joint + radius.
Radial head #: young, fall on out-stretched hand, restricted supination & pronation.
Dis-placed # of the anatomical neck of the humerus → hemi-arthro-plasty to prevent avascular

necrosis.
Impacted # of the surgical neck (stable) → conservative ttt (collar & cuff for 3 weeks then physio-
therapy).
Injury of axillary n. & circum-flex humeral vs.
Mid-shaft humerus & distal humerus (Holstein Lewis): injury of radial n..
Shoulder dis-location:
If anterior → injury of anterior (infrior) glenoid labrum (Bankart lesion).
Hill Sachs lesion → gleno-humeral dis-location due to contact of cartilage surface with rim of glenoid.
Adhesive capsulitis (frozen shoulder): loss of passive external rotation, pain → joint stiffness. TTT:
physio-therapy.
Acromio-clavicular joint dis-location: direct injury to superior aspect of acromion, loss of shoulder
contour & prominent clavicle.
Rotator cuff tear: elderly, minor trauma or long-standing impingement, shoulder pain & weakness
(impaired active abduction).
TTT: > 2 cm → surgical repair.
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Lower limbs
Ankle:
Pott’s: bi-malleolar ankle # (un-stable). Reduction & application of back slap →
fixation.
Weber B #: un-dis-placed ankle fracture distal to Ankle boot or below-knee plastar cast.
syndesmosis.
Maisonneuve #: medial malleolar #, proximal fibular # & Surgical fixation.
widening of the syndesmosis.
Tibial #:
Comminuted, intra-articular & distal Reduction & splinting → external fixator → CT scan → surgical
planning.
Open + neuro-vascular intact IV ABs, photo-graphy, saline-sauked gauze with im-permeable
dressing. Later → skeletal & soft tissue re-construction.
Open + no peripheral pulse IV ABs, immediate vascular shunting, temporary skeletal
stabilization → vascular re-construction.
Spiral # + overlying healthy tissue Planter ro long leg cast.
If failed → IM nail (NO open reduction & fixation so as not to
strip off healthy tissue).
Sub-trochanteric # IM nail.
Inter-trochanteric # Dynamic hip screw (DHS) or gamma nail.
Infection after total hip replacement: removal of metal work & implantation of local ABs → delayed
revision.
Femoral neck # (hip joint #): short & externally rotated neck.
Young → reduction & fixation.
> 70 years, fit & mobile → total hip re-placement.
Old & less active → hemi-arthro-plasty (lateral approach (Harding’s) → division of the transverse
branch of the lateral circum-flex a.).
Avascular necrosis: radiological changes occur late (radio-lucency & sub-chondral collapse).
Garden’s classification:
I: in-complete or impacted. III: minimally-dis-placed, rotated femoral head in
II: non-dis-placed, through both cortices. the acetabulum.
IV: complete dis-places.
Hip dis-location: Allis technique for reduction.
Open pelvic #: mortality rate 50%.
Achille’s tendon rupture:

Thompson-Simmonds test: lack of plantar flexion when calf is squeezed.
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Knee
Torn meniscus: twisting injury, delayed knee swelling, in-abiltiy to fully extend the knee.
+ve Mcmurray test.
Most do not heel with conservative ttt. TTT: arthro-scopic menisectomy.
MCL: foot-baller, +ve valgus stress test, minimal effusion.

ACL: foot-baller, twisting injury to a slightly flexed knee or pivot injury, rapid knee swelling, “pop”,
anterior drawer sign, +ve Lachman’s test.
PCL: direct blow to the antero-medial aspect of the knee.

PCL: knee trauma, tibia lies back on the femur, can be drawn forward during paradoxical draw test.
Dis-located patella: knee trauma, tense & swollen knee (hem-arthrosis), normal X-ray.
Donoghue’s (un-happy) triad: ACL, MCL & menisceal tear.
Injury of the calcaneo-navicular (Spring) ligament → flat foot.
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 which supports the medial longitudinal arch.
Chondro-malacia patellae: F, teenager, pain on walking down the stairs, quadri-ceps wasting, pseudo-
locking of the knee. TTT: physio-therapy.
Direct patellar trauma → stellat (comminuted) #.
Osgood Shlatters disease: teenager, athletic, knee pain during activity, swelling & tenderness over
tibial tuberosity.
TTT: rest & physio-therapy.
Pre-patellar bursitis (house-maid’s knee): pain with walking only, tenderss & swelling over the
patella, ↓ range of flexion.
Pes anserinus bursitis: sportsmen, medial proximal tibial pain, -ve Mcmurray test.
Hem-arthrosis: spontaneous, tense swollen knee, hemo-philia A & B.
146
Pediatric orthopedics
Perthes diseaese Slipped upper femoral epi-physis
M, 4-10 years, short stature, hyper-activity, F, obese, adolescent (10-16 years), knee pain
Clinical antalgic gait, pain on internal hip rotation. (noraml knee!), antalgic gait, limited internal
hip rotation.
Early: hip MRI (sclerosed femoral head). Hip X-ray: dis-placed femoral epi-physis,
Invest.
Late: hip X-ray (flattened femoral head). Southwich angle.
Keeping the femoral head in the Rest, non-weight bearing crutches.
TTT
acetabulum by braces, casts or surgery.
Developmental dys-palsia of the hip (DDH): breech delivery (20%), hip U/S (screening) at 4-6 weeks.
Pain-less limp, asymmetrical gluteal skin crease, waddling gait, ↑ lumbar lordosis.
Ortolani’s test: clunk of reduction as the hip is flexed & then abducted.
Hip X-ray: completely destructed femoral head & narrow acetabulum.
Transient synovitis: viral illness, ab-normal gait, mild ↑ in WBCs & ESR.
Green stick #: uni-lateral cortical disruption, peri-osteal hematoma.
Neuro-blastoma: lytic bone lesions (commonest cause in children).
Non-accidental injury: delayed presentation.
Talipes equino-varus: bi-lateral in 50%.

Edward’s $ (Tri-somy 18): talipes, omphalo-cele, micro-cephaly, crytorchidism.
Achondro-plasia: AD.
Infection
Osteo-myelitis: salmonella (if there is sickle cell anemia, relative brady-cardia).
Invest.: Widal test (serological test).
TTT: medical (anti-staph. ABs), joint wash-out (if septic joint).
Vertebral osteo-myelitis: fever, IV drugs users, TB (cerivcal → thoracic).
Psoas abscess: recurrence 15-20%.
Kocher criteria for septic arthritis:

WBCs > 12.
In-ability to weight bear.
> 90% chance of septic arthritis.
Fever.
ESR > 40.
Madura foot: chronic granulomatous fungal disease mainly affecting the limbs.
147
Other diseases
Rickets Small for age, large head, failure to thrive, bony
(childhood osteo- Vitamin D deficiency deformities.
malacia) X-ray: cupped epi-physis of the wrist.
Osteo-malacia Invest.: ↓ Ca & P – ↑ ALP.
F, post-meno-pause.
↓ normally
Invest.: DEXA scan (< 75 years only), normal Ca & ALP.
Osteo-porosis mineralized osteoid
TTT: vitamin D, Ca supplements & bis-phosphonates
matrix
(e.g. alendronate).
Young adult.
Anemia or thrombo-cyto-penia, throat/chest infection,
Osteo-petrosis: Defective osteo-clast
gradual loss of vision.
AR function
X-ray: marble bone (lack of differentiation between
cortex & medulla).
Adloescent.
Defective osteoid Small for age, poor muscular development, hyper-
Osteo-genesis
formation, failure of mobile fingers, blue sclera.
im-perfecta
collagen maturation X-ray: trans-lucent bones, multipel long bone #,
wormian bones (patches of ossification), trefoil pelvis.
Skull: vault expansion, sensori-neural hearing loss,
osteo-sarcoma, chondro-sarcoma.
Thickened & sclerotic long bones (meta-physis).
Paget’s disease
Invest.: normal Ca, ↑ ALP.
X-ray: Codman's triangle (osteo-sarcoma).
TTT: bis-phosphonates (e.g. alendronate).
Parsonage Turner $: peripheral neuro-pathy after viral illness, spontaneous resolution.
Spondylo-lithesis: F, young, athletic.
Pseudo-gout: swollen painful knee, Ca pyro-phosphate crystals.

↑ trans-ferrin saturation if the cause is hemo-chromatosis.
Compartment $: supra-condylar humeral or tibial shaft #.

Warfarin worsens it.
Loss of arterial pulsation occurs late.
Pressure > 20 is ab-normal, > 40 is diagnostic.
TTT: replacing a ful lcase by a backslab → fasciotomy.
Ankylosing spondylitis: HLA-B27, ulcerative colitis, cervical & thoracic kyphosis.
Gout: cyclo-phosphamide (used in lymphoma), uric acid stones, -ve birefringenet crystals.
Callus becomes visible on radio-graphs after 2-3 weeks.
Ewing’s sarcoma (small round blue cell tumor): M, children.

Dia-physis of long bones (tender, warm & swollen), fever, weight loss.
X-ray: onion-peel sign. TTT: chemo-therapy & excision.
Osteo-clastoma (benign): pathological #. X-ray: lytic & lucent areas (saop bubble appearance).
Osteo-chondroma (exostosis): commonest benign bone tumor affecting individuals < 21 years.
Osteoid osteoma: M, young adult, long bones, small radio-lucent zone surrounded by a larder
sclerotic zone.
148
CARDIO-THORACIC SURGERY
Safe triangle for chest tube insertion: 5th inter-costal space – mid-axillary line (bounded by latissimus
dorsi, pectoralis major, line superior to the nipple & apex at the axilla) – 2/0 silk.
Penetrating thoracic trauma followed by cardiac arrest: ER thoracotomy.
Clam shell thoracotomy: significant mediastinal & lung injuries.
Malignant mesothelioma: commonest malignant pleural tumor.

Asbestos exposure (ship building & insulation) – not linked to cigarette smoking.
Invest.: pleural biopsy.
Lung cancers
Non-small cell SCC Small (oat) cell
 Non-smokers.  Smokers.
 Peripheral.  Central (cavitary lesion  Central (large air-ways).
in a proximal bronchus).
 Better prognosis.  Poor prognosis.
 Adeno-carcinoma is  Para-neoplastic  Para-neoplastic syndromes:
commmonest non-small syndrome (PTH-related 1. Ectopic ACTH secretion → Cushing syndrome.
cell & commonest 1ry lung peptide → hyper-Ca). 2. SIADH (↓ Na)1.
cancer. 3. Lambert-Eaton myasthenic syndrome.
TNM staging for 1ry lung cancer:

1ry tumor LNs
o T1: ≤ 3 cm. o N0.
o T2: 3-5 cm. o N1: ipsi-lateral broncho-pulmonary or
o T3: 5-7 or extension to pleura, chest wall, diaphragm, hilar LNs.
peri-cardium, within 2 cm of carina or total atelectasis. o N2: ipsi-lateral mediastinal or sub-
o T4: invasion of mediastinal organs (e.g. esophagus, carinal LNs.
trachea, great vessels or heart), malignant pleural o N3: contra-lateral mediastinal or hilar,
effusion or satellite nodules within the 1ry lobe. or any supra-clavicular LNs.
Contra-indications to lung cancer surgery:

1. SVC obstruction. 2. FEV < 1.5.
3. Malignant pleural effusion. 4. Vocal cord paralysis.
The lung is the commonest site for metastatic neoplasms.

Pulmonary mets are the commonest neoplasms involving the lung.
A 3 cm LN has about 60-70% chance of showing malignant infiltration.
Pulmonary hamartoma is the commonest benign tumor of the lung.

The patient is usually healthy, asymptomatic & non-smoker.
Bronchial carcinoid is characterized by:

1. Localized bronchiectasis.
2. Ectopic secretion of ACTH, growth hormone or gastrin hormone.
The only surgical procedure that absolutely needs 1-lung ventilation is video-assisted thoraco-scopic
surgery (VATS).
1 Its presence suggests ir-resictable tumor.
149
HEART
Beck’s triad (cardiac tamponade): hypo-tension, ↓ heart sounds & ↑ JVP.
CXR: globular cardiac out-line.
Mitral stenosis: commonest cause of cardiac ab-normality occurring in pregnant women, non-UK,
rheumatic heart disease, mid diastolic murmur (left lateral position), risk of AF, pulmonary edema.
During cardiac surgery: controlled hypo-tension & controlled hypo-thermia.
Cardio-pulmonary by-pass surgery is associated with:

1. Thrombo-cytosis.
2. ↓ serum cortisol level.
It is instituted via ascending aorta & Rt atrium.
CABG → aspirin → ↓ risk of myo-cardial infarction.
051
GENERAL
COLLECTIONS
050
ANESTHESIA
Inguinal hernia repair Sevoflurane + laryngeal mask.
Surgery in distal fore-arm or hand Bier’s Block (1% prilocaine).
Uni-lateral Zadeks procedure (excision of toe nail) Ring block with 1% lignocaine alone
Scalp 1% lignocaine with 1 in 200.000 adrenaline
Local anaesthetics are relatively in-effective when used in infected tissues.

Local anaesthetic toxicity treatment = Intra-lipid 20%.
Lidocaine 1% (10 mg/ml): 3 mg/kg in adults (7 mg/kg with adrenaline).

It acts on Na receptors.
Bupivacaine: 2 mg/kg (-/+ adrenaline) – cardio-toxicity.
Prilocaine: met-haemoglobinaemia (cyanosis & dyspnea) Vs. IV methylene blue.

Most local anaesthetics are amino-amide types except procaine & benzocaine (amino-ester groups
metabolised by pseudo-cholinesterases).
Lignocaine: blockage of neuronal Na channels.
Absolute contra-indicaitons in spinal anesthesia: hypo-volemia, hypo-tension.

Spinal & epi-dural anesthesia → hypo-tension from blocking sympathetic out-flow → splanchnic
vaso-dilatation.
Anatommical differences between adults & children (larger head size, U-shaped epi-glottis & larger
tongue) make intubation more difficult.
Etomidate has the most favorable cardiac safety profile but induces adrenal suppression.
Ketamine has a strong analgesic effect & is ideal for hypo-tensive patients (↑ BP & HR) but causes
dissociative anesthesia.
Propofol has anti-emetic properties (advantage in day case anesthesia).
Drug Reversal
Opiates Naloxone.
Benzodiazepines (midazolam, Its use pre-operatively ↓ long- Flumazenil.
diazepam) term post operative cognitive
dys-function.
Atracurium: non-depolarizing muscle relaxant – degraded by ester hydro-lysis – may produce

histamine release. Vs. neostigmine.
Suxamethonium: depolarizing muscle relaxant – Induces hyper-K (generalized muscular contractions

followed by relaxation) – no histamine release – broken down by plasma cholin-esterase – malignant
hyper-thermia (AD with variable penetrance).
Hexamethonium: blocks transmission in post-synaptic autonomic fibers.
Na thiopentone causes myo-cardial depression.
Analgesia for:
Lower mid-line labarotomy incision: patient controlled analgesic infusion.
Upper: epi-dural anesthetic.
Orchido-pexy: caudal block.
Milligan Morgan haemorrhoidectomy: caudal block.
Metaraminol: α-receptor agonist – can be administered via a peripheral line.
051
CVP line: lower SVC – 2-8 cmH2o – ↑ during PPV.

Allows pulmonary a. catheterization via a Swan-Ganz catheter.
Intermittent PPV: requires ETT or tracheostomy1, ↑ in main air-way pressure, ↓ CO, complication:
pneumo-thorax.
Milrinone: phospho-di-esterase inhibitor.
Epi-dural catheter causing tingling in both legs → obtain MRI of the spine.
Classes of shock
I II III IV
Vlood loss (ml) 750 750-1500 1500-2000 > 2000
Blood loss (%) < 15% 15-30% 30-40% > 40%
BP Normal Normal (↓ pulse pressure) SBP < 100 SBP < 70
HR (beats/min) Normal 100-120 120-140 > 140
RR (breaths/min) Normal 20-30 30-40 > 40
Mental status Normal Mild anxiety Confusion Lethargy
Urine out-put (ml/h) > 30 20-30 20 Negligible
PRE-, PERI- & POST-OPERATIVE

MRSA
Emergency surgery + nasal MRSA not followed an MRSA eradication protocol → admit the patient
for the procedure, cover with appropriate AB prophylaxis & ensure a side room is available post-
operatively.
Rt hemi-colectomy for cecal cancer + nasal & groin MRSA → admit the patient for the procedure &
de-colonize before surgery (mupirocin nasal ointment & chlorhexidine wash).
Fluids
Daily requirements for a 70 kg patient: 1500-2400 ml, carbo-hydrates 2 g/kg.
Na 70-100 mmol & K 40-80 mmol.
Feeding
CVA → PEG tube.
If esophagectomy → jejunostomy tube.
TPN → peripherally inserted central catheter.
VOLUMES
Pleural fluid: 2-10 ml.
Blood volume = 85 ml/kg. Massive hemorrhage: loss of 50% of blood volume in 3 hours.
Bile: 0.5-1.5 L.
RADIATION
Imaging Radiation dose Back-ground radiation
Abdominal X-ray 0.7 mSv 4 months
Hip X-ray 0.3 mSv 7 months
4.5 years
CT abdomen & pelvis 10 mSv
(1 in 2000 ↑ life-time additional risk of fetal cancer)
1 Involves division of the thyroid isthmus.
051
NERVES
Procedure/fracture Nerve injury Effect
Ligation of MMA close to its
Auriculo-temproal n. Parasthesia of the ipsilateral external ear.
origin
Extraction of an imapacted Anesthesia on the antero-lateral aspect
Lingual n.
3rd molar of the tongue.
Greater auricular n.
Superficial parotidectomy (commonest).
Facial n.
Sub-mandibular sial- Marginal mandibular
adenectomy branch of facial n.
Sterno-mastoid mobilization
LN biopsy from the postero- Spinal accessory n. Sterno-mastoid & trapezius paralysis.
lateral aspect of the neck
Anesthesia of the axillary skin (upper

Sentinel LN biopsy Inter-costo-brachial n.
medial arm).
Long thoracic n. Winging of the scapula (serratus
Axillary LN clearance
Thoraco-dorsal n. anterior).
Atrophy of latissimus dorsi (evident with
Latissimus dorsi flap re- repetitive arm movements where the
Thoraco-dorsal n.
construction arm is elevated & moving up and down
(such as in painting)).
Abdomino-perineal excision
Hypo-gastric plexus Impotence.
of the colon & rectum
Inguinal hernia repair If entrapped in the mesh → neuroma →
Ilio-inguinal n.
Pfannenstiel incision pain.
Waddling (Trendelenburg) gait (abductor
muscle weakness – dipping of the pelvis
Superior gluteal n.
on the opposite side) + difficult thigh
abduction.
Common fibular Numbness of the antero-lateral leg &

Fibular #
(peroneal) n. dorsum of the foot.
Nerves passing through the supra-orbital fissure (SOF):

Live Frankly To See Absolutely No Insult (Lacrimal, Frontal, Trochlear, Superior Division of Oculomotor,
Abducens, Nasociliary & Inferior Division of Oculomotor n.).
Nerve supply:
Lower teeth: inferior alveolar n.
Lateral aspect of the tongue & gingiva: lingual n.
Erb Duchenne’s paralysis Klumpke’s pralysis

C5-6. C8-T1.
Shoulder dystocia during difficult birth. Delivery with arm extended.
Loss of arm abbduction. Loss of wrist flexors.
Arm is pronated & medially rotated. Claw hand.
Nerve injury:
Axono-temesis: damage to both axon & myelin sheath, preserved epi-, peri- & endo-neurium, stretch
or severe crush injury (closed fracture/dis-location).
051
Lymphatic drainage
 Tip of the tongue o Sub-mental.
 Posterior 1/3 of tongue o Deep cervical.
 Lobule of ear o Superficial cervical.
 Larynx - Supra-glottic: upper deep cervical.

- Infra-glottic: pre-lyngeal, pre-tracheal & inferior deep cervical.
 Esophagus - Upper 1/3: upper cervical.
- Middle 1/3: pre- & para-aortic.
- Lower 1/3: celiac.
 Pancreas o Celiac & para-duodenal.
 Uterine body & upper

o Iliac.
vagina
 Cervix o Obturator.
 Upper ureter, ovary & testis o Para-aortic (& supra-clavicular for testis).
 Lower ureter o Common iliac.
 Female urethra o Internal iliac.
 Male urethra - Prostatic & membranous (& prostate itself): internal iliac.
- Spongy & glans: deep inguinal.
 Rectum above dentate line o Meso-rectal (inferior mesentric).

 Rectum below dentate line,
anal canal & anus o Superficial inguinal (vertical group in case of acute paronychia
 Lower vagina & labia majora involving the big toe).
 Penile shaft & scrotum
 Deep popliteal LNs o Deep inguinal.
VITAMINS
 A o Rhodopsin synthesis.  Impaired night vision.
 Epithelial meta-plasia.
 C (ascorbic acid) o Collagen synthesis.  Bleeding gums, poor healing.
 B1 (Thiamine) o  Alcoholics → Wernicke-Korsakoff’s
$ (confusion, ataxia, amnesia).
TUMOR MARKERS
CA 15-3: breast.
BRCA 1 & 2: breast, ovarian.
CA 125: ovarian.
AFP: hepato-cellular carcinoma.

CA 19-9: pancreas.
CEA: colo-rectal1, pancreas – ulcerative colitis & smoking.
PRE-MALIGNANT
Human herpes 8: kaposi sarcoma.
HPV 16: cervical carcinoma, anal cancer.
EBV: glandular fever – pharyngitis & tonsillitis – generalized lymph-adenopathy – splenomegaly –
spontaneous splenic rupture.
Burkitt's lymphoma – Post-transplantation lymphoma – Hodgkin's lymphoma – Naso-pharyngeal
carcinoma.
1 It is only recommended for monitoring recurrence in patients with previously treated colo-rectal cancer.
055
TUBERCULOSIS
 1ry tuberculosis is characterized by:
1. Sub-pleural nodule, predominantly in the lower lung, usually in one site 1.
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
 Rifampicin o Inhibition of DNA-dependent RNA poly-merase.
 Ethambutol o Inhibition of the formation of the bacterial cell wall.
 Isoniazid o Inhibition of mycolic acid synthesis in the bacterial cell wall.
 In tuberculosis, those patient contacts who have a +ve skin test but no other signs of disease
should receive prophylactic isoniazid.
GRADING OF ORGAN INJURY

Kidney Spleen Liver
Hematoma Contusion or non-expanding Sub-capsular < 10% surface area
I
Laceration < 1 cm deep
Sub-capsular 10-50%
H Expanding
II Parenchymal < 5 cm
L < 1 cm without extravasation 1-3 cm
Sub-capsualr > 50%

Expanding or ruptured
H
III Parenchymal > 5 cm Parenchymal > 10 cm
Trabecular vs. Active bleeding
L > 1 cm > 3 cm
Renal segmental a. or v. with Segmental or hilar vs. →

H
contained hematoma > 25% de-vascularization
IV
Through cortico-medulalr 25-75% or 1-3 segments of
L
junction into collecting system lobe
Hilar vs. → de- Juxta-hepatic venous injury

H Renal pedicle injury or avulsion
V vascularized spleen. (IVC or hepatic v.)
L Shuttered Shuttered > 75% or > 3 segments of lobe
VI Hepatic avulsion
1 The 1ry lesion (Gohn focus) is located in the lower part of the upper lobe or the upper part of the lower lobe.
051
AUDIT & STATISTICS

Sensitivity = T +ve / T +ve + F -ve
Specificity = T -ve / T -ve + F +ve
Positive predictive value = T +ve / T +ve + F +ve
Audit: a process that seeks to improve patient care & outcome through systematic review of care
against explicit criteria & the implementation of change.
Cohort study: individuals are classified according to a feature (e.g. suture type) & are then followed
forward in time to see whether oen group is more or less likely to develop a disease.
Cross-over study: ↓ errors associated with individual differences.
Bias:
Inter-observer bias: different observers measure the same ↓ by double-blinding.
quantitiy differently.
Selection bias: use of un-re-presentative sample in a study. ↓ by randomization.
Lead-time bias occurs screening programs for cancer.
Statistical tests:
Kaplan-Meier graphs with long-rank test: comparison of outcomes over a period of time (e.g.
recurrence rates).
Pearson’s correlation co-efficient: analyses the strength of a relationship between 2 continuous
variables. Data follows a Gaussian (normal) distribution. The modal value is always equal to the
mean.
Student’s t-test: appropriate for analysing para-metric (normally-distributed) data.
Chi-squared test: compares counts of categorial responses between ≥ 2 in-dependent groups.
CONSENT
1. Form 1: adult patient, conscious, have the capacity to make the decision.
2. Form 2: < 16 years old, can be signed by the parents -/+ the patient.
3. Form 3: procedures that do not involve impairment of consciousness (e.g. flexible cysto-scopy).
4. Form 4: patients that lack the capacity to consent (can be signed by relatives).
 Proceed without consent in life-threatening emergency (consultant-in-charge gives consent).

 Patients < 16 years cannot refuse surgery even if they are Gillick competent.

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What are the characteristics of a primary tuberculous lesion?

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1

BASIC SCIENCE & SURGERY

1st edition - 1441

[email protected] – Drma7moud.blogspot.com – 02001014139579

NOTES BEFORE YOU START

 All (Surgery Part) is important.

 Most of general collections are very important.

 How to use this summary:

 PATHOLOGY, MICRO-BIOLOGY & PHARMACOLOGY ……...................... 90

 GENERAL SURGERY ……………………………………………………………………... 104

 GENERAL COLLECTIONS ……………………………………………….. 150

 C6 = start of trachea = junction between pharynx & esophagus.

 The posterior inter-costal a.a:

 1st aortic inter-costals supply the right bronchus.

 The thoracic wall is innervated by the inter-costal n.n.:

2) Dorsal 1ry rami provide:

DIAPHRAGM OPENINGS (VEA)

 Nerve supply (mnemonic): C3, 4 & five keeps diaphragm alive!

 The great cardiac v. is the largest tributary of the coronary sinus.

 The following cardiac v.v. do not end in the coronary sinus:

 An anomalous SVC drains via the coronary sinus.

 A part of the right branch of AV bundle is carried by the crsita terminalis.

 The left brachio-cephalic v. courses across the mediastinum in a horizontal fashion.

 Contents of the posterior mediastinum:

UPPER LIMB & BREAST

Anastomosis around elbow joint

 From lateral to medial – from proximal to distal:

1 Blood supply: dorsal carpal branch of radial a.

Dermatomes of the upper limb

Ulnar a. & n. in the wrist & hand

Verden Zones of the hand

9. Pronator teres  Production of the main movement of the

1The upper sub-scapular n. is an infra-clavicular branch of the brachial plexus.

 Branches of the axillary a. (devided by the pectoralis minor):

 Arteria princeps pollicis supplying the thumb is a branch of the radial a.

 The quadrangular space of the shoulder contains:

 The anatomical snuff-box contains

1. Tibial n. (long head).  Extension of the hip & flexion

 Muscle attachment on greater trochanter: POGO:

ARTERIES & VEINS

 Ligamnetum teres contains arterial supply to the head of femur in children.

 Femoral a. = 1-2 cm inferior to the mid-inguinal point.

 Arteries supplying the hip joint:

1. Obturator & femoral a.a.

 Superficial external pudendal a. passes through the saphenous opening.

 Profunda femoris (deep femoral) a. gives:

2. Lateral popliteal (common peroneal) n. gives:

1 Its function is affected in a fracture of the sustentaculum tali.

 Those with * pass also through the lessser sciatic foramen.

 Ischial tuberosities are used for sitting on.

 Boundaries of the femoral triangle:

 The femoral sheath is divided into 3 compartments:

 Sub-sartorial (Hunter's or adductor) canal contains:

 Popliteal fossa is bounded by: